How to be confident to challenge a Prescriber in Pharmacy

Welcome all newly qualified pharmacists to the profession. You have been tested and examined so much over the past 5 years and you are now part of this profession. If you are in primary (community) or secondary (hospital) care setting, you are now required as a pharmacist to challenge the safety and efficacy of prescribers because the patient’s care stops with you.

Being prepared to challenge a Prescriber

Up until registering this point can be for a lot of newly qualified pharmacists. It is quite a daunting thing as before now, there has always been the registered pharmacist to turn to for support or to step in to back up when you’re challenging. Even for registered pharmacists, challenging a prescriber is not an easy experience and takes practice to get used to doing. So what will you need to know before challenging a prescriber and why? The first thing you will need to do is know why you’re challenging. Is there a clinically significant interaction with other medications? Is the patient suffering a side-effect that can be improved? Has the patient changed their lifestyle that deems taking the  medication unnecessary, or the condition has improved? All these basic questions about why you’re going to challenge need answering as it is the basis for your challenge. Then what you will need is a good history from the patient. What condition is the medication for? What led to this medication being started, ie test results, lifestyle changes, personal factors? What concerns have they raised to you about the medication that means you should challenge? Have there been recent test results that contraindicate the medication? These questions will often allow you to be more confident about challenging and also will prevent you challenging when there is no need to challenge. On occasions the patient is aware of what to look out for or it has been recently discussed with the prescriber and the decision to continue was made even after knowing the risks.

Due Dilligence

So you have done your due diligence and are sure that the prescriber needs contacting due to the risk of an interaction that can cause patient harm, here is where the sector you work in can become a challenge. A hospital pharmacist will have the ability to go straight to the prescriber and discuss the issue directly with them, and you should certainly do that. Even if not certain you’re working directly with the doctor,  think of it as a peer discussion rather than a challenge. If you are a community pharmacist you will either need to contact the GP or on rare occasions, the hospital specialist who initiated the therapy if you feel the interaction is that serious. So contacting a GP surgery you will have to get past the team who answers the phones which can be quite a challenge. Knowing the seriousness of the interaction will help you here. If it is a medication and a therapy that has been used for a while but you notice the patient is suffering a side effect that can be corrected, ask them for a GP call back later in the day and also tell the patient to contact their GP about the issue. If the interaction is more serious ie anticoagulants and enzyme inducers or inhibitors that has been missed previously, you need to speak to a prescriber while the patient is waiting for their medication as it is unsafe and incorrect of you to dispense something you know can cause harm. One of the fastest ways to get a prescriber on the phone is to first ask and explain that you are challenging a potentially serious interaction and if still no luck, request the member of staff’s name, and position at the practice. This is because you need to document who you spoke to and why you were unable to contact a prescriber if harm does come to the patient. This usually gets a prescriber on the phone quickly or at the very least a very urgent call back. You might feel under pressure to not bother challenging the prescriber as you will have a lot of checking to do and the patient might be saying “but I have been on this years and haven’t had any problems yet”.  Your job as the pharmacist is patient’s safety and welfare as your main concern and not the item number or MUR targets. You need to remember that and stick to that core and central role of our profession.

Minimum recordings

Whatever the outcome of the conversation, make a note on the patient’s medical record recording as a minimum, it should include the following:-

• Date
• Time
• Who you spoke to
• Why you challenged
• The outcome of the challenge

This is required to help any future pharmacists be aware of what has been done previously and also to ensure you have a record in case anything does happen, because saying you challenged and proving you challenged are two different things. If you are the regular pharmacist in a store, it would be wise and beneficial to arrange meetings with the local practice managers to start a dialogue about how you can raise prescribing queries and if they can set up a different system or a local area agreement that will allow you to speak to a prescriber on the phone quicker for any challenges. This might require you using a day off but first discuss this with your area manager if they can get a locum to cover you for a day and arrange to attend practice meetings usually just one afternoon a month.

We hope this helps you to feel more confident in why you are challenging a prescriber and how to do it. You will probably still feel quite nervous when you do challenge but there is a difference between nervous and incorrect, remember if you have a legitimate concern, you will need to raise it and also document that you have raised the issue.

Written by Harry Cottrill