Set rules early
The provision of medicines via a staged supply process is common practice in many pharmacies. While the benefits are apparent for the patient, prescribers and pharmacies, there are also challenges for pharmacists responsible for managing the supply process. These challenges may be prevented or better managed through the use of good procedures and clear communication.
Reports to the PDL Professional Officers highlight several common themes and this article will raise these issues and provide some suggestions to assist members. Those issues include:
- Request for early supply of the medicine
- Unclear or inconsistent instructions from the prescriber
- Request to supply to a third party
- Allegations of mismanagement of the remaining stock on hand
- Financial difficulties for the patient
- Questions regarding termination of a staged supply agreement
A request from the patient for supply before the due date is the most common staged supply enquiry received at PDL. We suggest that patients be provided with a very clear understanding of the prescriber’s directions, including the supply interval. It should be emphasised that these directions are like any other prescription and that changes can only be made following the prescriber’s endorsement. It should be agreed that it’s the patient’s responsibility to contact the prescriber and seek approval for any change to the prescription. The procedure required to allow early supply should be documented in the staged supply agreement and patient’s agreement can be used to reiterate this arrangement when challenges arise. PDL is aware that patients will often use intimidation or implied threats to their health when seeking early supply. Often this occurs after-hours or on weekends when weekday staff such as the Pharmacist-in-charge are unavailable. While this situation is confronting for some pharmacists, a consistent professional approach to staged supply must be applied by all pharmacists to prevent inappropriate supply or a precedent that can be used to manipulate other pharmacists.
Some prescribers are unaware of the logistics of the staged supply process and the prescription details can be less than ideal. PDL suggests it is valuable for the prescriber and the pharmacy to agree on a process for ordering and maintaining staged supply medicines for their patients. Clear directions including intervals are essential. A letter from the prescriber accompanying the prescription may provide for variations for certain patients and allow the pharmacy some flexibility for situations such as public holidays and weekends. These variations would be similar to the direction provided by prescribers of opioid-replacement therapy and are equally valid for any staged supply patient. Other actions could include sending a copy of the agreement form to the prescriber for their records. This documentation is particularly valuable for other doctors dealing with a staged supply patient when the prescriber is unavailable. Providing the patient with a reminder for a new prescription with an indication of the remaining supply will also prevent last minute demands for medicine.
It is not unheard of for a third party to attend the pharmacy seeking supply of the medicine on behalf of the client. This may be reasonable if the client has difficulties with mobility, transport or general health. However, there is also risk of supply under false pretences. Pharmacists often supply medicines to agents of the client. However greater vigilance may be required for medicines that can be misused or diverted. PDL would recommend that notification of approved third parties be included in the original staged supply agreement. Furthermore, an agreed means to confirm the validity of the request should be put in place at the beginning of the arrangement. This could entail listing all approved third parties or a copy of the client’s signature kept on hand to verify any written request for third party supply. Alternatively, supply only following phone confirmation is logical and easy to manage. In the case of some doubt, supply of a minimal quantity may be justifiable. In the case of one-off cases of third-party pickup, some form of ID from the third party could be recorded. The following case study highlights the challenges pharmacists may face in this area.
Case Scenario
“I was asked by the partner of a patient to collect a medication for him, as he was currently overseas and could not visit the pharmacy himself. This was not uncommon in my experience, so I asked if I could speak to him, and we agreed that email was best to reach him. I received an email from the ‘patient’ and dispensed the medication. A few weeks later, the patient himself came into the pharmacy asking us why his partner was given his medication, as she had taken it with the intention to self-harm and consequently got into a car accident (the medication was a benzodiazepine). We then realised the email was written by the partner and fraudulent, unbeknownst to me at the time. I have since contacted the police”
– Pharmacist member of PDL
Accurate record keeping and clear communication by all pharmacists involved in staged supply is vital. Patients need to be clear about the number of tablets supplied and the number remaining. Other aspects that need to be clarified at the beginning of the supply arrangement include establishing the identity of any other family member who may be permitted to collect the medicine as the patient’s agent. This agreement may include a copy of some photo identification to ensure only those approved to collect the medicine are able to do so. PDL has received reports of situations where an acquaintance who knows of the staged supply arrangement will attempt to collect the medicine under false pretences.
PDL also receive reports where the patient alleges some of their medicine has been misplaced or lost. For this reason, it is important that every supply is documented and preferably countersigned by the patient. The staged supply templates available via PSA or QCPP allow for this option as well as the balance on hand to be displayed. Be aware of reports where a client is shown the remaining stock on hand and snatches the medicine, leaving the pharmacy with all remaining supply. Preparation of staged supply should occur away from the client and in a manner that reduces the risk of this action. While this situation would lead to the cancellation of the arrangement, there is also the risk of harm or diversion that needs to be addressed in such a circumstance.
Financial disputes are another area of contention. Once again, a clear understanding and agreement between both parties is vital. Accumulation of charges can occur and all pharmacists in the pharmacy need to have a consistent approach to managing payment and any outstanding debts.
There are occasions when a pharmacist feels that it’s no longer appropriate to provide staged supply. These occasions can be confronting and PDL are aware of complaints made to AHPRA and other regulators by patients who are dissatisfied with the termination of the staged supply arrangement. PDL would urge pharmacists to include a statement in the staged supply agreement that allows either party to cease the arrangement at any time. This action is reasonable so long as the patient is given sufficient notice to allow them to organise an alternative supply location. The prescriber should also be informed of the termination at the earliest opportunity. Arrangements need to be made for the transfer of any remaining medicine, with the prescriber’s approval, and typically this should occur without the involvement of the patient i.e. direct to the new pharmacy.
In summary, PDL would suggest the following practises may reduce incidents with staged supply:
- Good documentation
- Clear communication
- Engagement with prescribers
- Consistency by all pharmacists involved in staged supply
PDL would like to thank Amy Minion and the SA PDL Local Advisory Committee for their assistance in developing this article.
For immediate advice and incident support, call PDL on 1300 854 838 to speak with one of our Professional Officers. We are here to support our pharmacist members 24/7, Australia-wide.
