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The Last Possible Source of Error *
The Last Possible Source of Error * By Bernard G. Keller Jr. and Raymond J. Bennett
here is much talk today of the T practicing pharmacist as a professional person. Thelma McCormack in a study of pharmacy as a marginal occupation stated that the professionally oriented pharmacists were especially interested in furthering their professional roles and identities. 1 As Martin Rosner pointed out at the 1963 convention of the National Pharmaceutical Association in Chicago-"The desire for greater professional identity comes at a time when therapeutic advances have increased the pharmacist's potential for rendering service to his patient."2 The past few years have witnessed incredible revisions in the curriculum to which our pharmacy students are exposed. The question that is posed to today's educators by today's practitioners is whether our schools are over-training this entity-which we shall term the "pharmacist of the future." We are witnessing in our day the most fantastic innovations in the health sciences. The physician is S'O over-burdened that some schools are already training a new class of technician called the physician's aide or assistant. Many dental schools are contemplating the same type of personnel for the undertaking of the more simple, basic tasks. A Look article a little over a year ago asked the provocative question-"Where have all the nurses gone?" It is a common occurrence to be an inpatient in a hospital and see a registered nurse no more than once a day. Nurses' aides do m'Ost of the basic tasks that nurses used to pride themselves in and carried out with such "Tender Loving Care." Yes, we are training a very sophisticated product-this "pharmacist of the future." We can visualize him as a much more influential member of the health team. In the future when he speaks on the subject which he knows best-drugs-the other health professionals will have to listen because drug therapy will be so extensive and so complicated, there will be no latitudes for error. o Presented to the Academy of General Practice of Pharmacy at the APhA Annual Meeting in
Montreal, May 19, 1969.
As educators we are not training diagnosticians or "watered down" physicians. We are endeavoring to train drug specialists. We are trying to impress on our student pharmacists and on the other members of the health team that the pharmacist is "the last possible source of error" with respect to drugs. In 'o rder to serve in this role as "the last possible source of error," the following are a few of the many possible avenues open-( 1) clinical pharmacy, (2) pharmacist-consultants with respect to nursing homes, small hospitals and extended care facilities; (3) institutional acceptance of the unit dose system, (4) development of more professional practice centers, (5) development of more group practices and (6) the acceptance of our responsibility as the professionals who must be charged with detecting potential drug interactions. It is extremely probable that recognition of drug interactions by pharmacists may become the sole factor that will be capable of elevating the contempor'ary practice of pharmacy from a purely technical operation to a truly intellectual pursuit. Pharmacists who were willing to exercise some degree of introspection have been searching for this sort of activity for years. The salient feature of this activity is that it is a service of which the value is readily recognized by physicians and laymen alike. This innovation is so important because it is applicable to all types of pharmaceutical practice, including commun~ty practice. In full honesty, there is probably a much greater need for detecting drug interactions in community practice because there is less oontrol over patient action than there is in the institution. In order to fulfill this last function, much has been written concerning the utility and advisability of a prescription record system. Roger W. Cain once stated that3Regardless of the time and cost factor in providing patient or family prescription record systems, it appears essential that every pharmacist, in order to provide pharmaceutical service to his patrons, should adopt and utilize a system for maintaining patient prescription records.
