Why a pharmacist dispensed a lethal prescription despite her better judgement

Coroner makes recommendations on power balance with doctors
risk-safety

Pharmacists must be empowered with the confidence to refuse to dispense risky prescriptions, a coroner has ruled, after a man died from methotrexate toxicity.

The pharmacist who dispensed the medication had done so against her better judgement after the prescriber insisted during a phone call that the dose was correct.

Ian Gilbert, 77, who had renal issues, died from methotrexate toxicity after taking a 5mg dose daily for a flare-up of his psoriasis.

While unable to explain why she dispensed the drug, the pharmacist said she believed there was a power imbalance between doctors and pharmacists.

Coroner Rosemary Carlin recommended the PSA and Pharmacy Board set up an advice service to “embolden” pharmacists when there is conflict with a doctor.

She found that the pharmacist gave the GP too much respect “or at least lost sight of her role as an independent safeguard against inappropriate prescribing”.

One of the purposes of the inquest into Mr Gilbert’s death was to determine how pharmacists could be “empowered” to observe their professional obligations.

“In my view, the single most effective measure would be a professional advice service.

“Such a service could … be staffed by senior pharmacists who volunteer to receive calls on a rotational basis.”

The pharmacist, who has 35 years’ experience, initially adjusted the instructions on the label before rethinking her decision and changing them back.

While she completed a clinical intervention form, the coroner found simply filing it away for later use missed an opportunity to avert disaster in the first place.

In this case, she could have provided a copy to Dr Lim or given a copy to the patient’s two daughters, who had presented with the prescription.

Mr Carlin recommended the PSA review clinical intervention guidelines and consider when it would be appropriate for pharmacists to provide a copy to the prescriber or other people.

“Faced with a document outlining [the pharmacist’s] concerns, it is possible Dr Lim may have sought to recall his prescription and/or Mr Gilbert’s daughters may have sought alternative advice.”

Ms Carlin rejected a pharmacy expert’s opinion that another pharmacy may have dispensed the medication if the pharmacist had refused to supply it.

The daughters would have been unlikely to go to another pharmacy if the pharmacist explained why she wouldn’t dispense the prescription.

“In any case… I see nothing preventing the pharmacist from noting on the prescription he or she had refused to dispense it and why.”

The pharmacy expert concluded the pharmacist should have told Mr Gilbert’s daughters she was holding the prescription while she conducted more research.

Armed with new information she could have been more “forceful” in her dealings with the GP, the coroner noted.

Pharmacists on standby to help with doctor conflicts.