Home' Australian Pharmacist : Australian Pharmacist April 2013 Contents 6
Australian Pharmacist April 2013 I ©Pharmaceutical Society of Australia Ltd.
The HMR program
Accredited pharmacists have recently endured
the trauma of a possible suspension of the HMR
program which, fortunately, the Minister did not
concur with. The following case underscores the
essential societal benefit that patients derive
from a medication review. In my opinion it also
highlights why reviews conducted in a doctor's
surgery are, for many patients, an example
of best practice, in line with the medical
application of beneficence.
I visited Mrs TS, aged 77 years at 10am a
few weeks ago. She had a current history
of congestive cardiac failure, GORD,
ischaemic heart disease, depression,
osteoarthritis, vitamin D deficiency, and a past
history of pulmonary embolism. She was taking:
• warfarin 2.5mg nocte
• Efexor 37.5mg mane
• Lanoxin PG 1 mane
• Lasix 40mg 1 mane
• Micardis 80mg 1 mane
• Nexium 20mg 1 mane
• Osteovit D liquid, 2ml on Monday
• Panamax 500mg 2 tds
• Tenormin 50mg 1 mane
• Zocor 10mg 1 nocte
• Lexatan 6mg ½ prn for anxiety.
Her medications were prepared by her
daughter on a weekly basis in a Dossette tray
and all had been taken.
Her Vitamin D = 54nmol/L and triglycerides
= 2.4mmol/L. Her TSH, eGFR, iron studies, folate,
B12 and magnesium were unremarkable. No
digoxin level was supplied though she had no
classical symptoms of digoxin excess (fatigue,
blurred vision, change in colour vision, anorexia,
nausea, vomiting, diarrhoea, abdominal pain,
headache, dizziness, confusion, delirium.)
During the course of the interview I asked about
her blood pressure (BP). She had a monitor and
showed me how she used it. Her technique was
wrong, with the microphone in the cuff being
placed on the outside of the upper arm, away
from the brachial artery.
After correcting this I took a reading. It was
207/126, HR = 66. I continued on with the
interview then rechecked it after five minutes:
212/110, HR = 65. At this point I placed a call to
her GP. I explained the situation to the secretary,
including the readings. The GP could not be
disturbed as he was involved in an important
family conference, but I was told that he would
call back. Concerned that the monitor might be
faulty I took my BP as a control -- the machine
was accurate. After another 15 minutes I called
the surgery again but received the same reply.
Knowing that this was a serious hypertensive
issue I texted my daughter, a HMO in
Melbourne. She confirmed that attendance at
the emergency department (ED) was the best
option, as a haemorrhagic stroke could occur.
Simultaneously another family member was
organising transport to Royal North Shore for
Mrs TS via another sibling. Further readings
for Mrs TS were 223/144 HR = 67 and 225/129,
HR = 72. This last reading was accompanied by
slight chest pain.
An ED review showed she was negative
for troponins and had a normal ECG with
sinus rhythm. Her BP was 196/110. She was
discharged four days later, with digoxin
ceased, Micardis changed to Micardis Plus
80/12.5mg, and Tenormin 50mg replaced with
metoprolol 50mg 1 bd.
In my view this case highlights two
1. The earlier proposed moratorium on HMRs
might have cost this lady her life, or at least,
left her severely disabled due to a stroke.
2. The unavoidable delay in speaking with
the patient's doctor would not have
arisen in a medical practice, based upon
my experience. Another GP would have
promptly seen the patient and organised
all necessary interventions. Importantly,
patient anxiety would have been assuaged.
It is to be hoped that if there is any refining
of the current HMR model, surgery based
reviews -- where it is the patient's wish --
will continue, and without a diminution in
Consultant Pharmacist, Baulkham Hills, NSW.
Berating Bridget is not the
Betty Chaar's analysis of the ethical situation
facing Bridget after being directed by her
employer not to talk to patients or doctors
about their medication is excellent.
I would like to make some other observations
about the matter.
Many of the pharmacy profession's practice
standards and guidelines are very specific
that it is a pharmacist's professional duty,
when dispensing prescriptions, to resolve
any concerns for the patient's safety --
including consulting with the prescribing
doctor -- and ensuring that the patient
understand how the medicine should be
used safely and properly, in order to achieve
the desired therapeutic outcome. It is not
necessary to enumerate them all here.
If Bridget was to obey this direction from her
employer to practise in this way, such conduct
would clearly fall under the definition of
unprofessional conduct, or even professional
misconduct if done more than once, as set out
in the Health Practitioner Regulation National
When discovered, Bridget would be liable to
the penalties in that law. She cannot claim
that she had to follow the direction of her
employer, for the employer cannot lawfully
issue such a direction.
Further, any employer who issues a direction
to not practice in accordance with accepted
standards would almost certainly be regarded
as directing or inciting a pharmacist to do
something that amounts to unprofessional
conduct or professional misconduct, for which
there are substantial penalties [up to $30,000
for an individual].
Bridget would also have to consider whether,
by issuing such a direction, the employer
might be placing the public at risk of
harm because s/he caused the staff at the
pharmacy to practise in a way that constitutes
a significant departure from accepted
professional standards. This is how notifiable
conduct is defined in the national law.
If Bridget reasonably forms the belief that such
notifiable conduct had occurred, she would be
required to notify the national agency 'as soon
Indeed the national law makes it an offence
for Bridget not to notify the Agency, and if it is
discovered by the Agency that she has been
derelict in this duty, she can be dealt with by it!
The national law has been framed in this
way to make it clear to health practitioners
that they are all, individually and personally,
responsible to take reasonable steps to
ensure unprofessional conduct or professional
misconduct is dealt with promptly and
effectively, so that harm to the public does
Bridget faces the ethical dilemmas outlined by
Ms Chaar as well as the legal duties outlined
above. Let us hope she has the intestinal
fortitude to deal with them all responsibly.
Links Archive Australian Pharmacist March 2013 Australian Pharmacist May 2013 Navigation Previous Page Next Page