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[post_content] => AI is transforming pharmacy practice — but without the right safeguards, it can also put your registration at risk.
AI is no longer an emerging consideration for pharmacists – it’s already embedded in practice.
Using large language models (LLMs) such as ChatGPT to answer clinical questions and AI scribes like Heidi Health to capture consultation notes is becoming more commonplace. With agentic AI – systems that act autonomously on a patient’s behalf – now growing in popularity, the pace of AI adoption is only set to increase.
But these opportunities come with obligations – and without a distinct regulatory framework. Here, PSA Digital Health Lead and Victorian state manager Jarrod McMaugh MPS outlines the sixAI traps pharmacists need to avoid.
1. Entering identifiable patient information into AI platforms
One of the most significant risks pharmacists face when using AI is entering patients’ health information into AI platforms. Regardless of the purpose or the pharmacist’s intent, it may constitute a breach of Australian privacy law.
‘Let's say you were providing a Home Medicines Review (HMR) and you put the patient’s details into ChatGPT and asked, “What medicines is this person missing for their diagnosed conditions?” That would be a breach of privacy regulations,’ Mr McMaugh said.
‘Any information put into AI is stored. And therefore, where it is stored must adhere to the Australian privacy requirements.’
However, pharmacists who use LLMs to check for missed medicines or potential interactions can do so legitimately, provided no identifying information is included.
And while taking out a patient's name and address is a good first step, this may not adequately deidentify them.
‘You could prompt an LLM by saying, “I have a person who is taking medicines, x, y, z, and they have these diagnoses. Can you identify any missed medicines or any interactions?”’ Mr McMaugh said.
‘As long as there's no way to identify the individual, and it's just down to what is clinically appropriate, it's not a breach of any privacy matters.’
2. Assuming a business account equals compliance
You may think that moving from a free AI account to a paid business subscription resolves any compliance concerns.
But to be compliant, business or enterprise AI subscriptions must explicitly confirm that the platform meets Australian privacy regulations in the delivery of that service.
'You would need to be satisfied that the LLM, under contract, specifically states that it meets Australian privacy regulations,’ Mr McMaugh said.
‘It's similar to the agreement you have with your dispensing software [provider] or the clinical platform you use to record scope of practice work.’
3. Using AI scribes without proper consent
For pharmacists conducting clinical consultations, such as accredited and prescribing pharmacists, AI scribes can be incredibly useful for collecting and collating patient information.
But deploying them without meeting the required consent obligations creates significant professional risk.
‘You must get consent from the person whose session is being recorded by the AI tool,’ Mr McMaugh said. ‘And you must have the ability to turn it off if somebody says, “I want the service, but I don't want the AI tool recording our discussion”.’
For pharmacists uncertain about what adequate consent looks like in practice, he suggests the following approach: 'I'm going to use an AI scribe in this session. It will record our conversation and take notes on our behalf. It will create a copy that I'll keep on record, and you have the right to access that record any time you request it. Are you comfortable with me proceeding?’
Pharmacists should also ensure that the AI tool is not in an active learning phase, with systems that continue to learn from patient interactions requiring an additional layer of consent.
‘For the vast majority of pharmacists, that shouldn't be a scenario they find themselves in – unless they're involved in clinical research about an intervention or research about the AI tool,’ he said.
‘For the vast majority of pharmacists, that shouldn't be a scenario they find themselves in – unless they're involved in clinical research about an intervention or research about the AI tool,’ he said.
Pharmacists should confirm that AI dictation tools don't record voice snippets or retain details to improve the quality of their systems. Utilising AI models that are actively learning is generally not appropriate outside of a clinical trial with the accompanying level of consent seen in a trial setting.
Using an ‘active learning’ AI requires well documented consent for the person's health information to be used in this way, and is usually out of scope for most clinical settings.
4. Failing to check transcription accuracy
The second area of risk when using AI scribes is accuracy. While generally reliable, they can make mistakes; and the professional obligation to maintain accurate records rests with the pharmacist, not the AI tool.
To prevent errors, pharmacists should still take notes while the AI scribe is working in the background, particularly around critical details such as dosing.
'If you were in a position in the future where something has gone wrong and you're in front of AHPRA or another regulator, and they say, “Why are your notes incorrect?” just assuming that the digital scribe was doing its job is not sufficient for meeting your professional obligations,’ Mr McMaugh said.
AI and handwritten notes should also be reviewed at the end of each session, while details of the consultation are still fresh.
'If you use an AI scribe during an HMR interview and you don't review the transcript until a week later, how are you going to correct the information that it got wrong?’ Mr McMaugh said. ‘From a workflow perspective, and to adhere to professional obligations, you need to make sure it's accurate.’
5. Trusting AI output without checking the references
AI platforms can produce clinical responses that are well structured, but are actually incorrect. These AI ‘hallucinations’, where LLMs return fabricated or inconsistent information, are commonplace.
Another, more subtle risk is when LLMs draw on international sources rather than Australian-specific guidelines.
‘If you ask what the standard dose of a medication is, you might get a generally acceptable dose that's not applicable to specific Australian scenarios,’ Mr McMaugh said.
Antibiotic selection is a clear example, with resistance patterns varying between countries, meaning recommendations based on international data may be inappropriate or inadequate for an Australian patient.
'You should therefore always ask LLMs for references so you can confirm the information is correct,’ he added.
And don’t forget to check these references also, which aren’t immune to AI hallucinations.
6. Accepting an AI-generated booking as genuine patient consent
Agentic AI is a system designed to act autonomously on a person's behalf, booking appointments, managing schedules and completing transactions.
While these tools have the potential to streamline service appointments, such as vaccinations, pharmacists must be vigilant around digital bookings.
When an AI agent books a consultation on a patient's behalf, it’s not possible to confirm at the point of booking whether the patient themselves made an informed, active decision to attend.
‘If booked online, pharmacists should double-check that a person has provided consent to have a particular service when they come in,’ Mr McMaugh said. 'This is a good way to confirm that consent has been provided by the [person] receiving the service – not the AI that is booking on their behalf.’
To close any gaps in the consent chain, he suggests:
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[post_content] => A new transitions of care model is helping high-risk patients in rural and remote areas avoid medication misadventure and hospital readmission through virtual pharmacist-led care.
After patients are discharged from the hospital, their transition back into the community can be high-risk, with significant potential for medicine-related harm. These risks are amplified significantly for rural communities due to sparse healthcare facilities, fragmented continuity of care and workforce shortages.
The TIC TOC program in Western NSW is tackling these issues via a virtual model designed to support patients who are struggling to access care during vulnerable post-discharge periods.
The TIC TOC program will be further explored at the CPC26 conference later this month and is set to demonstrate how digital health and multidisciplinary collaboration can help bridge the gap between hospital and home.
Ahead of the program’s launch, AP spoke with Linda Krogh, the Virtual Transitions-of-Care Stewardship Pharmacist with the Western NSW Local Health District and a current PhD candidate with the University of Sydney.
A virtual model of care
‘Transitions of care are deeply complex – even more so in remote settings due to factors such as distance, workforce, and community care,’ said Ms Krogh.
The CPC26 presentation will outline how the model translates into practice, including identifying high-risk patients, virtual medication reconciliation, multidisciplinary communication, and rapid coordination of Home Medicines Reviews (HMRs).
The Transitions of Care (ToC) Pharmacist role was introduced to provide virtual support across 19 towns, ensuring high-risk patients receive an optimal discharge and follow up, particularly when onsite pharmacy services are unavailable.
The layout of the model means that the ‘TOCS pharmacist monitors the patient’s hospital admission and supports the onsite or virtual clinical pharmacist to ensure all required discharge activities are completed,’ Ms Krogh said.
This includes reviewing electronic medical records to identify medicines that were commenced, ceased, changed, or continued during admission.
‘The role includes medication reconciliation, patient counselling, preparation of patient-friendly medication lists and direct communication with GPs and consultant pharmacists to facilitate timely post-discharge medication reviews,’ she said.
Through virtual work, pharmacists can connect hospital teams, patients, carers, and primary care providers across geographically disconnected areas.
The risk in transitions
The severely limited access to GP services and healthcare facilities delays crucial follow-up appointments and check-ins after discharge. In most rural communities, locum professionals make up a significant part of the primary care workforce, creating significant challenges in ensuring continuity of care.
‘Patients are often discharged from hospitals located a long distance from home, which can delay access to medicines and follow-up post-discharge,’ Ms Krogh said.
Patients are identified as high risk for medicines misadventure and readmission based on criteria including ‘use of high-risk medicines such as insulin, alongside a hospital readmission within the previous 6 months.’
‘These factors can increase the risk of medication discrepancies, misunderstandings, and adverse events once the patient returns home,’ she added.
Fast-tracking post-discharge HMRs
A key feature of the program is its focus on ensuring HMRs occur when they are needed – not when they are possible.
To ensure time-sensitive cases are addressed, the TOC pharmacist prepares a HMR referral for the patient’s GP before discharge. If the referral cannot be signed within a 48-hour window, the program activates the hospital-initiated HMR pathway, to avoid delays.
‘The goal is for the post-discharge HMR to be completed within 10 days,’ Ms Krogh said.
Patients can choose whether they prefer their HMR conducted face-to-face or virtually, allowing referrals to be matched to credentialed pharmacists based on patient preference and location.
The TOCs pharmacist then books a GP appointment to ‘review the HMR recommendations and develop medication management plans, helping to close the loop on the patient's transition of care,’ she said.
By clearly identifying patients as high-risk, reception staff are better able to triage appointment availability where demand exceeds capacity.
Connecting hospital and community care
A major strength of the TIC TOC model is its ability to connect traditionally siloed parts of the healthcare system by facilitating communication between hospital clinicians, GPs, and community pharmacists – improving continuity of care throughout each patient’s journey.
‘In rural towns where GP appointments are often booked out weeks in advance, this model ensures high-risk patients have their medications reviewed promptly by a pharmacist,’ Ms Krogh said.
With post-discharge HMRs frequently identifying medication misunderstandings, the early identification of medication-related issues also allows GP appointments to focus more efficiently on clinical decision-making and care planning.
The most common errors identified relate to patients’ misunderstanding of how to take their medicines following discharge, as well as short-term medicines that pose a point of confusion, such as tapered prednisolone regimens and analgesics.
‘In one case, a patient stopped taking an antihypertensive medication after overhearing nursing staff say it should be withheld during admission, not realising the change was only temporary,’ Ms Krogh said.
‘Another patient discharged with two antibiotics misunderstood the instructions and intended to take the medicines sequentially rather than concurrently.’
Multidisciplinary action
The TIC TOC model encapsulates a broader theme of multidisciplinary collaboration that will underpin CPC26.
With healthcare systems championing the importance of coordinated care, this program demonstrates how pharmacists can play a central role in ensuring patient safety during transitions of care, particularly for vulnerable rural populations where limited access to timely healthcare poses challenges.
Further insights into the TIC TOC program and the virtual TOC's pharmacist role will be shared during the CPC26 conference session, held between 29 – 31 May 2026 at the RACV Royal Pines Resort, Gold Coast.
Click here to register.
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[post_content] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps placing pressure on both practitioners and patients.
HMR services remain a vital safeguard for improving health literacy among vulnerable Australians living with chronic illnesses, complex medicine regimens and mental health conditions.
But pharmacists on the ground warn the model is increasingly unsustainable under current funding arrangements. Restrictive caps, rising fuel costs, and extensive travel times are making the reality of HMRs nearly impossible to keep up with.
AP spoke with Mitchell Everlyn, consultant pharmacist, qualified diabetes educator, and locum based in Brisbane, Australia, about the impact of these pressures.
Unsustainability of HMRs
Growing demand for HMRs, increased clinical complexity and systemic constraints are reshaping the extent of the services pharmacists can realistically provide.
Balancing extreme travel distances with capped funding arrangements has left many questioning how long they can continue carrying the weight of HMR practice.
When asked about the sustainability of HMRs, Mr Everlyn said that ‘unless funding increases with caps or indexes upwards, I'm better off working in a pharmacy than I am doing consultant stuff.’
With 30-per-month caps set in place, Mr Everlyn said that ‘the time and money you're getting back from HMRs works out to be about $22 an hour. These financial pressures directly impact which patients pharmacists can realistically afford to fit in.’
At the same time, patient demands continue to climb. HMR waitlists can stretch for months for many pharmacists, particularly in rural areas where these services are a cornerstone in healthcare.
Urgent referrals continue to flood in, yet pharmacists are unable to exceed service limits.
‘I get follow-up emails asking why I haven't seen an acute patient… and it’s because I’ve hit my cap and I can’t,’ Mr Everlyn said.
Despite the growing clinical complexity of patients receiving HMRs, remuneration has been at a standstill since 2019, and service caps have remained largely unchanged, creating a widening gap between the work required and the compensation available.
Under PSA’s 2026-27 Federal Budget recommendations, caps have been recommended to increase to 60 HMRs per month from 1 July 2026.
Professional isolation in rural practice
For pharmacists servicing rural and regional areas, the challenges extend well beyond funding, triggering a push towards incorporating telehealth to ease the strain of providing rural HMR services.
Loading allowance is only extended to $125 per visit, which is designed to contribute towards the costs incurred, not necessarily to cover all costs, ultimately leaving pharmacists out of pocket.
