Six case studies

Medication errors, patient aggression, owing scripts, doctor pressure and forged signatures… PDL explores some sticky situations and how pharmacists should best deal with them

An incident or error is something most pharmacists will probably come across at some point in their career, PDL professional officer and community pharmacist Georgina Woods said in a presentation at NAPSA Congress in Newcastle this month. 

However if they’re dealt with correctly and in a timely manner, this often stops the situation from being escalated into something further, she explained. 

“It’s a common reflection that the patient really just wants an explanation of how the error occurred, so they know it won’t occur again to themselves or to someone else, and a really sincere apology. We’re lucky in Australia, an apology is not an admission of guilt,” said Ms Woods. 

She shared six case studies across various topics to showcase what types of incidents pharmacists may be involved in and how they could have best resolved the situation. 

1. Prednisolone medication error

In this case some prednisolone syrup was prescribed 5mg/mL, 15mg daily for three days, but the pharmacist dispensed it as 15mL (75mg) at night for a two-year-old child. 

“Thankfully only one dose was given and the child experienced diarrhoea and agitation, and the medication was ceased and the child did make a full recovery,” said Ms Woods. 

Her advice for what to do in the scenario/prevention: 

  • Straight away you would want to refer that child to a medical professional – whether that’s the hospital or to ring the prescriber and explain what’s happened. The child needs to be assessed to make sure everything is okay. 
  • Talking to the parents, they would be quite distressed about their child so that’s really important. 
  • Reporting it to PDL and documenting the situation. 
  • In terms of prevention, there can be a pop-up note so that every time prednisolone is dispensed there’s a big warning that says, ‘please check dose, mg/mL’. 
  • Slow down and think about what you’re doing. “I’ve noticed a bit of a disconnect between the dispensing process and the thought process,” said Ms Woods. “A 15mL dose is large. It doesn’t look right, and prednisolone only comes in a 30mL bottle, so in two doses we’re going to use up the bottle. That should’ve been a red flag for this pharmacist, but I think they were just rushing and weren’t thinking about it.” 

2. Methotrexate dosage issue

In 2015 methotrexate was prescribed 2.5mg twice daily for a flare-up of psoriasis. This medicine is generally used once a week. The pharmacist actually picked up the error and phoned the GP with “extreme concerns”, but the GP said they did not wish the dose changed. And so the pharmacist actually dispensed that dose. 

Unfortunately the patient died and the autopsy report attributed the death directly to the methotrexate dose. 

“Obviously the family were very distressed about this. [The inquiry] did call in an expert witness in the case who was a community pharmacist and she told the court she believed a culture existed amongst prescribers of not always responding to the concerns of pharmacists,” explained Ms Woods. 

“We need to change this culture. There is a disparity of power between doctors and pharmacists, and it’s not with everyone but there’s no need to apologise for phoning up a doctor and clarifying something. That’s our job as a health professional,” she said. 

“It’s really important to be aware that just because a doctor has prescribed something, it doesn’t necessarily mean it’s safe or appropriate. It’s up to us to be the medicines experts and assess each prescription individually so we’re aware and happy for that to go out.” 

Her advice for what to do in the scenario/prevention: 

  • Unfortunately the pharmacist didn’t make any further inquiries. Often a specialist is involved in care so you could try and ring a specialist to see if there was further information you could gather. You could do your own research, you do see some unusual doses that doctors prescribe, they might have read a random paper somewhere and they’re using that. 
  • In this case, the pharmacist should not have dispensed that script. They should have explained to the patient that they weren’t comfortable with dispensing that script, and that they should perhaps seek a second opinion or further advice. 
  • Again, documenting all your actions with something like this. 

3. Dealing with patient aggression

In this particular case a patient arrived at 7.30pm to pick up a script for escitalopram, it’s an antidepressant. The faxed prescription had not been received, and the surgery was closed. 

The pharmacist offered three-day emergency supply but the patient wasn’t particularly happy about that. They became aggressive and accused the pharmacist of lying and refused to leave the store. Verbal abuse continued while the pharmacist carried on dispensing and serving other patients. 

angry customer patient pharmacist pharmacyThe patient still refused to leave, so the police were contacted and the patient was escorted from the pharmacy. 

Ms Woods’ advice for what to do in the scenario: 

  • There’s a few options we have in this situation. In NSW and several other states, it means you can actually give a three-day supply. Alternatively, you can politely explain, look it’s not my fault, the fax isn’t here, maybe I can’t help you. You can refer to another pharmacy if you want to or try and send them to another doctor. 
  • You will come across entitled patients. Patients do claim to know more than you quite frequently, ut it’s really important to be aware and very skilled in your own state legislation. It’s much easier to be assertive if you actually know the rules,” said Ms Woods. 
  • She added: “We do see a lot of patients trying to get their way, they like to bully, they’ll often say to you, ‘I’m going to ring my lawyer’ or ‘I’m going to report you to a regulator’. If you’re not doing anything wrong, it’s very hard to get you in trouble. No one can get you in trouble for doing the right thing. Over 50% of things that get reported to AHPRA just get thrown out because they’re unreasonable or vexatious. 