The key word in Cain's statement is "utilize." To merely keep a record system-but to neglect proper utilization of this system-is just one step better than not having the system at all. Many pharmacists have gone to the expense and time to develop such a system and yet will not even detect the most blatant drug interaction because they are not really utilizing the system or what they have been taught. Others have stated that the maintenance of a patient or family prescription record system is merely a stepping stone to a much more medically useful file that could be developed. This ultimate goal would be the development of a patient or family drug sensitivity record or adverse drug reaction record. Problem
Today the major therapeutic incompatibilities that are witnessed occur as a result of drug interactions. Increasingly each day with the advent of so many potentially dangerous drugs and also with the advent of more and more self-medication, the possibility of a patient creating an interaction which could prove quite harmful or even fat'al, has been recognized. Also the fact that many patients, as a matter of course, pursue treatment from more than one physician has raised the possibility that one physician may be treating a condition with one drug product that is contraindicated in the treatment of another disease or in combination with some other drug product that already has been prescribed by another physician. The final possibility that a single physician might very easily prescribe two or more drug products that are inherently contraindicated also has been Tecognized. The problem, therefore, lies in the fact that anyone of these three situations might exist and that in any case the potential harm to the patient involved might be tremendous. Purpose The purpose of this project was to present an analysis of the possibility of potentially dangerous drug interactions that can arise from the patient's use of many physicians. From such an analVol. NS10, No.8, August 1970
451
ysis it is hoped that the .need for. m?re complete patient or famIly pr~~cnptlOn record systems (properly uttllz~d) . or some sim~lar method of momtonng medication consumption could be demonstrated. Methodology The analysis was conducted on the new prescriptions and renewal p:escriptions in a suburban communIty pharmacy in the N ew Orlea~s metropolitan area. The co~munity pharmacy chosen to be studIed had the following characteristics-( 1) there were 352 charge accounts, (2) there were two full-time pharmacists and one relief pharmacist, who was employed once a week, (3) there were. two fulltime ,c ashiers and one part-tIme cashier (4) there were two full-time drug cle~ks and one part-time drug cle:k, (5) there were 11,828 new prescnption orders dispensed by the pharmacy in the study year, (6) there were ~p proximately 15,000 renewal prescnptions in the year and (7) net sales were over $250,000. The charge account files were utilized to obtain infoI1mation concerning renewal prescriptions. By necessity, all the results were limited to those consumers who had charge accounts at this pharmacy. All of the charge files for the study year and all new prescriptions for the year were microfilmed and cross-referenced for detail study. Types of Drug Interactions McKiver4 has stated that there are basically six types of possible drug interactions. He classified these as1. Straightforward potentiation, either by additive effect or by synergistic action. 2. Enzymatic inhibition, whereby one drug prevents the normal metabolism of another drug with cumulative effect and enhanced toxicity. 3. Stimulation of enzyme systems, whereby one drug increases the rate of metabolism of another. 4. Displacement of one drug from plasma or tissue protein by another drug which has a greater affinity for the protein binding site, causing the unbound drug to reach toxic levels. 5. Electrolyte imbalance, such as the loss of potassium induced by thiazide diuretics-causing increased toxicity of digoxin or muscle relaxants. 6. Interference with urinary excretion. Most of the drug interactions that were noted in this study were either straightforward potentiation or the use of drugs whose concomitant use is questionable. Use of Many Physicians One particular case study was disclosed which demonstrates emphatical452
Bernard G. Keller Jr. is chairman of Southwestern State College department of pharmaceutics. Having earned his BS in pharmacy at Loyola University of New Orleans, Keller went on to receive his MS and PhD in pharmacy administration from the University of Mississippi. A former community pharmacist, he also has been a pharmacy consultant and manager. Keller has authored a number of articles and currently is conducting a study on the effective utiliza-, tion of patient record systems. He is a member of APhA, Academy of Pharmaceutical Sciences, ASHP, AACP conference of teachers, Rho Chi and Kappa Psi.
Raymond J. Bennett is currently a faculty member at the University of Montana and previously was a member of the University of Mississippi faculty. Former pharmacy owner and community pharmacist, Bennett earned his BS in pharmacy at Idaho State University and MBA and PhD in pharmacy administration at the University of Wisconsin. He is a member of Montana State Pharmaceutical Association and serves as secretary of the association's board of directors.