The PSA has estimated that reforming HMR delivery would cost $135.1 million over 4 years, which includes introducing HMR payments linked to rurality (MMM3-7). Such investments would reduce preventable hospitalisations and improve rural access.
Mr Everlyn recently had to reduce the distance he travels due to financial strain.
‘I'm now needing to prioritise HMRs that are a lot closer to home, which sucks to say.’
Mr Everlyn has been increasingly providing private HMRs, explaining that patients are not prepared to wait 3 months.
Mr Everlyn recalled one HMR consult in a completely isolated area where healthcare access was severely limited, Mr Everlyn said ‘the patient was having an acute schizophrenic attack, and the closest hospital was an hour away.’
It is commonplace for credentialed pharmacists to conduct reviews completely alone, which leaves them with the task of navigating highly complex medical situations without any form of backup.
Patient and practitioner safety
As wait times blow out across the healthcare system, pharmacists are increasingly encountering patients whose conditions have escalated well beyond medicines management.
‘There have been times where I've gone to a patient's house and had to call ambulances because they need acute care,’ Mr Everlyn said.
‘I saw someone recently who's been in hospital three times this year for suicide attempts, and there is a 6-month wait list for a psychiatrist. So then you’re talking about patient safety.’
Naturally, these experiences have an impact on a practitioner's emotional wellbeing. ‘After situations like that, who do you call? Where's the support net? It can be very isolating,’ Mr Everlyn said.
Fuel crisis and a push to telehealth
Fuel shortages and rising petrol costs are putting the longevity of HMR practice in a compromising position, which places vulnerable patients at immense risk.
Increasing fuel prices have added yet another layer of pressure for pharmacists who are already operating on tight margins.
With travel taking up large portions of the workday, and an increase in fuel costs, there has been a recent push towards incorporating telehealth into HMR services.
PSA national president Professor Mark Naunton MPS said ‘the support these patients need, such as medication reviews, is becoming rapidly unsustainable amid the current fuel crisis, unless the government reinstates telehealth.’
‘We know telehealth worked effectively and efficiently during the COVID-19 pandemic, so why not now?
‘I did one HMR on Easter Sunday, which was a 120 km round trip, and then with roadworks, it took me two hours to get there. One full day's work worked out to be $200,’ Mr Everlyn added.
‘The push over to telehealth would alleviate so much time.’
While he acknowledges the value of in-person assessments, he argues that not every consultation requires pharmacists to travel hours to gain the required clinical information.
‘You can tell a lot by how someone's moving… but I don't need to travel 3 hours one way just to see that.’
For many pharmacists, the reluctance to modernise HMR services feels increasingly behind broader innovation.
‘In this day and age we have AI, but we can't do telehealth,’ Mr Everlyn says.
The reinstatement of telehealth is included in the reforms PSA is advocating for to ensure that care is accessible for all Australians.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
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[post_content] => Busy pharmacies, bright lights and confined spaces can heighten fear surrounding vaccination, particularly among children who are neurodiverse.
[caption id="attachment_32071" align="alignright" width="300"]
Yvette Anderson MPS[/caption]
Understanding how to create a safe, calm environment is essential to delivering patient-centred care.
A time sensitive vaccination window
With winter around the corner, pharmacies should be in peak winter vaccine campaign mode – including the recently introduced intranasal vaccine, FluMist.
But pharmacists new to vaccinating children are often nervous that immunising school-aged children can be tricky. The Child Health Poll reported that 1 in 4 children experience needlephobia – which often intensifies with age. These challenges are amplified amongst children who are neurodiverse, calling for an enhancement of personalised care throughout the vaccination process.
Yvette Anderson MPS – founder of Spectrum Pharmacist, which sets out to bridge the gap for neurodivergent families – told AP her top tips.
Fear surrounding the vaccination experience
Neurodiverse children can often experience heightened levels of sensory sensitivity, differences in communication, and increased anxiety in unfamiliar settings.
‘Early signs of anxiety and sensory overload vary from child to child,’ Ms Anderson said. ‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.’
During vaccination, early signs of overwhelm may include:
‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.'
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Case scenarioDavid, 68, presents to the pharmacy 7 days before a scheduled colonoscopy. He says the written instructions from the clinic were ‘hard to follow’ and asks whether he should stop ‘all his tablets’. David has type 2 diabetes, hypertension and atrial fibrillation. He uses a weekly dose administration aid (DAA) prepared by the pharmacy. His regular medicines include apixaban, ramipril, empagliflozin, metformin and atorvastatin. He also takes ibuprofen intermittently for knee pain and a garlic supplement. He has been advised to fast and complete bowel preparation the day before the procedure and is unsure which medicines to continue, stop or restart. |
Australians make 440 million visits to their pharmacist each year,1 with community pharmacists frequently consulted by patients preparing for diagnostic or minor surgical procedures. These encounters often occur when instructions are unclear, leaving patients unsure which medicines to stop, when to stop them, and how to safely resume therapy. Temporary medicine changes can be particularly confusing for patients using dose administration aids (DAAs), increasing the risk of dosing errors or procedural delays.
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Pharmacists are well placed to address this gap. As accessible healthcare professionals with medicines expertise, pharmacists can identify medicines that increase peri-procedural risk, clarify instructions, and support safe temporary changes.
This article provides a practical, evidence-based overview of medicines commonly withheld prior to procedures, counselling strategies to minimise confusion, guidance for managing DAAs, and pharmacy-based interventions to support patient safety.
Patients preparing for diagnostic investigations or minor surgical procedures are often advised to temporarily withhold selected medicines to reduce peri-procedural risk. The decision to continue or withhold a medicine involves balancing potential risks of the procedure (such as bleeding, infection, haemodynamic instability, renal impairment, metabolic disturbance or interactions with medicines used in the peri-procedural period) against the risk of disease exacerbation or withdrawal effects. Pharmacists play a critical role in identifying medicines that may require review, clarifying prescriber instructions and supporting safe temporary modification of therapy.2
Anticoagulants and antiplatelet agents are among the most frequently managed medicines in the peri-procedural setting. Oral anticoagulants, including warfarin and direct oral anticoagulants, increase bleeding risk during procedures such as colonoscopy, dermatological excisions, and some dental or ophthalmic surgeries.3 Antiplatelet therapy presents a more nuanced risk-benefit balance. For many minor procedures, including cataract surgery and simple dental or dermatological procedures, aspirin may be safely continued, while procedures with a higher bleeding risk may necessitate temporary cessation.4
The decision to withhold antithrombotic therapy is highly individualised and should always be clinician-directed. Pharmacists should avoid advising cessation independently but can support patient safety by reinforcing clear stop and restart dates, and emphasising the importance of timely recommencement to minimise thromboembolic risk.3,4
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly withheld prior to procedures due to their reversible inhibition of platelet aggregation and their potential to impair renal perfusion, particularly in the context of peri-procedural dehydration or exposure to contrast media.2,5 Platelet function typically normalises within several days of NSAID discontinuation, although this varies by agent.5 From a pharmacy perspective, the most significant risk arises from unrecognised over-the-counter NSAID use. Pharmacists should proactively enquire about non-prescription analgesics and recommend suitable alternatives, such as paracetamol, where appropriate.2,5
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remain an area of clinical debate. Continuation has been associated with an increased risk of intraoperative hypotension, while cessation may increase the likelihood of postoperative hypertension.9-11 Evidence supports an individualised approach, taking into account the indication for therapy, baseline blood pressure, and the nature of the procedure and anaesthesia.9,10 In practice, many clinicians elect to withhold these agents on the morning of surgery when hypotension risk is high and resume therapy promptly post-procedure. Failure to recommence ACEIs or ARBs within 24–48 hours postoperatively has been associated with increased short-term mortality.9–11 Pharmacists should reinforce clinicians’ pre-procedure instructions, provide rationale and highlight the importance of timely recommencement.
Complementary and herbal products require review in the peri-procedural period, as evidence indicates their use remains highly prevalent among surgical patients, yet disclosure to healthcare professionals is often incomplete.1,12 Herbal medicines may exert clinically significant pharmacodynamic and pharmacokinetic effects that increase peri-procedural risk, including impaired platelet aggregation (e.g. garlic, ginkgo biloba, ginseng), increased sedative effect (e.g. kava, valerian) and altered metabolism of anaesthetic or perioperative medicines through cytochrome P450 enzyme induction (e.g. St John’s wort).2,13 Risk assessment is further complicated by variability in product composition, dosing and bioactive constituents, meaning effects are not always predictable or dose dependent.11 As a result, many contemporary guidelines recommend discontinuation of non-essential herbal medicines at least 1–2 weeks prior to procedures, depending on the agent and procedural risk.2,13
Diabetes medicines and peri-procedural blood glucose managementMedicines used to manage diabetes often require review in the peri-procedural period. Temporary changes may be needed to reduce medicine-related risk during fasting and recovery, and pharmacists play an important role in supporting patient understanding and continuity of care.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors warrant specific attention in the peri-procedural period due to the risk of diabetic ketoacidosis (DKA), which may occur with near-normal or only mildly elevated blood glucose levels (euglycaemic DKA). The risk is increased during periods of fasting, reduced carbohydrate intake (including bowel preparation), dehydration, acute illness and surgical stress. Importantly, normoglycaemia does not exclude DKA, and blood ketone testing should be considered where clinical suspicion exists. Clinical guidelines advise that SGLT2 inhibitors should be withheld for at least 3 days prior to procedures requiring fasting or bowel preparation (and 4 days for ertugliflozin).6
Physiological stress related to illness, fasting, anxiety and surgical intervention activates counter-regulatory hormones such as cortisol and catecholamines, leading to increased hepatic glucose output and reduced insulin sensitivity.7 When combined with altered oral intake and temporary medicines changes, this stress response can result in significant glycaemic variability, even in patients with previously stable diabetes.2,3
Extremes of blood glucose pose specific risks in the peri-procedural setting. Hyperglycaemia is associated with dehydration, impaired immune function and an increased risk of postoperative infection, while hypoglycaemia may result in neuroglycopenic symptoms, cardiovascular instability or loss of consciousness – particularly in the context of fasting or reduced caloric intake.8 For most adults, general peri-procedural targets include fasting blood glucose levels of approximately 4–8 mmol/L and random levels below 10 mmol/L, although individual targets should be tailored based on comorbidities, frailty and procedural complexity.8 Pharmacists play an important role in reinforcing blood glucose monitoring plans, supporting sick-day management principles, therapy modification during temporary medicine cessation, and identifying when abnormal readings require medical review. Clear counselling on when and how to safely recommence withheld medicines once normal oral intake has resumed is essential to minimise metabolic complications and support safe transitions of care.2,6
Patients who use DAAs are at increased risk of medication error when medicines are changed, particularly when temporarily withheld in the peri-procedural period.14 These patients often rely on the pack as their primary prompt for medicine administration and may not be familiar with individual medicines or their indications. Temporary cessation without appropriate pharmacist intervention can lead to duplication or unintended continuation of withheld medicines. Pharmacists therefore play a critical role in coordinating safe, structured modifications in response to procedural instructions.
Best practice involves pharmacist-led removal of specific medicines from affected doses, rather than advising patients to self-remove tablets, which increases the risk of error and pack disruption. Clear documentation should accompany any changes, including written instructions outlining which medicines have been withheld, the duration of cessation, and the planned date of recommencement, where possible. If feasible, pharmacists should provide a simple, procedure-specific DAA and schedule follow-up to ensure medicines are safely reintroduced post-procedure.
Liaison with prescribers may be required if instructions are unclear or if the patient’s clinical status changes. Through proactive management of DAAs, pharmacists can significantly reduce confusion, support continuity of care, and minimise preventable medicine-related harm and delays in the peri-procedural setting.
Community pharmacists can proactively review medicines prior to procedures, identify medicines that may require temporary cessation, clarify clinician-directed stop-restart instructions, and manage changes to DAAs.
By reinforcing written advice, reviewing over-the-counter and complementary medicine use, and supporting blood glucose monitoring during periods of fasting or medicine withholding, pharmacists minimise confusion and prevent medicine-related harm. Pharmacists can also support peri-procedural care by encouraging patients to bring all medicines for review and by providing an accurate medicines list to assist communication across care settings.
Pharmacists play a critical role in supporting patients preparing for common procedures through proactive medicines review, clear counselling and practical support for temporary medicine changes. This role is particularly important for patients using DAAs, where structured pack modification and follow-up can reduce medication errors and delays to care. As peri-procedural medicines management becomes increasingly complex, pharmacist-led interventions are essential to safe, coordinated and patient-centred care.
| Case scenario continued You review all prescription, over-the-counter and complementary medicines, and clarify the clinic’s instructions. High-risk medicines potentially requiring temporary cessation are identified, including apixaban, empagliflozin, ibuprofen and the garlic supplement, while other medicines can be continued as directed. Given David’s use of a DAA, you undertake pharmacist-led pack modification based on the clinic’s instructions. You provide clear written directions outlining withheld medicines, monitoring advice during fasting, and when medicines should be restarted once oral intake resumes. You use the teach-back method to confirm understanding, and a follow-up is arranged after the procedure to safely reintroduce medicines into the DAA. |
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[post_content] => AI is transforming pharmacy practice — but without the right safeguards, it can also put your registration at risk.
