See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/270734007

Should Hospital Pharmacists Prescribe?

Article  in  The Canadian journal of hospital pharmacy · October 2014

CITATIONS READS

3 80

2 authors:

Yvonne Pudritz Holly Mansell

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Tutor Plus - Train the Trainer View project

Lehrfilme für das Seminar Klinische Pharmazie II - Apothekenrelevante Fallbeispiele View project

All content following this page was uploaded by Yvonne Pudritz on 12 January 2015.

The user has requested enhancement of the downloaded file.

Should Hospital Pharmacists Prescribe? of the Canadian Pharmacists Association states that “pharmacists
will take on increased accountability for patient-centred, outcomes
THE “PRO” SIDE focused care”,5 and the Canadian Society of Hospital Pharmacists
“advocates the role of pharmacists as capable prescribers and
Should hospital pharmacists be prescribing medications? This supports the pharmacist’s role in a collaborative prescribing
question reminds me of the age-old record player in my cabin, which model”.6 These views are not limited to Canada.7 The 2008 Basel
keeps playing the same song over and over. Although in the past this Statements, reflecting the perceptions of pharmacists from
question has been debated numerous times, recent changes to our 98 countries, acknowledged the benefits of allowing hospital
practice landscape may finally help us to answer this question once pharmacists to prescribe.8
and for all. Clearly, support for prescribing by hospital pharmacists is
Formerly recognized mainly for distributive functions, growing, so what is the impetus for this trend? In an era of rising
pharmacists in all settings are now involved in health promotion, health care costs, pharmacists have been referred to as an under-
disease-state management, and pharmaceutical care, as well as utilized health care system resource.9 Traditionally, pharmacists’
both collaborative and independent prescribing. As our roles have interventions have been retrospective in nature,7 representing
evolved to become more clinically focused, prescribing has reactions to drug-related problems after they have occurred.
become a logical extension of the provision of comprehensive Often, however, the most cost-effective therapy focuses on
pharmaceutical care.1 Hospital pharmacists have a long history of prevention, including avoiding drug-related problems.10 For
being leaders in prescribing, such as in pharmacokinetic dosing instance, the “9000 Points of Care” plan, developed by the
services, anticoagulation management, and therapeutic inter- Canadian Association of Chain Drug Stores, has estimated that
change programs. So, when the question is asked, “Should allowing pharmacists to proactively treat minor ailments and
hospital pharmacists prescribe?” the answer is obvious! We have administer vaccines would prevent up to 600 000 visits to the
been doing it for decades. emergency department and 1500 hospital admissions and would
While not an entirely new concept, prescribing by hospital free up 2.4 million physician hours.11 In essence, expanding the
pharmacists has continued to expand in recent years. According professional scope of pharmacists to include prescribing might
to the 2011/2012 Hospital Pharmacy in Canada survey, 55% of help to address some of the significant challenges in health care,
responding hospitals indicated that pharmacist prescribing existed including safety, medication costs, and access to care.
in their institutions.2 An increase in independent prescribing To support these claims, the positive impact of including a
activities (as opposed to independent prescribing) was also noted, pharmacist on clinical teams is well established.12 For instance, in
relative to previous years. For instance, in the 2007/2008 survey, one study, a 78% reduction in drug errors was noted after a
about a quarter (24%) of respondents reported having independ- pharmacist became involved in routine medical rounds,13 and in
ent prescribing rights for dosage adjustments, and the proportion another, US$270 000 (1995 dollars) was saved annually by
doubled, to 48%, in the 2011/2012 survey.2,3 The trend for including a pharmacist in physician rounds in an intensive care
increasing prescribing by pharmacists is likely to continue, given unit.14 The provision of pharmaceutical care facilitated by
changes to the legal framework that are occurring across Canada. prescriptive agreements or protocols has improved therapeutic
Alberta was the first province to grant pharmacists prescribing outcomes in clinical areas such as anticoagulation, heart failure,
privileges (in 2007), and currently all provinces have some form dyslipidemia, hypertension, and diabetes mellitus, as well as
of expanded scope-of-practice legislation in place4 and are at antibiotic and thromboembolic prophylaxis.14-25 For example, a
various stages of obtaining prescriptive authority. pharmacist-managed heart failure titration clinic increased
Support for pharmacist prescribing is echoed by our national the proportion of patients receiving appropriate pharmaco-
pharmacy societies, which continue to advocate for prescriptive therapy,15 and a pharmacist-managed anticoagulation monitoring
authority. For example, the Blueprint for Pharmacy envisions that service reduced the risk of associated complications relative to
pharmacists will “initiate, modify and continue drug therapy and what occurred with usual care.16
order tests”.4 The Position Statement on Pharmacist Prescribing Within the hospital, the nature of pharmacist prescribing will