ly the dire need for better drug control at both the physician level and the pharmacist level. A female patient, age 35, was receiving ethchlorvynol 500 mg capsules and chlorprothixene 100 mg tablets from one physician. Another physician, with no knowledge of th~s fact, prescribed in the same time period more ethchlorvynol 500 mg capsules, pentobarbital sodium 100 mg capsules and tranylcypromine 10 mg tablets. Thus we can witness the potentiation of the ethchlorvynol, the pentobarbital sodium and the chlorprothixene, while at the same time a monoamine oxidase inhibitor such as tranylcypromine is contraindicated with a major tranquilizer such as chlorprothixene. About three months later, this same patient was administered thioridazine HCI 10 mg tablets arid pentobarbital sodium 100 mg capsules by a third physician. One of the other physicians, whom she had been visiting all along in the same time period, prescribed glutethimide 0.5 gm tablets, more pentobarbital sodium 100 mg capsules and ethchlorvynol 500 mg capsules. We already have established that ,t he patient was receiving tranylcypromine tablets, but one of the other physicians prescribed imipramine HCl 25 mg tablets. It is
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
well documented that the concurrent administration of a monoamine oxidase inhibitor and a tricyclic antidepressant results in potentiation of the antidepressant and should be avoided because of the danger of a hypertensive crisis. The last encounter with this patient came near the end of the study year. At that time she received a prescription for 40 chlorprothixene 25 mg tablets, 15 ethchlorvynol 500 mg capsules and 50 meprobamate 400 mg tablets. The physician authorized renewals in such a manner that within 19 days, the woman had in her possession 160 chlorprothixene 25 mg tablets. During 30 days, she had 90 ethchlorvynol 500 mg capsules and during 70 days she had 450 meprobamate 400 mg tablets. Was it any wonder that during this "mixed" drug regime she developed cardiac insufficiency and also was placed on digitoxin 0.2 mg tablets? It would appear that the physicians and the pharmacists involved all should have been cognizant of
tions are allowed to exist in this day and age, but we must keep in mind that we are a nation of people who believe in the specialization of medicine. This may partially account for the prevalence of these types of interactions. Stated simply, it appears that the sophisticated patient of the 70's enjoys consulting with more than one physician. This certainly builds into the relationship an inherent problem drug situation.
Conclusions This study produced a dramatic case of drug interactions. Admittedly many of the examples cited were exceptional. Also admittedly, this study was based solely on the facts that were observed and obtained in one community pharmacy. Nevertheless, to the person who suffers from one of these reactions it is little comfort to know that his is an exception to the rule. Nonetheless, this case certainly substantiates that the problem exists in everyday community practice. It points out dynamically that something must be done. Certainly a well-defined course of action might be1. Institute a patient record system
from which the drug data can be readily retrieved. 2. Develop and nurture the proper sci-
Legal Problems (continued from page 450)
Drug Administration regulations notwithstanding-the pharmacist has no one to share the blame for any resulting damage to the patient. N or can he, in most cases, shift the blame to the manufacturer who under present law has a quite respectable defense in the fact that his label conforms to government requirements. True, FDA permits the sale of proprietaries on an assumption that the patient reads and comprehends a label which complies with Federal specifications and is thereafter on his own. The speciousness of this assumption is apparent to any pharmacist and has not escaped the attention of diligent plaintiff's counsel. Suppose for example, that the pharmacist knows that the purchaser cannot read English or that she is incapable of reading sm;all print with or without her glasses. And suppose that this hypothetical patient is purchasing a cold remedy containing substantial a~ounts of atropine or an antihistamIne with substantial atropine-like effects, and that the pharmacist knows
entific knowledge and professional judgment necessary to recognize and evaluate drug interactions. This can be done by carefully reading the leading pharmaceutical journals and newsletters which are devoting more time and space to these interactions. The schools of pharmacy also can prove helpful to the pharmacy practitioner by offering expanded continuing education seminars that deal with these pertinent topics. 3. Strive to develop the necessary tact and diplomacy that are needed to get such situations corrected. From the patient's point of view it can increase your stature as a professional person. From the viewpoint of interprofessional relations, the physician will soon begin to be cognizant of what a well-informed and potentially powerful colleague he has. Who then is responsible for preventing such reactions? Certainly the physicianmust share in this responsibility. But who clai'ms to be an expert on drugs? Who has had massive quantities of medicinal chemistry, pharmacology and biopharmaceutics to enable him to understand the mechanisms of drug interaction? The answer is inevitably the pharmacist. Therefore, the pharmacist must share the responsibility for detecting and preventing adverse drug in-
teractions-perhaps even more so than the physician. As a panel of experts on drug interactions recently concluded5-
that she has glaucoma because he has for years been dispensing and renewing her eye physician's prescriptions for pilocarpine? What is his professional responsibility in this case? Or suppose the teen-age member of a family well known to the pharmacist and known to be a devotee of drag racing comes in to purchase large quantities of an antihistamine-containing cold remedy because he is "getting a cold and wants to be in good shape for the big race tomorrow afternoon." Where do the pharmacist's professional responsibilities lie here? With respect to proprietaries, the community pharmacist who knows something of his patients and their situations is in an ideal position to prevent possible harm in the misuse of propr-ietaries. He is, on the other hand, more vulnerable to suit should injury occur from a failure to warn and advise a patient whose situation, whose ailments or whose limitations are well known to him. I know pharmacists who make it a practice to warn and to advise in professional terms and within the limits of
their professional training all purchasers of any proprietaries which carry a significant hazard or risk of misuse. There are probably a few physicians and pharmacists around who would regard this as improper and verging on the practice of medicine. As a physician I admire the professionalism and concern for the public demonstrated by careful pharmacists and as a lawyer I applaud their wisdom. No court today is likely to penalize 'a trained professional for the proper exercise of his professional responsibilities in protecting the public who are his customers on the theory that he is thereby engaging in the practice of medicine. And few counts are likely to respond to a defense based on a theory that the patient has adequate protection under Federal labeling law if the pharmacist is in a position to know that in the case at hand this simply was not so. Despite present uncertainties and ignorance, the future of medicine and of pharmacy is being determined today. By our collective action or sepavate defaults, it will be largely what we make it. •
In the future, you may be able to count more heavily on pharmacists in the hospital and at the corner pharmacy to assist you (the physician) in predicting possible interactions and guarding against them. A new breed of pharmacist equipped to provide this type of consultation · is now being educated in some of the schools of pharmacy across the country.
