Table 5

Polypharmacy and safety

Tension pharmacy staff face between dispensing multiple medicines safely and ability to challenge instances of polypharmacyExamples from fieldnotes and interviews
Clinical checks and the distancing of the pharmacy from polypharmacy as a safety concernWhen I ask Mo about checking the dosettes, he says this is a ‘clinical check and an accuracy check’. When I ask what a clinical check is he tells me it is about looking for things like interactions between the meds and checking if a dose is too high for example. He goes on to explain that it might be ‘accurate but not safe!’ Mo says that the checks will have been done in the last round (by which he means same patient, last month’s round of dosettes) but that they check every round nevertheless. I cautiously ask about the fact that some patients are on very long lists of medicines—as this is something we are particularly interested in. He says that often there is a ‘primary’ condition but that sometimes drugs cause side effects and this might lead to other prescriptions. Mo concedes this is difficult, and goes on to explain that the (pharmacy conducted) Medicine Use Reviews are mainly about how and if the patient is using the meds… if there are adherence or side effects problems—but it’s not a ‘full clinical’ review about whether the drugs are working for example. He says that this is mainly the responsibility of the prescriber.
(Fieldnote Willow, 11/12/2018, DS)
NF: Is it ever the pharmacist’s role to talk to patients about stopping the medicines or …?
Zane: Sometimes … well, we wouldn’t initiate the stop here, no.
NF: Right.
Zane: If there’s a stop, like for example, if a patient has been given an antibiotic, some of them interact with cholesterol medications, so you just need to let them know to stop taking that (cholesterol) medication for a week.
NF: Like temporarily?
Zane: Yeah, but it’s just a temporary stop. We never say completely stop taking it, because ultimately that’s the doctor’s decision.
(Interview, Pharmacist, Foxglove, 06/02/2019)
Polypharmacy as a norm but staff not in a position to challenge itIn this interview, Raheem recounted his shock of having to dispense a prescription of over 10 items of medication to a young child. NF asked him if he had the same sense of shock when he’s making up a prescription of many items for an older person:
Raheem: Yes, but it’s not as much because—I know it sounds bad—but I’m a bit used to it here. And I seem more shocked when I see a 65 year old with less medication than usual.
NF: Oh right
Raheem: We actually had a lady that was around about 66 or something, she only took two medication and that just for pain maybe, and it was no diabetes, gastric or anything else, so I was shocked.
(Interview, Technician, Foxglove, 04/02/2019)