Pharmacy Daily | Board issues warning

PHARMACISTS need to use their professional judgement to deny supply of potentially hazardous medicines and ensure their quality control provisions are fit for purpose, the Pharmacy Board of Australia believes.

Following recommendations from the Coroner's Court of Victoria, the Board launched an analysis of notifications involving oral methotrexate (MTX) in Australia between 2010 and 2019.

The review found 28 notifications involving 26 pharmacists and 23 incidents were made between 01 Jul 2010 and 30 Jun 2019, with seven fatalities recorded and a further nine patients requiring hospital care.

More than half (54%) of the notifications related to dose administration aids being packed with once-daily dosing instead of weekly dosing, with problems with labelling also featuring prominently.

"In reviewing these cases, half of all errors involved a failure in packing or checking of DAAs," the Board said.

"Pharmacists, including proprietors of pharmacies must ask themselves, what quality control provisions are in place to avoid once-weekly MTX being inadvertently packed once-daily?

"Consideration must be given to what solutions could mitigate error in this hazardous process.

"Appropriate labelling of medicines is always important and is even more so for medicines such as MTX with a narrow therapeutic index, which have the possibility to cause lethal toxicity if directions for the patient are absent, ambiguous or incorrect on the primary container."

The Board noted that in two cases pharmacists had failed to gatekeep prescription errors made by prescribers, and dispensed MTX as prescribed.

"While the number of notifications involving oral MTX was relatively low, the outcomes were frequently catastrophic," the Board said.

"Pharmacists need to ensure their own processes and those of the pharmacy where they are practising support them to exercise their professional responsibilities in the safest way possible."