The Pharmacist Defence Association (PDA) have issued urgent guidance to all of its members. The move comes in response to a series of critical incidents involving patients deaths.
The defence team at the PDA has become increasingly concerned about incidents of unsafe practice which have started to emerge as the number of independent prescribers working in GP practices has risen.
The PDA has said that some of these recent cases are linked in some way to pharmacists prescribing inappropriately or offering poor advice, often underpinned by an assumption of competence which was ill-founded. They have reminded members of the importance of seriously considering their levels of experience and skill at all times before making a clinical decision and issuing a prescription.
The PDA has identified the following as high-risk situations:
- Undertaking prescribing or providing clinical advice for patients who are not physically present.
- Undertaking prescribing for patients without reference to their clinical records.
- Undertaking prescribing for walk-in patients where a diagnosis may be required.
- Prescribing alternative medicines due to shortages (particularly where the medicine to be replaced is a member of a high-risk group such as opiates and/or you are unfamiliar with the use of your chosen replacement). The PDA have suggested checking with a GP or a colleague with relevant specialist experience and ensuring any online or print reference sources that are relied upon are both appropriate for the scenario in which you are prescribing and that you keep a note of those you relied upon.
The guidance issued by the PDA also makes reference to online pharmacies offering a choice of prescription-only medicines for sale and the risks associated with prescribing under these circumstances since the prescriber cannot see the patient or examine them directly.
In addition, the prescriber will usually have no access to the patient’s clinical notes. In some cases we are aware that employers in online pharmacies may place expectations upon their pharmacist employees to prescribe high-risk prescription-only medicines, such as controlled drugs or medicines for conditions that require regular monitoring, without any communication with the patient’s GP, either to check that a medicine has been prescribed before or to advise the GP of the supply made.
The PDA has stated clearly that this is unsafe and unacceptable practice.
The issue of remote prescribing is deemed so serious that high-level principles for good practice in remote consultations and prescribing have been produced which are co-authored and agreed by a range of healthcare regulators and organisations.
The PDA has urged all members with prescribing responsibilities (wherever they work) to adopt these principles in their daily practice, to regularly reflect on their competency and to contact the PDA should they find themselves expected to adopt practices which they believe are unsafe. [The PDA has produced the Boundaries of my Clinical Practice Statement (BCPS) form to facilitate reflection on competency and we urge all prescribing pharmacists to complete such an exercise at their earliest opportunity. Those who do so only after a critical incident has already occurred will find it of relatively limited benefit in terms of the defence of their reputation].
The team at the PDA has also reminded members that whilst the GPhC principles include expectations on the conduct of employers, healthcare professionals are responsible for their own conduct and will be held accountable for their actions regardless of whether the organisational systems and culture within which they work are also deemed unsafe or inappropriate.
If something goes badly wrong
In the event of a critical incident, any subsequent investigation (for example a coroner’s inquest, police or regulatory investigation) will not only examine the conduct of the pharmacist to establish if it caused harm, but also whether the pharmacist was acting within or outside of their competence. In such a situation, the Boundaries of my Clinical Practice Statement (BCPS) could help to demonstrate that the pharmacist had properly assessed their competence prior to engaging in a particular prescribing episode or clinical service and was therefore not working as a maverick in a professional vacuum but as a considered professional.
The authorities will also study carefully the behaviour of the pharmacist after any critical event has occurred. Did the pharmacist demonstrate insight into what they had done, did they take immediate and appropriate action or did they try to downplay an incident or retrospectively create an explanation? What did they say to a patient or the family of a patient, what exact words were used? Were they contrite and what did they write in the initial incident report form?
All of these can be used as evidence in any subsequent investigation. Any remarks made in the immediate aftermath of the incident which demonstrate a lack of insight, judgement or appreciation of the gravity of the matter could be highly damaging to the pharmacist’s prospects. Such comments can cause damage irrespective of what the pharmacist later says in front of a formal investigating body after further reflection.
You can find a copy of the high-level principles here.
You can find the earlier PDA article on competency including a link to the BCPS form here.
You can find the PDA response to the GPhC consultation on Guidance for Pharmacist Prescribers here.
Pharmacy in Practice has asked for comment from the PDA.