AI is no longer an emerging consideration for pharmacists – it’s already embedded in practice.
Using large language models (LLMs) such as ChatGPT to answer clinical questions and AI scribes like Heidi Health to capture consultation notes is becoming more commonplace. With agentic AI – systems that act autonomously on a patient’s behalf – now growing in popularity, the pace of AI adoption is only set to increase.
But these opportunities come with obligations – and without a distinct regulatory framework. Here, PSA Digital Health Lead and Victorian state manager Jarrod McMaugh MPS outlines the sixAI traps pharmacists need to avoid.
1. Entering identifiable patient information into AI platforms
One of the most significant risks pharmacists face when using AI is entering patients’ health information into AI platforms. Regardless of the purpose or the pharmacist’s intent, it may constitute a breach of Australian privacy law.
‘Let's say you were providing a Home Medicines Review (HMR) and you put the patient’s details into ChatGPT and asked, “What medicines is this person missing for their diagnosed conditions?” That would be a breach of privacy regulations,’ Mr McMaugh said.
‘Any information put into AI is stored. And therefore, where it is stored must adhere to the Australian privacy requirements.’
However, pharmacists who use LLMs to check for missed medicines or potential interactions can do so legitimately, provided no identifying information is included.
And while taking out a patient's name and address is a good first step, this may not adequately deidentify them.
‘You could prompt an LLM by saying, “I have a person who is taking medicines, x, y, z, and they have these diagnoses. Can you identify any missed medicines or any interactions?”’ Mr McMaugh said.
‘As long as there's no way to identify the individual, and it's just down to what is clinically appropriate, it's not a breach of any privacy matters.’
2. Assuming a business account equals compliance
You may think that moving from a free AI account to a paid business subscription resolves any compliance concerns.
But to be compliant, business or enterprise AI subscriptions must explicitly confirm that the platform meets Australian privacy regulations in the delivery of that service.
'You would need to be satisfied that the LLM, under contract, specifically states that it meets Australian privacy regulations,’ Mr McMaugh said.
‘It's similar to the agreement you have with your dispensing software [provider] or the clinical platform you use to record scope of practice work.’
3. Using AI scribes without proper consent
For pharmacists conducting clinical consultations, such as accredited and prescribing pharmacists, AI scribes can be incredibly useful for collecting and collating patient information.
But deploying them without meeting the required consent obligations creates significant professional risk.
‘You must get consent from the person whose session is being recorded by the AI tool,’ Mr McMaugh said. ‘And you must have the ability to turn it off if somebody says, “I want the service, but I don't want the AI tool recording our discussion”.’
For pharmacists uncertain about what adequate consent looks like in practice, he suggests the following approach: 'I'm going to use an AI scribe in this session. It will record our conversation and take notes on our behalf. It will create a copy that I'll keep on record, and you have the right to access that record any time you request it. Are you comfortable with me proceeding?’
Pharmacists should also ensure that the AI tool is not in an active learning phase, with systems that continue to learn from patient interactions requiring an additional layer of consent.
‘For the vast majority of pharmacists, that shouldn't be a scenario they find themselves in – unless they're involved in clinical research about an intervention or research about the AI tool,’ he said.
‘For the vast majority of pharmacists, that shouldn't be a scenario they find themselves in – unless they're involved in clinical research about an intervention or research about the AI tool,’ he said.
Pharmacists should confirm that AI dictation tools don't record voice snippets or retain details to improve the quality of their systems. Utilising AI models that are actively learning is generally not appropriate outside of a clinical trial with the accompanying level of consent seen in a trial setting.
Using an ‘active learning’ AI requires well documented consent for the person's health information to be used in this way, and is usually out of scope for most clinical settings.
4. Failing to check transcription accuracy
The second area of risk when using AI scribes is accuracy. While generally reliable, they can make mistakes; and the professional obligation to maintain accurate records rests with the pharmacist, not the AI tool.
To prevent errors, pharmacists should still take notes while the AI scribe is working in the background, particularly around critical details such as dosing.
'If you were in a position in the future where something has gone wrong and you're in front of AHPRA or another regulator, and they say, “Why are your notes incorrect?” just assuming that the digital scribe was doing its job is not sufficient for meeting your professional obligations,’ Mr McMaugh said.
AI and handwritten notes should also be reviewed at the end of each session, while details of the consultation are still fresh.
'If you use an AI scribe during an HMR interview and you don't review the transcript until a week later, how are you going to correct the information that it got wrong?’ Mr McMaugh said. ‘From a workflow perspective, and to adhere to professional obligations, you need to make sure it's accurate.’
5. Trusting AI output without checking the references
AI platforms can produce clinical responses that are well structured, but are actually incorrect. These AI ‘hallucinations’, where LLMs return fabricated or inconsistent information, are commonplace.
Another, more subtle risk is when LLMs draw on international sources rather than Australian-specific guidelines.
‘If you ask what the standard dose of a medication is, you might get a generally acceptable dose that's not applicable to specific Australian scenarios,’ Mr McMaugh said.
Antibiotic selection is a clear example, with resistance patterns varying between countries, meaning recommendations based on international data may be inappropriate or inadequate for an Australian patient.
'You should therefore always ask LLMs for references so you can confirm the information is correct,’ he added.
And don’t forget to check these references also, which aren’t immune to AI hallucinations.
6. Accepting an AI-generated booking as genuine patient consent
Agentic AI is a system designed to act autonomously on a person's behalf, booking appointments, managing schedules and completing transactions.
While these tools have the potential to streamline service appointments, such as vaccinations, pharmacists must be vigilant around digital bookings.
When an AI agent books a consultation on a patient's behalf, it’s not possible to confirm at the point of booking whether the patient themselves made an informed, active decision to attend.
‘If booked online, pharmacists should double-check that a person has provided consent to have a particular service when they come in,’ Mr McMaugh said. 'This is a good way to confirm that consent has been provided by the [person] receiving the service – not the AI that is booking on their behalf.’
To close any gaps in the consent chain, he suggests:
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[post_content] => A new transitions of care model is helping high-risk patients in rural and remote areas avoid medication misadventure and hospital readmission through virtual pharmacist-led care.
After patients are discharged from the hospital, their transition back into the community can be high-risk, with significant potential for medicine-related harm. These risks are amplified significantly for rural communities due to sparse healthcare facilities, fragmented continuity of care and workforce shortages.
The TIC TOC program in Western NSW is tackling these issues via a virtual model designed to support patients who are struggling to access care during vulnerable post-discharge periods.
The TIC TOC program will be further explored at the CPC26 conference later this month and is set to demonstrate how digital health and multidisciplinary collaboration can help bridge the gap between hospital and home.
Ahead of the program’s launch, AP spoke with Linda Krogh, the Virtual Transitions-of-Care Stewardship Pharmacist with the Western NSW Local Health District and a current PhD candidate with the University of Sydney.
A virtual model of care
‘Transitions of care are deeply complex – even more so in remote settings due to factors such as distance, workforce, and community care,’ said Ms Krogh.
The CPC26 presentation will outline how the model translates into practice, including identifying high-risk patients, virtual medication reconciliation, multidisciplinary communication, and rapid coordination of Home Medicines Reviews (HMRs).
The Transitions of Care (ToC) Pharmacist role was introduced to provide virtual support across 19 towns, ensuring high-risk patients receive an optimal discharge and follow up, particularly when onsite pharmacy services are unavailable.
The layout of the model means that the ‘TOCS pharmacist monitors the patient’s hospital admission and supports the onsite or virtual clinical pharmacist to ensure all required discharge activities are completed,’ Ms Krogh said.
This includes reviewing electronic medical records to identify medicines that were commenced, ceased, changed, or continued during admission.
‘The role includes medication reconciliation, patient counselling, preparation of patient-friendly medication lists and direct communication with GPs and consultant pharmacists to facilitate timely post-discharge medication reviews,’ she said.
Through virtual work, pharmacists can connect hospital teams, patients, carers, and primary care providers across geographically disconnected areas.
The risk in transitions
The severely limited access to GP services and healthcare facilities delays crucial follow-up appointments and check-ins after discharge. In most rural communities, locum professionals make up a significant part of the primary care workforce, creating significant challenges in ensuring continuity of care.
‘Patients are often discharged from hospitals located a long distance from home, which can delay access to medicines and follow-up post-discharge,’ Ms Krogh said.
Patients are identified as high risk for medicines misadventure and readmission based on criteria including ‘use of high-risk medicines such as insulin, alongside a hospital readmission within the previous 6 months.’
‘These factors can increase the risk of medication discrepancies, misunderstandings, and adverse events once the patient returns home,’ she added.
Fast-tracking post-discharge HMRs
A key feature of the program is its focus on ensuring HMRs occur when they are needed – not when they are possible.
To ensure time-sensitive cases are addressed, the TOC pharmacist prepares a HMR referral for the patient’s GP before discharge. If the referral cannot be signed within a 48-hour window, the program activates the hospital-initiated HMR pathway, to avoid delays.
‘The goal is for the post-discharge HMR to be completed within 10 days,’ Ms Krogh said.
Patients can choose whether they prefer their HMR conducted face-to-face or virtually, allowing referrals to be matched to credentialed pharmacists based on patient preference and location.
The TOCs pharmacist then books a GP appointment to ‘review the HMR recommendations and develop medication management plans, helping to close the loop on the patient's transition of care,’ she said.
By clearly identifying patients as high-risk, reception staff are better able to triage appointment availability where demand exceeds capacity.
Connecting hospital and community care
A major strength of the TIC TOC model is its ability to connect traditionally siloed parts of the healthcare system by facilitating communication between hospital clinicians, GPs, and community pharmacists – improving continuity of care throughout each patient’s journey.
‘In rural towns where GP appointments are often booked out weeks in advance, this model ensures high-risk patients have their medications reviewed promptly by a pharmacist,’ Ms Krogh said.
With post-discharge HMRs frequently identifying medication misunderstandings, the early identification of medication-related issues also allows GP appointments to focus more efficiently on clinical decision-making and care planning.
The most common errors identified relate to patients’ misunderstanding of how to take their medicines following discharge, as well as short-term medicines that pose a point of confusion, such as tapered prednisolone regimens and analgesics.
‘In one case, a patient stopped taking an antihypertensive medication after overhearing nursing staff say it should be withheld during admission, not realising the change was only temporary,’ Ms Krogh said.
‘Another patient discharged with two antibiotics misunderstood the instructions and intended to take the medicines sequentially rather than concurrently.’
Multidisciplinary action
The TIC TOC model encapsulates a broader theme of multidisciplinary collaboration that will underpin CPC26.
With healthcare systems championing the importance of coordinated care, this program demonstrates how pharmacists can play a central role in ensuring patient safety during transitions of care, particularly for vulnerable rural populations where limited access to timely healthcare poses challenges.
Further insights into the TIC TOC program and the virtual TOC's pharmacist role will be shared during the CPC26 conference session, held between 29 – 31 May 2026 at the RACV Royal Pines Resort, Gold Coast.
Click here to register.
[post_title] => Virtually easing transitions of care
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[post_content] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps placing pressure on both practitioners and patients.
HMR services remain a vital safeguard for improving health literacy among vulnerable Australians living with chronic illnesses, complex medicine regimens and mental health conditions.
But pharmacists on the ground warn the model is increasingly unsustainable under current funding arrangements. Restrictive caps, rising fuel costs, and extensive travel times are making the reality of HMRs nearly impossible to keep up with.
AP spoke with Mitchell Everlyn, consultant pharmacist, qualified diabetes educator, and locum based in Brisbane, Australia, about the impact of these pressures.
Unsustainability of HMRs
Growing demand for HMRs, increased clinical complexity and systemic constraints are reshaping the extent of the services pharmacists can realistically provide.
Balancing extreme travel distances with capped funding arrangements has left many questioning how long they can continue carrying the weight of HMR practice.
When asked about the sustainability of HMRs, Mr Everlyn said that ‘unless funding increases with caps or indexes upwards, I'm better off working in a pharmacy than I am doing consultant stuff.’
With 30-per-month caps set in place, Mr Everlyn said that ‘the time and money you're getting back from HMRs works out to be about $22 an hour. These financial pressures directly impact which patients pharmacists can realistically afford to fit in.’
At the same time, patient demands continue to climb. HMR waitlists can stretch for months for many pharmacists, particularly in rural areas where these services are a cornerstone in healthcare.
Urgent referrals continue to flood in, yet pharmacists are unable to exceed service limits.
‘I get follow-up emails asking why I haven't seen an acute patient… and it’s because I’ve hit my cap and I can’t,’ Mr Everlyn said.
Despite the growing clinical complexity of patients receiving HMRs, remuneration has been at a standstill since 2019, and service caps have remained largely unchanged, creating a widening gap between the work required and the compensation available.
Under PSA’s 2026-27 Federal Budget recommendations, caps have been recommended to increase to 60 HMRs per month from 1 July 2026.
Professional isolation in rural practice
For pharmacists servicing rural and regional areas, the challenges extend well beyond funding, triggering a push towards incorporating telehealth to ease the strain of providing rural HMR services.
Loading allowance is only extended to $125 per visit, which is designed to contribute towards the costs incurred, not necessarily to cover all costs, ultimately leaving pharmacists out of pocket.
