Delaying or declining supply of medication

The PDL Professional Officers often manage calls, incident reports and occasional regulatory complaints following a pharmacist’s decision to decline supply of a medication.

Recently, the Professional Officers have also taken calls from pharmacists seeking advice on declining supply when they believe the prescribing of a 60-day supply (60 Day Dispensing or 60DD) does not align with the PBS restricted benefit listing. PBS information states it is clearly the prescriber’s responsibility to determine if a patient is entitled to receive a restricted benefit. PBS information makes no reference to pharmacists interpreting or policing the PBS prescribing restrictions.

Therefore, when it comes to 60DD prescriptions for a new medicine, or a new strength of an existing medicine, a pharmacist’s considerations regarding supply should focus on patient safety. Pharmacists should consider factors such as the indication, prior medication history, clinical decisions made by the prescriber and the patient’s understanding of risk and benefit of the medication. The Professional Officers advise that any discussion with the prescriber should focus on the pharmacist’s obligation to ensure the safety and wellbeing of the patient.

While it is understandable that pharmacists and pharmacy owners may be concerned about the broader financial impacts of 60DD, this is unlikely to be considered a valid reason for declining supply if a regulatory complaint is lodged against a pharmacist. Furthermore, broad non-clinical issues would not be relevant to pharmacists’ clinical documentation when supply is declined.

Considerations before delaying or declining supply

The Professional Officers would always encourage a pharmacist to be mindful of their obligations and professional expectations before declining to supply a medicine. The Professional Officers believe that such a serious action should only be contemplated when the pharmacist has a concern for the patient’s safety. Explanations to the patient should reinforce that all actions are being taken out of concern for the patient’s health and wellbeing. It’s PDL’s understanding that if supply is delayed or declined based on a pharmacist’s clinical decision with a focus on patient safety, then the concern of a regulatory agency is likely to be low.

Pharmacists are obliged to ensure all medications supplied are clinically appropriate for the patient, however there is a common misconception among patients that pharmacists must supply anything that is prescribed without question. This misconception can create conflict between the patient and pharmacist and can be stressful and upsetting for both parties, sometimes leading to complaints to pharmacy management and/or regulators.

Reasons for declining supply may include:

• the medication, directions or quantity are clinically inappropriate for the patient;
• the interval between dispensing is too short;
• the pharmacist requires further information from the prescriber before dispensing;
• the prescription does not explicitly comply with legislative requirements;
• the medication is out of stock or unavailable;
• the patient does not have a valid prescription for the supply; and
• the patient behaves in an aggressive or threatening manner.

Appropriate, contemporaneous documentation of clinical reasoning for declining supply of any medicine, particularly for a chronic condition, would be critical should a complaint or regulatory action occur.

Good communication is essential when delaying or declining supply and can often prevent complaints and situations from escalating. The Professional Officers also recommend:

• remaining calm throughout the interaction;
• actively listening to the patient’s concerns and showing empathy for their situation;
• discussing your concerns with the patient about the prescription. Clearly outlining your obligations as a pharmacist to ensure the medication is appropriate and the patient’s wellbeing is the focus;
• in cases where you might be willing to supply the medicine once further information is available, explain to the patient that it’s a delay rather than denial of supply;
• obtaining consent, where possible, to contact their prescriber. If consent is refused, clearly reiterate that without the requested information you may be unable to fill the prescription;
• where appropriate and legal, consider offering options such as supplying a smaller quantity or a staged supply service before verification with a prescriber or deciding to decline supply;
• if declining supply is appropriate, clearly outline the reasons for your decision to the patient, referring them to their prescriber and notify the prescriber of your decision to ensure there is an opportunity for continuity of care; and
• documenting the reasons for your decision and all relevant information in the patient’s notes.

Inappropriate patient behaviour

If the patient behaves in an aggressive or threatening manner, it is important to ensure that your safety and that of your colleagues and other clients is not compromised. If there is a threat to safety, call the police immediately. Every pharmacy should have a zero-tolerance policy for inappropriate behaviour and a procedure for managing difficult customers.

To de-escalate a confronting situation where safety is not immediately compromised, the Professional Officers recommend:

• asking the patient to allow you an opportunity to explain your concerns and obligations;
• remaining calm and firmly asking the patient to refrain from the inappropriate behaviour;
• warning the patient that you will ask them to leave the pharmacy if their inappropriate behaviour continues;
• if the behaviour does not improve, asking them to leave the pharmacy until they are calm;
• if the patient refuses to leave the pharmacy, explaining that you will need to call the police;
• if they refuse to leave, calling the police; and
• documenting the incident as soon as practicable and contacting PDL for further advice.

As a private business, a pharmacy can choose to ban a person from entering the pharmacy and notice of that action should be conveyed to the person with support/input from pharmacy owners.

Proprietors have a duty of care to their staff and must ensure that procedures for managing these situations are documented and that staff training for these procedures are up to date. This may include using role plays or staff meetings to discuss how to manage aggressive clients.

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.