390 C J H P – Vol. 67, No. 5 – September–October 2014 J C P H – Vol. 67, no 5 – septembre–octobre 2014
vary depending on provincial legislation, institutional policies, 6. Task Force on Pharmacist Prescribing (Pearson G, Yuksel N, Card D, Chin
T, Gray M, Hawbold J, et al.). Statement on pharmacist prescribing. Can
and the clinical situation. The prescriptive authority granted to
J Hosp Pharm. 2002;55(1):55.
hospital pharmacists does not translate into an obligation to 7. Emmerton L, Marriott J, Bessell T, Nissen L, Dean L. Pharmacists and
prescribe, and the question of “whether or not to prescribe” may prescribing rights: review of international developments. J Pharm Pharm
Sci. 2005;8(2):217-25.
be dictated by circumstance. For instance, a pharmacist partici-
8. The Basel Statements on the future of hospital pharmacy. Am J Health Syst
pating in medical rounds may be more inclined to provide clinical Pharm. 2009;66(5 Suppl 3):s61-6.
input by making a suggestion, given the direct accessibility of a 9. American Pharmacists Association Foundation and American Pharmacists
Association. Consortium recommendations for advancing pharmacists’
physician team member. A pharmacist performing medication
patient care services and collaborative practice agreements. J Am Pharm
reconciliation, however, may find it appropriate to use prescriptive Assoc (2003). 2013;53(2):e132-41.
authority to correct a medication error immediately, rather than 10. Viktil KK, Blix HS. The impact of clinical pharmacists on drug-related
problems and clinical outcomes. Basic Clin Pharmacol Toxicol. 2008;
waiting for a cosignature to implement his or her suggestion.
102(3):275-80.
Taken in this context, prescribing by hospital pharmacists should 11. 9000 points of care: improving access to affordable healthcare [website].
be viewed as a tool that may be used as needed to assist in provid- North York (ON): Canadian Association of Chain Drug Stores; 2013 Apr
[cited 2014 May 30]. Available from: http://9000pointsofcare.ca/contact-
ing pharmaceutical care in the most efficient manner possible.
us/
As is the case with all practice change affecting many 12. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists
disciplines, there will always be early adopters and those who are and inpatient medical care: a systematic review. Arch Intern Med.
2006;166(9):955-64.
less convinced. The Canadian Medical Association and the
13. Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on
American Medical Association have both expressed opposition to rounding teams reduce preventable adverse drug events in hospital general
pharmacist prescribing.26,27 Perhaps the best way to convince these medicine units. Arch Intern Med. 2003;163(17):2014-8.
14. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI,
groups is to approach the issue from a grassroots level, by working
et al. Pharmacist participation on physician rounds and adverse drug events
collaboratively with our colleagues to demonstrate that our goal in the intensive care unit. JAMA. 1999;282(3):267-70.
is to complement (not replace) the role of the physician. The ar- 15. Martinez AS, Saef J, Paszczuk A, Bhatt-Chugani H. Implementation of a
pharmacist-managed heart failure medication titration clinic. Am J Health
gument that there is insufficient evidence to support improved
Syst Pharm. 2013;70(12):1070-6.
outcomes for pharmacist prescribing should cease if we continue 16. Hall D, Buchanan J, Helms B, Eberts M, Mark S, Manolis C, et al. Health
to produce sound scientific research in this area. In the meantime, care expenditures and therapeutic outcomes of a pharmacist-managed
anticoagulation service versus usual medical care. Pharmacotherapy. 2011;
we have a professional responsibility to work toward establishing
