Epi Pens in Community Pharmacy

[mik30102]

Hello everyone I just read a sad article: http://www.dailymail.co.uk/news/art...-adrenaline-injection-didnt-prescription.html, and was wondering what protection if any pharmacists have under the law to administer epinephrine without a prescription. Personally I would administer it regardless even at the risk of my license but I was wondering if such a thing would be covered under a good Samaritan law?

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[zelman]

I can only dispense an epipen if the patient has a prescription/refill for one.

However, I can administer one if someone has an allergic reaction after I administer a vaccine.

So, if someone shows up dying, I will fill an epipen prescription if they've had one (getting refills from the MD after the fact if need be-not because it's legal to do so, but because no MD will deny the fill). If not, I can give them a flu shot or gardasil or whatever I can grab the fastest and then use an epipen on them and it's all legal (-ish...depends on their age and the state, but whatever).

 

[Jell0]

If not, I can give them a flu shot or gardasil or whatever I can grab the fastest and then use an epipen on them and it's all legal (-ish...depends on their age and the state, but whatever).

You're thinking too much. Even though pharmacy is the most regulated profession, you still have the reason of "Professional Judgment" to OBVIOUSLY do the right thing in a life threatening situation.

Definitely administer the shot then follow up w/ the patient's doctor for a proper prescription. The pharmacist in the article is a disgrace

 

[GatorPharm]

The comments on that article are crazy. I know I wouldn't have given the epipen w/o a prescription unless it was legal to do so. Sorry that you forgot your daughter's epipen and decided to eat at a nut-heavy Chinese buffet, but expecting the pharmacist to break the law and possibly face both a job loss and legal action because of your negligence is insane.

 

[eagles22]

This is a mostly pointless thought experiment. Community pharmacies are not meant to be an emergency facility. Most people react to an emergency by calling 911 or going to the hospital, not hopping into the car and going to the CVS drive thru. I don't understand why this mother didn't call 911 (or the Irish equivalent) and instead tried to go to a pharmacy.

 

[opinionfree]

Unfortunately, people under the stress of an emergency 'do' things like this. They run into the pharmacy and scream help. This is really a great opportunity to think about how we as pharmacists will react. To read the article and feel nothing but anguish over the situation is heartless. Why on Earth are you working in a Healthcare, if not to help people?

Over the decades I've had people run into the pharmacy with gun shots, stabbings, a finger amputation, parking lot car accidents and seizures. These were terrifying experiences, that I was never prepared for. I was taught in school what to do for a patient suffering an acute asthmatic attack, not bleeding.
The first one was the finger amputation. A son bringing his mother and her finger into the pharmacy for me to reattach it. They get to the counter, the son puts the mother's bloody hand and finger on the counter and makes a sewing motion. I'm not proud to admit, I vomited (I thank God, it didn't get on the hand or finger). I run shrieking/vomiting, to the phone and dialed 911. Threw the stool over the counter to seat the mother (still shrieking/less vomiting). Emptied the first aid isle of gauze pads and prayed for the paramedics to hurry. Oh and they only spoke Portuguese.
This was far from an ideal solution to the emergency situation. I'm so much better now. Be prepared to react and do whatever is necessary to save a life, or get the Hell out of the profession. The idea anyone could stand and watch a person die and offer no assistance is unimaginable and even worse for a healthcare worker.

 

[zelman]

Wait, so you'd seriously give someone in anaphylaxis a flu shot just so you could qualify for giving emergency epi?

It hasn't come up, yet. But I've considered how to do it legally, and this is the only way I've come up with.

 

[BenJammin]

For being such a highly education profession, we have some of the dumbest people on the planet. Seriously. You are a ***** if you refuse to give a known anaphylaxis alert patient an EpiPen because none of you will have the courage to face a jury of 9 people and tell them that you had the key to saving this person's life and you kept it for yourself. That you would do it again. That your license was more important than this woman's life.

Enjoy the lawsuits, folks. Jail time > state board fine.

 

[eagles22]

Unfortunately, people under the stress of an emergency 'do' things like this. They run into the pharmacy and scream help. This is really a great opportunity to think about how we as pharmacists will react. To read the article and feel nothing but anguish over the situation is heartless. Why on Earth are you working in a Healthcare, if not to help people?

Over the decades I've had people run into the pharmacy with gun shots, stabbings, a finger amputation, parking lot car accidents and seizures. These were terrifying experiences, that I was never prepared for. I was taught in school what to do for a patient suffering an acute asthmatic attack, not bleeding.
The first one was the finger amputation. A son bringing his mother and her finger into the pharmacy for me to reattach it. They get to the counter, the son puts the mother's bloody hand and finger on the counter and makes a sewing motion. I'm not proud to admit, I vomited (I thank God, it didn't get on the hand or finger). I run shrieking/vomiting, to the phone and dialed 911. Threw the stool over the counter to seat the mother (still shrieking/less vomiting). Emptied the first aid isle of gauze pads and prayed for the paramedics to hurry. Oh and they only spoke Portuguese.
This was far from an ideal solution to the emergency situation. I'm so much better now. Be prepared to react and do whatever is necessary to save a life, or get the Hell out of the profession. The idea anyone could stand and watch a person die and offer no assistance is unimaginable and even worse for a healthcare worker.

