The Dilemma
You are a pharmacist prescriber who runs a clinic for a local surgery, specialising in respiratory medicine (ie asthma/COPD patients). A patient come to the pharmacy for an annual review of their condition, and you have access to their medical notes so are aware of their co-morbidities and regular repeat medication. At the end of a consultation, you are busy writing out the relevant prescription, the patient asks: "While I'm here, could you just prescribe me some of my water tablets?" The patient has been on furosemide 40mg OD for several months. What do you do?
Discussion
The RPSGB advises that all pharmacist prescribers, whether supplementary or independent, must prescribe within their competencies and only medication appropriate for the patient. You know that the patient is already being prescribed the requested item by a GP, but it is for a condition that you do not normally deal with.
If the patient asks for something that I would normally be comfortable selling to them over the counter, such as emollients, antihistamines, or laxatives then I would not have a problem issuing them with their normal prescription. However, if they were asking for their usual medication for a more serious condition, such as heart failure or epilepsy, I would have to refuse as I do not have expertise in those areas.
Patients can put a lot of pressure on pharmacists and, as you know they usually get the medicine, it would be easy to cave in. Remember, however, it is your signature on the prescription and you would be held to be legally responsible if anything were to go wrong even if it is normally prescribed by a GP. It would be difficult to defend your actions in a court of law if you could not demonstrate your expertise in a particular area.
In Scotland, pharmacists are able to prescribe on a Community Pharmacy Urgent Supply (CPUS) prescription any repeat medication that a patient gets for their usual quantity (ie generally up to two to three months), as long as the patient is registered with a Scottish GP. If the patient is from elsewhere in the UK, pharmacists have to do an Emergency Supply, as in England and Wales, and can only give up to 30 days plus levying a charge for the medication.
Where Does the Law Stand?
The July 2010 edition of the Society's Medicines, Ethics and Practice (which will only have been in place for two months or so when it is superseded, because it will be replaced by a new Code on 27th September 2010 when the GPhC takes over pharmacist regulation) provides that "Pharmacist independent prescribers can prescribe any medicine (licensed or unlicensed) with the exception of Controlled Drugs for any clinical condition, but they must only prescribe within their professional and clinical competence".
It is difficult to imagine that the GPhC will adopt a different approach to pharmacist prescribing from 27th September because the GPhC backed away from wholesale reform of the Code of Ethics earlier this year.
Since a breach of the Code of Ethics may be evidence of misconduct, any pharmacist prescribing which falls outside of the pharmacist's "professional and clinical competence" could lead to an investigation by the Society (or the GPhC).
There could be other consequences of prescribing errors, however. For example, if a patient falls ill as a result of a prescription written by a pharmacist then, like a doctor, that pharmacist could be the subject of a claim for damages. The patient would have to show that the pharmacist owed a duty of care to the patient (which would almost certainly be the case), that the pharmacist's actions were negligent (that is, that his actions fell below the standard reasonably to be expected of a reasonably competent pharmacist) and that the patient suffered injury or loss as a result of that failure. Pharmacist prescribers should ensure that their professional indemnity insurance extends to prescribing to avoid facing a potentially costly legal claim.
If a patient were to die as a result of a prescription written by a pharmacist, that pharmacist could also be investigated by the police for manslaughter. It would have to be proved that the pharmacist's actions fell well below those that could be expected of a pharmacist prescriber (this is sometimes referred to as gross negligence or reckless manslaughter), and that the death arose (at least in part) out of that negligence. Experience of manslaughter investigations against pharmacists suggests that such prosecutions are rare.
In conclusion, given the consequences of an error, care should always be taken when prescribing. The pharmacist in this scenario (who refused to prescribe the item despite pressure from the patient) is adopting the wisest course of action.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
