What is the role of pharmacists in drug-related deaths?

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A review of coronial findings saw one case where the pharmacist contributed to cause of death, however most others did not make any recommendations to pharmacists

Researchers from the University of Canberra and the University of Tasmania have evaluated coronial findings of non-opioid and non-benzodiazepine drug-related deaths published online between January 2012 and October 2017.

The study identified a total of 52 scheduled pharmaceutical drugs and four unscheduled substances with pharmaceutical properties, across 33 coronial findings from six states.

There were increases in coronial cases associated with antidepressants and antipsychotics over the studied period.

Alcohol was found to be the leading implicated drug (n = 5), followed by quetiapine (n = 3).

Digoxin was found to be the sole contributor on two occasions.

Citalopram and paracetamol were found to be the sole drug in a single event, and each was implicated in a multidrug toxicity event.

Narrow therapeutic index drugs were attributed to six (18.1%) deaths: warfarin (n = 2), digoxin (n = 2), lithium (n = 1) and clozapine (n = 1).

Two findings (6%) were attributed to an anaphylactic reaction.

The most prevalent co-existing conditions were anxiety and depression (12 cases, 36%), other mental health disorders (11 cases, 33%) and alcohol abuse (seven cases, 21%).

Meanwhile pharmacists, with the exception of when submitting evidence as expert opinion, were only mentioned in 15% of findings (five cases).

In four of these, the dispensing pharmacist provided a statement of evidence.

There was one finding in which the pharmacist was found to have contributed to the cause of death.

In this case, from 2014, the pharmacist had identified that the dosage on a prescription for methotrexate appeared to be wrong, with directions to administer the drug daily instead of weekly.

The evidence suggested that the pharmacist had failed to confirm the dosage with the prescriber, and had dispensed the drug and labelled the container with “No directions specified please check with prescriber if unsure of usage” and had counselled the deceased using the Consumer Medicine Information leaflet.

The coroner made a comment that: “The cause of the failure was an inexplicably incompetent error by a suitably qualified general practitioner, which error had been identified but not effectively corrected by an apparently competent pharmacist for reasons that cannot now be ascertained.”

The Pharmacy Board of Australia provided a statement to the coroner, and their 2005 Guidelines for Dispensing of Medicines were submitted as evidence.

The coroner added: “I must confess that prior to hearing the evidence at the inquest and subsequently receiving information from the Pharmacy Board of Australia and from the Pharmaceutical Society of Australia website, I had assumed that pharmacists would consider themselves obliged to comply with the directions of prescribing doctors. I have since been disabused of that misconception.”

The circumstances of the death were referred to AHPRA for consideration.

No other findings across the 33 cases studied made formal recommendations directed at pharmacists or pharmacies.

Comments pertaining to pharmacists were limited to the requirement to maintain accurate records of drug interventions.

“It was apparent that coroners, in general, may not have a well-developed understanding of the professional role of a pharmacist,” said the authors.

They said that if the role of the pharmacist as the independent gatekeeper of safety between subscriber and patient was understood by coroners, “then we would have expected to see many more recommendations pertaining to the prevention of accidental drug-related deaths directed to pharmacists.

“Many of the recommendations made to general practitioners were equally relevant to pharmacists, including the need for increased monitoring when commencing a narrow therapeutic index drug or adding an additional drug,” they said.

“In addition, anaphylactic reactions accounted for 6% of deaths, reiterating the requirement to vigilantly enquire about and clearly document patient allergies.”

This article was published in the Journal of Pharmacy Practice and Research, the official journal of the SHPA.

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