In conclusion, let us consider the following-no drug, no chemical, no prescription can cause harm to a patient until dispensed by the pharmacist. When dispensing, the pharmacist asserts, that to the best of his knowledge this drug is both safe and effective. Truly then the pharmacist is the last possible source of ·error. • References 1. McCormack, Thelma R., "T4e Druggists Dilemma: Problems of a Marginal Occupation," Am. J. Soc., 61, 308 2. Rosner, Martin M., "Attitudes Toward Maintaining Family Records on Drug Sensitivities," JAPhA, NS4, 169 (April 1964) 3. Cain, Roger W., "New Prescription PracticesPatient Record Systems," JAPhA, NS4, 168 (April 1964) 4. "Incompatibilities Now Occur Inside Patient," Am. Druggist, 35 (Dec. 4, 1967) 5. "Drug Interactions That Can Affect Your Patients," Patient Care, 1,23 (Nov. 1967)
Vol. NS10, No.8, August 1970
453
here is much talk today of the T practicing pharmacist as a professional person. Thelma McCormack in a study of pharmacy as a marginal occupation stated that the professionally oriented pharmacists were especially interested in furthering their professional roles and identities. 1 As Martin Rosner pointed out at the 1963 convention of the National Pharmaceutical Association in Chicago-"The desire for greater professional identity comes at a time when therapeutic advances have increased the pharmacist's potential for rendering service to his patient."2 The past few years have witnessed incredible revisions in the curriculum to which our pharmacy students are exposed. The question that is posed to today's educators by today's practitioners is whether our schools are over-training this entity-which we shall term the "pharmacist of the future." We are witnessing in our day the most fantastic innovations in the health sciences. The physician is S'O over-burdened that some schools are already training a new class of technician called the physician's aide or assistant. Many dental schools are contemplating the same type of personnel for the undertaking of the more simple, basic tasks. A Look article a little over a year ago asked the provocative question-"Where have all the nurses gone?" It is a common occurrence to be an inpatient in a hospital and see a registered nurse no more than once a day. Nurses' aides do m'Ost of the basic tasks that nurses used to pride themselves in and carried out with such "Tender Loving Care." Yes, we are training a very sophisticated product-this "pharmacist of the future." We can visualize him as a much more influential member of the health team. In the future when he speaks on the subject which he knows best-drugs-the other health professionals will have to listen because drug therapy will be so extensive and so complicated, there will be no latitudes for error. o Presented to the Academy of General Practice of Pharmacy at the APhA Annual Meeting in
Montreal, May 19, 1969.
