Patients rely on pharmacists and prescribers having mutual respect for one another, while maintaining their independence. We take a look at striking the right balance.
Ian John Gilbert, 77, had a psoriasis flare-up. He visited his GP, got a script filled and headed home for some relief. Days later he died a ‘needless and entirely preventable’ death from ‘complications of methotrexate toxicity’, according to findings by Victorian Coroner Rosemary Carlin.
‘The dispensing pharmacist immediately recognised that the daily dose prescribed by the GP was potentially dangerous and called him to convey her extreme concern,’ stated the Coroner’s report released in June.
‘The GP assured her that he had checked the dose and it was correct. Though she was not at all reassured, the pharmacist felt obliged to dispense the medication in accordance with the prescription and did so.’
The Coroner went on to make a number of recommendations regarding ways to prevent inappropriate dispensing.
‘Doctors and pharmacists should trust and respect each other, whilst retaining their independence. In dismissing her concerns, it appears that the GP did not afford the pharmacist the respect she deserved,’ the Coroner stated.
‘In dispensing methotrexate despite her concerns, it appears that the pharmacist afforded the doctor too much respect, or at least lost sight of her role as an independent safeguard against inappropriate prescribing.’
The pharmacist/prescriber relationship
So what should the pharmacist/prescriber relationship look like in order to best prevent patient harm? Pharmaceutical Defence Limited Professional Officer Gary West said: ‘Longstanding convention has evolved that a pharmacist’s role is to be an independent check on the safety and appropriateness of doctors prescribing.
‘A pharmacist who does not act appropriately when a potential problem is detected may be called to account by a pharmacy regulator for unprofessional conduct.’
He pointed to Pharmacy Board of Australia Dispensing guidelines,1 which provide clear direction regarding pharmacists’ responsibilities.
‘In dispensing a prescription, a pharmacist has to exercise an independent judgement to ensure the medicine is safe and appropriate for the patient, as well as that it conforms to the prescriber’s intentions,’ the guidelines state.
‘Where clarification is required, the patient or their agent should be consulted and if necessary, the prescriber contacted.’
Additional guidance on the prescriber/ pharmacist relationship can be found in the PSA Code of Ethics for Pharmacists,2 including Integrity Principle 2 which states: ‘A pharmacist only practises under conditions which uphold the professional independence, judgement and integrity of themselves and others’.
The National Competency Standards3 stress that pharmacists must use their expertise to minimise medication misadventure.
There are many reasons that pharmacist/prescriber relationships can stray from the ideal, acknowledged PDL Professional Officer John Guy.
‘As was alluded to in the Coroner’s report, this relationship can break down if the prescriber is unwilling to engage effectively with a pharmacist who may have a concern,’ he said. ‘In some instances pharmacists are lacking in confidence when interacting with doctors.’
Added PDL’s Mr West: ‘Impediments to appropriate communication between pharmacists and prescribers may include workload pressures and interruption to practice, misunderstanding the intention of each health practitioner, poor communication skills and lack of mutual respect.’
Another common occurrence was for familiarity to compromise independence, noted PSA Victorian Branch Committee member, Jarrod McMaugh.
‘The more a pharmacist works with a particular doctor, especially if you have any kind of relationship outside of work, then you can get to the point where you think “oh I’ve known this doctor forever, they know what they’re doing”,’ explained the Managing Partner at Capital Chemist Coburg North.
Rebalancing the relationship
Be well informed and prepared
PSA Senior Pharmacist Carolyn Allen said that when it came to improving collaboration with prescribers it was important that pharmacists were well informed and well prepared.
‘If you’re concerned about a prescription, obtain as much relevant medicines and medical history and information as you can from the patient and research respected and approved references,’ Ms Allen said.
‘Check three or more standard Australian reference sources, and discuss with other pharmacists if you need to.’
Then when you phone the prescriber you’ll be able to confidently explain that you’re concerned that the prescription is not consistent with the references.
‘Do not relay this discussion through a practice nurse or secretary, but ask to talk directly with the prescriber,’ said Ms Allen.
‘Be ready to offer an alternative solution that is consistent with the references. Aim to be clear and concise in your discussion.’
Improve professional relationships
PDL’s Mr West said collaboration could also be improved through good relationships with prescribers.
‘Make an effort to build a relationship with local prescribers by demonstrating your willingness to work collaboratively with them to improve the care of your mutual patients,’ he said.
‘Prescribers will recognise the value of pharmacists if their interactions with a pharmacist are professional, appropriate and patient-centred.’
Mr Guy added that it could also help to ask prescribers if there were more appropriate times or ways of communicating with the prescriber, for example, email.
‘That can demonstrate consideration for the prescriber and their patients,’ Mr Guy said.
Engage throughout patient care
Any interaction you have with a patient can be an opportunity to ensure appropriate prescribing, Mr McMaugh said.
‘There’s always an opportunity for us to identify issues with the way people are using their medication,’ said Mr McMaugh.
‘It could come up in a MedsCheck or any other interaction we have with the patient.’ These interactions present both an opportunity and a responsibility.
‘If we’re finding an issue then that should always generate a conversation with the patient and the prescriber,’ Mr McMaugh said. ‘Our role is to protect patients from medications and prescriber error. That sounds a bit abrupt but really, when you really boil it down, that’s exactly what we’re here to do’.
Pharmacists deal with medicines so regularly that they can become complacent about just how dangerous they can be. ‘But the reality is,’ Mr McMaugh said, ‘people can die if we don’t do our job properly.’
And as the Victorian Coroner’s findings stressed: ‘pharmacists should not underestimate their own importance’.
Kickstarting the conversation
In August, PSA hosted a summit bringing together key stakeholders to discuss the question of how doctors and pharmacists can work together more effectively to support patient care through the safe use of medicine.
