what would you have done?

[Smithy]

fact --- 18 week pregnant lady goes to gp with constipation

gp for some unknown reason prescribes lactulose and cyclophosphamide

lady goes to pharamacy and pharmacist comes out an says "we dont keep these tablets in stock we can get them for tomorrow"

lady goes back and gets tablets and takes them for constipation-- after day or two stops tablets as lactulose has worked.

i am trying to establish if the pharmacist on the clapham bus would have queried this medication.

i do not know if pil was given out or not

as this is a genuine case please keep confidential

[Jeff]

Re: what would you have done?

i am trying to establish if the pharmacist on the clapham bus would have queried this medication.

i do not know if pil was given out or not

as this is a genuine case please keep confidential

Was the pharmacist aware that the patient was pregnant?

If it's confidential should it be on a public forum?

Jeff

[Pharmanaut]

Re: what would you have done?

Was the pharmacist aware that the patient was pregnant?

If it's confidential should it be on a public forum?

Jeff

Apart from confidentiality...
Is the patient a regular at that pharmacy...
Was there a drug history of previous treatment with cyclophosphamide on the PMR?

[Smithy]

Re: what would you have done?

justr trying to establish what colleagues think they would have done

is this a public forum in that sense of the word??

I do not know if the pharmacist was aware that the patient was pregnant

she was in early thirtys -- all i want to know is if this should have raised concerns in the mind of the pharmacist

[Jeff]

Re: what would you have done?

justr trying to establish what colleagues think they would have done

Depends on how busy I was at the time and how familiar I was with the dispensary etc.
I'd like to think I'd have questioned it, but who knows.

is this a public forum in that sense of the word??

Anyone can see what has been posted here - it's is in no way private.

I do not know if the pharmacist was aware that the patient was pregnant she was in early thirtys -- all i want to know is if this should have raised concerns in the mind of the pharmacist

Should have - certainly. Not sure why it would be prescribed in a primary care setting.
Would have - depends on workload and levels of distraction.

Jeff

[Jeff]

Re: what would you have done?

Was there a drug history of previous treatment with cyclophosphamide on the PMR?

Dangerous trap - even if there was - should it be repeated?

"Prescriptions should not be repeated except on the instructions of a specialist."
eBNF 8.1 Cytotoxic drugs

I'd like to see what warnings (if any) flash up on PMR systems.

Jeff

[johnep]

Re: what would you have done?

Repeats was the cause of the prescibing of mephalan resulting in death, by the head of dispensing drs organisation. He got a slap on the wrist. If the script had been dispensed by a pharmacist????
johnep

[Pharmanaut]

Re: what would you have done?

Dangerous trap - even if there was - should it be repeated?

"Prescriptions should not be repeated except on the instructions of a specialist."
eBNF 8.1 Cytotoxic drugs

I'd like to see what warnings (if any) flash up on PMR systems.

Jeff

Agreed, but its a start.
Cegedims Pharmacy Manager puts up a warning about cytotoxics, I'll see if cyclophosphamide is covered.

[Smithy]

Re: what would you have done?

just to clarify a point

it was not the intention of the gp to prescribe the cyclophos he/she messed up the script.
so it follows that the patient had no cytotoxics on record--

issues that arise are --- should all systems have a red alert like the one for methotrexate? what would liability be? etc cregedim does not have one as far as i can see.

thanks for all the feed back much of it is what my first thoughts were ie a lot depends on the circumstances etc etc and, as always, hindsight is a great thing.

[Jeff]

Re: what would you have done?

Repeats was the cause of the prescibing of mephalan resulting in death, by the head of dispensing drs organisation. He got a slap on the wrist. If the script had been dispensed by a pharmacist????
johnep

Similar thing happened in Yorkshire a few years ago, a vartiety of GP's at one surgery repeated scripts for a cytotoxic a variety of locum pharmacists dispensed it.
AFAIK no action as meaningful as Dr Roberts "slap the wrists" took place.

Jeff

[Jeff]

Re: what would you have done?

issues that arise are --- should all systems have a red alert like the one for methotrexate?

Yes - but I doubt that they do. Can we make representations to the PMR and GP systems manufacturers ? Has the incident been reported to the NPSA?
National Patient Safety Agency | Patient Safety Division,National Patient Safety Agency,WWW service eForm,Report An Incident

what would liability be?

Go directly to your insurer - do not pass go - do not collect £200. And above all don't admit liability without professional advice.

Jeff

[Pharmanaut]

Re: what would you have done?

just to clarify a point

it was not the intention of the gp to prescribe the cyclophos he/she messed up the script.
so it follows that the patient had no cytotoxics on record--

issues that arise are --- should all systems have a red alert like the one for methotrexate? what would liability be? etc cregedim does not have one as far as i can see.

thanks for all the feed back much of it is what my first thoughts were ie a lot depends on the circumstances etc etc and, as always, hindsight is a great thing.

Here's the warning from Cegedims Pharmacy Manager.
It is displayed in the message box but does not pop up like the NPSA alert does for methotrexate.

"Caution: Preparation with specialised/in-patient use. Take appropriate steps to ensure that it is still required and the dosage regimen is correct, especially on repeat prescriptions."

I guess everything could have one pop-up warning or another so we would soon start to ignore them anyway, especially if they fire up a dozen or so for each dispensed item.
How can we make them only alert us when it is appropriate?

The one for Methotrexate must be acknowledged or the system will not let you proceed at all. This is in line with the NPSA guidelines. Here's the cegedim Pharmacy Manager one...

"ALERT:Methotrexate is usually prescribed WEEKLY and requires regular monitoring and blood tests.

Repeat Prescription Pattern - check scripts are being presented at intervals consistent with weekly usage.

Check correct strength and regimen, that treatment is still required and that patient understands.

Ask to see patients blood monitoring and dosage record book. If patient does not have one communicate this to prescriber or clinic."

Sorry if I'm labouring this, but it is worrying me; when more prescriptions come in via EPSR1 and EPSR2 which puts us under even more pressure to keep up with the computer to do the ever increasing number of prescriptions around these days.....

[howe928]

Re: what would you have done?

Similar thing happened in Yorkshire a few years ago, a vartiety of GP's at one surgery repeated scripts for a cytotoxic a variety of locum pharmacists dispensed it.
AFAIK no action as meaningful as Dr Roberts "slap the wrists" took place.

Jeff

ask any pharmacists what they would do when checking for a script for repeat medications, most of the time, if it is repeat, go ahead, ignore all the warnings. it is very time consuming to check all interactions by referring to BNF especially if a pharmacist start practising in a new busy pharmacy


for the case above: was it a call back? if it was pharmacist might not know she is pregnant. some pharmacists might assume it has been checked by doctor or it is from hospital, if an inspector go and check pharmacy intervention record, quite a lot of them cannot be found because not recorded (another time consuming things that was not possible when dispensing by volume still the norm unless working overtime not getting paid to make record entry)