Pharmacists have been reminded of the need to follow correct standards and procedures in the preparation of dose administration aids (DAAs) following a warning from the Pharmacy Board of Australia over a medication incident involving the drug methotrexate.
The Board said this resulted in a death and while the medication was dispensed correctly, the resultant packaging of the drug into a dose administration aid by a pharmacy technician was incorrect and the packing error was not detected by the pharmacist.
National President of the Pharmaceutical Society of Australia (PSA), Grant Kardachi, said DAAs were extremely effective in assisting in compliance and adherence to medication regimens but pharmacists needed to be robust in their procedures.
“PSA has in place guidelines and standards for DAAs and these were developed to help ensure a DAA service meets the safety and quality requirements of professional practice,” Mr Kardachi said.
“These standards and guidelines stipulate that a pharmacist should introduce procedures for quality control, quality assurance and monitoring of DAA provision.
“They also say audits should be carried out before starting a DAA service and at six-monthly intervals. The performance and results of these activities should be recorded together with any action taken, or outcome.”
Mr Kardachi said millions of DAAs were prepared annually in Australia and were proven to be highly effective in improving the nation’s health, with non-compliance of medicines still a major factor in adding significant costs to the health system.
“Pharmacists every year actually prevent thousands of medication mishaps through DAAs and the case highlighted by the Pharmacy Board is a rare, but unacceptable, incident,” Mr Kardachi said.
“I would also remind pharmacists involved in DAAs to have a separate area of the pharmacy dedicated to this work so that all those involved in the preparation and checking of DAAs are able to work in an environment that allows the standards and guidelines to be met.
“As detailed in PSA’s Code of Ethics, patient wellbeing and their health outcomes are paramount for everything that pharmacists do and DAAs are no exception.”
Mr Kardachi said PSA had also developed four checklists in its guidelines to assist pharmacists with: