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MMI Scenario 10
Vicky, one of your regular daily supervised methadone patients comes into your pharmacy to collect her daily instalment of 40ml Methadone 1mg/ml mixture. It is the Saturday before the bank holiday Monday. When you go to hand out the instalment you notice the script has not been correctly written to allow for take away doses for store closure on the bank holiday. There is no approved home office wording either. How would you handle this situation? What legal vs ethical decision-making dilemmas does this case present?
Patient care and safety: As a pharmacy professional we have a duty of care and the welfare/health of Vicky should be the centre of any decision making. If we choose not to issue her with the Monday dose due to an incorrectly written MDA script would could be the patient outcome? Damage Vicky’s trust and relationship with the pharmacy? With you the pharmacist? Her welfare, if she doesn’t receive her Monday dose should could be at risk of relapsing and seeking illicit drug use to maintain her craving. This could lead to criminal activity which could put Vicky and others at risk of abuse.
Decision making steps:
Decision making steps:
- Supply the take-home dose: For Monday even though not indicated on the MDA script- unlawful supply, but could liaise with key working, drug and alcohol clinic on the Tuesday and get the script amended to cover this supply. Alternatively, is there an OOH DAS contact we could seek advice from, is there any scope to get the script amended before the end of the working day and work with Vicky to get this done before the end of the day. Any conversations/decisions must be fully documented within the patient care record, internal incident report system, CD accountable officer incident form, and referenced on what decision was made, why and a summary of how you came to this decision.
- Withhold the Monday dose and inform Vicky nothing can be done: This would be legal based on how the MDA script has been written but would damage trust and the care we provide to Vicky. Withholding Monday’s dose could leave Vicky at risk of withdrawal, relapse of drug addiction/substance misuse, and increase her risk of contracting blood borne viral illness from injections.
- Refer Vicky to out of hour services (OOH) service/hospital teams: If there is a known OOH drug and alcohol services nearby this might be a solution, but who else could do this, we would ideally need a new script to cover the weekend take-away doses, since we wouldn’t hand back an already endorsed/partly dispensed MDA script to Vicky. Could we send a member of the pharmacy team after telephoning OOH, or could we organise a courier to drop the prescription off before store closure. Referring Vicky blindly to OOH/hospital could cause problems as not all OOH prescribers have a license to prescribe methadone and could lead to inappropriate referral and further complicate this already challenging situation.
- Do nothing - supply the take-away instalment and endorse the script accordingly. The drug and alcohol team must have made a mistake and since the store is closed, I must supply Mondays installment in advance. Although this may seem like a common thought and it may well be correct, it is unlawful and not documenting or making appropriate arrangements to get the script amended would leave you as an individual exposed to litigation. It is imperative that any decision making is fully documented.