The public safety risk of expanding pharmacists’ powers to prescribe medicines is under the spotlight as new data reveals one in five people involved in prescription-related incidents suffer serious injury.
Australia’s largest medical indemnity insurer Avant, which analysed 16,000 claims against medical practitioners over five years, is calling on governments to halt expansion of autonomous pharmacist prescribing across the country until a national safety framework is established.
“We need to get some guardrails into place before we go any further,” said Avant’s chief medical officer Steve Robson. “Once we’ve done it, we can’t undo it. It will be too late. This data highlights why it’s so important to get this right.”
The Prescribing and Patient Safety report findings come as prescribing powers for trained pharmacists are expanded nationally, with NSW to trial adding chronic conditions including high blood pressure and chronic obstructive pulmonary disease, and Victoria becoming the first jurisdiction to allow for the resupply of menopause hormone therapy.
The Pharmacy Guild of Australia hit back at Avant’s warning, pointing out the data is based on doctors’ prescribing and claiming it was driven by a long-running turf war.
Queensland president Chris Owen said pharmacists and doctors operate under the same therapeutic guidelines. “If you have the appropriate training, you should be able to practise,” he said. “The level of treatment that I would determine under my scope of practice is quite low risk. Any complications beyond that is a referral point [to a GP].”
The report found prescription-only Section 4 drugs were involved in 81 per cent of prescription-related claims, led by medicines for conditions like depression and schizophrenia. Schedule 8 medicines such as opioids were involved in 36 per cent of cases.
Trained pharmacists can prescribe some Section 4 medicines such as antibiotics, steroids and contraceptives in most states. However, they cannot prescribe more tightly controlled Section 8 drugs – a restriction Owen would like reversed.
Prescribing pharmacists missed cases of cancer, pancreatitis, chlamydia and domestic violence in case studies documented by the Royal Australian College of General Practitioners for a submission to the Pharmacy Board of Australia.
President Michael Wright said GPs and pharmacists should work together, rather than doubling up.
“The concern for me is that we prioritise access to care and forget that safety is core to what we should be prioritising in the health system,” he said. “The person who is best placed to provide a prescription is someone who has an understanding of you and your history.”
Data from the Australian Bureau of Statistics shows 99 per cent of people can access a GP when they need to, but 26 per cent cent have waited longer than they felt was acceptable to get an appointment. Most needed a prescription when they saw a GP.
Refusing to write scripts or reducing dosage was the source of 17 per cent of prescription claims against medical practitioners in the report – but this nearly always proved correct.
The RACGP points to a potential conflict of interest in allowing pharmacists to both prescribe and dispense medicines, arguing there should be financial separation. The guild denies this is an issue, pointing to professional ethics and saying doctors’ surgeries don’t declare financial benefits from follow-up consultations.
Pharmacists who undergo extra training can already treat uncomplicated urinary tract infections (UTI) and issue scripts for the oral contraceptive pill.
In NSW, pharmacists graduating this year will also be able to treat conditions such as nausea and vomiting, hay fever, reflux, acne, musculoskeletal pain and several skin conditions. Victoria has a similar list, plus the resupply of MHT was added this month.
Sydney pharmacist Catherine Bronger described her 18-month university training to prescribe as “exceptionally rigorous” and said patients were grateful to have another option, especially for early treatment of UTIs. “Patient safety is of the utmost importance and we are very protocol-driven,” she said. “We work within the health care system with GPs – not instead of them.”
Robson said the extent of problems with prescribing had come as a surprise. “When we look at the data, even experienced doctors with technology around them get the diagnosis wrong a lot of the time,” he said. “Expecting a poor pharmacist who has none of that to get it right is a bit much.”
The report has been sent to health ministers.
Alix Shanahan, a senior associate specialising in medical negligence at Shine Lawyers, doesn’t anticipate a surge in cases involving prescribing pharmacists.
“No one goes into healthcare with the intent to cause harm, but that doesn’t mean harm doesn’t happen,” she said. “There will always be someone who suffers a delayed or missed diagnosis and it’s something the pharmacist profession will assume responsibility for.”
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