The importance of the pharmacist clinical check

From Mr D. Tyas, MRPharmS

While concluding our Agenda article examining the delegation of accuracy checking in community pharmacy (PJ, 14 January 2012, p45), we noted the dangerous folly that is the trend to use this delegation as a justification not to employ pharmacists sufficiently to keep pace with increasing volumes of prescription workload. 

The crucial importance of the pharmacist clinical check, along with the serious consequences of cutting corners, has been recognised in civil case law, whereby the failure of pharmacists in their duty of care to prevent patient harm have led to judgments of negligence. In cases involving the injurious supply of Migril without intervention concerning the dosage regimen, and that of Daonil without seeking clarification of ambiguity, the pharmacies and pharmacists in question accepted the bulk of the liability, paying more in damages than the respective doctors.¹ The precedent set in the Migril case laid the foundations for the judgment in the dexamethasone case, the content of which Joy Wingfield has described as providing a legal interpretation of the then code of ethics phrase “professionally assessed” (C&D, 14 June 2008, p16), which has now been elaborated on in Royal Pharmaceutical Society guidance on clinical checks (PJ, 25 June 2011, p757). She also explained how that judgment recognises the status of pharmacy procedures, which have now been enshrined in statute by the responsible pharmacist legislation, and which, in accepted practice, require a clinical check to be undertaken by a pharmacist.

The “pivotal” role of pharmacists as a “safety net” in picking up prescribing errors via the clinical check before supply has been acknowledged in the EQUIP study by Dornan et al, which found from 124,260 hospital medication orders that 11,077 such errors were detected by pharmacists alone (PJ, 12 December 2009, p640).

Evidently, even if the issues raised in our article on the delegation of accuracy checking can be addressed satisfactorily, pharmacist resources must be adequate to fulfil our potential to provide pharmaceutical care via meaningful clinical checks. Malone et al found that the risk of preventable errors happening during dispensing increased significantly through factors including pharmacist workload and pharmacy staffing.² Thus, it seems to us that the rate-limiting step with respect to prescription turnover must be the time needed for a pharmacist to perform a meaningful clinical check on each prescribed medicine. As such, and mindful of the need also to allow for the appropriate supervision of medicines supply, for patient counselling, and for the provision of newer consultation services, we call for regulatory standards to be set and enforced with respect to pharmacist workload and to workplace conditions, including staffing.

David Tyas
Chairman, on behalf of the PDA Union Locum Membership Group

The views expressed here are those of the group and do not necessarily reflect those of the Royal Pharmaceutical Society Assembly or national pharmacy boards, on which some group members sit. — EDITOR.

If I may clarify, the preventable errors that are referred to from the study by Malone et al are preventable medical errors — specifically, the potentially clinically important drug–drug interactions of the title of their study. They found that the risk of these prescribing errors being dispensed to patients (and thus slipping undetected and without intervention through the pharmacist clinical check “safety net”) increased significantly through factors including pharmacist workload and pharmacy staffing.

David Tyas

References

1. Mullan K. Writing a wrong. BMJ 1988;297:470–1.
2. Malone DC, AbarcaJ, Skrepnek GH et al. Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug-drug interactions. Medical Care 2007;45:456–62.