Break confidentiality or not? Please help

[goldenpharm]

Hi, I have a scenario regarding 'breaking patient confidentiality'... i would like to know how this situation should be handled.

'A patient brings in a prescription for herself for Exforge 5/80 and bendroflumethiazide 2.5mg tablets. you note from her PMR that she has not had them prescribed previously, and that her previous prescription was for amlodipine 5mg and valsartan 80mg daily. you dispense the prescription then counsel the patient. during this counselling, the patient tells you that the doctor has changed her prescription as her blood pressure is not being adequately controlled (the doctor says it is very high at '200 over 130). she confesses to you, that she has not been taking either the amlodipine or valsartan as she finds the side effects unacceptable. she is adamant that she does not want the doctor to know she has not been taking her tablets as she thinks that "he will be angry".'

** Would you break the patients confidentiality and make the doctor aware, that the patient was not taking her previous medication... and if she had been doing then her BP would have been adequately controlled?

**Would you dispense the new prescription and advise the patient that she could potentially be harming her health and be puitting her safety ar=t risk if she takes the medication that has ben prescribed on this new prescription? as her BP could fall critically low.

** What should a pharmacist do in the above scenario? I am unsure whether i should break patient confidentiality or not.


Thank you for your help.

[johnep]

Re: Break confidentiality or not? Please help

A sticky one this. Why not do an MUR and find out what the real problem is.
johnep

[goldenpharm]

Re: Break confidentiality or not? Please help

"you dispense the prescription then counsel the patient."

If the prescription has been dispensed.. can you take it back?

An MUR has been dne and u realise that she should take the medication at night rather that in the morning as this will helkp the side effects she is experiencing

I really dont know how to handle this situation...
Would i be breaking the law if i broke confidentiality?

[Linnear]

Re: Break confidentiality or not? Please help

I think the first course of action would be to try to talk the patient into telling the Dr what she has just told you.


If that didn't work, say that the new Rx could be very dangerous and see where she goes with that.


If she's determined to take the new Rx then I think you would have to inform the prescriber.

[goldenpharm]

Re: Break confidentiality or not? Please help

those were my intial thoughts and after looking at rpsgb guidance i found you can break confidentiality where...

"Where necessary to prevent serious injury or damage to the
health of a patient, a third party or to public health.
For example, this situation may arise where a patient that should not be
driving (possibly due to epilepsy, diabetes) continues to do so without
appropriate disclosures."


any thorts??? or difeering suggestions welcome

[Zoggite]

Re: Break confidentiality or not? Please help

Hang on, if you've done an MUR, then surely the patient must have consented to it, and therefore to her GP receiving a copy, on which you have indicated her non-compliance?

[johnep]

Re: Break confidentiality or not? Please help

Yes, lds recently made sure that all pts signed as sometimes forgotten.
johnep

[pharout]

Re: Break confidentiality or not? Please help

First of all, I agree completely with what Linnear said. At this point, it would be important to first of all explain to the pt why it is important to take the med. If her bp is as elevated as she truely describes, she is at definite risk for stroke sooner rather than later. She is in the htn urgency/emergency category with this bp. The number 1 reason people fall into this is that they are non-adherent to medical therapy. The doctor should have known this and questioned this when he saw her (I'm assuming he had previous bps to compare to). I think it is also important to find out "why" the pt didn't tolerate it (e.g. bp dropped too fast and began having dizziness, had headache, peripheral edema?). It is almost always explainable and cause is usually due to one specific agent. This would lead down the road to making a recommendation for an alternative.
Second, if a pt discloses info to you that was not disclosed to the physician and this new info compromises a pt's risk, you are obliged to let the physician know. You would be doing a great disservice if you didn't. I would also not dispense the prescription. If you know it caused problems, it is important to clarify what these were and let the physician make the decision. If you did dispense, then you are medicolegally liable (not sure the physician is since he didn't know).
Third, since I'm from the U.S., could someone explain to me what an MUR is? Medical Utilization Review???
thanks...

[Jeff]

Re: Break confidentiality or not? Please help

Third, since I'm from the U.S., could someone explain to me what an MUR is? Medical Utilization Review???
thanks...

Medicines Use Review, forms to fill in - copy sent to GP - and payment received for doing them.

Idea was to pay community pharmacy for the use of cognitive skills rather than just the supply function - payment requires paperwork - so MUR forms.

My main difficulty is that it's that it's stuff we do by talking to patients anyway.Formalising the process has made it a financial rather than patient or professional imperative.

I can't, however, think of a better way of encouraging payment for cognitive/clinical input.

Jeff

[Zoggite]

Re: Break confidentiality or not? Please help

Pharout,
here is the link [ http://www.psnc.org.uk/uploaded_txt/...%20(final).dot ] to the form we're talking about, so you can see the kind of questions that we ask patients. The pharmacy owner gets £27 (about $50) for every such review we undertake, hence the huge pressure that employers/pharmacy owners put their pharmacists under to complete as many of these reviews as possible, up to a limit of 400/year (limit set by the Govt.).
At present there is no means of controlling the quality of the reviews, only the quantity; this tends to negatively affect their usefulness...

[pharout]

Re: Break confidentiality or not? Please help

Thanks to Jeff and Zoggite for clarifying, pardon my naiveness. This is a great system since it is linked to payment. I wish we had a system like that here. Obviously, since the government is a key stakeholder, there is interest to provide funding. That is the problem here. We have a system, Medwatch, which is great but provides no incentive to report. Everyone knows it is the right thing to do, but everyone also knows that the reported cases (e.g. side effects of meds, etc.) are a gross underestimate. They also do not go directly to the prescriber. Very interesting system and makes perfect sense to me. Thanks for the info.