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What Went Wrong? Patient Profiles and
Adverse Drug Reactions
Case Review
In March 2015, a pharmacist dispensed allopurinol to a patient which interacted with her existing medication, azathioprine. The drug-drug interaction between allopurinol and azathioprine is serious and well-known. These medications were then refilled (by two other pharmacists) for the next two months until the patient began experiencing symptoms of pancytopenia and was admitted to the hospital. The patient remained in the hospital for 18 days during which she received multiple blood transfusions and required blood tests to determine the cause of her symptoms.
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Note: This is similar to a previous case in 2013 with almost the exact same drug-drug interaction. In that case, a pharmacist dispensed mercaptopurine (a derivative of azathioprine) to a patient, while another pharmacist dispensed a refill of the patient’s existing medication, allopurinol. Within a few short days, the patient experienced symptoms of pancytopenia, was admitted to the hospital and died. |
The pharmacists involved did not conduct a PharmaNet review, contrary to HPA Bylaws – Part 1, s. 6 and s. 11, and failed to detect the drug-drug interaction. Patient counseling, and the quality thereof, was suspect in both cases and the patient was not alerted of the drug-drug interaction before releasing the medications. In the interest of public safety, the pharmacists had their licences suspended for 1 month and undertook educational remediation.
Discussion
The College would like to remind all registrants that pharmacists are required to conduct a thorough review of the patient’s medication history and PharmaNet profile for every prescription dispensed (including refills). Before releasing a prescription to a patient, a pharmacist must:
- Review the patient’s health record and PharmaNet database,
- Review the patient’s health information for potential drug interactions and any other potential problems,
- Consult with the patient and practitioner(s) about the patient’s drug history, other personal health information and drug therapy,
- Conduct a full pharmacist/patient consultation,
- Document the identity of the registrant who conducted pharmacist/patient consultation, and
- Take appropriate action to address a drug related problem when identified (e.g. drug interactions).
Compliance with these basic standards ensures that adverse drug reactions are caught and resolved. Reviewing a patient’s PharmaNet profile is a foundational element of pharmacy practice and the Board chose it as a Practice Review Program focus area due to its impact on patient safety. However, relying on PharmaNet alone is inadequate; pharmacists should keep current in clinical pharmacy knowledge. Registrants are reminded that while PharmaNet is an extremely useful tool, it cannot – and should not – replace the professional intervention of a pharmacist. Checking a patient’s PharmaNet profile is a required and critical step in providing quality pharmacy care, and in many cases, saves lives.
- What Went Wrong, PharmaNet, Practice Review Program