4. Owing prescriptions

A Facebook post put up at the end of last year was about a dentist who was wanting to get some Viagra as an owing prescription. He didn’t have any repeats left, and the pharmacist told them so. Then he started to get annoyed and passive aggressively demanded for an ‘owing’. 

The post read: “Slightly intimidated, I gave him four tablets but man I hate this ‘owing’ phrase being constantly thrown in my face and if I refuse they throw a fit, totally ruins my day…” 

“In this case, the pharmacist did give in to a bit of bullying and unfortunately in NSW, where this has occurred, there was no provision under the law to actually [provide script owing],” said Ms Woods. 

Her advice for what to do in the scenario: 

  • The things we need to consider in these kinds of situations is, firstly, is there a provision for it? What happens if the patient gets harmed? What happens if they come back again saying, ‘you did it last time, can I just have it again?’ 
  • It’s really important to not get bullied or cajoled into these situations, because if something happens, if there’s a critical incident or adverse outcome, you are not protected because you haven’t done the correct thing. 
  • Read the PDL article Owing prescriptions – are you courting danger? It discusses owing prescriptions and the fact that dispensing software lets pharmacists do owings but there actually isn’t any legislation that covers us when  providing owings without some sort of order from the doctor. 
  • “It is really common practice, it happens everyday in community pharmacies all around Australia but just be aware that just because you’ve done an owing doesn’t mean a doctor will give you a prescription for it. And they’re under no obligation to do that,” said Ms Woods. 

Doctor on the phone5. Privacy issues

You are a pharmacist working in a community pharmacy. One evening the mother of a 15-year-old regular patient of the pharmacy asks to speak to you.  She tells you that she has just found out that her daughter has been having medications prescribed for her by the family GP and thinks it might be ‘the pill’, she wants to know what her daughter is taking.” 

Ms Woods’ advice for what to do in the scenario: 

  • We are covered in Australia by the Privacy Act 1988, and that protects individuals’ personal information regardless of their age. If you have a request like this, it’s really up to the organisation to assess each individual basis and think about whether that individual has the ability to consent to having this kind of question surrounding privacy. Some 17-year-olds might not have the capacity and some 13-year-olds might have the capacity. It needs to be established on an individual basis and you would need to document everything. 
  • In this case, if a mother came in like that, I would explain that her daughter has the right to privacy under Australian law, and unfortunately you are unable to help her with her request. So she’s welcome to come in with her daughter and we can discuss the situation together, or otherwise she’ll just have to talk to her daughter. But there’s no provision for you to provide that information for the mum. 
  • If it’s the police or an official organisation such as the Department of Family Services requesting it, a lot of the time you have to comply, but what we say to people is to get that request in writing, so you actually have got some documentation to ensure it’s a bona fide request. 

6. Pharmacy interns reported to AHPRA

There was an intern who decided to take half of a 2mg Suboxone film which was retained after a patient requested a reduced dose, explains Ms Woods. 

“After an hour I felt extremely sick with nausea and vomiting so I went home to take a rest.  I realised it was an S8 medication, so I reported the incident to my preceptor,” said the intern. 

In response, the  preceptor contacted the Department of Health and were advised to notify  AHPRA of the intern’s behavior. 

Her advice for what to do in the scenario: 

  • “I don’t really know what happened to this guy but I’m not sure his reference for the next job would have been super good,” said Ms Woods. “I urge you not to experiment with drugs at work, we’ve had issues where people have also taken medications that have been returned by patients or put in the RUM bin. Just keep in mind that there’s mandatory reporting to AHPRA, so if one your colleagues sees you doing something wrong, dipping into the drug safe or whatever that may be, they are required to report you. 
Image: PDL.

Meanwhile a different intern decided to forge their employer’s signature on documentation pertaining to their supervised hours. “The pharmacist was a bit busy, so the intern thought, ‘oh well, I’ll just sign it myself’,” said Ms Woods. 

AHPRA was notified and the intern contacted PDL. PDL was not able to assist them under their policy, because they actually didn’t do the right thing. The intern was suspended. 

Her advice for what to do in the scenario: 

  • We can’t help you if you’ve done something illegal. Our PDL policy is fantastic – we will assist you, but we won’t assist you in your criminal endeavoursWe can’t help you if you’ve done something illegal. 
  • “They were suspended before they’d even started their pharmacy career. It didn’t go particularly well,” said Ms Woods. 
  • Interns are registered practitioners. Be mindful of your actions when practising. 


PDL can be contacted 24/7 on 1300 854 838

Disclaimer: This information is general in nature and designed only to highlight issues for your consideration. Before acting on this information you should consider the appropriateness of the advice, having regard to your own situation and needs and obtain independent advice as appropriate.

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