The PSA has estimated that reforming HMR delivery would cost $135.1 million over 4 years, which includes introducing HMR payments linked to rurality (MMM3-7). Such investments would reduce preventable hospitalisations and improve rural access.
Mr Everlyn recently had to reduce the distance he travels due to financial strain.
‘I'm now needing to prioritise HMRs that are a lot closer to home, which sucks to say.’
Mr Everlyn has been increasingly providing private HMRs, explaining that patients are not prepared to wait 3 months.
Mr Everlyn recalled one HMR consult in a completely isolated area where healthcare access was severely limited, Mr Everlyn said ‘the patient was having an acute schizophrenic attack, and the closest hospital was an hour away.’
It is commonplace for credentialed pharmacists to conduct reviews completely alone, which leaves them with the task of navigating highly complex medical situations without any form of backup.
Patient and practitioner safety
As wait times blow out across the healthcare system, pharmacists are increasingly encountering patients whose conditions have escalated well beyond medicines management.
‘There have been times where I've gone to a patient's house and had to call ambulances because they need acute care,’ Mr Everlyn said.
‘I saw someone recently who's been in hospital three times this year for suicide attempts, and there is a 6-month wait list for a psychiatrist. So then you’re talking about patient safety.’
Naturally, these experiences have an impact on a practitioner's emotional wellbeing. ‘After situations like that, who do you call? Where's the support net? It can be very isolating,’ Mr Everlyn said.
Fuel crisis and a push to telehealth
Fuel shortages and rising petrol costs are putting the longevity of HMR practice in a compromising position, which places vulnerable patients at immense risk.
Increasing fuel prices have added yet another layer of pressure for pharmacists who are already operating on tight margins.
With travel taking up large portions of the workday, and an increase in fuel costs, there has been a recent push towards incorporating telehealth into HMR services.
PSA national president Professor Mark Naunton MPS said ‘the support these patients need, such as medication reviews, is becoming rapidly unsustainable amid the current fuel crisis, unless the government reinstates telehealth.’
‘We know telehealth worked effectively and efficiently during the COVID-19 pandemic, so why not now?
‘I did one HMR on Easter Sunday, which was a 120 km round trip, and then with roadworks, it took me two hours to get there. One full day's work worked out to be $200,’ Mr Everlyn added.
‘The push over to telehealth would alleviate so much time.’
While he acknowledges the value of in-person assessments, he argues that not every consultation requires pharmacists to travel hours to gain the required clinical information.
‘You can tell a lot by how someone's moving… but I don't need to travel 3 hours one way just to see that.’
For many pharmacists, the reluctance to modernise HMR services feels increasingly behind broader innovation.
‘In this day and age we have AI, but we can't do telehealth,’ Mr Everlyn says.
The reinstatement of telehealth is included in the reforms PSA is advocating for to ensure that care is accessible for all Australians.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => HMR waitlists can stretch for months
[post_excerpt] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps.
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[post_content] => Busy pharmacies, bright lights and confined spaces can heighten fear surrounding vaccination, particularly among children who are neurodiverse.
[caption id="attachment_32071" align="alignright" width="300"] Yvette Anderson MPS[/caption]
Understanding how to create a safe, calm environment is essential to delivering patient-centred care.
A time sensitive vaccination window
With winter around the corner, pharmacies should be in peak winter vaccine campaign mode – including the recently introduced intranasal vaccine, FluMist.
But pharmacists new to vaccinating children are often nervous that immunising school-aged children can be tricky. The Child Health Poll reported that 1 in 4 children experience needlephobia – which often intensifies with age. These challenges are amplified amongst children who are neurodiverse, calling for an enhancement of personalised care throughout the vaccination process.
Yvette Anderson MPS – founder of Spectrum Pharmacist, which sets out to bridge the gap for neurodivergent families – told AP her top tips.
Fear surrounding the vaccination experience
Neurodiverse children can often experience heightened levels of sensory sensitivity, differences in communication, and increased anxiety in unfamiliar settings.
‘Early signs of anxiety and sensory overload vary from child to child,’ Ms Anderson said. ‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.’
During vaccination, early signs of overwhelm may include:
‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.'
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Case scenarioDavid, 68, presents to the pharmacy 7 days before a scheduled colonoscopy. He says the written instructions from the clinic were ‘hard to follow’ and asks whether he should stop ‘all his tablets’. David has type 2 diabetes, hypertension and atrial fibrillation. He uses a weekly dose administration aid (DAA) prepared by the pharmacy. His regular medicines include apixaban, ramipril, empagliflozin, metformin and atorvastatin. He also takes ibuprofen intermittently for knee pain and a garlic supplement. He has been advised to fast and complete bowel preparation the day before the procedure and is unsure which medicines to continue, stop or restart. |
Australians make 440 million visits to their pharmacist each year,1 with community pharmacists frequently consulted by patients preparing for diagnostic or minor surgical procedures. These encounters often occur when instructions are unclear, leaving patients unsure which medicines to stop, when to stop them, and how to safely resume therapy. Temporary medicine changes can be particularly confusing for patients using dose administration aids (DAAs), increasing the risk of dosing errors or procedural delays.
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Pharmacists are well placed to address this gap. As accessible healthcare professionals with medicines expertise, pharmacists can identify medicines that increase peri-procedural risk, clarify instructions, and support safe temporary changes.
This article provides a practical, evidence-based overview of medicines commonly withheld prior to procedures, counselling strategies to minimise confusion, guidance for managing DAAs, and pharmacy-based interventions to support patient safety.
Patients preparing for diagnostic investigations or minor surgical procedures are often advised to temporarily withhold selected medicines to reduce peri-procedural risk. The decision to continue or withhold a medicine involves balancing potential risks of the procedure (such as bleeding, infection, haemodynamic instability, renal impairment, metabolic disturbance or interactions with medicines used in the peri-procedural period) against the risk of disease exacerbation or withdrawal effects. Pharmacists play a critical role in identifying medicines that may require review, clarifying prescriber instructions and supporting safe temporary modification of therapy.2
Anticoagulants and antiplatelet agents are among the most frequently managed medicines in the peri-procedural setting. Oral anticoagulants, including warfarin and direct oral anticoagulants, increase bleeding risk during procedures such as colonoscopy, dermatological excisions, and some dental or ophthalmic surgeries.3 Antiplatelet therapy presents a more nuanced risk-benefit balance. For many minor procedures, including cataract surgery and simple dental or dermatological procedures, aspirin may be safely continued, while procedures with a higher bleeding risk may necessitate temporary cessation.4
The decision to withhold antithrombotic therapy is highly individualised and should always be clinician-directed. Pharmacists should avoid advising cessation independently but can support patient safety by reinforcing clear stop and restart dates, and emphasising the importance of timely recommencement to minimise thromboembolic risk.3,4
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly withheld prior to procedures due to their reversible inhibition of platelet aggregation and their potential to impair renal perfusion, particularly in the context of peri-procedural dehydration or exposure to contrast media.2,5 Platelet function typically normalises within several days of NSAID discontinuation, although this varies by agent.5 From a pharmacy perspective, the most significant risk arises from unrecognised over-the-counter NSAID use. Pharmacists should proactively enquire about non-prescription analgesics and recommend suitable alternatives, such as paracetamol, where appropriate.2,5
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remain an area of clinical debate. Continuation has been associated with an increased risk of intraoperative hypotension, while cessation may increase the likelihood of postoperative hypertension.9-11 Evidence supports an individualised approach, taking into account the indication for therapy, baseline blood pressure, and the nature of the procedure and anaesthesia.9,10 In practice, many clinicians elect to withhold these agents on the morning of surgery when hypotension risk is high and resume therapy promptly post-procedure. Failure to recommence ACEIs or ARBs within 24–48 hours postoperatively has been associated with increased short-term mortality.9–11 Pharmacists should reinforce clinicians’ pre-procedure instructions, provide rationale and highlight the importance of timely recommencement.
Complementary and herbal products require review in the peri-procedural period, as evidence indicates their use remains highly prevalent among surgical patients, yet disclosure to healthcare professionals is often incomplete.1,12 Herbal medicines may exert clinically significant pharmacodynamic and pharmacokinetic effects that increase peri-procedural risk, including impaired platelet aggregation (e.g. garlic, ginkgo biloba, ginseng), increased sedative effect (e.g. kava, valerian) and altered metabolism of anaesthetic or perioperative medicines through cytochrome P450 enzyme induction (e.g. St John’s wort).2,13 Risk assessment is further complicated by variability in product composition, dosing and bioactive constituents, meaning effects are not always predictable or dose dependent.11 As a result, many contemporary guidelines recommend discontinuation of non-essential herbal medicines at least 1–2 weeks prior to procedures, depending on the agent and procedural risk.2,13
Diabetes medicines and peri-procedural blood glucose managementMedicines used to manage diabetes often require review in the peri-procedural period. Temporary changes may be needed to reduce medicine-related risk during fasting and recovery, and pharmacists play an important role in supporting patient understanding and continuity of care.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors warrant specific attention in the peri-procedural period due to the risk of diabetic ketoacidosis (DKA), which may occur with near-normal or only mildly elevated blood glucose levels (euglycaemic DKA). The risk is increased during periods of fasting, reduced carbohydrate intake (including bowel preparation), dehydration, acute illness and surgical stress. Importantly, normoglycaemia does not exclude DKA, and blood ketone testing should be considered where clinical suspicion exists. Clinical guidelines advise that SGLT2 inhibitors should be withheld for at least 3 days prior to procedures requiring fasting or bowel preparation (and 4 days for ertugliflozin).6
Physiological stress related to illness, fasting, anxiety and surgical intervention activates counter-regulatory hormones such as cortisol and catecholamines, leading to increased hepatic glucose output and reduced insulin sensitivity.7 When combined with altered oral intake and temporary medicines changes, this stress response can result in significant glycaemic variability, even in patients with previously stable diabetes.2,3
Extremes of blood glucose pose specific risks in the peri-procedural setting. Hyperglycaemia is associated with dehydration, impaired immune function and an increased risk of postoperative infection, while hypoglycaemia may result in neuroglycopenic symptoms, cardiovascular instability or loss of consciousness – particularly in the context of fasting or reduced caloric intake.8 For most adults, general peri-procedural targets include fasting blood glucose levels of approximately 4–8 mmol/L and random levels below 10 mmol/L, although individual targets should be tailored based on comorbidities, frailty and procedural complexity.8 Pharmacists play an important role in reinforcing blood glucose monitoring plans, supporting sick-day management principles, therapy modification during temporary medicine cessation, and identifying when abnormal readings require medical review. Clear counselling on when and how to safely recommence withheld medicines once normal oral intake has resumed is essential to minimise metabolic complications and support safe transitions of care.2,6
Patients who use DAAs are at increased risk of medication error when medicines are changed, particularly when temporarily withheld in the peri-procedural period.14 These patients often rely on the pack as their primary prompt for medicine administration and may not be familiar with individual medicines or their indications. Temporary cessation without appropriate pharmacist intervention can lead to duplication or unintended continuation of withheld medicines. Pharmacists therefore play a critical role in coordinating safe, structured modifications in response to procedural instructions.
Best practice involves pharmacist-led removal of specific medicines from affected doses, rather than advising patients to self-remove tablets, which increases the risk of error and pack disruption. Clear documentation should accompany any changes, including written instructions outlining which medicines have been withheld, the duration of cessation, and the planned date of recommencement, where possible. If feasible, pharmacists should provide a simple, procedure-specific DAA and schedule follow-up to ensure medicines are safely reintroduced post-procedure.
Liaison with prescribers may be required if instructions are unclear or if the patient’s clinical status changes. Through proactive management of DAAs, pharmacists can significantly reduce confusion, support continuity of care, and minimise preventable medicine-related harm and delays in the peri-procedural setting.
Community pharmacists can proactively review medicines prior to procedures, identify medicines that may require temporary cessation, clarify clinician-directed stop-restart instructions, and manage changes to DAAs.
By reinforcing written advice, reviewing over-the-counter and complementary medicine use, and supporting blood glucose monitoring during periods of fasting or medicine withholding, pharmacists minimise confusion and prevent medicine-related harm. Pharmacists can also support peri-procedural care by encouraging patients to bring all medicines for review and by providing an accurate medicines list to assist communication across care settings.
Pharmacists play a critical role in supporting patients preparing for common procedures through proactive medicines review, clear counselling and practical support for temporary medicine changes. This role is particularly important for patients using DAAs, where structured pack modification and follow-up can reduce medication errors and delays to care. As peri-procedural medicines management becomes increasingly complex, pharmacist-led interventions are essential to safe, coordinated and patient-centred care.
| Case scenario continued You review all prescription, over-the-counter and complementary medicines, and clarify the clinic’s instructions. High-risk medicines potentially requiring temporary cessation are identified, including apixaban, empagliflozin, ibuprofen and the garlic supplement, while other medicines can be continued as directed. Given David’s use of a DAA, you undertake pharmacist-led pack modification based on the clinic’s instructions. You provide clear written directions outlining withheld medicines, monitoring advice during fasting, and when medicines should be restarted once oral intake resumes. You use the teach-back method to confirm understanding, and a follow-up is arranged after the procedure to safely reintroduce medicines into the DAA. |
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[post_content] => AI is transforming pharmacy practice — but without the right safeguards, it can also put your registration at risk.
