“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.
SUMMARY OF THE INCIDENT
This incident occurred when a complainant raised concerns about services provided by a pharmacy to her cousin, who has developmental disabilities and lives in a group home. The complainant has power of attorney for her cousin’s affairs and raised a number of issues regarding the pharmacy, including that pharmacy staff obtained consent from a personal support worker who did not have the authority to provide it and sought to have her cousin sign forms despite her cousin having questionable capacity to do so. She also noted that the pharmacy failed to seek authorization for payments on her credit card, that they were not transparent about costs and fees, and that she had trouble getting both receipts and answers to her questions about fees. Finally, the complainant was sent another patient’s personal information during her interactions with the pharmacy.
WHY DID THIS HAPPEN?
This incident occurred because there was a lack of clear systems, good communication and attention to detail at the pharmacy.
The pharmacy did not have a structure in place to determine and record who was authorized to provide consent for patients. The Designated Manager inappropriately relied on the group home staff to assess whether the patient had the capacity to sign the document.
There was a significant breach of patient privacy when pharmacy staff gave the complainant personal information about another patient.
There was no record of notification to the complainant of changes to the pharmacy’s billing practices and no written documentation of payment authorization, including consent by the complainant to ongoing payment and use of the credit card. When the complainant raised concerns about costs and fees, the Designated Manager delegated her pharmacy technician to contact the complainant, even though it was clear the complainant was already frustrated and that this case involved a vulnerable patient, which meant that the situation should have been handled more thoughtfully.
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 had a number of concerns about how the pharmacy approached and responded to each of the issues identified in the complaint. The panel noted that there was no clear system in place at the pharmacy related to the authorization of charges and felt that the billing system should be clearly explained to the patient/agent and written documentation obtained before any charges are made.
In regards to the issues raised about costs and fees, and the complainant’s concern about insufficient transparency, the panel pointed out that the Designated Manager should have paid special attention to communication in this matter, considering that the patient was vulnerable due to the inability to give consent. While there was disagreement between the Designated Manager and the complainant as to whether the changes to the pharmacy’s billing system were discussed, there was no record of any discussions or other notification on the patient’s file.
The panel was concerned that there was no system to determine who could provide consent for a patient and ensure that that information was documented. The panel pointed out that the Designated Manager and staff should have taken extra care to ensure informed consent was obtained, especially for a vulnerable patient, and should not have relied on the group home staff to validate that.
Finally, the panel noted that the breach of patient privacy pointed to a lack of attention to detail at the pharmacy. They felt that the Designated Manager did not appropriately react to the breach, including not reporting it to the affected patient or the Information and Privacy Commissioner and not providing an appropriate action plan to prevent it from happening again in the future.
In light of the above, the panel issued the Designated Manager an Oral Caution and required the completion of specified remediation on professional responsibility to assist in analyzing pharmacy processes, identifying areas of risk, addressing those areas of risk and improving communication with patients and agents.
LEARNINGS FOR PHARMACY PROFESSIONALS
There were numerous issues involved in this complaint, with each presenting the opportunity to highlight learnings for pharmacy professionals and particularly Designated Managers.
Designated Managers are responsible for the overall operation of the pharmacy including professional supervision of the pharmacy, record keeping and documentation, training and orientation and safe medication practices.
Policies and procedures must be in place for consistent record-keeping and documentation to ensure that all staff are aware of when it is necessary to document information. Relevant information should be recorded in a manner that is timely, readily retrievable and easily accessible. Thorough and complete documentation demonstrates accountability and responsibility for a pharmacy professional’s decisions, and also supports both patient and professional understanding of the discussions, decisions and actions that have occurred.
Clear and transparent communication on fees supports the development of relationships with patients and their agents that are marked by professional courtesy, effective communication skills and a caring and professional attitude. The Code of Ethics requires that pharmacy professionals are transparent in the fees that they charge and ensure that these are communicated to patients in advance of the provision of the service or product provided.
Additionally, open and timely communication with patients/agents may help to resolve misunderstandings or concerns sooner, thus providing an opportunity to potentially de-escalate challenging situations and support ongoing patient relationships.
Situations that present red flags, such as those involving patients who may not have the capacity to provide informed consent, require particular attention and care from the pharmacy professionals involved. Appropriate consent should be obtained before providing care, including critically assessing who can provide that consent. Documentation of consent should be recorded on the patient record to ensure that all staff at the pharmacy are aware.
It is a serious issue to breach patient privacy. Designated Managers are responsible for making sure that appropriate pharmacy protocols are in place to ensure that the privacy of patients’ health information is protected. This includes informing patients when the confidentiality of their personal information may have been compromised. Additionally, pharmacies are considered health information custodians under the Personal Health Information Protection Act (PHIPA), which require them to meet certain expectations and put safeguards in place. In the event of a privacy breach, the responsible health information custodian must notify the individual(s) affected at the first reasonable opportunity. When the custodian notifies a patient of a privacy breach, they must also inform the patient that they can make a complaint about the breach to the Information and Privacy Commissioner of Ontario.
Finally, it is the Designated Manager’s responsibility to ensure that there are processes in place to evaluate the quality of the pharmacy services provided and make the necessary changes to improve practice. When a complaint, breach, incident or other issue is raised, it is incumbent on the Designated Manager to critically assess what additional measures may be required to prevent it from happening again.
USEFUL RESOURCES FOR PRIVACY BREACHES
- Quick links to the Office of the Information and Privacy Commissioner of Ontario
- Pharmacy Connection article Reporting Privacy Breaches