Emergency supply

[confused.com]

I would like advice on the following situation and as to how to proceed with it. A patient came in for an emergency supply of Nystatin on friday evening for a new born baby. I was assured that the baby had recieved this medication from the hospital which had ran out, the community midwife had requested to put a new prescription in at the surgery for Nystatin, however the parent had failed to get the prescription as the surgery had closed at 6pm. The parent came in to the pharmacy for an emergency supply of Nystatin and assured me that the prescription had been written out for the baby, however I recieved a call from the babys GP saying it was illegal for me to do this. That the Nystatin is not suitable for the baby and that the medication was not suitable for the baby and that there will be a complaint put in. As far as i was aware i completed my legal obligation, by giving the Nystatin. The parent had brought in a previous Nystatin bottle that was given to the baby at the hospital only a few days ago.

Basically, my thought process at that time was that the baby had recieved the medication before from the hospital and that there was a prescription for nystatin waiting for me to collect the prescrption on monday, and that this baby needed this medication to cover him for the weekend. Therefore were my actions right in giving the parent the medication or was this wrong?

[admin]

Personally, I don't think you've done anything wrong here. What did the GP say when you told him the hospital and midwife were prescribing this for the baby? You were in a no win situation (the usual) and you had the babies best interests in your mind.

To cover yourself, I'd try to speak to the hospital Dr who prescribed it, ring the company and find out the exact age this is licensed for, and call the PDA just in case.

[crit care]

i dont see a problem with that...although you would have to question how a bottle of nystatin could run out after only a few days..30ml bottle, assuming an adult dose is 1ml qds..thats a 7day supply...

you say midwife had requested a prescription...that mean she was the one writing it, or was asking the dr to generate a prescription? if the latter is the case, it might be that the GP wasn't happy to sign off a rx for the nystatin for whatever reason.

If the nystatin wasn't licensed in this baby, then it is the prescribing dr taking responsibility

[lamzee]

Why is nystatin not suitable?????? I dispense it for small tots all the time .

[Nik]

Used frequently in paeds. However stumbling block may be that it's not licensed for treatment in neonates (miconazole isn't licensed for under 4 months also). In hospital docs will likely go ahead anyway as it's generally a safe drug, used locally and has topical effect. GP prob didn't want responsibility of unlicensed indication.

[johnep]

This is a new one. Believe MEP used to refer to a previous script issued by Dr licensed in UK. Some hospital Drs may not be licensed to prescribe outside of the hospital. The pt should have been referred back to the hospital. Anyway, if just oral thrush not really desperately urgent.. although would be to mother.
Need an opinion from GPhC on legality of emergency supply against hospital previously prescribing. Few meds actually licensed for new borns.. would you allow your precious bundle to take part in a double blind trial?
johnep

[bobbin]

I think you did what you thought was in the best interests of the baby, and I suspect that it was. I'm sure that no harm will come of it,.

Personally, I wouldn't do any emergency supplies for newborns. I can't really think of a situation in which it would be wise to do so. I would refer to the out-of-hours doctor if a prescription was necessary. In other cases I would suggest waiting until Monday morning. I think you have to be extremely cautious when supplying medication to babies.

In order for an emergency supply to be legal there needs to be... a) an immediate need for the medication and b) it must be impractical to obtain a prescription without undue delay. In this case, I doubt that the requirement for nystatin was urgent. Also, if the baby had already been treated with one bottle without effect they would need to be reviewed by a doctor, which could have been arranged out-of-hours if the child was unwell.

If medication is to be loaned, you need to be very sure that you are actually going to receive a prescription. If there is uncertainly surrounding who is going to be prescribing or whether you are really going to be getting a script, loaning meds is not a good idea. If the midwife had contacted you to say that she would be writing a prescription, it would be different. Some doctors do not like to be told what to prescribe, which I suspect is part of the problem here. It is not good for their egos. If I were you, I would now be speaking to the midwife to get a prescription.

[hibernia]

Therefore were my actions right in giving the parent the medication or was this wrong?

It was a judgement call, the kind we have to make every day, under pressure without support or backup. It isn't right or wrong, black or white just shades of grey.

If we are going to refer every case that require making a judgement back to the doctor or the hospital or the out of hours service then there is no need for pharmacist, a well trained dispenser can do the others. If we are ever to make a decision we have to do so in the knowledge that sometimes we will get it wrong and sometimes those wrong decisions could have very serious consequences, although I find it hard to imagine what harm a parent could do to a baby with a bottle of nystatin.

You did what you thought was best, given the information you had available at the time. You had no reason to doubt the mother's word. If it makes you feel better I would have done exactly the same. Oral thrush may make it difficult for a baby to feed so it is serious and urgent.
If the doctor wants to make a song and dance about the legalities of situation it might be no harm to land any script he writes that doesn't have every i dotted and t crossed right back on his desk until he wises up.

[bobbin]

If we are going to refer every case that require making a judgement back to the doctor or the hospital or the out of hours service then there is no need for pharmacist

You are right, I just think you have to be extra careful with newborns. For example, they'd already used one bottle and it hadn't worked, perhaps something else was wrong rather than (or as well as) thrush? On the other hand, you can't really go wrong with nystatin because it's very well tolerated. Maybe I tend to be overcautious with babies. I would support whatever decision a pharmacist came to in this situation because it's not black and white, as you say.

It would be better if pharmacists could just write a prescription in these cases, rather than worrying about emergency supplies.

[El-loco]

I doubt very much that the baby will come to any harm. I am accredited to supply nystatin suspension under a PGD on a minor ailment scheme and the only problem I can see is that the baby had received it before and it has not worked. It is then essential that the baby be referred to the G.P. (or hospital) to determine the underlying cause.

Sounds as if the G.P. is being a PITA about it though.