AI is no longer an emerging consideration for pharmacists – it’s already embedded in practice.
Using large language models (LLMs) such as ChatGPT to answer clinical questions and AI scribes like Heidi Health to capture consultation notes is becoming more commonplace. With agentic AI – systems that act autonomously on a patient’s behalf – now growing in popularity, the pace of AI adoption is only set to increase.
But these opportunities come with obligations – and without a distinct regulatory framework. Here, PSA Digital Health Lead and Victorian state manager Jarrod McMaugh MPS outlines the sixAI traps pharmacists need to avoid.
1. Entering identifiable patient information into AI platforms
One of the most significant risks pharmacists face when using AI is entering patients’ health information into AI platforms. Regardless of the purpose or the pharmacist’s intent, it may constitute a breach of Australian privacy law.
‘Let's say you were providing a Home Medicines Review (HMR) and you put the patient’s details into ChatGPT and asked, “What medicines is this person missing for their diagnosed conditions?” That would be a breach of privacy regulations,’ Mr McMaugh said.
‘Any information put into AI is stored. And therefore, where it is stored must adhere to the Australian privacy requirements.’
However, pharmacists who use LLMs to check for missed medicines or potential interactions can do so legitimately, provided no identifying information is included.
And while taking out a patient's name and address is a good first step, this may not adequately deidentify them.
‘You could prompt an LLM by saying, “I have a person who is taking medicines, x, y, z, and they have these diagnoses. Can you identify any missed medicines or any interactions?”’ Mr McMaugh said.
‘As long as there's no way to identify the individual, and it's just down to what is clinically appropriate, it's not a breach of any privacy matters.’
2. Assuming a business account equals compliance
You may think that moving from a free AI account to a paid business subscription resolves any compliance concerns.
But to be compliant, business or enterprise AI subscriptions must explicitly confirm that the platform meets Australian privacy regulations in the delivery of that service.
'You would need to be satisfied that the LLM, under contract, specifically states that it meets Australian privacy regulations,’ Mr McMaugh said.
‘It's similar to the agreement you have with your dispensing software [provider] or the clinical platform you use to record scope of practice work.’
3. Using AI scribes without proper consent
For pharmacists conducting clinical consultations, such as accredited and prescribing pharmacists, AI scribes can be incredibly useful for collecting and collating patient information.
But deploying them without meeting the required consent obligations creates significant professional risk.
‘You must get consent from the person whose session is being recorded by the AI tool,’ Mr McMaugh said. ‘And you must have the ability to turn it off if somebody says, “I want the service, but I don't want the AI tool recording our discussion”.’
For pharmacists uncertain about what adequate consent looks like in practice, he suggests the following approach: 'I'm going to use an AI scribe in this session. It will record our conversation and take notes on our behalf. It will create a copy that I'll keep on record, and you have the right to access that record any time you request it. Are you comfortable with me proceeding?’
Pharmacists should also ensure that the AI tool is not in an active learning phase, with systems that continue to learn from patient interactions requiring an additional layer of consent.
‘For the vast majority of pharmacists, that shouldn't be a scenario they find themselves in – unless they're involved in clinical research about an intervention or research about the AI tool,’ he said.
‘For the vast majority of pharmacists, that shouldn't be a scenario they find themselves in – unless they're involved in clinical research about an intervention or research about the AI tool,’ he said.
Pharmacists should confirm that AI dictation tools don't record voice snippets or retain details to improve the quality of their systems. Utilising AI models that are actively learning is generally not appropriate outside of a clinical trial with the accompanying level of consent seen in a trial setting.
Using an ‘active learning’ AI requires well documented consent for the person's health information to be used in this way, and is usually out of scope for most clinical settings.
4. Failing to check transcription accuracy
The second area of risk when using AI scribes is accuracy. While generally reliable, they can make mistakes; and the professional obligation to maintain accurate records rests with the pharmacist, not the AI tool.
To prevent errors, pharmacists should still take notes while the AI scribe is working in the background, particularly around critical details such as dosing.
'If you were in a position in the future where something has gone wrong and you're in front of AHPRA or another regulator, and they say, “Why are your notes incorrect?” just assuming that the digital scribe was doing its job is not sufficient for meeting your professional obligations,’ Mr McMaugh said.
AI and handwritten notes should also be reviewed at the end of each session, while details of the consultation are still fresh.
'If you use an AI scribe during an HMR interview and you don't review the transcript until a week later, how are you going to correct the information that it got wrong?’ Mr McMaugh said. ‘From a workflow perspective, and to adhere to professional obligations, you need to make sure it's accurate.’
5. Trusting AI output without checking the references
AI platforms can produce clinical responses that are well structured, but are actually incorrect. These AI ‘hallucinations’, where LLMs return fabricated or inconsistent information, are commonplace.
Another, more subtle risk is when LLMs draw on international sources rather than Australian-specific guidelines.
‘If you ask what the standard dose of a medication is, you might get a generally acceptable dose that's not applicable to specific Australian scenarios,’ Mr McMaugh said.
Antibiotic selection is a clear example, with resistance patterns varying between countries, meaning recommendations based on international data may be inappropriate or inadequate for an Australian patient.
'You should therefore always ask LLMs for references so you can confirm the information is correct,’ he added.
And don’t forget to check these references also, which aren’t immune to AI hallucinations.
6. Accepting an AI-generated booking as genuine patient consent
Agentic AI is a system designed to act autonomously on a person's behalf, booking appointments, managing schedules and completing transactions.
While these tools have the potential to streamline service appointments, such as vaccinations, pharmacists must be vigilant around digital bookings.
When an AI agent books a consultation on a patient's behalf, it’s not possible to confirm at the point of booking whether the patient themselves made an informed, active decision to attend.
‘If booked online, pharmacists should double-check that a person has provided consent to have a particular service when they come in,’ Mr McMaugh said. 'This is a good way to confirm that consent has been provided by the [person] receiving the service – not the AI that is booking on their behalf.’
To close any gaps in the consent chain, he suggests:
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[post_content] => A new transitions of care model is helping high-risk patients in rural and remote areas avoid medication misadventure and hospital readmission through virtual pharmacist-led care.
After patients are discharged from the hospital, their transition back into the community can be high-risk, with significant potential for medicine-related harm. These risks are amplified significantly for rural communities due to sparse healthcare facilities, fragmented continuity of care and workforce shortages.
The TIC TOC program in Western NSW is tackling these issues via a virtual model designed to support patients who are struggling to access care during vulnerable post-discharge periods.
The TIC TOC program will be further explored at the CPC26 conference later this month and is set to demonstrate how digital health and multidisciplinary collaboration can help bridge the gap between hospital and home.
Ahead of the program’s launch, AP spoke with Linda Krogh, the Virtual Transitions-of-Care Stewardship Pharmacist with the Western NSW Local Health District and a current PhD candidate with the University of Sydney.
A virtual model of care
‘Transitions of care are deeply complex – even more so in remote settings due to factors such as distance, workforce, and community care,’ said Ms Krogh.
The CPC26 presentation will outline how the model translates into practice, including identifying high-risk patients, virtual medication reconciliation, multidisciplinary communication, and rapid coordination of Home Medicines Reviews (HMRs).
The Transitions of Care (ToC) Pharmacist role was introduced to provide virtual support across 19 towns, ensuring high-risk patients receive an optimal discharge and follow up, particularly when onsite pharmacy services are unavailable.
The layout of the model means that the ‘TOCS pharmacist monitors the patient’s hospital admission and supports the onsite or virtual clinical pharmacist to ensure all required discharge activities are completed,’ Ms Krogh said.
This includes reviewing electronic medical records to identify medicines that were commenced, ceased, changed, or continued during admission.
‘The role includes medication reconciliation, patient counselling, preparation of patient-friendly medication lists and direct communication with GPs and consultant pharmacists to facilitate timely post-discharge medication reviews,’ she said.
Through virtual work, pharmacists can connect hospital teams, patients, carers, and primary care providers across geographically disconnected areas.
The risk in transitions
The severely limited access to GP services and healthcare facilities delays crucial follow-up appointments and check-ins after discharge. In most rural communities, locum professionals make up a significant part of the primary care workforce, creating significant challenges in ensuring continuity of care.
‘Patients are often discharged from hospitals located a long distance from home, which can delay access to medicines and follow-up post-discharge,’ Ms Krogh said.
Patients are identified as high risk for medicines misadventure and readmission based on criteria including ‘use of high-risk medicines such as insulin, alongside a hospital readmission within the previous 6 months.’
‘These factors can increase the risk of medication discrepancies, misunderstandings, and adverse events once the patient returns home,’ she added.
Fast-tracking post-discharge HMRs
A key feature of the program is its focus on ensuring HMRs occur when they are needed – not when they are possible.
To ensure time-sensitive cases are addressed, the TOC pharmacist prepares a HMR referral for the patient’s GP before discharge. If the referral cannot be signed within a 48-hour window, the program activates the hospital-initiated HMR pathway, to avoid delays.
‘The goal is for the post-discharge HMR to be completed within 10 days,’ Ms Krogh said.
Patients can choose whether they prefer their HMR conducted face-to-face or virtually, allowing referrals to be matched to credentialed pharmacists based on patient preference and location.
The TOCs pharmacist then books a GP appointment to ‘review the HMR recommendations and develop medication management plans, helping to close the loop on the patient's transition of care,’ she said.
By clearly identifying patients as high-risk, reception staff are better able to triage appointment availability where demand exceeds capacity.
Connecting hospital and community care
A major strength of the TIC TOC model is its ability to connect traditionally siloed parts of the healthcare system by facilitating communication between hospital clinicians, GPs, and community pharmacists – improving continuity of care throughout each patient’s journey.
‘In rural towns where GP appointments are often booked out weeks in advance, this model ensures high-risk patients have their medications reviewed promptly by a pharmacist,’ Ms Krogh said.
With post-discharge HMRs frequently identifying medication misunderstandings, the early identification of medication-related issues also allows GP appointments to focus more efficiently on clinical decision-making and care planning.
The most common errors identified relate to patients’ misunderstanding of how to take their medicines following discharge, as well as short-term medicines that pose a point of confusion, such as tapered prednisolone regimens and analgesics.
‘In one case, a patient stopped taking an antihypertensive medication after overhearing nursing staff say it should be withheld during admission, not realising the change was only temporary,’ Ms Krogh said.
‘Another patient discharged with two antibiotics misunderstood the instructions and intended to take the medicines sequentially rather than concurrently.’
Multidisciplinary action
The TIC TOC model encapsulates a broader theme of multidisciplinary collaboration that will underpin CPC26.
With healthcare systems championing the importance of coordinated care, this program demonstrates how pharmacists can play a central role in ensuring patient safety during transitions of care, particularly for vulnerable rural populations where limited access to timely healthcare poses challenges.
Further insights into the TIC TOC program and the virtual TOC's pharmacist role will be shared during the CPC26 conference session, held between 29 – 31 May 2026 at the RACV Royal Pines Resort, Gold Coast.
Click here to register.
[post_title] => Virtually easing transitions of care
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[post_content] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps placing pressure on both practitioners and patients.
HMR services remain a vital safeguard for improving health literacy among vulnerable Australians living with chronic illnesses, complex medicine regimens and mental health conditions.
But pharmacists on the ground warn the model is increasingly unsustainable under current funding arrangements. Restrictive caps, rising fuel costs, and extensive travel times are making the reality of HMRs nearly impossible to keep up with.
AP spoke with Mitchell Everlyn, consultant pharmacist, qualified diabetes educator, and locum based in Brisbane, Australia, about the impact of these pressures.
Unsustainability of HMRs
Growing demand for HMRs, increased clinical complexity and systemic constraints are reshaping the extent of the services pharmacists can realistically provide.
Balancing extreme travel distances with capped funding arrangements has left many questioning how long they can continue carrying the weight of HMR practice.
When asked about the sustainability of HMRs, Mr Everlyn said that ‘unless funding increases with caps or indexes upwards, I'm better off working in a pharmacy than I am doing consultant stuff.’
With 30-per-month caps set in place, Mr Everlyn said that ‘the time and money you're getting back from HMRs works out to be about $22 an hour. These financial pressures directly impact which patients pharmacists can realistically afford to fit in.’
At the same time, patient demands continue to climb. HMR waitlists can stretch for months for many pharmacists, particularly in rural areas where these services are a cornerstone in healthcare.
Urgent referrals continue to flood in, yet pharmacists are unable to exceed service limits.
‘I get follow-up emails asking why I haven't seen an acute patient… and it’s because I’ve hit my cap and I can’t,’ Mr Everlyn said.
Despite the growing clinical complexity of patients receiving HMRs, remuneration has been at a standstill since 2019, and service caps have remained largely unchanged, creating a widening gap between the work required and the compensation available.
Under PSA’s 2026-27 Federal Budget recommendations, caps have been recommended to increase to 60 HMRs per month from 1 July 2026.
Professional isolation in rural practice
For pharmacists servicing rural and regional areas, the challenges extend well beyond funding, triggering a push towards incorporating telehealth to ease the strain of providing rural HMR services.
Loading allowance is only extended to $125 per visit, which is designed to contribute towards the costs incurred, not necessarily to cover all costs, ultimately leaving pharmacists out of pocket.