31(7):686-94.
a better health care system that could improve the outcomes and 17. Witt DM, Sadler AM, Shanahan RL, Mazzoli G, Tillman DJ. Effect of a
cost-effectiveness of drug therapy.6 It is simply not cost-effective centralized clinical pharmacy anticoagulation service on the outcomes of
anticoagulation therapy. Chest. 2005;127(5):1515-22.
to pay a pharmacist wage to track down a physician to fix an
18. Cording MA, Engelbrecht-Zadvorny EB, Pettit BJ, Eastham JH, Sandoval
inpatient medication order or cosign a therapeutic substitution, R. Development of a pharmacist-managed lipid clinic. Ann Pharmacother.
when prescriptive authority could be used as an immediate 2002;36(5):892-904.
19. Smith MC, Boldt AS, Walston CM, Zillich AJ. Effectiveness of a pharmacy
solution—nor does it seem beneficial to the patient.
care management program for veterans with dyslipidemia. Pharmacotherapy.
To conclude, the question of whether or not hospital 2013;33(7):736-43.
pharmacists should prescribe has expired. Instead of spending our 20. Magid DJ, Olson KL, Billups SJ, Wagner NM, Lyons EE, Kroner BA. A
pharmacist-led, American Heart Association Heart360 Web-enabled home
time debating it, we should spend more time tackling the hurdles
blood pressure monitoring program. Circ Cardiovasc Qual Outcomes.
and embracing the opportunities. 2013;6(2):157-63.
21. Morgado MP, Morgado SR, Mendes LC, Pereira LJ, Castelo-Branco M.
References
Pharmacist interventions to enhance blood pressure control and adherence
1. Pearson GJ. Evolution in the practice of pharmacy—not a revolution.
to antihypertensive therapy: review and meta-analysis. Am J Health Syst
CMAJ. 2007;176(9):1295-6.
Pharm. 2011;68(3):241-53.
2. Babich M, Bornstein C, Bussières JF, Doucette D, Hall KW, Lefebvre P, et
22. Anaya JP, Rivera JO, Lawson K, Garcia J, Luna J Jr, Ortiz M. Evaluation of
al., editors. Hospital pharmacy in Canada 2011/2012 report. Eli Lilly; 2012
pharmacist-managed diabetes mellitus under a collaborative drug therapy
[cited 2014 May 20]. Available from: www.lillyhospitalsurvey.ca/hpc2/ agreement. Am J Health Syst Pharm. 2008;65(19):1841-5.
content/rep_2012_toc.asp 23. Taveira TH, Dooley AG, Cohen LB, Khatana SA, Wu WC. Pharmacist-
3. Babich M, Bussières JF, Hall KW, Harding J, Johnson N, Lefebvre P, et al., led group medical appointments for the management of type 2 diabetes
editors. Hospital pharmacy in Canada 2007/2008 report. Eli Lilly; 2008 [cited with comorbid depression in older adults. Ann Pharmacother. 2011;45(11):
2014 Mar 20]. Available from: www.lillyhospitalsurvey.ca/hpc2/ 1346-55.
content/rep_2008_toc.asp 24. Brummel AR, Soliman AM, Carlson AM, de Oliveira DR. Optimal
4. Blueprint for Pharmacy Steering Committee. Blueprint for Pharmacy: our diabetes care outcomes following face-to-face medication therapy manage-
way forward. Ottawa (ON): Canadian Pharmacists Association; 2013 [cited ment services. Popul Health Manag. 2013;16(1):28-34.
21May2014]. Available from http://blueprintforpharmacy.ca/docs/pdfs/ 25. Galindo C, Olivé M, Lacasa C, Martínez J, Roure C, Lladó M, et al.
blueprint-priorities---our-way-forward-2013---june-2013.pdf Pharmaceutical care: pharmacy involvement in prescribing in an acute-care
5. CPhA position statement on pharmacist prescribing. Ottawa (ON): hospital. Pharm World Sci. 2003;25(2):56-64.
Canadian Pharmacists Association; 2007 [revised 2011; cited 2014 May 26. e-Panel survey summary: pharmacist prescribing. Ottawa (ON): Canadian
23]. Available from: www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the- Medical Association; 2007 [cited 2014 May 23]. Available from:
issues/PPPharmacistPrescribing.pdf www.guidespratiqueclinique.ca/e-panel-pharmacist-prescribing,

