Welcome to your September issue of Irish Pharmacist, which we hope will provide information, informed opinion and even a smile or two.
In this issue, your colleague Terry Maguire writes about the tragic death of a 20-month-old child due to fentanyl overdose. During the child’s inquest, the narrative was that he had somehow come into contact with the patch his terminally ill uncle had been using for pain relief.
The Coroner identified the case as the first of its kind in Ireland, although it has been said in other jurisdictions where a similar tragedy happened that it must “never happen again”.
Terry handles the matter with great care, and asks the question regarding how far a pharmacist’s responsibility goes. In supplying the drug, with ‘All medicines must be kept out of the reach of children’ clearly printed on the label, the onus of responsibility is passed on to the patient or their carer.
Of course, pharmacists’ duty of care includes providing explicit advice and warnings, if necessary, when supplying a drug. But patients or carers also have a duty of care to heed these warnings and read the PIL and/or SPC. Patient awareness is key when it comes to potentially dangerous drugs, which, in reality, includes almost all drug therapies.
I emphasise that I am discussing these issues in a general context, rather than in direct reference to the tragic death that Terry discusses.
He points out that the Institute of Safe Medication Practice (ISMP) in the US, which was founded 20 years ago, uses a helpful system that might contribute to addressing these incidents. The ISMP uses a framework process that is built upon a non-punitive approach and system-based solutions. These fall into five key areas: Knowledge, analysis, education, co-operation, and communication.
Overall, it’s an unsettling reminder of what can sometimes happen when medicines leave the dispensary.
Terry’s contribution this month is one of a number of thought-provoking pieces by your columnists, which we hope you will enjoy along with our clinical content, which can earn you 2 CPD points.
Have a wonderful September.