As educators we are not training diagnosticians or "watered down" physicians. We are endeavoring to train drug specialists. We are trying to impress on our student pharmacists and on the other members of the health team that the pharmacist is "the last possible source of error" with respect to drugs. In 'o rder to serve in this role as "the last possible source of error," the following are a few of the many possible avenues open-( 1) clinical pharmacy, (2) pharmacist-consultants with respect to nursing homes, small hospitals and extended care facilities; (3) institutional acceptance of the unit dose system, (4) development of more professional practice centers, (5) development of more group practices and (6) the acceptance of our responsibility as the professionals who must be charged with detecting potential drug interactions. It is extremely probable that recognition of drug interactions by pharmacists may become the sole factor that will be capable of elevating the contempor'ary practice of pharmacy from a purely technical operation to a truly intellectual pursuit. Pharmacists who were willing to exercise some degree of introspection have been searching for this sort of activity for years. The salient feature of this activity is that it is a service of which the value is readily recognized by physicians and laymen alike. This innovation is so important because it is applicable to all types of pharmaceutical practice, including commun~ty practice. In full honesty, there is probably a much greater need for detecting drug interactions in community practice because there is less oontrol over patient action than there is in the institution. In order to fulfill this last function, much has been written concerning the utility and advisability of a prescription record system. Roger W. Cain once stated that3Regardless of the time and cost factor in providing patient or family prescription record systems, it appears essential that every pharmacist, in order to provide pharmaceutical service to his patrons, should adopt and utilize a system for maintaining patient prescription records.
The key word in Cain's statement is "utilize." To merely keep a record system-but to neglect proper utilization of this system-is just one step better than not having the system at all. Many pharmacists have gone to the expense and time to develop such a system and yet will not even detect the most blatant drug interaction because they are not really utilizing the system or what they have been taught. Others have stated that the maintenance of a patient or family prescription record system is merely a stepping stone to a much more medically useful file that could be developed. This ultimate goal would be the development of a patient or family drug sensitivity record or adverse drug reaction record. Problem
Today the major therapeutic incompatibilities that are witnessed occur as a result of drug interactions. Increasingly each day with the advent of so many potentially dangerous drugs and also with the advent of more and more self-medication, the possibility of a patient creating an interaction which could prove quite harmful or even fat'al, has been recognized. Also the fact that many patients, as a matter of course, pursue treatment from more than one physician has raised the possibility that one physician may be treating a condition with one drug product that is contraindicated in the treatment of another disease or in combination with some other drug product that already has been prescribed by another physician. The final possibility that a single physician might very easily prescribe two or more drug products that are inherently contraindicated also has been Tecognized. The problem, therefore, lies in the fact that anyone of these three situations might exist and that in any case the potential harm to the patient involved might be tremendous. Purpose The purpose of this project was to present an analysis of the possibility of potentially dangerous drug interactions that can arise from the patient's use of many physicians. From such an analVol. NS10, No.8, August 1970
451
ysis it is hoped that the .need for. m?re complete patient or famIly pr~~cnptlOn record systems (properly uttllz~d) . or some sim~lar method of momtonng medication consumption could be demonstrated. Methodology The analysis was conducted on the new prescriptions and renewal p:escriptions in a suburban communIty pharmacy in the N ew Orlea~s metropolitan area. The co~munity pharmacy chosen to be studIed had the following characteristics-( 1) there were 352 charge accounts, (2) there were two full-time pharmacists and one relief pharmacist, who was employed once a week, (3) there were. two fulltime ,c ashiers and one part-tIme cashier (4) there were two full-time drug cle~ks and one part-time drug cle:k, (5) there were 11,828 new prescnption orders dispensed by the pharmacy in the study year, (6) there were ~p proximately 15,000 renewal prescnptions in the year and (7) net sales were over $250,000. The charge account files were utilized to obtain infoI1mation concerning renewal prescriptions. By necessity, all the results were limited to those consumers who had charge accounts at this pharmacy. All of the charge files for the study year and all new prescriptions for the year were microfilmed and cross-referenced for detail study. Types of Drug Interactions McKiver4 has stated that there are basically six types of possible drug interactions. He classified these as1. Straightforward potentiation, either by additive effect or by synergistic action. 2. Enzymatic inhibition, whereby one drug prevents the normal metabolism of another drug with cumulative effect and enhanced toxicity. 3. Stimulation of enzyme systems, whereby one drug increases the rate of metabolism of another. 4. Displacement of one drug from plasma or tissue protein by another drug which has a greater affinity for the protein binding site, causing the unbound drug to reach toxic levels. 5. Electrolyte imbalance, such as the loss of potassium induced by thiazide diuretics-causing increased toxicity of digoxin or muscle relaxants. 6. Interference with urinary excretion. Most of the drug interactions that were noted in this study were either straightforward potentiation or the use of drugs whose concomitant use is questionable. Use of Many Physicians One particular case study was disclosed which demonstrates emphatical452
Bernard G. Keller Jr. is chairman of Southwestern State College department of pharmaceutics. Having earned his BS in pharmacy at Loyola University of New Orleans, Keller went on to receive his MS and PhD in pharmacy administration from the University of Mississippi. A former community pharmacist, he also has been a pharmacy consultant and manager. Keller has authored a number of articles and currently is conducting a study on the effective utiliza-, tion of patient record systems. He is a member of APhA, Academy of Pharmaceutical Sciences, ASHP, AACP conference of teachers, Rho Chi and Kappa Psi.
