The Yellow Book

[131131]

Hello,

I've been a Warfarin user for some three years by now, under the care of Salisbury Hospital. Of course I have blood tests regularly as directed by their Anti-coag Clinic, with adjustments to the dosage as they decree from time to time and my use of the drug is reviewed along with my other medication by my GP
However this is not to continue apparently as the Pharmacy I use have started asking to see the book, implying on one occasion that without it dispensing Warfarin would not be possible. This morning I was told that I could have it "on this occasion" without it but that it would not be acceptable in future. When I asked precisely why not, it was suggested that I consult my GP as the idea had been at the request of GPs following "an alarming number of deaths by overdose"
My GP told me later that although it may be advisable, the pharmacy vetting of my dose is not mandatory and it is not empowered to withhold Warfarin on those grounds.
Can anyone anyone tell me the real position?
Incidentally if there truly have been all these deaths, one wonders why the press haven't been raising a hue and cry by now!
Many thanks

[johnep]

Govnmt worried re number of hospital admissions where found warfarin not being taken correctly and some pts not checked. Hence all pharmacists asked to confirm with pts:
1) Have yellow book.
2) Getting blood tests on regular basis.
johnep

[131131]

Thank you johnep
BUT
1. They know I have a book because they've seen it - Surely not necessary to produce it every time?
2. Can they refuse to issue drug??
Thanks

[johnep]

So many times have pts said 'you know my telephone number', and then we cannot recall or find it. Therefore, best option....always show yellow book.
Refusal should only be, if convinced you have no book and have not had tests.
johnep

[roper]

I went to a training evening and came back convinced I should be asking to see the book each time and making my own judgement on the acceptable frequency of testing and confirming suitable range. I guiltily tried it for about a week whilst writing up CPD then found it seemed to offend most patients! That CPPE course seemed irrelevant in the light of patient's unwillingness to share this information in the pharmacy.

[Zoggite]

However this is not to continue apparently as the Pharmacy I use have started asking to see the book, implying on one occasion that without it dispensing Warfarin would not be possible. This morning I was told that I could have it "on this occasion" without it but that it would not be acceptable in future. When I asked precisely why not, it was suggested that I consult my GP as the idea had been at the request of GPs following "an alarming number of deaths by overdose"
My GP told me later that although it may be advisable, the pharmacy vetting of my dose is not mandatory and it is not empowered to withhold Warfarin on those grounds.
Can anyone anyone tell me the real position?

Your Pharmacist was not "Withholding warfarin", he/she was merely following the latest guidance issued by the National Patient Safety Agency:
Community pharmacy plays its part in making anticoagulation therapy safer

We Pharmacists can now be sued for negligence if we have failed to check that the warfarin dose was reasonable.
I have started asking for INR details every time I am supplying Warfarin, and I have encountered some hostility at first, but after explaining to patients the reason for the increased "interrogation", they now all understand and readily provide me with the required information.
There have been highly-publicised cases of pharmacists who have been sued by patients for supplying inadequately high doses of medicines even though the GP's prescription had called for that high dose: the Judge's argument was that the Pharmacist "should have double-checked and questioned the dose"; So we feel like we're damned if we do, and damned if we don't!

I have personally prevented a serious accident thanks to my warfarin checking: a patient was told to take 3mg of warfarin/day, was prescribed 100 warfarin 3mg tablets, and when I asked her how she took them, she said "I take three blue tablets every day, like the nurse said: three milligrammes." I immediately 'phoned her surgery, asked them to book her for a blood test; 2 days later, they told me the results: her INR was 9.8 and she'd had a lucky escape...

[GAZ]

Thank you johnep
BUT
1. They know I have a book because they've seen it - Surely not necessary to produce it every time?
2. Can they refuse to issue drug??
Thanks

they know you've got a yellow book - BUT have they ever asked you if you fully understand it's contents? Have they ever asked you if you know what to do if you miss a dose of warfarin?

The guidelines from the National Patient Safety Agency states that " ensure that before dispensing a (repeat) prescription for anticoagulant medication, they (the pharmacy) check that the patient's INR is being monitored regularly and that it is at a safe level for the repeat prescription to be dispensed. One way of doing this is to ask to see the patient-held INR record..."

this information was sent to EVERY PHARMACY IN ENGLAND & WALES, so every pharmacy should be following BEST DISPENSING PRACTICE and checking details each time they dispense scripts for anticoagulants -
HOW THEY GO ABOUT THIS IS KEY!!! I suspect nobody at the surgery or pharmacy has explained things very well & the pharmacy really shouldn't be going down the path of talking about NOT dispensing your warfarin - if they actually did this they could be in breach of their NHS terms of service -

I would suggest you go in to this pharmacy and ask (AS LOUDLY AS POSSIBLE!!) for a MEDICINE USAGE REVIEW (MUR) with the pharmacist - this will give you an opportunity to sit down with the pharmacist and discuss HOW YOU USE YOUR MEDICATION etc - and talk about your concerns - pharmacist are there to work in your best interest & i'm sure after your MUR you'll understand this!!??


I hope this helps!!??

[bobbin]

When I asked precisely why not, it was suggested that I consult my GP as the idea had been at the request of GPs following "an alarming number of deaths by overdose"

The new guidelines for pharmacists were not produced by GPs.

Warfarin is the most effective drug for the prevention of certain types of dangerous blood clots. Nevertheless, serious bleeding can occur if the INR gets too high, which is most likely if patients are not being monitored closely.

It is interesting that some people seem to be hostile when asked for their yellow book given that the pharmacist is only trying to ensure patient safety.

[hibernia]

It is interesting that some people seem to be hostile when asked for their yellow book given that the pharmacist is only trying to ensure patient safety.

There seems to have been a communication problem. The patient is used to getting their warfarin without any questions, without any yellow book. This has changed so they want to know why. Understandable. Most people are not comfortable with change, even if there is a good reason for it. The patient feels they have enough checking and don't need or want any more.

The explaination doesn't seem to have been very satisfactory and caused the patient to worry that there might be a problem getting supplies in the future.
Biggest problem is that pharmacy and GP said something different and patient is now more confused than ever.
Only thing to do is take a big breath, say "sorry I haven't explained this very well to you. This is what the proceedure will be in the future. Does it cause you a problem? If so how can we, working together, solve this problem?"

Pharmacists and patients aren't perfect. We all have bad days. You just have to try and try again to get it right. It would help if we had some backup from other health professionals who might check with the pharmacy if they aren't aware of the change in advice.

[Pharmanaut]

I always ask if they can bring along there yellow book next time they visit the pharmacy, with the explanation that is so that no-one gets overlooked.
If they haven't got the book we check that they are having regular tests and remind them to advise clinic of any changes in habits or medication including anything purchased themselves including herbal etc.