C J H P – Vol. 67, No. 5 – September–October 2014 J C P H – Vol. 67, no 5 – septembre–octobre 2014 391
 27. Weiss D. AMA opposes giving pharmacists prescription authority. Pharm UK, ward pharmacists review patients within 24 h of admission,
Times. 2012 Jul 10 [cited 2014 May 23]. Available from: www.pharmacy-
reconcile their medications, and discuss any omissions or
times.com/news/AMA-Opposes-Giving-Pharmacists-Prescription-
Authority necessary changes with the medical team; additionally, they
regularly review medical charts of all inpatients and check any
new prescriptions for potential drug interactions or patient
Holly Mansell, BSP, PharmD contraindications. At our local hospital, all discharge prescriptions
Assistant Professor
College of Pharmacy and Nutrition
also receive a clinical check by a ward pharmacist; otherwise, the
University of Saskatchewan prescription will not be dispensed by the hospital dispensary.
Saskatoon, Saskatchewan The following examples illustrate why we should be very
Competing interests: None declared. cautious about destabilizing this effective system by introducing
pharmacist prescribing.
Nissen6 stated that pharmacist prescribers would have to
adhere to the same rules as medical prescribers, including review
of their prescriptions by a nonprescribing pharmacist. Reflecting
this statement, prescribing of medication and subsequent dispens-
ing must be kept separate,6 and one implication of this approach
THE “CON” SIDE is fragmentation of the pharmacy workforce into “prescribers” and
“nonprescribers”.7 A second implication is that a new system, and
Over recent years, the way health care is delivered and by whom
new resources, would be needed to deliver the gatekeeper and
has been subject to continual change. This is a global phenomenon,
safety-net roles previously performed by the pharmacist. In
especially in the developed world, and reflects changes in workforce,
practice, this rarely happens, perhaps because (in the UK and
budgetary constraints, and demand. The evolution of prescribing
rights is one example of such a change. Prescribing is no longer a possibly elsewhere) pharmacists often take on prescribing at an
unique privilege for medical doctors. For example, nurses and individual practitioner level, operating within an area of special
pharmacists have been able to prescribe to some degree in the United interest or expertise, rather than taking a strategic approach
States since the 1970s.1 The first prescribing course for pharmacists involving service redesign.8 This situation has potential risks for
in Scotland was offered in 2003.2 This course initially covered patient safety.
supplementary prescribing, a format whereby pharmacists could Secondly, I fear there will be a decline in bedside teaching of
prescribe within a set treatment plan that was discussed with a medical prescribing skills by pharmacists to medical doctors. Emmerton
prescriber. After legislative changes that extended the rights of and others7 have highlighted that prescribing by pharmacists is
pharmacists and nurses in the United Kingdom, these health care more efficient, as it is no longer necessary to chase medical staff
professionals can now prescribe from the whole range of the British for amendments to prescriptions, because the pharmacists have
National Formulary without consulting a medical doctor.3 Nonmed- the authorization to make these changes themselves. However,
ical prescribing has been seen to maximize the skills and contributions a significant downside is the loss of opportunities to educate
of pharmacists within multidisciplinary teams.4 Canadian jurisdic- medical prescribers about errors. Thus, the medical workforce be-
tions have started to expand pharmacists’ prescribing rights over the comes “deskilled”. The UK Foundation Programme curriculum
past few years, and as of August 2010, pharmacist prescribing was sets out the learning outcomes for the first 3 years of medical train-
possible in nearly all provinces.5 ing after graduation from medical school.9 In the section on “safe
Despite the advantages of pharmacists prescribing in second- prescribing”, it states that Foundation Year 1 doctors should be
ary care, there are disadvantages to independent pharmacist able to take an accurate drug history and to prescribe drugs and
prescribing that must be considered carefully before this practice treatment “appropriately, clearly and unambiguously”9 and that
is implemented locally. they are expected to work “closely with pharmacists and more
Currently, hospital pharmacists are well-respected members experienced prescribers”.9 In a recent review in Scotland of
of multidisciplinary teams, often involved in ward rounds. Their prescribing errors made by medical staff, the majority of junior
traditional role has been that of a gatekeeper and safety-net doctors interviewed were under the impression that their prescrib-
provider. Prescriptions written by one member of the clinical ing errors would be picked up by the ward pharmacist.10 This
team, usually a junior doctor, are reviewed by the pharmacist, might be true during pharmacist working hours, but seldom can
either on the ward or at the point of dispensing. The pharmacist the pharmacy provide a 24/7 service, which results in the risk that
provides an independent review and opinion within the multi- outside regular working hours, prescribing errors will reach
disciplinary team, from the pharmaceutical perspective, and patients. Junior medical staff have to be supported through
supports clinical and cost-efficient decisions. This is all done from experiential training to make optimal prescribing decisions and
a therapeutic viewpoint rather than a diagnostic viewpoint. In the translate these into correctly written prescriptions.