Raymond J. Bennett is currently a faculty member at the University of Montana and previously was a member of the University of Mississippi faculty. Former pharmacy owner and community pharmacist, Bennett earned his BS in pharmacy at Idaho State University and MBA and PhD in pharmacy administration at the University of Wisconsin. He is a member of Montana State Pharmaceutical Association and serves as secretary of the association's board of directors.
ly the dire need for better drug control at both the physician level and the pharmacist level. A female patient, age 35, was receiving ethchlorvynol 500 mg capsules and chlorprothixene 100 mg tablets from one physician. Another physician, with no knowledge of th~s fact, prescribed in the same time period more ethchlorvynol 500 mg capsules, pentobarbital sodium 100 mg capsules and tranylcypromine 10 mg tablets. Thus we can witness the potentiation of the ethchlorvynol, the pentobarbital sodium and the chlorprothixene, while at the same time a monoamine oxidase inhibitor such as tranylcypromine is contraindicated with a major tranquilizer such as chlorprothixene. About three months later, this same patient was administered thioridazine HCI 10 mg tablets arid pentobarbital sodium 100 mg capsules by a third physician. One of the other physicians, whom she had been visiting all along in the same time period, prescribed glutethimide 0.5 gm tablets, more pentobarbital sodium 100 mg capsules and ethchlorvynol 500 mg capsules. We already have established that ,t he patient was receiving tranylcypromine tablets, but one of the other physicians prescribed imipramine HCl 25 mg tablets. It is
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
well documented that the concurrent administration of a monoamine oxidase inhibitor and a tricyclic antidepressant results in potentiation of the antidepressant and should be avoided because of the danger of a hypertensive crisis. The last encounter with this patient came near the end of the study year. At that time she received a prescription for 40 chlorprothixene 25 mg tablets, 15 ethchlorvynol 500 mg capsules and 50 meprobamate 400 mg tablets. The physician authorized renewals in such a manner that within 19 days, the woman had in her possession 160 chlorprothixene 25 mg tablets. During 30 days, she had 90 ethchlorvynol 500 mg capsules and during 70 days she had 450 meprobamate 400 mg tablets. Was it any wonder that during this "mixed" drug regime she developed cardiac insufficiency and also was placed on digitoxin 0.2 mg tablets? It would appear that the physicians and the pharmacists involved all should have been cognizant of
tions are allowed to exist in this day and age, but we must keep in mind that we are a nation of people who believe in the specialization of medicine. This may partially account for the prevalence of these types of interactions. Stated simply, it appears that the sophisticated patient of the 70's enjoys consulting with more than one physician. This certainly builds into the relationship an inherent problem drug situation.
