Do I Have to Fill This Prescription?
By Don R. McGuire, Jr., RPh, JD
Many pharmacists have asked the question, “I have some doubts about this prescription, do I have to fill it?” We will deal with this question in terms of therapeutics and patient health. We will reserve the topic of conscientious objection for a different time. When I was a young pharmacist, a more experienced colleague at the hospital received a phone order for IV propranolol, but at an oral dosage. The other pharmacist refused to dispense it, even in the face of verbal threats from the prescriber. In the end, the order wasn’t filled and any potential harm to the patient was avoided. What should you do if faced with a prescription that you believe is harmful to the patient?
This harm may come from serious side effects, drug interactions, or possible addiction to controlled substances. Some states deal directly with this question in their regulations. For example, California states that pharmacists can refuse to fill prescriptions that would be against the law or that could potentially have a harmful effect on a patient’s health. Indiana states that the pharmacist can refuse to fill a prescription that is contrary to law, that is against the best interests of the patient, that would aid or abet an addiction or habit, or that is contrary to the health and safety of the patient. Two general rules can be formulated from these examples.
Prescriptions that are illegal or invalid can’t be filled – this is one of the most difficult scenarios for a pharmacist when it comes to controlled substances. The DEA takes the position that to be valid; a prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice. The DEA believes that the law does not require a pharmacist to dispense a prescription of doubtful, questionable, or suspicious origin. It is difficult for a pharmacist to know when the
- line has been crossed from legitimate treatment to addiction. I think it is safe to say that if the current prescription presented to you is causing you to ask the question, then the line is very close or perhaps already crossed.
- Prescriptions that could harm the patient shouldn’t be dispensed – This seems obvious, but is not always easy to apply in the real world. The dosage is on the high side of normal, the patient has had penicillin before, the drug interacts with a previous prescription, or any other scenario that you can imagine where the prescriber directs you to go ahead and fill the prescription. However, if you think there is a high probability that the patient will be harmed, no one can order you to dispense the prescription.
While California and Indiana spell out the responsibility of the pharmacist in these two situations, I believe that the same responsibility exists even in jurisdictions that don’t explicitly cite it. If not, then why bother to require that drug utilization reviews be performed? And if the pharmacist is powerless to act when something is detected, again, why require them? We all know that there are some risks associated with every drug and every treatment. What we are talking about here are the large, severe risks. In the propranolol example given earlier, the pharmacist was convinced that the patient would die if he dispensed that order as prescribed. If the prescriber can overrule the pharmacist’s professional judgment in this situation, then the chances of an irreversible, negative outcome increase. But you can’t make these decisions in a vacuum. Discussion with the prescriber will probably be necessary. Perhaps discussions with the patient also will be necessary. Use the information from these discussions in conjunction with your professional knowledge, experience and judgment.
As I tell pharmacists in these situations, it is much easier to defend a case where the pharmacist refuses to fill a questionable prescription than it is to defend a case where the pharmacist has doubts about what was dispensed. You don’t want your answer to the deposition question, “And what did you do when you became aware of this potential danger?” to be, “Nothing.” We can’t insure 100% safety, but we want to avoid high probabilities of serious harm.
Pharmacists owe patients their highest efforts to treat their health problems and try to protect them from avoidable harm. The pharmacist’s duty to a patient does not require the pharmacist to do anything illegal. However, I do believe that it requires the pharmacist to use their professional judgment for the patient’s benefit. That may mean refusing to dispense a particular prescription. And that situation may require some intestinal fortitude on the part of the pharmacist.
© Don McGuire, Jr., RPh, JD, is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.
This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.
This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and the Tennessee Pharmacists Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products to the pharmacy community.