392 C J H P – Vol. 67, No. 5 – September–October 2014 J C P H – Vol. 67, no 5 – septembre–octobre 2014
 Finally, in secondary care, multidisciplinary teams with 5. Law MR, Ma T, Fisher J, Sketris IS. Independent pharmacist prescribing in
Canada. Can Pharm J. 2012;145(1):17-23.e1.
nonmedical prescribers, such as nurses or pharmacists, could also
6. Nissen L. Current status of pharmacist influences on prescribing of medi-
suffer from the syndrome of “too many cooks spoil the broth”. I cines. Am J Health Syst Pharm. 2009;66(5 Suppl 3):S529-34.
have personally experienced situations in which a medical doctor 7. Emmerton L, Marriott J, Bessell T, Nissen L, Dean L. Pharmacists and
changed pain medication on the ward round in the morning, with prescribing rights: review of international developments. J Pharm Pharm
Sci. 2005;8(2):217-25.
the prescribing pain nurse amending the prescription a mere 8. Latter S, Blenkinsopp A, Smith A, Chapman S, Tinelli M, Gerard K, et al.
2 hours later, with no verbal communication taking place between Evaluation of nurse and pharmacist independent prescribing. UK Department
the prescribers. This results in confusion for the patient and a of Health Policy Research Programme Project 016 0108. University of
Southampton and Keele University; 2010.
system with increased potential for errors. Dean and others,11 in 9. The Foundation Programme: curriculum and assessment. Cardiff (Wales):
their program of work on prescribing errors noted, in 2002 UK Foundation Program Office; 2014 [cited 2014 Jun 18]. Available from:
(before the introduction of nonmedical prescribing in the UK), www.foundationprogramme.nhs.uk/pages/home/training-and-assessment
10. Ryan C, Ross S, Davey P, Duncan EM, Francis JJ, Fielding A, et al.
that team factors such as poor communication and unclear lines
Prevalence and causes of prescribing errors: the prescribing outcomes for
of responsibility are risk factors for prescribing errors. More than trainee doctors engaged in clinical training (PROTECT) study. PLOS One.
a decade later, Ryan and others10 found that junior doctors in par- 2014;9(1):e79802.
ticular were still confused by the number of individuals and teams 11. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing
errors in hospital inpatients: a prospective study. Lancet. 2002;359(9315):
that can be involved in prescribing, and team factors remained 1373-8.
problematic. These issues will be further increased by adding more
prescribers to the mix.
In conclusion, pharmacists are an invaluable resource in any
multidisciplinary team in secondary care and are in the best
position to advise prescribers about initiation, continuation, or
amendments of prescriptions. However, in multidisciplinary
teams in hospitals, they are better used as gatekeepers and
providers of a safety net for other prescribers, medical and
nonmedical, than as prescribers themselves.
References
1. Cooper RJ, Anderson C, Avery T, Bissell P, Guillaume L, Hutchinson A, et Yvonne M Hopf, MPharmS, MSc, PhD
al. Nurse and pharmacist supplementary prescribing in the UK—a thematic Centre of Academic Primary Care
review of the literature. Health Policy. 2008;85(3):277-92. University of Aberdeen
2. Pharmacist prescribing [website]. Edinburgh (Scotland): NHS Education Foresterhill, Aberdeen, Scotland
for Scotland; 2014 [cited 2014 Jun 18]. Available from: www.nes.
scot.nhs.uk/education-and-training/by-discipline/pharmacy/pharmacists/ Dr Hopf is also a teacher practitioner in clinical pharmacy at the hospital
pharmacist-prescribing.aspx of the Ludwig-Maximilians-Universität München (LMU Munich) in
3 Tonna AP, Stewart D, West B, McCaig B. Pharmacist prescribing in the Munich, Germany.
UK—a literature review of current practice and research. J Clin Pharm Ther. Competing interests: Yvonne Hopf has received a National Health
2007;32(6):545-56. Service Applied Programme Grant and a postdoctoral fellowship from
4. Crown J. Review of prescribing, supply and administration of medicines: final the Chief Scientist Office of Scotland for work outside the scope of this
report. London (UK): Department of Health; 1999 [cited 2014 Jun 25]. article. She is registered as an independent pharmacy prescriber with the
Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/ General Pharmaceutical Council but does not currently utilize her
en/Publicationsandstatistics/Publications/PublicationsPolicyand prescribing rights. Her current post is funded by the Dr August and
Guidance/DH_4077151 Dr Anni Lesmüller Foundation.

C J H P – Vol. 67, No. 5 – September–October 2014 J C P H – Vol. 67, no 5 – septembre–octobre 2014 393

View publication stats