Close-Up on Complaints

“Close-Up on Complaints” explores incidents reported to the College that have occurred in the provision of patient care and which present learning opportunities. Ideally, pharmacists and pharmacy technicians will be able to identify areas of potential concern within their own practice, and plan and implement measures to help avoid similar incidents from occurring in the future.

A FUNDAMENTAL DUTY TO PUT THE PATIENT’S WELLBEING FIRST

SUMMARY OF THE INCIDENT
This incident occurred when a husband attended the pharmacy on a statutory holiday to fill a hydromorphone 2mg prescription for his wife from a Quebec physician. The patient required the prescription to manage the pain of a broken tibial plateau until she was able to see another doctor at their local hospital. The pharmacist indicated to the patient that he could not dispense the prescription because the prescriber did not write down the patient’s health card number on the prescription; he referenced that per Ontario’s Narcotic Monitoring System, prescribers are required to record the patient’s identification number, such as their health card, on any prescription for a monitored drug.

The patient returned to the hospital and, following a five hour wait, received a new prescription which was dispensed the following day.

WHY DID THIS HAPPEN?
This incident illustrates a lack of compassion for the patient, and an adherence to rules over the wellbeing of the patient.

The pharmacist insisted on rigid observance of the rules and regulations. He did not exhibit empathy for the patient nor did he seem to understand how he could use his professional judgment and discretion to make a decision that would have put the patient’s interest first by providing quicker treatment.

COMPLAINT OUTCOME
The College’s Inquiries, Complaints & Reports Committee oversees investigations of each complaint the College receives. A committee panel considers a pharmacy professional’s conduct, competence and capacity by assessing the facts of each case, reviewing submissions from both the complainant and the professional, and evaluating the available records and documents related to the case.

In this case, the panel noted that the patient was required to wait a significant amount of time, until the next day, for pain relief. While pharmacy professionals must adhere to dispensing rules overall, particularly with respect to narcotic prescriptions, there are accommodations that can be made for particular situations. The pharmacist may not have been able to dispense the entirety of the prescription until certain aspects were verified with the prescriber. However, the panel notes that there are more options besides dispensing in full and not dispensing – for example, he could have dispensed a few tablets to provide pain relief while waiting for verification.

The panel emphasized that pharmacists must first and foremost consider the patient and their wellbeing. There was no reason to believe that the prescription was fraudulent and the pharmacist had information to support the authenticity of the prescription, including the availability of the patient who was in a vehicle outside of the pharmacy. The health card number could have been confirmed verbally or by fax with the physician or the clinic. While the prescription was not written exactly as required by Ontario regulations, the pharmacist could have used his judgment and discretion in how the prescription was confirmed and how identifiers were used, recognizing that the physician was from another province.

Furthermore, the panel felt that the pharmacist displayed no compassion for his patient and, in his communication with the patient and response to the investigation, sought only to protect himself.

Due to the seriousness of the incident and the lack of appropriate patient care provided, the panel ordered that the pharmacist appear in person to receive an oral caution, and that he complete remedial training — a specified continuing education or remediation program (SCERP) – related to ethics.

LEARNINGS FOR PHARMACY PROFESSIONALS
The Code of Ethics clearly articulates the ethical principles and standards which guide the practice of pharmacists and pharmacy technicians in fulfilling the College’s mandate to serve and protect the public by putting patients first. The first foundational principle is that pharmacy professionals must actively and positively serve and benefit the patient and society. Specifically, Standard 1.1 states that “members ensure that their primary focus at all times is the well-being and best interests of the patient.” This means that pharmacy professionals must maintain the patient’s best interests as the core of all activities. They should not place their own interests – or self-preservation – above the patient. Furthermore, pharmacy professionals must be diligent in their efforts to do no harm and, whenever possible, prevent harm, such as unnecessary pain and suffering, from occurring.

Patients seek care because they believe and trust that pharmacy professionals will apply their knowledge, skills and abilities to make them better. Standard 1.2 of the Code of Ethics states that “members utilize their knowledge, skills and judgment to actively make decisions that provide patient-centred care and optimize health outcomes for patients.” Pharmacists should, when appropriate, look beyond black and white decision making to ensure they are properly assessing and acting on the big picture – incorporating what they know about the patient, the situation, the medication and any other key factors. When making a decision, documentation is critical, including making a note on the rationale for the decision and how it supports the best possible health outcome for the patient.

The Standards of Practice are clear that pharmacists must demonstrate a caring, empathetic and professional attitude. They should seek to understand the patient’s perspective and communicate with compassion, recognizing that many individuals seeking healthcare are in pain, frightened or vulnerable. A lack of compassion, and tactful communication, can end up making the situation worse.

CONCLUSION
With Ontario’s current opioid crisis, there is a significant focus on narcotics and how pharmacies manage and dispense them. Pharmacy professionals must be diligent in how they assess narcotic prescriptions, manage narcotic inventory and dispense narcotics, including respecting laws and regulations. However, due diligence and caution should not interfere with the fundamental duty that a pharmacist or pharmacy technician has as a healthcare professional to put patients and their wellbeing first and foremost. Pharmacists must use their professional judgment to make appropriate decisions in the best interests of their patients.