Interview - Dr Mukesh Haikerwal, AMA Vice President, Melbourne: The role of doctors, pharmacists and prescribing

QUESTION:         Can I just ask your reaction to the article in The Age, the study in the British Journal.

HAIKERWAL:      Look, wWhat the studies are showing around this pharmacy issue is that there is an important role for a team approach to the delivery of health care, and that's not just in hospitals but also in the community.  What we're finding is that it's very important that when people are dealing with medications, and there are millions of prescriptions every day, that at the time of prescribing there need to be checks, at the time of dispensing there need to be checks, and of course at the time it's taken, there also needs to be checks there, too.

Now, the reports show that there are a few slip-ups that have happened and been picked up by pharmacists, and that's excellent.  Obviously,  the fewer the slip-ups the better.  And there are many many checks and balances that have been put in place.  These have been put in place both at the hospital level,  but also at the state level at quality councils and federally with the federal quality council.  And these things have been evolving with time and have made the situation much safer now than it used to be five or ten years ago. 

QUESTION:         Is it a pharmacist's role to try and check out the doctor's prescription?

HAIKERWAL:      The pharmacists have a role to check the prescriptions that come to them are okay, and it's very important that teamwork is there between the pharmacists and the doctors to make sure that if there are problems that they're dealt with before they become major problems.

QUESTION:         Is it good enough though that prescriptions are being sent through that are endangering the patients' lives.

HAIKERWAL:      What's important is that when a prescription's written, it's written for a good cause, that the right dose is written, and also the right preparation.  Sometimes there needs to be checks and balances within the community and that's what the role of the pharmacist is, both in the community and in the hospital setting.

What the report is showing, of course, is that the teamwork is important and that there are many people involved in making sure that the safety of the patient is maintained through the system.

QUESTION:         How widespread do you think the problem is?  Is there any work that the AMA has done to find out how widespread it is?

HAIKERWAL:      The role of  finding out how widespread this is, is very difficult.  There are many people involved.  Obviously the hospital pharmacists have got a specific role that they've looked into with their study, and we have community studies too.

Generally we've seen very few - overall in the greater scheme of things - very few cases that are problematic and that's because the quality control that's being put through the system is much better now than it used to be.   And even one mistake is one mistake too many.  We'd like to see those minimised and reduced to zero.  And we're doing that through things like computerised prescribing which also does checking for interactions.  At the point of dispensing, the computer there helps with that, too.

But it's also important that we as individuals, when we take medications, we check that we've got the right medications, we know what they're for, and we know that we need to keep taking them.

QUESTION:         So there's onus on the patient as well, do you think?

HAIKERWAL:      It's a team effort, the effort is there between all members of the team.  The doctor, the patient of course, and the pharmacist I see as being a bit of a back stop as well to make sure things don't drop off at the time of dispensing medication.

QUESTION:         Is there anything else you think that could be put in place that could help stop these few cases that are slipping through the cracks?

HAIKERWAL:      I think the most important thing is time.  And what we've seen as time's gone by, the average level of time in a general practice for a consultation has gone up to around 15 minutes.  That helps.  The safe rostering of doctors in hospitals, which is been an AMA program, that helps.  And these sorts of things that facilitate time to think in the consultation and at the bedside of the hospital have all been health and safety measures, not only for the doctor but also for the patients.

QUESTION:         Do you agree that the figures mentioned in the article are a fair representation of the prevalence?

HAIKERWAL:      I think that they've obviously done their figures in some of the major teaching hospitals.  And we've got to remember that Peter Macallum, where one of the studies is based, is a cancer hospital.  Each of the drugs that are given there can be quite toxic in the wrong sorts of doses. When you take that across smaller hospitals and across the community, I think we're probably over-estimating things because most people don't have that high level of dose medication being prescribed and dispensed. 

QUESTION:         Are there risks associated with any prescription?

HAIKERWAL:      Every prescription has a risk associated with it, from simple paracetamol,  which you mustn't exceed the daily dose, through to the very toxic drugs we use for treating cancers.  And, indeed, antibiotics can have their problems, too.  We have to be very careful every stage with prescribing. We make sure that there has to be a reason for taking the medication and the medication is at the right dose and at the right strength and the right method of being dispensed.  And that's something that we, as individual doctors, do.  We, as patients who take the medication, need to ask the right questions, too.  And obviously at the time of dispensing at the  pharmacy there is a role for pharmacists to ensure that the right medication is actually given out to the patient.

QUESTION:         Is there a major problem at the moment with incorrect prescriptions for patients?

HAIKERWAL:      I think that the checks and balances that we have in place now with computerised prescribing, with quality control, and measures throughout the system are at a professional level.  We've seen the situation being identified and addressed and that's the most important thing, identifying  addressing and dealing with a situation so it can't spiral out of control.  In fact, it's become much better controlled.

QUESTION:         So there has been a problem but it's becoming minimised?

HAIKERWAL:      The problems of the past weren't huge, but they're much less now.

QUESTION:         Do you think there's a need for greater controls or anything else that can be put in place?

HAIKERWAL:      I don't believe that much more needs to be done immediately.  We need to evaluate what we have in place, and make sure that the prescribing software and the dispending software are all working and making clear what the concerns may be with certain prescribing practices.

QUESTION:         And human error, there's a still margin for that?

HAIKERWAL:      There's always going to be human error where human beings are concerned, and machines don't necessarily make things better.  They can make things several times worse if you simply rely on mechanisation.  I think we have to be sensible about the way in which we do our prescribing and our dispensing.

QUESTION:         And do you think there's a ...  I mean this study's concentrating on hospital prescriptions.  Is there a big problem outside, in general practices?

HAIKERWAL:      Look, I don't think there's a big problem in the community or in hospitals.  But there are problems that have been highlighted from the past, and we need to make sure that we have these checks and balances in place to ensure that often where prescribing is performed, and the dispensary goes through in much the same way.  This is very true for children, children obviously have a  much greater risk because they're smaller and they need smaller doses. 

Much of the trial work that's done with drugs often isn't done with children, and therefore we have to be sure that children do have particular care taken with their medication.

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