Close Up on Complaints: Taking Appropiate Care When Handling Opioid Prescriptions
“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
This incident occurred when a patient visited the pharmacy with a prescription, containing only a stamped signature, for fentanyl 100 mcg/hr patches, once daily, 30 as needed for a 30 day supply*. The patient presented an empty box of fentanyl patches, labelled and dispensed by another pharmacy. The pharmacist reported that he checked the old label with the patient’s name on his health card and checked the name of the physician who prescribed the medication previously and noticed it was the same physician.
As it was the patient’s first time at the pharmacy, and it was a narcotic prescription, the pharmacist gave the patient a couple of patches and said he would have to verify the prescription with the physician before dispensing more. The pharmacist said that he phoned the physician’s office and asked to speak with the physician, although there was no documentation or record of the phone call. The receptionist put him on hold and then an individual answered and confirmed the prescription when asked. The pharmacist dispensed the prescription as written.
It was subsequently discovered that the individual who answered the phone was not the physician, but rather a member of the physician’s staff. It was also confirmed that the patient in question was not a patient of the physician whose name was on the prescription and that the prescription was, in fact, a forgery.
Why Did This Happen?
This incident illustrates a lack of appropriate care with a narcotic prescription.
The prescription as presented was for the highest possible strength for fentanyl patches and was from a new patient unknown to the pharmacy. The dose specified, 100mcg once daily, was not therapeutically appropriate. The prescription did not have an authentic signature, a necessary component for a valid prescription. These are all significant red flags, or issues of concern, that the pharmacist failed to notice or address.
Complaint Outcome
The College’s Inquiries, Complaints & Reports Committee (ICRC) 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 significant concerns with the pharmacist’s practice in relation to this prescription. The pharmacist dispensed a forged prescription that did not make therapeutic sense. While the pharmacist stated that he telephoned the physician’s office and verified the prescription, he failed to document it, making it impossible to verify that this occurred.
The pharmacist was also the pharmacy’s Designated Manager. Designated Managers have additional obligations to ensure that the pharmacy’s procedures in filling narcotics prescriptions are appropriate, comply with all relevant policies and legislation, and are fully in place at the pharmacy.
ORAL CAUTIONS
An oral caution is issued as a remedial measure for serious matters where a referral to the Discipline Committee would not be appropriate. Oral cautions require the pharmacy professional to meet with the ICRC in person for a face-to-face discussion about their practice and the changes they will make that will help avoid a similar incident from occurring in the future.
REMEDIAL TRAINING (SCERPS)
A SCERP is ordered when a serious care or conduct concern requiring a pharmacist or pharmacy technician to upgrade his or her skills has been identified. The ICRC orders SCERPs when they believe that remediation is necessary.
For all complaints filed after April 1, 2015, the College posts a summary of the oral caution and/or SCERP and its date on the “Find a Pharmacy or Pharmacy Professional” tool.
The Panel noted that the pharmacist failed to effectively implement these requirements in his pharmacy and, in his response to the College’s investigation, did not provide details on the changes he would make as result of this incident.
Due to the seriousness of the incident, the panel ordered that the pharmacist appear in person to receive an oral caution, and that he complete remedial training — a specified continuing education or remediation program (SCERP) – on pharmacy management as well as review the College’s resources on narcotics dispensing.
Learnings for Pharmacy Professionals
Pharmacy professionals must comply with all legal requirements and ethical principles of practice, including federal and provincial legislation, regulations, by-laws, Standards of Practice, policies and guidelines. It is a basic tenet that pharmacists ensure that prescriptions received are complete, authentic and appropriate.
Pharmacists should take a systematic approach to screening prescriptions before filling, such as checking the dose, frequency, and the indications for drug use. In this case, a therapeutic assessment would have identified that the prescription was not appropriate for the patient, thus raising a red flag for the pharmacist. Speaking with and observing the patient may also provide clues suggesting a fraudulent prescription. As per the College’s Fact Sheet: Identifying Forgeries and Fraudulent Prescriptions, considerations can revolve around four key areas: the patient (e.g. their behavior, their medication history), the prescriber (e.g. familiarity with them and their practice), the prescription (e.g. alterations or errors, appropriate for indication) and the situation (e.g. patient in a hurry).
When assessing any prescription, if a pharmacist is unsure of either its authenticity or appropriateness, it is their responsibility to confirm the prescription with the prescriber (see the College’s position statement on Authenticity of Prescriptions using Unique Identifiers for Prescribers).
Additionally, the Standards of Practice require that pharmacists document their decisions and actions, including rationale for making any decisions and all communication of relevant patient care information to a patient’s healthcare providers (such as confirming the authenticity of a prescription).
Learnings for Designated Managers
Designated Managers must ensure that systems and training are in place at the pharmacy to support the verification of the authenticity and appropriateness of prescriptions prior to dispensing. Staff members must also be appropriately trained on the steps to be taken when they identify a forged or suspect prescription.
Under the Narcotic Control Regulations, any thefts, losses or forgeries of controlled substances must be reported to the Office of Controlled Substances no later than 10 days after its discovery. Reporting a forgery is the same as reporting a loss with one exception: a forgery must be reported even if the forged prescription was not filled.
Appropriate narcotic dispensing goes hand in hand with appropriate narcotic inventory management and staff training. Designated Managers must ensure that they are regularly engaging in narcotic inventory counts and narcotic reconciliations to identify any shortages or other issues, as per the College’s Medication Procurement and Inventory Management Policy. As with any medication incident, the Designated Manager should use an incident of prescription forgery as an opportunity for staff discussion, with the goal of sharing learnings and identifying possible changes to systems, policies or procedures.
Putting Patient Safety First
Pharmacy professionals are entrusted to appropriately procure, manage and dispense narcotics and other controlled substances for use in patient care. Accordingly, they must use their medication expertise, knowledge and skills to support appropriate use and access as well as engage with other healthcare professionals to care for their patients.
In line with the Code of Ethics, and especially with the ongoing opioid crisis, pharmacists and pharmacy technicians must recognize that they have a professional responsibility to identify and implement ways they can help decrease the harm that opioids are doing to their patients, community and society.
