Understanding your Liability when Collaborating with Prescribing Pharmacists

The SMA has received a number of inquiries from physicians regarding liability issues when working in collaborative relationships with pharmacists. The SMA sought advice from the Canadian Medical Protective Association (CMPA). The CMPA states that the successful implementation of any collaborative care model must include two key components:

1. Adequate and timely communication between participating health care professionals.
2. The mandatory requirement that all members of the collaborative health care team have adequate liability protection.

Steps should be taken to mitigate risks and prevent adverse outcomes. Physicians should consider the following:

- Establish clearly delineated roles, responsibilities, and processes with pharmacists with whom you collaborate in the care of a patient.

- Consider establishing and documenting a formal method of communication with prescribing pharmacists.

- When contacted by a pharmacist regarding a patient's care following a pharmacist's prescription, ask the pharmacist his/her plans for the future and explain your expectations regarding roles and responsibilities.

- Establish measures to review, in a timely manner, communications received from pharmacists regarding patients.

- Document exchanges with pharmacists regarding prescribing and follow up.


Background information on enhanced prescriptive authority for pharmacists

In the past few years, a growing number of provinces/territories have enacted legislation to expand the scope of practice of health care professionals. Recent efforts have included expanding the scope of practice for pharmacists. The SMA's position is that physicians want to work with pharmacists in collaborative relationships that benefit the patient. As of March 4, 2011, Saskatchewan pharmacists have enhanced prescribing authority. Amendments to the Saskatchewan College of Pharmacists' bylaws recognize the ability of pharmacists with advanced training to have an expanded role in prescribing medications while working in collaborative relationships with physicians.

The legislation authorizes Level I (basic), which includes services such as extending refills on existing prescriptions and providing emergency supplies of prescribed medications, and Level II (advanced), which will enable pharmacists to prescribe certain medications for minor ailments in the near future when prescribing within collaborative practice environments. Level I activities are within the competency of all pharmacists licensed in the province of Saskatchewan. A collaborative relationship is presumed to exist for all level I prescribing actions between all Saskatchewan physicians and all Saskatchewan pharmacists. At present, only level I prescribing actions are occurring in Saskatchewan. A collaborative practice environment means that collaboration in the relationship between the pharmacist and practitioner involved in the care of the patient must be sufficient so that the practitioner can rely upon the basic skills of the pharmacist to prescribe in the best interests of the patient, communicate those decisions back to the practitioner, and refer the patient to them or other health care providers as appropriate. Ongoing communication between the pharmacist and the practitioner is expected.

The legislation also authorizes Level II authority where the pharmacist possesses advanced skills and/or where there are more sophisticated or advanced relationships between pharmacists and practitioners. It is permitted within formal, written agreements between pharmacists and practitioners. Generally, such agreements stipulate the conditions, limitations, or qualifications to the authority of a pharmacist to prescribe. Both parties formally agree that the pharmacist prescribe within the parameters of the agreement. Level II prescribing has not yet occurred in Saskatchewan.

Physicians have had questions in two particular areas:

- Practitioners' responsibility when receiving a pharmacist assessment report – It is the physician's responsibility to review the information, the same way they review the information from a homecare nurse or when they are copied on a letter from an optometrist. The physician has the right to expect that the pharmacist, as an autonomous professional, is doing their job professionally and competently. They are not required to check the refill for accuracy.

- Practitioners' ability to opt out – Under certain conditions, a physician has the ability to notify a pharmacist, either verbally or in writing, that the physician does not want the pharmacist to prescribe to their patient or a certain class of their patients. Such a notification must be based on sound medical reasons. This means that a pharmacist would have to consult with the physician before dispensing the medication.

More information on level I and II prescribing is available on the Saskatchewan College of Pharmacists website: saskpharm.ca. If you have additional concerns, please contact the SMA at (306) 244-2196.