1. Problem 1 Who decides what is an emergency? Lecture No : 11, 10/04/2011 Smitha C Francis

2. Introduction In the past, supply of Prescription only medications (POM) by pharmacists– criminal offence. Late 1970s, ‘Emergency Supply Provisions’ under the Medicines Act- urgent supply may be made. Minimum conditions for an ‘emergency supply’. Code of Ethics- pharmacists must use their knowledge for the well-being and safety of patients and the public.

3. Scenario The weekend visit of the mother who has diabetes Mrs Fraser comes into your pharmacy on Saturday afternoon and says that her mother, who has diabetes and is frail, is at Mrs. Fraser’s home in a difficult situation. Her mother has come to stay for the weekend and forgot to pack her tablets. Mrs. Fraser has tried ringing her own local hospital but could get no reply. What can you do to help?

4. Issues to consider Criteria for making an ‘emergency supply’. Restrictions on the supply of POM. Principles of negligence. Key responsibilities of a pharmacist in the Code of Ethics. Limits of vicarious liability Therapeutics: Management of diabetes. Good practice: use of patient medication records.

5. Stages 1. Gather relevant facts. 2. Prioritize and ascribe values. 3. Generate options. 4. Choose an option

6. Stage 1: Gather relevant facts Establish the name and other details of the medicine(s) being taken by Mrs Fraser’s mother. Move to decision making. Laws applicable here. Guidance by Code of Ethics here. Professional knowledge of information provider here. Where to look and ask for help?

7. Laws applicable Criminal, NHS,Civil. Criminal law – POM may only be supplied against the written authority of a medical practitioner. Interview the requestor regarding: - immediate need of POM. - impracticable to obtain a prescription? - the medicine had been prescribed by a doctor registered in the country, before? - Details of dose to be taken are established.

8. The problem here is whether you, as the supplying pharmacist, are satisfied that there is an ‘immediate need’ and that it is impracticable to obtain. To assess this, more information on Mrs Fraser’s mother’s condition and treatment and the local arrangements for contacting a doctor are needed. Patient can be personally interviewed – medication, previous prescription and dose.

9. NHS law Permits urgent supply of POM medicines to be made provided the provisions of the Medicines Act are met. ‘Emergency supply’ – one can sell or supply POM without the authority of a prescription, subject to all the legal requirements. NHS patients – free medications. So can you ask for payment that is refundable when a NHS prescription is presented later? Yes. The question of payment is entirely up to you. ‘Emergency supply’ provisions are intended for isolated circumstances not for regular ones (repeat prescriptions) and one may give a maximum of five days’ supply in most cases.

10. Civil law Consequences of supplying and not supplying the medication. ‘What a reasonably competent pharmacist’ will do here? If you supply- liability for correct identification, right strength and dose and advise as to what further action Mrs Fraser need to take. If you do not supply – liable for any adverse consequences to both mother and daughter. Principle of negligence- action or inaction is reasonable or not.

11. Guidance by Code of Ethics Your key responsibility is to use your knowledge for the wellbeing and safety of Mrs Fraser’s mother. Is this an emergency? If so, standard 15 of the Code:- Civil law- you should consider the medical consequences of not supplying the medication.

12. Royal Pharmaceutical Society’s Guidelines 1.The pharmacist should consider the medical consequences of not supplying a medicine in an emergency. 2.If the pharmacist is unable to make an emergency supply of a medicine the pharmacist should advise the patient how to obtain essential medical care.

13. Professional knowledge Academic knowledge of diabetes and its management. Substitute medicines – not POM / dietary advice sufficient? Length of stay of Mrs. Fraser’s mother- arrangement for a prescription to be obtained after five days. Age of patient, mobility, transport arrangements for patient- availability of local doctors Above factors- help in deciding ‘immediate need?’ and whether ‘impracticable’ to obtain an authorizing prescription.

14. Where to look and ask for help? Annual MEP guide published by RPSGB. All pharmacies – patient medication records. Telephone Mrs. Fraser’s mother’s pharmacy. (location of patient’s details –confirm) Empty bottle, repeat medication card, repeat slip etc..? Try to contact her doctor, verify treatment with the medication records Out of hours GP service- whether supply can be authorized by prescription? …’emergency supply at the request of a doctor’ which can be possible with a prescription provided within 72 hours.

15. Stage 2: Prioritise and ascribe values Patient - whether it is in the interest of the patient to make the supply and deciding that it is Patient’s relatives, carers and contacts- Mrs Fraser Other HC professionals, your profession-steps to involve a medical practitioner / your authority to use ‘emergency supply’ provisions. Employer- emergency supply provision, individual pharmacist is responsible, your professional judgement Yourself – diabetes – continuous medication control, no moral or cultural concern

16. Stage 3: Generate Options What could you do? 1.Do not make the supply – Mrs. Fraser’s mother hyperglycemic and seriously ill. Action of a responsible pharmacist??? 2.Do not make the supply and suggest further action -defensible if you can locate a doctor who would provide prescription, but that prescription would have to be dispensed somewhere (unless doctor supplies). So consider local arrangements for dispensing. If the patient has another medication?? Here no.

17. 3. Make the supply in accordance with the ‘emergency supply’ provisions. 4. Contact a doctor and make an emergency supply on his instructions- if you can contact one. 5. Delay to seek advice -unlikely to be helpful unless the advice you seek is immediately to hand. 6. Refer to accident and emergency department or walk-in centre - relatively new option which may be possible.

18. Stage 4: Choose an option What should you do? 3- Make the supply in accordance with the ‘emergency supply’ provisions. Best option, defensible in the interests of the patient. Person requesting the medicine should be contacted. Conduct the interview over telephone.( make sure the person was Mrs. Fraser’s mother.) Or offer to deliver the medicine personally and conduct the interview with Mrs Fraser’s mother at home.

19. Challenges- RPSGB’s inspector, your own staff, other pharmacists, GP who looks after Mrs. Fraser’s mother?? Make a written record of the details including a note on the ‘nature of the emergency’. (Defence) Circumstances that led to your decision. (time of day, nature of the patient’s condition, questions you asked, facts you established)

20. All these will justify your professional judgment that giving a limited quantity of the patient’s oral antidiabetic tablets was the right thing to do. CONCLUSION