Your responsibility to the patient doesn't end when the patient leaves the pharmacy

November 2, 2016

Lessons Learned

A recent hearing tribunal issued its written decision on the merit and orders regarding the conduct of a pharmacist who admitted his failure to properly notify, report, and care for a patient after causing a needlestick injury while administering the patient’s influenza vaccination.

Although the needlestick injury was in itself preventable, the pharmacist failed to properly care for the patient and failed to report the incident to the pharmacy licensee. The pharmacist’s omission to follow-up with the patient, once the patient left the pharmacy, was a significant factor in this matter. The hearing tribunal found that the pharmacist not only placed the patient at risk, but also harmed the integrity of the profession.

In their decision the tribunal stated:

The public and other health care professionals are scrutinizing pharmacy and the relatively new practice of administering injections. They need to know and trust that pharmacists are following practices that put patient safety first.

  • Review your professional responsibilities and ethical duties. Principles 1 and 6 of the Code of Ethics will provide you with valuable guidance in this respect. Also, review your responsibilities with regards to administering injections (see Standards 16 & 17 of the Standards of Practice for Pharmacists and Pharmacy Technicians (SPPPT), and participating in a quality assurance program (see Standards 1.9 & 1.10 of the SPPPT, and Standard 6 of the Standards for the Operation of Licensed Pharmacies).
  • Ensure you are competent and technically proficient in providing pharmacy services, especially for ones you may not provide on a regular basis, such as administering injections. If you don’t provide regular and frequent injection services throughout the year, don’t wait until the start of the influenza vaccine season to hone your skills on the patient. Refresh your injection technique before you provide this service to patients.
  • Ensure that you have, and are familiar with, plans in place when errors and omissions occur. Consider ‘worst case’ scenarios, and plan accordingly. For example, develop and implement a needlestick protocol within your practice before you need to rely on one. Consider using the ACP’s Framework for Mitigating Risk (FMEA) tools to proactively review your practice or the operation of your pharmacy.
  • Actively participate in quality assurance programs. Don’t let fear or professional embarrassment prevent you from fully caring for your patient, nor sharing errors and incidents with other members of your pharmacy team. Acknowledge and share errors and omissions so that you, and others, can better care for your current and future patients.

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