What to do when faced with prescribing errors

What is best practice for community pharmacists for addressing GP prescribing errors?

One outcome of a pharmacist’s responsibility may be the need to contact a prescriber to clarify a dose, resolve a duplication in treatment, ­flag a potential interaction or discuss a perceived ‘error’. The frequency of this type of contact may increase as pharmacists gain access to more detail of patients’ medical information through the introduction of electronic health records.

PSA has prepared a hierarchy of guidance that underpins pharmacists’ practice [see PSA Code of Ethics]. Both the Pharmacy Board of Australia Registration Standards and Guidelines and the PSA Code of Ethics are high in the hierarchy and provide pharmacists with direction on how to respond when addressing a GP’s prescribing errors.

At all times, the pharmacist must place the patient’s interests first.

Care Principle 1 of the Code of Ethics states: ‘A pharmacist is required to make the health and wellbeing of the patient their first priority and exercise professional judgement in the interests of the patient.’

Pharmacists do this every day, normally without issue. The matter under consideration here is how to manage this responsibility when the pharmacist perceives an error has occurred and there is consequently a need to contact the prescriber.

Firstly, the patient should be made aware of the need for the contact without raising alarm or causing undue concern or undermining the competence or position of the prescriber.

The pharmacist must apply their professional knowledge and judgement in the patient’s interest.

Care Principle 1, part F states: ‘A pharmacist promotes the safe, judicious and efficacious use of medicines and prevents the supply of unnecessary and/or excessive quantities of medicines, or any products which may cause harm.’

The pharmacist’s concern should be presented within the context of their expert body of knowledge. As the contact is likely to be brief, preparation should be undertaken in advance and a recommended course of action should be provided if possible. The contact should be without judgement and not be adversarial, as both parties have concern and responsibility for the patient’s safety.

The pharmacist’s responsibility to the patient does not stop with raising their concern with the prescriber.

The PBA Guidelines for Dispensing of Medicines state: ‘In dispensing a prescription, a pharmacist has to exercise independent judgement to ensure the medicine is safe and appropriate for the patient…‘

The pharmacist is the last professional standing between the patient and the medicine. A high degree of responsibility rests with them to ensure the patient will be, to the best of their judgement, safe. If the prescriber fails to convince the pharmacist of the validity of the original instruction, doesn’t recognise the pharmacist’s concern, or doesn’t agree with the pharmacist’s recommendation, the pharmacist must take further action.

In the event of uncertainty following discussion with the prescriber, the pharmacist should seek a second opinion from an independent and trusted source. They should annotate the prescription and note in their dispensing record their concern, actions and the outcome.

The ultimate step is to refuse to dispense the prescription, explaining to both the patient, and to other pharmacists through the annotation, why in their professional judgement they were not prepared to supply the medicine as prescribed.

John Jackson is the Director, Project Pharmacist, Centre for Medicine Use & Safety, Faculty of Pharmacy & Pharmaceutical Sciences at Monash University and 2018 PSA Pharmacist of the Year.