Our pharmacist is having quite a tough time and things are set to get worse.
This morning the pharmacist is doing a medication reconciliation and asks one of the GP partners for advice. The query relates to whether or not a patient should get aspirin. The consultant, via the discharge letter, has asked for the patient to receive aspirin 300mg in combination with clopidogrel 75mg for three years post-myocardial infarction. The patient is 78 years old and is not taking any gastro-protective medication.
Our pharmacist asks the advice of the one of the GPs suggesting that maybe the risk of bleeding is too high here over that proposed period of time. The GP snaps at our pharmacist that he should follow the instructions from the consultant. This conversation was never recorded. Our pharmacist follows this advice and writes and signs the prescriptions.
18 months into treatment the patient is admitted to hospital due to blood in his stools. Whilst in hospital he has a catastrophic bleed and dies.
On investigation of the incident, the GP denies the unrecorded conversation and blames the pharmacist for not intervening to prevent the bleed.
Who is to blame for the death of this patient?
- Pharmacist 43%
- GP 36%
- Consultant 10%
Have you got any thoughts on how this situation could have been avoided and are there any indemnity insurance implications in your view? (assuming the pharmacist went with the GP insurance scheme)
“Pharmacist could have initiated PPI after liaising with hospital Dr or a different GP in the practice. And definitely, document all conversations in patient consultations if your advice ignored.”
“Document advice given. If outside of competence may not be covered by indemnity insurance and insurance may cover GP rather than a pharmacist.”
“Pharmacist didn’t document the conversation or write to the consultant. If it’s not written down it didn’t happen. Should also be aware of NICE guidance.”
“This is tricky, I am edging toward blaming the pharmacist as he is clinically accountable for signing scripts. Again he should have followed local guidance and queried this with the consultant directly especially if there was conflicting advice. He may well find himself in a tricky situation if he hasn’t got adequate cover. He should be covered under the government indemnity scheme but in this scenario, there may be factors that directly put him directly responsible.”
“Pharmacist should follow national guidance.”
“The pharmacist should have refused to sign a script he was not happy to sign and passed the work to the GP (or made a decision about other action to take, such as contacting the consultant or starting a PPI). He should also have recorded the conversation in the notes, as should the GP. NHS indemnity will cover payments here, and the GP indemnity scheme will provide support and medicolegal advice for the pharmacist. They will have provision for keeping separate any other advice request from the GP concerned.”
“The pharmacist knew the patient needed a PPI at the very least. If the pharmacist wasn’t happy with the prescription he should have asked for advice from another source and not just taken the barked advice from a grumpy Gp. But at the end of the day, the script was provided by the pharmacist.”
“I would not have signed a prescription I am unhappy with. Also, the pharmacist should have called the specialist team to confirm the dosing. This is not appropriate. If the consultant insisted, then I would have asked him to write or speak to the GP.”
“The conversation or at least the decision made from it should have been recorded. The pharmacist should have prescribed gastro-protection alongside regardless. I do not think that the indemnity insurance will cover them in this situation, and there is a concern that the GPs may not be willing to claim on it.”
“The pharmacist should have insisted on getting the Consultant to confirm the instruction or at least refer the patient back to the GP as it was beyond his competency. The Pharmacist would probably not be covered by the GP Scheme unless there are provisions for pharmacist prescribers.”
“Pharmacist should have recorded conversation. Joint liability, not sole liability. Inappropriate recommendations from the consultant which should have been queried.”
“All three clinicians are a fault here. The pharmacist signed the prescription, therefore, accept legal responsibility for the post-MI care for 1. The Aspirin dose 2. Dual Anti-platelet for 3 years 3. absence of GI protection in a 78year old. Clearly, there is a breakdown in the GP-Pharmacist relationship here which is crucial in the collaborative nature of pharmacists in a GP practice. It’s very disappointing that the GP denied the conversation. The GP failed to safety net here and contact the consultant.
Clearly, the consultant gave inappropriate advice here.”
“They have all contributed to the error, although the bulk of the responsibly is the pharmacist who signed the prescription. It is concerning that being “snapped at” resulted in the pharmacist obeying the GP. They should have documented their concerns and refused to sign the prescription, leaving it instead for the GP to sign.”
“Regardless of what the GP says you are a clinician in your own right and are responsible for all Rx you sign. Pharmacist should have contacted the consultant directly. The pharmacist may not be covered depending on what is stipulated.”
“Unfortunately as the conversation was never recorded the pharmacist is the last professional to have acted on this so is therefore responsible. I was taught if it’s not written down it didn’t happen!! Personally, I would have contacted the consultant if I was concerned even after discussing with the GP and recorded it all in the patient notes – must remember if I am signing a script it is my responsibility to ensure it is safe! The GP indemnity will probably not cover this so the pharmacist is at risk as the GPs are blaming them.”
“The pharmacist should have offered a ppi. Tasked the Gp the question and possibly contacted the consultant for clarification of decision of dual therapy for 3 years.”
“All conversations should be recorded, was that his area of clinical expertise?”
“Pharmacist could have discussed the issue with a medicines inquiry service rather than blindly following the GP’s advice. Could also have contacted the consultant directly to ask advice.”
“The pharmacist should have 1) recorded this conversation, 2) also consulted another doctor and 3) trusted his/ her own clinical judgement. I would love to understand what the implications of the indemnity insurance are. I have no idea.”
“Pharmacist should have recorded the conversation on patient record but should have checked with the consultant regarding prescription and lack of PPI.”
“Simply recording advice on patient PMR and told he was following instruction and doctors name who he spoke to.”