The PSA has estimated that reforming HMR delivery would cost $135.1 million over 4 years, which includes introducing HMR payments linked to rurality (MMM3-7). Such investments would reduce preventable hospitalisations and improve rural access.
Mr Everlyn recently had to reduce the distance he travels due to financial strain.
‘I'm now needing to prioritise HMRs that are a lot closer to home, which sucks to say.’
Mr Everlyn has been increasingly providing private HMRs, explaining that patients are not prepared to wait 3 months.
Mr Everlyn recalled one HMR consult in a completely isolated area where healthcare access was severely limited, Mr Everlyn said ‘the patient was having an acute schizophrenic attack, and the closest hospital was an hour away.’
It is commonplace for credentialed pharmacists to conduct reviews completely alone, which leaves them with the task of navigating highly complex medical situations without any form of backup.
Patient and practitioner safety
As wait times blow out across the healthcare system, pharmacists are increasingly encountering patients whose conditions have escalated well beyond medicines management.
‘There have been times where I've gone to a patient's house and had to call ambulances because they need acute care,’ Mr Everlyn said.
‘I saw someone recently who's been in hospital three times this year for suicide attempts, and there is a 6-month wait list for a psychiatrist. So then you’re talking about patient safety.’
Naturally, these experiences have an impact on a practitioner's emotional wellbeing. ‘After situations like that, who do you call? Where's the support net? It can be very isolating,’ Mr Everlyn said.
Fuel crisis and a push to telehealth
Fuel shortages and rising petrol costs are putting the longevity of HMR practice in a compromising position, which places vulnerable patients at immense risk.
Increasing fuel prices have added yet another layer of pressure for pharmacists who are already operating on tight margins.
With travel taking up large portions of the workday, and an increase in fuel costs, there has been a recent push towards incorporating telehealth into HMR services.
PSA national president Professor Mark Naunton MPS said ‘the support these patients need, such as medication reviews, is becoming rapidly unsustainable amid the current fuel crisis, unless the government reinstates telehealth.’
‘We know telehealth worked effectively and efficiently during the COVID-19 pandemic, so why not now?
‘I did one HMR on Easter Sunday, which was a 120 km round trip, and then with roadworks, it took me two hours to get there. One full day's work worked out to be $200,’ Mr Everlyn added.
‘The push over to telehealth would alleviate so much time.’
While he acknowledges the value of in-person assessments, he argues that not every consultation requires pharmacists to travel hours to gain the required clinical information.
‘You can tell a lot by how someone's moving… but I don't need to travel 3 hours one way just to see that.’
For many pharmacists, the reluctance to modernise HMR services feels increasingly behind broader innovation.
‘In this day and age we have AI, but we can't do telehealth,’ Mr Everlyn says.
The reinstatement of telehealth is included in the reforms PSA is advocating for to ensure that care is accessible for all Australians.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => HMR waitlists can stretch for months
[post_excerpt] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps.
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[post_content] => Busy pharmacies, bright lights and confined spaces can heighten fear surrounding vaccination, particularly among children who are neurodiverse.
[caption id="attachment_32071" align="alignright" width="300"] Yvette Anderson MPS[/caption]
Understanding how to create a safe, calm environment is essential to delivering patient-centred care.
A time sensitive vaccination window
With winter around the corner, pharmacies should be in peak winter vaccine campaign mode – including the recently introduced intranasal vaccine, FluMist.
But pharmacists new to vaccinating children are often nervous that immunising school-aged children can be tricky. The Child Health Poll reported that 1 in 4 children experience needlephobia – which often intensifies with age. These challenges are amplified amongst children who are neurodiverse, calling for an enhancement of personalised care throughout the vaccination process.
Yvette Anderson MPS – founder of Spectrum Pharmacist, which sets out to bridge the gap for neurodivergent families – told AP her top tips.
Fear surrounding the vaccination experience
Neurodiverse children can often experience heightened levels of sensory sensitivity, differences in communication, and increased anxiety in unfamiliar settings.
‘Early signs of anxiety and sensory overload vary from child to child,’ Ms Anderson said. ‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.’
During vaccination, early signs of overwhelm may include:
‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.'
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Case scenarioDavid, 68, presents to the pharmacy 7 days before a scheduled colonoscopy. He says the written instructions from the clinic were ‘hard to follow’ and asks whether he should stop ‘all his tablets’. David has type 2 diabetes, hypertension and atrial fibrillation. He uses a weekly dose administration aid (DAA) prepared by the pharmacy. His regular medicines include apixaban, ramipril, empagliflozin, metformin and atorvastatin. He also takes ibuprofen intermittently for knee pain and a garlic supplement. He has been advised to fast and complete bowel preparation the day before the procedure and is unsure which medicines to continue, stop or restart. |
Australians make 440 million visits to their pharmacist each year,1 with community pharmacists frequently consulted by patients preparing for diagnostic or minor surgical procedures. These encounters often occur when instructions are unclear, leaving patients unsure which medicines to stop, when to stop them, and how to safely resume therapy. Temporary medicine changes can be particularly confusing for patients using dose administration aids (DAAs), increasing the risk of dosing errors or procedural delays.
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Pharmacists are well placed to address this gap. As accessible healthcare professionals with medicines expertise, pharmacists can identify medicines that increase peri-procedural risk, clarify instructions, and support safe temporary changes.
This article provides a practical, evidence-based overview of medicines commonly withheld prior to procedures, counselling strategies to minimise confusion, guidance for managing DAAs, and pharmacy-based interventions to support patient safety.
Patients preparing for diagnostic investigations or minor surgical procedures are often advised to temporarily withhold selected medicines to reduce peri-procedural risk. The decision to continue or withhold a medicine involves balancing potential risks of the procedure (such as bleeding, infection, haemodynamic instability, renal impairment, metabolic disturbance or interactions with medicines used in the peri-procedural period) against the risk of disease exacerbation or withdrawal effects. Pharmacists play a critical role in identifying medicines that may require review, clarifying prescriber instructions and supporting safe temporary modification of therapy.2
Anticoagulants and antiplatelet agents are among the most frequently managed medicines in the peri-procedural setting. Oral anticoagulants, including warfarin and direct oral anticoagulants, increase bleeding risk during procedures such as colonoscopy, dermatological excisions, and some dental or ophthalmic surgeries.3 Antiplatelet therapy presents a more nuanced risk-benefit balance. For many minor procedures, including cataract surgery and simple dental or dermatological procedures, aspirin may be safely continued, while procedures with a higher bleeding risk may necessitate temporary cessation.4
The decision to withhold antithrombotic therapy is highly individualised and should always be clinician-directed. Pharmacists should avoid advising cessation independently but can support patient safety by reinforcing clear stop and restart dates, and emphasising the importance of timely recommencement to minimise thromboembolic risk.3,4
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly withheld prior to procedures due to their reversible inhibition of platelet aggregation and their potential to impair renal perfusion, particularly in the context of peri-procedural dehydration or exposure to contrast media.2,5 Platelet function typically normalises within several days of NSAID discontinuation, although this varies by agent.5 From a pharmacy perspective, the most significant risk arises from unrecognised over-the-counter NSAID use. Pharmacists should proactively enquire about non-prescription analgesics and recommend suitable alternatives, such as paracetamol, where appropriate.2,5
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remain an area of clinical debate. Continuation has been associated with an increased risk of intraoperative hypotension, while cessation may increase the likelihood of postoperative hypertension.9-11 Evidence supports an individualised approach, taking into account the indication for therapy, baseline blood pressure, and the nature of the procedure and anaesthesia.9,10 In practice, many clinicians elect to withhold these agents on the morning of surgery when hypotension risk is high and resume therapy promptly post-procedure. Failure to recommence ACEIs or ARBs within 24–48 hours postoperatively has been associated with increased short-term mortality.9–11 Pharmacists should reinforce clinicians’ pre-procedure instructions, provide rationale and highlight the importance of timely recommencement.
Complementary and herbal products require review in the peri-procedural period, as evidence indicates their use remains highly prevalent among surgical patients, yet disclosure to healthcare professionals is often incomplete.1,12 Herbal medicines may exert clinically significant pharmacodynamic and pharmacokinetic effects that increase peri-procedural risk, including impaired platelet aggregation (e.g. garlic, ginkgo biloba, ginseng), increased sedative effect (e.g. kava, valerian) and altered metabolism of anaesthetic or perioperative medicines through cytochrome P450 enzyme induction (e.g. St John’s wort).2,13 Risk assessment is further complicated by variability in product composition, dosing and bioactive constituents, meaning effects are not always predictable or dose dependent.11 As a result, many contemporary guidelines recommend discontinuation of non-essential herbal medicines at least 1–2 weeks prior to procedures, depending on the agent and procedural risk.2,13
Diabetes medicines and peri-procedural blood glucose managementMedicines used to manage diabetes often require review in the peri-procedural period. Temporary changes may be needed to reduce medicine-related risk during fasting and recovery, and pharmacists play an important role in supporting patient understanding and continuity of care.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors warrant specific attention in the peri-procedural period due to the risk of diabetic ketoacidosis (DKA), which may occur with near-normal or only mildly elevated blood glucose levels (euglycaemic DKA). The risk is increased during periods of fasting, reduced carbohydrate intake (including bowel preparation), dehydration, acute illness and surgical stress. Importantly, normoglycaemia does not exclude DKA, and blood ketone testing should be considered where clinical suspicion exists. Clinical guidelines advise that SGLT2 inhibitors should be withheld for at least 3 days prior to procedures requiring fasting or bowel preparation (and 4 days for ertugliflozin).6
Physiological stress related to illness, fasting, anxiety and surgical intervention activates counter-regulatory hormones such as cortisol and catecholamines, leading to increased hepatic glucose output and reduced insulin sensitivity.7 When combined with altered oral intake and temporary medicines changes, this stress response can result in significant glycaemic variability, even in patients with previously stable diabetes.2,3
Extremes of blood glucose pose specific risks in the peri-procedural setting. Hyperglycaemia is associated with dehydration, impaired immune function and an increased risk of postoperative infection, while hypoglycaemia may result in neuroglycopenic symptoms, cardiovascular instability or loss of consciousness – particularly in the context of fasting or reduced caloric intake.8 For most adults, general peri-procedural targets include fasting blood glucose levels of approximately 4–8 mmol/L and random levels below 10 mmol/L, although individual targets should be tailored based on comorbidities, frailty and procedural complexity.8 Pharmacists play an important role in reinforcing blood glucose monitoring plans, supporting sick-day management principles, therapy modification during temporary medicine cessation, and identifying when abnormal readings require medical review. Clear counselling on when and how to safely recommence withheld medicines once normal oral intake has resumed is essential to minimise metabolic complications and support safe transitions of care.2,6
Patients who use DAAs are at increased risk of medication error when medicines are changed, particularly when temporarily withheld in the peri-procedural period.14 These patients often rely on the pack as their primary prompt for medicine administration and may not be familiar with individual medicines or their indications. Temporary cessation without appropriate pharmacist intervention can lead to duplication or unintended continuation of withheld medicines. Pharmacists therefore play a critical role in coordinating safe, structured modifications in response to procedural instructions.
Best practice involves pharmacist-led removal of specific medicines from affected doses, rather than advising patients to self-remove tablets, which increases the risk of error and pack disruption. Clear documentation should accompany any changes, including written instructions outlining which medicines have been withheld, the duration of cessation, and the planned date of recommencement, where possible. If feasible, pharmacists should provide a simple, procedure-specific DAA and schedule follow-up to ensure medicines are safely reintroduced post-procedure.
Liaison with prescribers may be required if instructions are unclear or if the patient’s clinical status changes. Through proactive management of DAAs, pharmacists can significantly reduce confusion, support continuity of care, and minimise preventable medicine-related harm and delays in the peri-procedural setting.
Community pharmacists can proactively review medicines prior to procedures, identify medicines that may require temporary cessation, clarify clinician-directed stop-restart instructions, and manage changes to DAAs.
By reinforcing written advice, reviewing over-the-counter and complementary medicine use, and supporting blood glucose monitoring during periods of fasting or medicine withholding, pharmacists minimise confusion and prevent medicine-related harm. Pharmacists can also support peri-procedural care by encouraging patients to bring all medicines for review and by providing an accurate medicines list to assist communication across care settings.
Pharmacists play a critical role in supporting patients preparing for common procedures through proactive medicines review, clear counselling and practical support for temporary medicine changes. This role is particularly important for patients using DAAs, where structured pack modification and follow-up can reduce medication errors and delays to care. As peri-procedural medicines management becomes increasingly complex, pharmacist-led interventions are essential to safe, coordinated and patient-centred care.
| Case scenario continued You review all prescription, over-the-counter and complementary medicines, and clarify the clinic’s instructions. High-risk medicines potentially requiring temporary cessation are identified, including apixaban, empagliflozin, ibuprofen and the garlic supplement, while other medicines can be continued as directed. Given David’s use of a DAA, you undertake pharmacist-led pack modification based on the clinic’s instructions. You provide clear written directions outlining withheld medicines, monitoring advice during fasting, and when medicines should be restarted once oral intake resumes. You use the teach-back method to confirm understanding, and a follow-up is arranged after the procedure to safely reintroduce medicines into the DAA. |
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[post_content] => AI is transforming pharmacy practice — but without the right safeguards, it can also put your registration at risk.
