3.3 Pharmacist factors
Decisions to prescribe were thought to have been enhanced when pharmacists were involved. Doctors habitually seek advice from pharmacists present on the ward to assist in making prescribing decisions. Surprisingly, the pharmacists themselves appeared to be unaware of the high esteem within which they were held in terms of their potential ability to influence prescribing decisions. They tended to describe their role as being supportive and more as a “checker” or safety-net provider. Moreover, the pharmacists tended to compare themselves favourably with their medical colleagues with regard to performing medication reconciliation. The latter is the formal process, described in a toolkit published by the Royal Pharmaceutical Society19, that ensures accurate and complete medication information is obtained at interfaces of care such as when a patient is admitted to and discharged from hospital.
Facilitator (to pharmacists): “When assessing medication on admission, what are you seeking to achieve?”“… I would take an accurate drug history and reconcile that with the meds that have been prescribed. If there are any discrepancies, highlight them to the doctors… [and] highlight any incorrect doses as well to the doctors. Just make sure the basic safety is there and it matches with the patient that is there”(Pharmacist ). ..” Also check allergies or anything that the doctors might not pick up such as eyedrops, creams, ointments, injections. (Pharmacist ) In response to a medication history documented in one of the case studies, one of the pharmacists commented: -I think …the drug history has probably been done by a doctor…[there are] a lot of things we would have picked up like apixaban, codeine - we wouldn’t just write ‘15-30mg prn’. We would write ‘qds prn’. …Then stuff like furosemide – we wouldn’t write ‘bd’. We would write 8am and 2pm. …Movicol – we wouldn’t write ‘bd’, we would write how many sachets they are having”(Pharmacist).
Doctors acknowledged that discharge prescriptions may be prepared based upon recommendations from pharmacists, as illustrated here: -
I think, most of the time, when we are reviewing the medication at the time of discharge, we do the ‘lifestyle’, and then we go through the medication they came in with - [and we check to see] if the pharmacists are concerned about anything [by pharmacist highlighting in the notes](Doctor A, 2016).“If you have a really good pharmacist (Doctor B, 2016).“Yeah” (Doctor C, 2016).“If the pharmacist hasn’t highlighted it, then actually they go home without those medications (Doctor D, 2016).
The pharmacists did not always appreciate the clinical reasoning that underpinned prescribing decisions when an alternative action would be more obvious to them:-
Pharmacist 1: “Why are they on digoxin? Maybe they have developed AF [atrial fibrillation]?” Pharmacist 2: “Yeah”, Pharmacist 3: “They are on bisoprolol 2.5mg, why don’t they just optimise that [bisoprolol] first before starting digoxin?”Pharmacist 2: “They’ve got the patient on senna [which] can actually cause hypokalaemia which can cause digoxin toxicity”.Pharmacist 1: “You would want to know if they are having palpitations”.
The full potential of pharmacists with therapeutic knowledge was not evident within the doctors’ focus group transcripts, a finding that has also been reported by Anderson et al.20 The skills of pharmacists appeared to be under-utilised with regard to new product prescribing, as has been reported by Tan et al.21 and in community pharmacy practice 22, as well as a lack of formal partnership between the two groups resulting in the actions of pharmacists’ being curtailed. Recent research in the UK demonstrates, however, that community pharmacists can conduct medication reviews and work effectively within a multidisciplinary team to tackle polypharmacy resulting in reduced re-admission rates after discharge from hospital.23 24
3.4 TrustworthinessThe concept of trustworthiness was relevant in terms of the veracity of medication records and, on a human level, between doctors themselves and their colleagues. Prescribing decisions reflected decision-making by doctors independently and in collaboration with pharmacists.
The way trustworthiness informed prescribing decisions was evident within the discourse of both doctors and pharmacists. On a ‘systems’ level, trustworthiness was apparent in terms of a perceived lack of reliability of the medication history and its currency in relation to the patient’s presenting condition. Drug histories were viewed with a healthy degree of scepticism even when taken directly from patients. For example– “I ask them: ‘Are you taking your medication’?” (Doctor 2, 2017)…“and they all say “yes”!’ (Doctor 5, 2017). This was modified by the extent to which they thought patients were adhering to prescribed regimens. On a human level, there was evidence that some of the more experienced doctors did not always trust junior colleagues as active decision-makers - “It is usually the junior doctors who access the system and make the changes on senior instructions - so on the system it may look like the juniors are making decisions but they are just acting on instructions” (Doctor, 2015). Pharmacists, regardless of their level, were trusted by doctors to be more accurate regarding the recording of drug histories. This perception was reinforced by some pharmacists, who also believed there was degree of reliance upon them to pick up problems.