Home' Australian Pharmacist : Australian Pharmacist March 2012 Contents Australian Pharmacist March 2012 I ©Pharmaceutical Society of Australia Ltd. 191
Ethics in day-to-day
By Dr Betty Chaar
At the Pharmacy Australia Congress in
Melbourne late last year, PSA unveiled
the new Code of Ethics for Pharmacists
which replaced the old Code of Conduct.
However, it is one thing to have a Code
tucked away on the shelf or in a filing
cabinet; it is another thing to understand
how it should be applied in professional
practice, especially in a busy stressful
environment. This month Dr Betty Chaar
from the University of Sydney takes the
Code, applies it to the pharmacy setting
and explains how it should underpin day-
to-day activities in pharmacy practice.
Soon after finishing her academic course,
Eva has obtained a position as an intern
in a busy pharmacy, operated as part of a
large chain of pharmacies. She was given
the task of recording the prescriptions in
While processing a prescription one
day, the computer indicated a major
interaction warning. Eva queried the
matter with the pharmacist in charge
who bypassed the warning without any
explanation, other than saying to just 'get
on with it' as the pharmacy was busy at
Similar occurrences happen a number
of times over the next few days. The
manager explained that the warnings
slowed down the dispensing process
and that they never really amounted to
anything significant anyway. They should
therefore be ignored.
Some time after this, Eva ignored a
warning of an interaction between
lithium and ibuprofen, and the dispensed
medicine was 'checked' by a pharmacist
before it was handed out.
The next day, Eva was told that the patient
had been hospitalised with lithium toxicity.
The manager observed that it was not their
problem because the prescriber should
have been more careful. Eva seeks advice
about what she should do.
Several issues can be identified in this
scenario, some more complex and layered
First and foremost is the major issue
of patient safety. The Code of Ethics for
Pharmacists (2011), Statement 1 clearly
'1. A pharmacist recognises the health and
wellbeing of the consumer as their first
Additionally, the first 'Obligations'
A pharmacist must:
1.1 Consider their duty of care to the
consumer first and foremost.
1.2 Utilise expert knowledge and
provide care in a compassionate and
1.3 Recognise consumers who are
particularly vulnerable and tailor the
provision of care accordingly.
1.4 Act to prevent harm to the
Reflecting on some key concepts in this
principle -- 'first priority', 'duty of care'
and 'prevent harm' -- it is concerning that
Eva's preceptor effectively ticks none of
these boxes in his dispensing methods.
His last remark that 'it was not their
problem because the prescriber should
have been more careful' is dismissive and
irresponsible. Not to mention slightly
ignorant. There is precedent at law
where the pharmacist has been accused
at court or found liable for a medicine
mishap, based on the expectation that
pharmacists are gatekeepers of restricted
therapeutic medicines. The literature
is littered with discussions about and
examples of the 'duty to warn' and 'latent
failures'* such as this one, which could
lead to adverse events.1--5
One recent case, discussed in US
Pharmacist, is quite similar to this
scenario.2 The pharmacist in this case3
did the right thing when a warning
appeared on his screen. He notified
the physician of the warning whilst
dispensing, indicating the risk of a drug/
drug interaction between the long-
standing lithium and the newly added
atenolol, and documented the call in
the patient's notes. The physician told
the pharmacist that he had noted the
pharmacist's concerns and promised
to monitor the patient. The patient,
soon after the second dispensing of
atenolol, died of lithium toxicity. That
was in January 2003. The physician had
not monitored the patient as agreed,
and in court denied the pharmacist's
warning. The result was a lengthy court
case in which the pharmacist, accused
of negligence in practice by not warning
the patient and physician, had to prove
his case in court. He had evidence in his
documentation in the patient's notes to
prove he had upheld his duty to warn.
Yet the law suit dragged on for years.
In February 2009, just when the jury
dismissed liability of the pharmacist,
the plaintiff (the deceased's husband)
appealed, instigating another round of
investigation, interrogation and defense.
The similarities of this case to our scenario
with Eva are unnerving. If Eva's patient
succumbs to the lithium toxicity and
dies as a result, there is every chance
the family could take legal action.
Dr Betty Chaar is a Lecturer in Pharmacy
Practice and Professional Ethics at the Faculty
of Pharmacy, The University of Sydney.
*Latent failures refer to less apparent failures in the design of
organisational systems, the environment, or equipment that are
often hidden until they contribute to the occurrence of errors or
allow errors to go unrecognised until they harm patients. Ignoring
warning signs due to workload or lack of care is an example of a
latent failure, and referred to as an 'accident waiting to happen'.
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