AI is no longer an emerging consideration for pharmacists – it’s already embedded in practice.
Using large language models (LLMs) such as ChatGPT to answer clinical questions and AI scribes like Heidi Health to capture consultation notes is becoming more commonplace. With agentic AI – systems that act autonomously on a patient’s behalf – now growing in popularity, the pace of AI adoption is only set to increase.
But these opportunities come with obligations – and without a distinct regulatory framework. Here, PSA Digital Health Lead and Victorian state manager Jarrod McMaugh MPS outlines the sixAI traps pharmacists need to avoid.
1. Entering identifiable patient information into AI platforms
One of the most significant risks pharmacists face when using AI is entering patients’ health information into AI platforms. Regardless of the purpose or the pharmacist’s intent, it may constitute a breach of Australian privacy law.
‘Let's say you were providing a Home Medicines Review (HMR) and you put the patient’s details into ChatGPT and asked, “What medicines is this person missing for their diagnosed conditions?” That would be a breach of privacy regulations,’ Mr McMaugh said.
‘Any information put into AI is stored. And therefore, where it is stored must adhere to the Australian privacy requirements.’
However, pharmacists who use LLMs to check for missed medicines or potential interactions can do so legitimately, provided no identifying information is included.
And while taking out a patient's name and address is a good first step, this may not adequately deidentify them.
‘You could prompt an LLM by saying, “I have a person who is taking medicines, x, y, z, and they have these diagnoses. Can you identify any missed medicines or any interactions?”’ Mr McMaugh said.
‘As long as there's no way to identify the individual, and it's just down to what is clinically appropriate, it's not a breach of any privacy matters.’
2. Assuming a business account equals compliance
You may think that moving from a free AI account to a paid business subscription resolves any compliance concerns.
But to be compliant, business or enterprise AI subscriptions must explicitly confirm that the platform meets Australian privacy regulations in the delivery of that service.
'You would need to be satisfied that the LLM, under contract, specifically states that it meets Australian privacy regulations,’ Mr McMaugh said.
‘It's similar to the agreement you have with your dispensing software [provider] or the clinical platform you use to record scope of practice work.’
3. Using AI scribes without proper consent
For pharmacists conducting clinical consultations, such as accredited and prescribing pharmacists, AI scribes can be incredibly useful for collecting and collating patient information.
But deploying them without meeting the required consent obligations creates significant professional risk.
‘You must get consent from the person whose session is being recorded by the AI tool,’ Mr McMaugh said. ‘And you must have the ability to turn it off if somebody says, “I want the service, but I don't want the AI tool recording our discussion”.’
For pharmacists uncertain about what adequate consent looks like in practice, he suggests the following approach: 'I'm going to use an AI scribe in this session. It will record our conversation and take notes on our behalf. It will create a copy that I'll keep on record, and you have the right to access that record any time you request it. Are you comfortable with me proceeding?’
Pharmacists should also ensure that the AI tool is not in an active learning phase, with systems that continue to learn from patient interactions requiring an additional layer of consent.
‘For the vast majority of pharmacists, that shouldn't be a scenario they find themselves in – unless they're involved in clinical research about an intervention or research about the AI tool,’ he said.
‘For the vast majority of pharmacists, that shouldn't be a scenario they find themselves in – unless they're involved in clinical research about an intervention or research about the AI tool,’ he said.
Pharmacists should confirm that AI dictation tools don't record voice snippets or retain details to improve the quality of their systems. Utilising AI models that are actively learning is generally not appropriate outside of a clinical trial with the accompanying level of consent seen in a trial setting.
Using an ‘active learning’ AI requires well documented consent for the person's health information to be used in this way, and is usually out of scope for most clinical settings.
4. Failing to check transcription accuracy
The second area of risk when using AI scribes is accuracy. While generally reliable, they can make mistakes; and the professional obligation to maintain accurate records rests with the pharmacist, not the AI tool.
To prevent errors, pharmacists should still take notes while the AI scribe is working in the background, particularly around critical details such as dosing.
'If you were in a position in the future where something has gone wrong and you're in front of AHPRA or another regulator, and they say, “Why are your notes incorrect?” just assuming that the digital scribe was doing its job is not sufficient for meeting your professional obligations,’ Mr McMaugh said.
AI and handwritten notes should also be reviewed at the end of each session, while details of the consultation are still fresh.
'If you use an AI scribe during an HMR interview and you don't review the transcript until a week later, how are you going to correct the information that it got wrong?’ Mr McMaugh said. ‘From a workflow perspective, and to adhere to professional obligations, you need to make sure it's accurate.’
5. Trusting AI output without checking the references
AI platforms can produce clinical responses that are well structured, but are actually incorrect. These AI ‘hallucinations’, where LLMs return fabricated or inconsistent information, are commonplace.
Another, more subtle risk is when LLMs draw on international sources rather than Australian-specific guidelines.
‘If you ask what the standard dose of a medication is, you might get a generally acceptable dose that's not applicable to specific Australian scenarios,’ Mr McMaugh said.
Antibiotic selection is a clear example, with resistance patterns varying between countries, meaning recommendations based on international data may be inappropriate or inadequate for an Australian patient.
'You should therefore always ask LLMs for references so you can confirm the information is correct,’ he added.
And don’t forget to check these references also, which aren’t immune to AI hallucinations.
6. Accepting an AI-generated booking as genuine patient consent
Agentic AI is a system designed to act autonomously on a person's behalf, booking appointments, managing schedules and completing transactions.
While these tools have the potential to streamline service appointments, such as vaccinations, pharmacists must be vigilant around digital bookings.
When an AI agent books a consultation on a patient's behalf, it’s not possible to confirm at the point of booking whether the patient themselves made an informed, active decision to attend.
‘If booked online, pharmacists should double-check that a person has provided consent to have a particular service when they come in,’ Mr McMaugh said. 'This is a good way to confirm that consent has been provided by the [person] receiving the service – not the AI that is booking on their behalf.’
To close any gaps in the consent chain, he suggests:
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[post_content] => A new transitions of care model is helping high-risk patients in rural and remote areas avoid medication misadventure and hospital readmission through virtual pharmacist-led care.
After patients are discharged from the hospital, their transition back into the community can be high-risk, with significant potential for medicine-related harm. These risks are amplified significantly for rural communities due to sparse healthcare facilities, fragmented continuity of care and workforce shortages.
The TIC TOC program in Western NSW is tackling these issues via a virtual model designed to support patients who are struggling to access care during vulnerable post-discharge periods.
The TIC TOC program will be further explored at the CPC26 conference later this month and is set to demonstrate how digital health and multidisciplinary collaboration can help bridge the gap between hospital and home.
Ahead of the program’s launch, AP spoke with Linda Krogh, the Virtual Transitions-of-Care Stewardship Pharmacist with the Western NSW Local Health District and a current PhD candidate with the University of Sydney.
A virtual model of care
‘Transitions of care are deeply complex – even more so in remote settings due to factors such as distance, workforce, and community care,’ said Ms Krogh.
The CPC26 presentation will outline how the model translates into practice, including identifying high-risk patients, virtual medication reconciliation, multidisciplinary communication, and rapid coordination of Home Medicines Reviews (HMRs).
The Transitions of Care (ToC) Pharmacist role was introduced to provide virtual support across 19 towns, ensuring high-risk patients receive an optimal discharge and follow up, particularly when onsite pharmacy services are unavailable.
The layout of the model means that the ‘TOCS pharmacist monitors the patient’s hospital admission and supports the onsite or virtual clinical pharmacist to ensure all required discharge activities are completed,’ Ms Krogh said.
This includes reviewing electronic medical records to identify medicines that were commenced, ceased, changed, or continued during admission.
‘The role includes medication reconciliation, patient counselling, preparation of patient-friendly medication lists and direct communication with GPs and consultant pharmacists to facilitate timely post-discharge medication reviews,’ she said.
Through virtual work, pharmacists can connect hospital teams, patients, carers, and primary care providers across geographically disconnected areas.
The risk in transitions
The severely limited access to GP services and healthcare facilities delays crucial follow-up appointments and check-ins after discharge. In most rural communities, locum professionals make up a significant part of the primary care workforce, creating significant challenges in ensuring continuity of care.
‘Patients are often discharged from hospitals located a long distance from home, which can delay access to medicines and follow-up post-discharge,’ Ms Krogh said.
Patients are identified as high risk for medicines misadventure and readmission based on criteria including ‘use of high-risk medicines such as insulin, alongside a hospital readmission within the previous 6 months.’
‘These factors can increase the risk of medication discrepancies, misunderstandings, and adverse events once the patient returns home,’ she added.
Fast-tracking post-discharge HMRs
A key feature of the program is its focus on ensuring HMRs occur when they are needed – not when they are possible.
To ensure time-sensitive cases are addressed, the TOC pharmacist prepares a HMR referral for the patient’s GP before discharge. If the referral cannot be signed within a 48-hour window, the program activates the hospital-initiated HMR pathway, to avoid delays.
‘The goal is for the post-discharge HMR to be completed within 10 days,’ Ms Krogh said.
Patients can choose whether they prefer their HMR conducted face-to-face or virtually, allowing referrals to be matched to credentialed pharmacists based on patient preference and location.
The TOCs pharmacist then books a GP appointment to ‘review the HMR recommendations and develop medication management plans, helping to close the loop on the patient's transition of care,’ she said.
By clearly identifying patients as high-risk, reception staff are better able to triage appointment availability where demand exceeds capacity.
Connecting hospital and community care
A major strength of the TIC TOC model is its ability to connect traditionally siloed parts of the healthcare system by facilitating communication between hospital clinicians, GPs, and community pharmacists – improving continuity of care throughout each patient’s journey.
‘In rural towns where GP appointments are often booked out weeks in advance, this model ensures high-risk patients have their medications reviewed promptly by a pharmacist,’ Ms Krogh said.
With post-discharge HMRs frequently identifying medication misunderstandings, the early identification of medication-related issues also allows GP appointments to focus more efficiently on clinical decision-making and care planning.
The most common errors identified relate to patients’ misunderstanding of how to take their medicines following discharge, as well as short-term medicines that pose a point of confusion, such as tapered prednisolone regimens and analgesics.
‘In one case, a patient stopped taking an antihypertensive medication after overhearing nursing staff say it should be withheld during admission, not realising the change was only temporary,’ Ms Krogh said.
‘Another patient discharged with two antibiotics misunderstood the instructions and intended to take the medicines sequentially rather than concurrently.’
Multidisciplinary action
The TIC TOC model encapsulates a broader theme of multidisciplinary collaboration that will underpin CPC26.
With healthcare systems championing the importance of coordinated care, this program demonstrates how pharmacists can play a central role in ensuring patient safety during transitions of care, particularly for vulnerable rural populations where limited access to timely healthcare poses challenges.
Further insights into the TIC TOC program and the virtual TOC's pharmacist role will be shared during the CPC26 conference session, held between 29 – 31 May 2026 at the RACV Royal Pines Resort, Gold Coast.
Click here to register.
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[post_content] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps placing pressure on both practitioners and patients.
HMR services remain a vital safeguard for improving health literacy among vulnerable Australians living with chronic illnesses, complex medicine regimens and mental health conditions.
But pharmacists on the ground warn the model is increasingly unsustainable under current funding arrangements. Restrictive caps, rising fuel costs, and extensive travel times are making the reality of HMRs nearly impossible to keep up with.
AP spoke with Mitchell Everlyn, consultant pharmacist, qualified diabetes educator, and locum based in Brisbane, Australia, about the impact of these pressures.
Unsustainability of HMRs
Growing demand for HMRs, increased clinical complexity and systemic constraints are reshaping the extent of the services pharmacists can realistically provide.
Balancing extreme travel distances with capped funding arrangements has left many questioning how long they can continue carrying the weight of HMR practice.
When asked about the sustainability of HMRs, Mr Everlyn said that ‘unless funding increases with caps or indexes upwards, I'm better off working in a pharmacy than I am doing consultant stuff.’
With 30-per-month caps set in place, Mr Everlyn said that ‘the time and money you're getting back from HMRs works out to be about $22 an hour. These financial pressures directly impact which patients pharmacists can realistically afford to fit in.’
At the same time, patient demands continue to climb. HMR waitlists can stretch for months for many pharmacists, particularly in rural areas where these services are a cornerstone in healthcare.
Urgent referrals continue to flood in, yet pharmacists are unable to exceed service limits.
‘I get follow-up emails asking why I haven't seen an acute patient… and it’s because I’ve hit my cap and I can’t,’ Mr Everlyn said.
Despite the growing clinical complexity of patients receiving HMRs, remuneration has been at a standstill since 2019, and service caps have remained largely unchanged, creating a widening gap between the work required and the compensation available.
Under PSA’s 2026-27 Federal Budget recommendations, caps have been recommended to increase to 60 HMRs per month from 1 July 2026.
Professional isolation in rural practice
For pharmacists servicing rural and regional areas, the challenges extend well beyond funding, triggering a push towards incorporating telehealth to ease the strain of providing rural HMR services.
Loading allowance is only extended to $125 per visit, which is designed to contribute towards the costs incurred, not necessarily to cover all costs, ultimately leaving pharmacists out of pocket.