Representatives of numerous medical and pharmacy organisations were in attendance, along with the Consumers Health Forum, AHPRA and the Medical and Pharmacy Boards of Australia.
The focus of the summit was developing principles of collaboration that the relevant organisations can commit to, with patient-centred care and patient safety the priority.
PSA National President Dr Shane Jackson said the organisations involved expressed a genuine desire to work together and foster inter-professional collaboration for better patient safety.
PSA is now working with those organisations to agree on those principles, and developing ways of embedding these principles in to the practice of health professionals.
Dr Jackson said part of this was an understanding and acknowledgement of the key role of pharmacists as medicines experts.
Dealing with potentially inappropriate prescribing behaviour
A script comes across the counter and your instincts say something is not quite right.
Trust them, said PSA Victorian Branch Committee member, Jarrod McMaugh. And then gather the evidence to back them up. Here’s a guide to dealing with potentially inappropriate prescribing behaviour.
1. DO YOUR RESEARCH. Have a solution and backups.
PSA Senior Pharmacist Carolyn Allen advised obtaining as much relevant information from the patient as possible, researching multiple respected and approved Australian references, and if needed, speaking with other pharmacists.
Come up with a few potential solutions. As Mr McMaugh observed: ‘If you put it on the prescriber to come up with a solution to something that they didn’t even know was a problem until you rang, then the conversation may not be productive,’ he said.
2. CONTACT THE PRESCRIBER. Be clear and concise.
Prepare notes if you’re feeling some trepidation.
‘You will feel so much better calling the prescriber with notes sitting in front of you saying “here’s the problem, here’s what supports it, here’s my suggested solution and backups”,’ Mr McMaugh said.
3. IF THE PRESCRIBER INSISTS.
If you still feel it is inappropriate, PDL recommends:
– Delaying supply until further information can be gathered
– Seeking advice from sources such as drug information centres
– Contacting other practitioners including specialists that the patient may have seen previously for the condition
– Considering whether it is vital that the medicine be supplied immediately, based on the indication and the severity of the condition. Consideration may also be given to limiting supply to a smaller quantity pending further investigation if this would support medication safety and if immediate use is warranted.
Further guidance can be found in a recent PDL Practice Alert.4
4. SPEAK WITH THE PATIENT. Document actions.
PDL recommended that pharmacists provide patients with a clear understanding of your concerns reinforced by documents, such as CMIs and even extracts from references. Then record all actions and the reasoning associated with them.
Mr McMaugh suggested telling the patient that you have spoken to the prescriber and that you are not happy to dispense the prescription, and explaining why you feel it is not safe. ‘I’d be saying: … ‘I think you should have this conversation with the prescriber again, or get a second opinion, and I’m going to annotate the prescription”. Then document everything in your own records as well’.
Partnership for Care: NZ model for collaboration
Collaboration between doctors and pharmacists has been enshrined in New Zealand in a vision statement that stresses the importance of the professions working together.
PSA Strategic Policy Manager Bob Buckham worked for the Pharmaceutical Society of New Zealand as it and the New Zealand Medical Association drafted the 2014 document.
‘The vision statement sought to state what the key roles for doctors are, what the key roles for pharmacists are, and how the two roles fi t together for providing care,’ he said.
‘One of the key benefits was having recognition of what the pharmacist knows and does – that pharmacists do have this specialised knowledge and role in medicines management and optimisation.’
Entitled Vision 2020: Partnership for Care,5 the document sets out six vision areas: The Patient’s Healthcare Journey, Health Professional Roles, A Shared Working Environment, Services, Professional Competence and Ethics, and Payment Arrangements for Services.
Building on this document, the organisations have established the Integrated Health Care Framework for Pharmacists and Doctors.6 It outlines what should be considered to help ensure any new service or model of practice is developed in an integrated and patient-centred way.
‘So rather than just submitting an application for a new service or medication rescheduling cold – with the medical organisations not knowing anything about it and then arguing ‘pharmacists shouldn’t be doing that’ – the framework helps ensure roles, purpose and boundaries of practice are determined beforehand to avoid all of that public back-and-forth,’ Mr Buckham said.
Ravi Sharma, an independent prescriber from the UK, will visit Australia and work with PSA to provide valuable insights on autonomous prescribing in the UK and how to progress pharmacist prescribing in Australia. Registration is available here.
- Pharmacy Board of Australia. Guidelines for dispensing of medicines. 2015. At: pharmacyboard.gov.au/documents/default.aspx?record=WD15%2F17694&dbid=AP&chksum=whuWgDvj9dwviuEOS%2BHzOg%3D%3D
- Pharmaceutical Society of Australia. Code of Ethics for Pharmacists. 2017. At: https://www.psa.org.au/downloads/codes/PSA-Code-of-Ethics-2017.pdf
- Pharmaceutical Society of Australia. National Competency Standards Framework for Pharmacists in Australia. 2016. At: psa.org.au/wp-content/uploads/National-Competency-Standards-Framework-for-Pharmacists-in-Australia-2016-PDF-2mb.pdf
- Pharmaceutical Society of New Zealand and New Zealand Medical Association. Vision 2020: Partnership for Care. 2014. At: nzma.org.nz__data/assets/pdf_file/0004/37669/Partnership-for-care-2020-Pharmacists-and-Doctors-working-together-2014-Vision-Printer.pdf
- Pharmaceutical Society of New Zealand and New Zealand Medical Association. Integrated Health Care Framework. 2017. psnz.org.nz/Folder?Action=View%20File&Folder_id=96&File=IntegratedHealthCareFramework_Final.pdf
- Pharmaceutical Defence Limited. PDL Practice Alert 5 July 2018: Medication Misadventure – Methotrexate. 2018. At: pdl.org.au/