Conclusions This study produced a dramatic case of drug interactions. Admittedly many of the examples cited were exceptional. Also admittedly, this study was based solely on the facts that were observed and obtained in one community pharmacy. Nevertheless, to the person who suffers from one of these reactions it is little comfort to know that his is an exception to the rule. Nonetheless, this case certainly substantiates that the problem exists in everyday community practice. It points out dynamically that something must be done. Certainly a well-defined course of action might be1. Institute a patient record system
from which the drug data can be readily retrieved. 2. Develop and nurture the proper sci-
Legal Problems (continued from page 450)
Drug Administration regulations notwithstanding-the pharmacist has no one to share the blame for any resulting damage to the patient. N or can he, in most cases, shift the blame to the manufacturer who under present law has a quite respectable defense in the fact that his label conforms to government requirements. True, FDA permits the sale of proprietaries on an assumption that the patient reads and comprehends a label which complies with Federal specifications and is thereafter on his own. The speciousness of this assumption is apparent to any pharmacist and has not escaped the attention of diligent plaintiff's counsel. Suppose for example, that the pharmacist knows that the purchaser cannot read English or that she is incapable of reading sm;all print with or without her glasses. And suppose that this hypothetical patient is purchasing a cold remedy containing substantial a~ounts of atropine or an antihistamIne with substantial atropine-like effects, and that the pharmacist knows
entific knowledge and professional judgment necessary to recognize and evaluate drug interactions. This can be done by carefully reading the leading pharmaceutical journals and newsletters which are devoting more time and space to these interactions. The schools of pharmacy also can prove helpful to the pharmacy practitioner by offering expanded continuing education seminars that deal with these pertinent topics. 3. Strive to develop the necessary tact and diplomacy that are needed to get such situations corrected. From the patient's point of view it can increase your stature as a professional person. From the viewpoint of interprofessional relations, the physician will soon begin to be cognizant of what a well-informed and potentially powerful colleague he has. Who then is responsible for preventing such reactions? Certainly the physicianmust share in this responsibility. But who clai'ms to be an expert on drugs? Who has had massive quantities of medicinal chemistry, pharmacology and biopharmaceutics to enable him to understand the mechanisms of drug interaction? The answer is inevitably the pharmacist. Therefore, the pharmacist must share the responsibility for detecting and preventing adverse drug in-
teractions-perhaps even more so than the physician. As a panel of experts on drug interactions recently concluded5-
that she has glaucoma because he has for years been dispensing and renewing her eye physician's prescriptions for pilocarpine? What is his professional responsibility in this case? Or suppose the teen-age member of a family well known to the pharmacist and known to be a devotee of drag racing comes in to purchase large quantities of an antihistamine-containing cold remedy because he is "getting a cold and wants to be in good shape for the big race tomorrow afternoon." Where do the pharmacist's professional responsibilities lie here? With respect to proprietaries, the community pharmacist who knows something of his patients and their situations is in an ideal position to prevent possible harm in the misuse of propr-ietaries. He is, on the other hand, more vulnerable to suit should injury occur from a failure to warn and advise a patient whose situation, whose ailments or whose limitations are well known to him. I know pharmacists who make it a practice to warn and to advise in professional terms and within the limits of
their professional training all purchasers of any proprietaries which carry a significant hazard or risk of misuse. There are probably a few physicians and pharmacists around who would regard this as improper and verging on the practice of medicine. As a physician I admire the professionalism and concern for the public demonstrated by careful pharmacists and as a lawyer I applaud their wisdom. No court today is likely to penalize 'a trained professional for the proper exercise of his professional responsibilities in protecting the public who are his customers on the theory that he is thereby engaging in the practice of medicine. And few counts are likely to respond to a defense based on a theory that the patient has adequate protection under Federal labeling law if the pharmacist is in a position to know that in the case at hand this simply was not so. Despite present uncertainties and ignorance, the future of medicine and of pharmacy is being determined today. By our collective action or sepavate defaults, it will be largely what we make it. •
In the future, you may be able to count more heavily on pharmacists in the hospital and at the corner pharmacy to assist you (the physician) in predicting possible interactions and guarding against them. A new breed of pharmacist equipped to provide this type of consultation · is now being educated in some of the schools of pharmacy across the country.
In conclusion, let us consider the following-no drug, no chemical, no prescription can cause harm to a patient until dispensed by the pharmacist. When dispensing, the pharmacist asserts, that to the best of his knowledge this drug is both safe and effective. Truly then the pharmacist is the last possible source of ·error. • References 1. McCormack, Thelma R., "T4e Druggists Dilemma: Problems of a Marginal Occupation," Am. J. Soc., 61, 308 2. Rosner, Martin M., "Attitudes Toward Maintaining Family Records on Drug Sensitivities," JAPhA, NS4, 169 (April 1964) 3. Cain, Roger W., "New Prescription PracticesPatient Record Systems," JAPhA, NS4, 168 (April 1964) 4. "Incompatibilities Now Occur Inside Patient," Am. Druggist, 35 (Dec. 4, 1967) 5. "Drug Interactions That Can Affect Your Patients," Patient Care, 1,23 (Nov. 1967)
Vol. NS10, No.8, August 1970
453