The PSA has estimated that reforming HMR delivery would cost $135.1 million over 4 years, which includes introducing HMR payments linked to rurality (MMM3-7). Such investments would reduce preventable hospitalisations and improve rural access.
Mr Everlyn recently had to reduce the distance he travels due to financial strain.
‘I'm now needing to prioritise HMRs that are a lot closer to home, which sucks to say.’
Mr Everlyn has been increasingly providing private HMRs, explaining that patients are not prepared to wait 3 months.
Mr Everlyn recalled one HMR consult in a completely isolated area where healthcare access was severely limited, Mr Everlyn said ‘the patient was having an acute schizophrenic attack, and the closest hospital was an hour away.’
It is commonplace for credentialed pharmacists to conduct reviews completely alone, which leaves them with the task of navigating highly complex medical situations without any form of backup.
Patient and practitioner safety
As wait times blow out across the healthcare system, pharmacists are increasingly encountering patients whose conditions have escalated well beyond medicines management.
‘There have been times where I've gone to a patient's house and had to call ambulances because they need acute care,’ Mr Everlyn said.
‘I saw someone recently who's been in hospital three times this year for suicide attempts, and there is a 6-month wait list for a psychiatrist. So then you’re talking about patient safety.’
Naturally, these experiences have an impact on a practitioner's emotional wellbeing. ‘After situations like that, who do you call? Where's the support net? It can be very isolating,’ Mr Everlyn said.
Fuel crisis and a push to telehealth
Fuel shortages and rising petrol costs are putting the longevity of HMR practice in a compromising position, which places vulnerable patients at immense risk.
Increasing fuel prices have added yet another layer of pressure for pharmacists who are already operating on tight margins.
With travel taking up large portions of the workday, and an increase in fuel costs, there has been a recent push towards incorporating telehealth into HMR services.
PSA national president Professor Mark Naunton MPS said ‘the support these patients need, such as medication reviews, is becoming rapidly unsustainable amid the current fuel crisis, unless the government reinstates telehealth.’
‘We know telehealth worked effectively and efficiently during the COVID-19 pandemic, so why not now?
‘I did one HMR on Easter Sunday, which was a 120 km round trip, and then with roadworks, it took me two hours to get there. One full day's work worked out to be $200,’ Mr Everlyn added.
‘The push over to telehealth would alleviate so much time.’
While he acknowledges the value of in-person assessments, he argues that not every consultation requires pharmacists to travel hours to gain the required clinical information.
‘You can tell a lot by how someone's moving… but I don't need to travel 3 hours one way just to see that.’
For many pharmacists, the reluctance to modernise HMR services feels increasingly behind broader innovation.
‘In this day and age we have AI, but we can't do telehealth,’ Mr Everlyn says.
The reinstatement of telehealth is included in the reforms PSA is advocating for to ensure that care is accessible for all Australians.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => HMR waitlists can stretch for months
[post_excerpt] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps.
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[post_content] => Busy pharmacies, bright lights and confined spaces can heighten fear surrounding vaccination, particularly among children who are neurodiverse.
[caption id="attachment_32071" align="alignright" width="300"] Yvette Anderson MPS[/caption]
Understanding how to create a safe, calm environment is essential to delivering patient-centred care.
A time sensitive vaccination window
With winter around the corner, pharmacies should be in peak winter vaccine campaign mode – including the recently introduced intranasal vaccine, FluMist.
But pharmacists new to vaccinating children are often nervous that immunising school-aged children can be tricky. The Child Health Poll reported that 1 in 4 children experience needlephobia – which often intensifies with age. These challenges are amplified amongst children who are neurodiverse, calling for an enhancement of personalised care throughout the vaccination process.
Yvette Anderson MPS – founder of Spectrum Pharmacist, which sets out to bridge the gap for neurodivergent families – told AP her top tips.
Fear surrounding the vaccination experience
Neurodiverse children can often experience heightened levels of sensory sensitivity, differences in communication, and increased anxiety in unfamiliar settings.
‘Early signs of anxiety and sensory overload vary from child to child,’ Ms Anderson said. ‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.’
During vaccination, early signs of overwhelm may include:
‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.'
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Case scenarioDavid, 68, presents to the pharmacy 7 days before a scheduled colonoscopy. He says the written instructions from the clinic were ‘hard to follow’ and asks whether he should stop ‘all his tablets’. David has type 2 diabetes, hypertension and atrial fibrillation. He uses a weekly dose administration aid (DAA) prepared by the pharmacy. His regular medicines include apixaban, ramipril, empagliflozin, metformin and atorvastatin. He also takes ibuprofen intermittently for knee pain and a garlic supplement. He has been advised to fast and complete bowel preparation the day before the procedure and is unsure which medicines to continue, stop or restart. |
Australians make 440 million visits to their pharmacist each year,1 with community pharmacists frequently consulted by patients preparing for diagnostic or minor surgical procedures. These encounters often occur when instructions are unclear, leaving patients unsure which medicines to stop, when to stop them, and how to safely resume therapy. Temporary medicine changes can be particularly confusing for patients using dose administration aids (DAAs), increasing the risk of dosing errors or procedural delays.
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Pharmacists are well placed to address this gap. As accessible healthcare professionals with medicines expertise, pharmacists can identify medicines that increase peri-procedural risk, clarify instructions, and support safe temporary changes.
This article provides a practical, evidence-based overview of medicines commonly withheld prior to procedures, counselling strategies to minimise confusion, guidance for managing DAAs, and pharmacy-based interventions to support patient safety.
Patients preparing for diagnostic investigations or minor surgical procedures are often advised to temporarily withhold selected medicines to reduce peri-procedural risk. The decision to continue or withhold a medicine involves balancing potential risks of the procedure (such as bleeding, infection, haemodynamic instability, renal impairment, metabolic disturbance or interactions with medicines used in the peri-procedural period) against the risk of disease exacerbation or withdrawal effects. Pharmacists play a critical role in identifying medicines that may require review, clarifying prescriber instructions and supporting safe temporary modification of therapy.2
Anticoagulants and antiplatelet agents are among the most frequently managed medicines in the peri-procedural setting. Oral anticoagulants, including warfarin and direct oral anticoagulants, increase bleeding risk during procedures such as colonoscopy, dermatological excisions, and some dental or ophthalmic surgeries.3 Antiplatelet therapy presents a more nuanced risk-benefit balance. For many minor procedures, including cataract surgery and simple dental or dermatological procedures, aspirin may be safely continued, while procedures with a higher bleeding risk may necessitate temporary cessation.4
The decision to withhold antithrombotic therapy is highly individualised and should always be clinician-directed. Pharmacists should avoid advising cessation independently but can support patient safety by reinforcing clear stop and restart dates, and emphasising the importance of timely recommencement to minimise thromboembolic risk.3,4
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly withheld prior to procedures due to their reversible inhibition of platelet aggregation and their potential to impair renal perfusion, particularly in the context of peri-procedural dehydration or exposure to contrast media.2,5 Platelet function typically normalises within several days of NSAID discontinuation, although this varies by agent.5 From a pharmacy perspective, the most significant risk arises from unrecognised over-the-counter NSAID use. Pharmacists should proactively enquire about non-prescription analgesics and recommend suitable alternatives, such as paracetamol, where appropriate.2,5
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remain an area of clinical debate. Continuation has been associated with an increased risk of intraoperative hypotension, while cessation may increase the likelihood of postoperative hypertension.9-11 Evidence supports an individualised approach, taking into account the indication for therapy, baseline blood pressure, and the nature of the procedure and anaesthesia.9,10 In practice, many clinicians elect to withhold these agents on the morning of surgery when hypotension risk is high and resume therapy promptly post-procedure. Failure to recommence ACEIs or ARBs within 24–48 hours postoperatively has been associated with increased short-term mortality.9–11 Pharmacists should reinforce clinicians’ pre-procedure instructions, provide rationale and highlight the importance of timely recommencement.
Complementary and herbal products require review in the peri-procedural period, as evidence indicates their use remains highly prevalent among surgical patients, yet disclosure to healthcare professionals is often incomplete.1,12 Herbal medicines may exert clinically significant pharmacodynamic and pharmacokinetic effects that increase peri-procedural risk, including impaired platelet aggregation (e.g. garlic, ginkgo biloba, ginseng), increased sedative effect (e.g. kava, valerian) and altered metabolism of anaesthetic or perioperative medicines through cytochrome P450 enzyme induction (e.g. St John’s wort).2,13 Risk assessment is further complicated by variability in product composition, dosing and bioactive constituents, meaning effects are not always predictable or dose dependent.11 As a result, many contemporary guidelines recommend discontinuation of non-essential herbal medicines at least 1–2 weeks prior to procedures, depending on the agent and procedural risk.2,13
Diabetes medicines and peri-procedural blood glucose managementMedicines used to manage diabetes often require review in the peri-procedural period. Temporary changes may be needed to reduce medicine-related risk during fasting and recovery, and pharmacists play an important role in supporting patient understanding and continuity of care.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors warrant specific attention in the peri-procedural period due to the risk of diabetic ketoacidosis (DKA), which may occur with near-normal or only mildly elevated blood glucose levels (euglycaemic DKA). The risk is increased during periods of fasting, reduced carbohydrate intake (including bowel preparation), dehydration, acute illness and surgical stress. Importantly, normoglycaemia does not exclude DKA, and blood ketone testing should be considered where clinical suspicion exists. Clinical guidelines advise that SGLT2 inhibitors should be withheld for at least 3 days prior to procedures requiring fasting or bowel preparation (and 4 days for ertugliflozin).6
Physiological stress related to illness, fasting, anxiety and surgical intervention activates counter-regulatory hormones such as cortisol and catecholamines, leading to increased hepatic glucose output and reduced insulin sensitivity.7 When combined with altered oral intake and temporary medicines changes, this stress response can result in significant glycaemic variability, even in patients with previously stable diabetes.2,3
Extremes of blood glucose pose specific risks in the peri-procedural setting. Hyperglycaemia is associated with dehydration, impaired immune function and an increased risk of postoperative infection, while hypoglycaemia may result in neuroglycopenic symptoms, cardiovascular instability or loss of consciousness – particularly in the context of fasting or reduced caloric intake.8 For most adults, general peri-procedural targets include fasting blood glucose levels of approximately 4–8 mmol/L and random levels below 10 mmol/L, although individual targets should be tailored based on comorbidities, frailty and procedural complexity.8 Pharmacists play an important role in reinforcing blood glucose monitoring plans, supporting sick-day management principles, therapy modification during temporary medicine cessation, and identifying when abnormal readings require medical review. Clear counselling on when and how to safely recommence withheld medicines once normal oral intake has resumed is essential to minimise metabolic complications and support safe transitions of care.2,6
Patients who use DAAs are at increased risk of medication error when medicines are changed, particularly when temporarily withheld in the peri-procedural period.14 These patients often rely on the pack as their primary prompt for medicine administration and may not be familiar with individual medicines or their indications. Temporary cessation without appropriate pharmacist intervention can lead to duplication or unintended continuation of withheld medicines. Pharmacists therefore play a critical role in coordinating safe, structured modifications in response to procedural instructions.
Best practice involves pharmacist-led removal of specific medicines from affected doses, rather than advising patients to self-remove tablets, which increases the risk of error and pack disruption. Clear documentation should accompany any changes, including written instructions outlining which medicines have been withheld, the duration of cessation, and the planned date of recommencement, where possible. If feasible, pharmacists should provide a simple, procedure-specific DAA and schedule follow-up to ensure medicines are safely reintroduced post-procedure.
Liaison with prescribers may be required if instructions are unclear or if the patient’s clinical status changes. Through proactive management of DAAs, pharmacists can significantly reduce confusion, support continuity of care, and minimise preventable medicine-related harm and delays in the peri-procedural setting.
Community pharmacists can proactively review medicines prior to procedures, identify medicines that may require temporary cessation, clarify clinician-directed stop-restart instructions, and manage changes to DAAs.
By reinforcing written advice, reviewing over-the-counter and complementary medicine use, and supporting blood glucose monitoring during periods of fasting or medicine withholding, pharmacists minimise confusion and prevent medicine-related harm. Pharmacists can also support peri-procedural care by encouraging patients to bring all medicines for review and by providing an accurate medicines list to assist communication across care settings.
Pharmacists play a critical role in supporting patients preparing for common procedures through proactive medicines review, clear counselling and practical support for temporary medicine changes. This role is particularly important for patients using DAAs, where structured pack modification and follow-up can reduce medication errors and delays to care. As peri-procedural medicines management becomes increasingly complex, pharmacist-led interventions are essential to safe, coordinated and patient-centred care.
| Case scenario continued You review all prescription, over-the-counter and complementary medicines, and clarify the clinic’s instructions. High-risk medicines potentially requiring temporary cessation are identified, including apixaban, empagliflozin, ibuprofen and the garlic supplement, while other medicines can be continued as directed. Given David’s use of a DAA, you undertake pharmacist-led pack modification based on the clinic’s instructions. You provide clear written directions outlining withheld medicines, monitoring advice during fasting, and when medicines should be restarted once oral intake resumes. You use the teach-back method to confirm understanding, and a follow-up is arranged after the procedure to safely reintroduce medicines into the DAA. |
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
