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Could pharmacists be part of the A&E problem?

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After hearing about a case where a pharmacist referred a child with a minor paracetemol overdose to A&E, Adam Pattison Rathbone wonders if pharmacists are equipped to be gatekeepers of the NHS.

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I’m usually not one to bad mouth my own profession but over the past few weeks I’ve been exposed to a few pharmacy-horror stories that have motivated me to write. A friend of mine called for some advice after her four-year old niece had been accidently overdosed on paracetamol suspension. My friend told me that the child’s mother had spoken to an A&E receptionist, who told her to call 111, who then told her to go and speak to a pharmacist. At this point I wondered why my friend had called me, surely any pharmacist would give the same advice as I would?

She’d called because she wanted a second opinion. The child had been given two 5ml spoonfuls of 120mg/5ml paracetamol suspension (240mg) and then been given one 2.5ml spoonful a few moments later (60mg). This meant that a four-year-old, average weight child has had a total one-off dose of 300mg.  On hearing this, the pharmacist, allegedly, advised that the child be taken to A&E immediately because there would be no symptoms of a paracetamol overdose and the child would need tests to ensure that she was okay.

I did some quick calculations and checked the British National Formulary for Children. Essentially this was a minor overdose that would probably do the child no harm whatsoever. I asked my friend a few more questions to find out if perhaps any key details had been missed out, perhaps a history of liver problems or chronic paracetamol misuse but there was nothing. The child’s mother took her to A&E and, although the child was sent home after being seen within an hour, was reassured by a doctor and a nurse that bringing the child to A&E was the right thing to do. I can’t help but feel somewhat confused about that.  

The mass media tells us almost daily that the NHS is crumbling, A&Es are overstretched and advises that we make better use of pharmacists for advice. As a pharmacist I felt confident that my knowledge about paracetamol dosing, the development of the liver, and the general robustness of most children after they’ve eaten, swallowed or chewed on something they shouldn’t have, meant that this child was almost certainly going to be fine and so I believe the best advice would be to drink plenty of fluids and keep an eye on her.

On reflection, one could consider the role of the mass media on my avoidance of sending patients to A&E. I feel like a professional, and part of that professionalism includes making appropriate referrals. Sending a patient to A&E who doesn’t actually need to be there is inappropriate and therefore unprofessional.

Reflecting further, one might consider the difficulties faced with a consultation with a young and anxious mother who is afraid she has inadvertently poisoned her child. Yet I still believe that, as practitioners, we should be able to deal with difficult consultations. Do pharmacists know that sometimes an appropriate referral is to do nothing? 

Perhaps the patient-consumer model of pharmacy prohibits a watch-and-wait approach. A patient-consumer who approaches a pharmacist wants something; the pharmacist-provider supplies it. If the patient-consumer wants a referral to the GP or A&E can a pharmacist-provider say no? Would that be seen to be bad for business?

Or perhaps some pharmacists simply do not have the confidence or believe they have the professional autonomy to make a decision and give advice. For decades, pharmacists have shared the responsibility for the sale of medicines with the Medicines and Healthcare products Regulatory Agency, which issues licenses to medicines for sale over the counter, or they have shared the responsibility for the supply of medicines with prescribers. Now pharmacists are being asked to take sole responsibility for turning patients away from an over-stretched A&E or over-worked GPs. Do most pharmacists feel confident to make decisions about patients that makes them the sole, responsible healthcare professional?

There is no use the Royal Pharmaceutical Society, the Department of Health and the NHS backing a pro-pharmacy agenda if pharmacists out there do not have the confidence to give people appropriate referrals when the referral is watch and wait. If pharmacists cannot advise patients to watch and wait, perhaps they are contributing to the workload of over-worked GPs and over-stretched A&Es through inappropriate referrals.

Readers' comments (4)

  • The pharmacists decision to refer may have been wrong, but he/she made the only decision that was available at that time, and I and any other pharmacist would have done the same. The fact is, if we just shrugged off every case where we thought these minor overdoses were not a problem, there would ultimately come a time where a minor overdose may cause an unforeseen complication, and we would be liable. Better to err on the side of caution, indeed, a GP probably would have made the same referral in the same circumstances.

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  • You've really made my argument for me - the reason pharmacists refer patients to general practitioners and a&e is to avoid liable, not to improve patient care or to use NHS resources efficiently but only to avoid taking responsibility themselves. What would the a&e consultant do incase they miss something? What does the general medicine consultant do if they miss something? Pharmacists in community, and general practitioners alike, should not use the 'what if I miss something and get sued' excuse for making unnecessary or dubious referrals. I wonder if you might make the same referals if you had to pay a fee if it was deemed inappropriate?

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  • Unhappily I do make your point for you, but given the reality of the situation we are in, pharmacists and GPs have to work in a broken system. Pharmacists are not sure where their responsibilities are when it comes to these kinds of cases, we are not trained and have no process/sop to follow in fact no protocol has ever been defined what are we liable for and what are we not liable for? The system has to modernise with pharmacists trained to prescribe and take over some of the more basic end of medical care, extending minor ailments to common ailments, where what we can treat and what we can't is clearly defined to a protocol. This would allow GPs to concentrate on the more complex cases. I think that this would unburden NHS a lot more than people just making some vague suggestion that 'pharmacists should take more responsibility'.

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  • I think it is difficult in certain situations to know whet the best course pf action is and i completely agree about changing common alliments to minor alliments.
    But also we do have a professional responsibility to use our knowlegde and refer when we feel it is appropriate and not to when its not and that at the end of the day is a judgement call alongside our trainig.
    Just as an example i had to deal with a similar situation myself. My cousin had tooth pain and someone gave her pain killers for this. she didint realise that what she had been given was oxycontin 20mg. Why this other person had this medication and was giving it out was also a concern my main priority was to deal with the immediate situation.
    When she arrived at my house she had already had an episode of vomiting and was feeling light headed. It had been a few hours since she had taken the medicine.
    I decided to give her a glass of water and lay her down as she was feeling dizzy. Instead of taking her to a&e i decided that i would monitor for the next few hours andif i felt her condition was deteriorating i would take her a&e.
    She vomited once more and then after a little lying down she seemed to be back to herself.
    Now when i spoke to my sister, who herself is a GP, she said she would have probably taken her to a&e.
    But i felt my decision was right as i saw her condition age, weight what she had taken and felt i apporached it correctly. And besides i knew that sitting in a&e for at least 1-2 hours would not make her condition any better.
    My background is over 10 years experience in hospital as a clinical pharmacist, so i feel i made the right decision.
    So even if we have clear guidance or SOP i think ultimatley it will come to how confident the pharmacist is to make a judgement call. And that i think will come from there experience and practice.

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