Protecting and Promoting the Health and Well-Being of Patients: Ethical Responsibility to Report Unsafe Practice
Under Standard 1 of the Code of Ethics, registrants are committed first and foremost to protecting and promoting the health and well-being of their patients. This may include reporting concerns of unsafe practice by colleagues or other healthcare professionals to the appropriate regulatory authority.
In 2015, the College completed an investigation where an individual impersonated two sisters by using their Personal Health Numbers to obtain over 260 narcotic prescriptions (mostly oxycodone) at multiple pharmacies over a period of six years. Despite the apparent pattern on PharmaNet of large amounts being dispensed with short intervals between each dispense, the impersonator was able to continue her conduct for six years.
A more detailed summary of the investigation, as reported by CBC, can be found here:
During the investigation, it was discovered that the impersonator frequently informed both physicians and pharmacists that she was travelling or had lost her tablets. Many pharmacists reported that they had called the prescribing physician when they noticed the patterns on PharmaNet, only to have the physician tell them that the patient was travelling and therefore it was okay to dispense early. Many pharmacists continued to dispense early and in high quantities despite the alarming patterns on PharmaNet, since the same physicians kept authorizing the prescriptions.
After its investigation and review of this case, the Inquiry Committee advised the involved pharmacists that if they had continued to dispense just because the prescriber indicated it was “okay to fill”, then they would not be acting in the best interests of the patient or the public. Such a scenario suggests that the patient was abusing and/or diverting narcotic medication, and continuing to dispense may have enabled the behaviour. If the prescribing physicians were not heeding the pharmacists’ concerns, the pharmacists should have reported their concerns to the College of Physicians and Surgeons of BC.
If in the course of caring for a patient a registrant becomes concerned about the conduct or action of another health care professional involved in the patient’s care, they have a professional and ethical obligation, in the best interest of the patient, to contact the regulatory body of the other health care professional to report their concerns.
What Went Wrong ReadLinks Series
Watch for What Went Wrong articles each month on ReadLinks. These articles highlight important pharmacy practice issues and real complaints cases identified through College investigations.