“Both the GP and the pharmacist are to blame. The pharmacist should have got a second opinion or at the very least recorded the conversation to cover themselves. The GP should have listened to the pharmacist’s concerns and not just brushed the pharmacist off.”
“The GP should have acknowledged the pharmacist’s concerns and looked into it further rather than dismissing him.”
“Document any advice from the said GP. Email or place a note in the patient’s computer file with the doctor to review.
Implications. Might be sued.”
“The pharmacist should have recorded the conversation but equally they should have taken the conversation further with the GP and expressed their concern at the risk for the patient.”
“Well, the pharmacist should have documented the conversation!!!! This is always the first thing you do after consulting a doctor or another pharmacists advice!!! In terms of insurance, if the conversation had been recorded, the pharmacist would have a higher chance of being covered.”
“Yes, the pharmacist should have made the record in the notes, detailing which GP and what was discussed. If it’s not documented it can be argued that it didn’t happen.”
“Every prescribing decision must be an evaluation and take responsibility, even if recommenced by another.”
“Conversation should have been documented. Pharmacist should have contacted the consultant if not happy.”
“Discuss with the consultant and add PPI. Discuss with another GP. The insurance will protect the interests of the surgery NOT the pharmacist.”
“Always record conversations.”
“Pharmacist should have gone with instinct and sought further advice from the consultant. This pharmacist was faced with the challenge of working in an unsupported environment. In this case, I feel the pharmacist was obligated to make changes in the prescribing systems in the practice and ensure there was review built into his work.”
“The pharmacist takes the highest responsibility shared with the consultant. Nothing is documented therefore didn’t happen thus resolving the GP. The dose should have been discussed with the consultant or hospital pharmacy team and gastro-protection added. The patient may still have had a bleed but as the action had been taken to prevent this then would be hard to prove negligence. Without gastroprotection or any documented evidence to discuss reduce aspirin dose then the court would most definitely go for a negligence claim.”
“Clarification with consultant initially, documentation of gap discussion at the time.”
“All aspects of patient care should be recorded in notes, there could be a conflict of interest for insurance company, clear national guidance on this which pharmacist should have made clear to GP and recorded in notes and if he had not followed guidance should have recorded that and reason why not.”
“Pharmacist should have recorded the outcome of the discussion with GP in the practice system in this patient’s record. It is unlikely that the GP insurance scheme would cover this pharmacist as the pharmacist has not documented the above. Also, the pharmacist has signed prescriptions as PIP in a clinical area he felt uncomfortable with and clearly out of his area of competence. Therefore moving into the risky territory as this will not be covered by the indemnity.”
“The conversation should have been documented. There should be a practice policy about gastro-protection where an exception to standard prescribing should be documented.”
“Nothing stopping the patient from contacting the consultant for clarification. Everything should be recorded in the notes. Pharmacist should have had their own indemnity to protect their own interests.”
“This should have been picked up on discharge from the hospital by the hospital pharmacy. The pharmacist should have refused to sign the prescriptions as he believed they were not an appropriate treatment.”
“The pharmacist was either prescribing outside their competence or was not acting in what they did know, if the latter, that would be more significant. Either way, they may feel bullied by the GP. They need to consider how they manage these conflicts.”
“Conversation should have been recorded, but the pharmacist is liable for signing prescriptions. Should have challenged with the consultant.”
“The GP has overall responsibility for the clinical care of the patient. Being a prescriber the pharmacist could, quite rightly have added in gastroprotection. The pharmacist should have recorded the conversation as it is of clinical significance, but even if they had, it does not absolve them of responsibility. However, overall, the GP should have considered the question more seriously, therefore, they are responsible.”
“Pharmacist should have queried the dose and lack of gastroprotective meds with the consultant after checking nice guidance and any local guidance.”
“If the pharmacist has good relationships with GPs this would have been avoided. A collaborative decision should have occurred and been documented.”
“The conversation should have been recorded. The pharmacist could have got in touch with the consultant.”
“Pharmacist should have refused to write the prescription and contacted the consultant for confirmation of the appropriateness of the regimen. Or advised the GP that it was outside of pharmacist’s competence so for GP to handle. Ref the indemnity insurance, as the previous sentence.”
“Haven’t selected one option – all contributing to this. The GP insurance may not cover this! The pharmacist could liaise directly with the consultant. The pharmacist could start GI protection if within the competency and feels confident about it. The pharmacist could’ve phoned the patient when discharge was received to explain. Ask if any protection was given. Let them know the implications and safety net. Whilst liaising with consultant + GP.”
“Any concerns about clinical decisions about a patient should be documented in the patient’s notes. This may include actions taken/ not taken, discussions with fellow colleagues and discussions with the patient. If the pharmacist has no indemnity cover of his own then there is no one to defend him for this act as the GP has already allotted the blame for the omission to the pharmacist, the insurance company may follow suit.”
“If an event is not recorded it didn’t happen is the advice I have been given.”
“Nice guidelines will recommend GI protection. The pharmacist needs to give evidence and develop their influencing skills. Keep record if they disagree with GP in the patient’s notes and ask again, or refuse to sign the script. Inform insurer.”
“The pharmacist should record all contact with the GP in the patient notes. However, the pharmacist should clinically be aware for the need of gastroprotection given combination and length of time. The GP insurance would support the GP, not the pharmacist.”
“Recording conversation in the patient records.”
“A record of conversations and advice should be included in the patient notes.”
“Thorough documentation of discussion. If unhappy with the GP decision document this and do not issue/sign the scripts.”