Any in all of the cases, you practice within the scope of your knowledge which is to provide basic first aid and then call 911. You don't give pain meds to the gunshot victim. You don't start antibiotics on the cut off finger. Medical emergencies are not meant to be dealt with at the community pharmacy. People know this and they should not expect anything but a quick call to the ambulance.

 

[opinionfree]

While I honestly applaud you for your idea, I think it still needs a little work.
So will the person in the midst of anaphylaxis, need to fill out the paperwork, wait till it's processed through the computer and sit patiently while you prepare to vaccinate them. Then afterwards, you will administer the life saving EpiPen injection. This seems like much more of a legal and medical ethics quagmire, then just administering the life saving, EpiPen.
I can't see a judge, jury or medical review board validating any decision, other than immediate administration of life saving epinephrine.
Imagine the public reaction if the person dies. Nothing short of a beheading, would satiate the public fury. Rightly so.
What will you feel like if the person dies? What will your family think of you, knowing you watched a person die over protocol? How could you ever consider yourself a healthcare professional again?
Do you think ANY pharmacy related employer would ever hire you again?

 

[opinionfree]

"Any in all of the cases, you practice within the scope of your knowledge which is to provide basic first aid and then call 911. You don't give pain meds to the gunshot victim. You don't start antibiotics on the cut off finger. Medical emergencies are not meant to be dealt with at the community pharmacy. People know this and they should not expect anything but a quick call to the ambulance."


What the public knows and how they react in an emergency, will become much more clear when you start working, after you finish in medical school. The old, 'any port in a storm', mentality kicks in fast. The examples listed, are ACTUALY events that have occurred during the 2+ decades I've experienced while working in a community pharmacy. Nowhere did I indicate the pharmacist should initiate antibiotics or pain medication. The inclusion of my experiences were to demonstrate the reality of what happens while working in the community pharmacy.
25 years ago, people didn't have cell phones or ambivalence about paying medical bills. They ran into pharmacies because it was access to cheap, immediate medical triage. They did it then and to this day, run into pharmacies with medical emergencies. I certainly don't wish to foster this in happenstance. I agree with you, medical emergencies shouldn't wind up in the pharmacy, they just do. Thinking otherwise and not expecting them to occur, is preposterous. Shared experiences will lend confidence in dealing with medical emergencies when they present themselves. Shrieking and vomiting weren't really included to be exemplary of good emergency response. Perhaps they will impart knowledge to others and prevent the same from happening to them.

 

[Digsbe]

If I was the pharmacist I would give the epipen. May or may not be illegal, may or may not be covered under laws, but if it saves someone in need I'll administer the epipen without a prescription and deal with the legality of it later. I'd rather stand before a board or court and explain myself for violating a law in good faith over having to explain to a family why her daughter needs to die and why I can't give her a medication she needs immediately to survive. Saving someone's life is more important than covering your own butt legally.

 

[npage148]

What if the Epi kills the kid? Think the mom will let you live in their bedroom after you lose your job and the family gets done sueing you?

 

[awval999]

"I can't give it to you. But (points to it on the shelf) I won't stop you."

 

[xiphoid2010]

I think we can agree that dispensing without a valid prescription is illegal. The pharmacist was in a tough situation, there are basically 4 outcomes and their likely effects:

(1) give the meds, breaking the law, the girl lives --> minor or no punishment, ~25% chance of getting fired
(2) give the meds, breaking the law, the girl dies --> heavy punishment, 100% fired and may lose license
(3) not give the meds, obey the law, the girl lives --> no punishment, no effect on the job
(4) not give the meds, obey the law, the girl dies --> no punishment, ~50% chance of getting fired

So (3) is the best and (2) the worst outcome. Faced with a no upside and only downside choice, the logic would be to minimize the probability and severity of the downside. Since the pharmacist can't actually know if the girl is going to live or die, he only has the choice of 2 pairs of outcomes (1)+(2) or (3)+(4). Which pair is the logical choice?

Limitation of this analysis is estimating probability, other laws may apply, intangibles such as morality, public popularity are not factored in.

 

[opinionfree]

It's funny, I try to watch at least 1 episode of Judge Judy everyday. It always features 2 cases where people have at issue, with their individual interpretations of the law. Judge Judy steps into clear up the 'I think the law says' nonsense and corrects the litigants about the true and correct meaning of the law in question. Calls everyone foolish, then rules. (I love that woman). The logic of the law is unbelievable simple. It becomes problematic when people try to morph it into protection of their circumstance. Hence the 'I think' defense.

Laws become important, when life saving measures are undertaken or refused, in the care of patients. That is why a Judge is employed to correctly assess the issue and rule on the spirit of the law. In a democracy like the USA, people are pro-life, for those already living. When looking at the nature of healthcare, we as pharmacists, care for health. That's what we do. Many are stuck on the idea if I give the epipen, without the prescription, I am breaking the law. Yes, you are. However, is that the most primary concern at issue? No, it's not. Healthcare is your primary concern. The laws regarding patient care were created to protect patients, not to be used in defense of your judgments.

As pharmacists, we work for healthcare (primary), law enforcement (not primarily). The law will address your obligation to healthcare first (your primary function as a pharmacist). That is where the problems regarding this issue should be focused upon. Judges and juries will frown on the pharmacist withholding the life saving measures (primary function) first, and most harshly. Using your interpretation of the law (not primary function), to withhold healthcare (primary function), will be at legal issue.

Pharmacies are in business to make money. Any pharmacist refusing to make sales (regardless of the reason) isn't making money for the pharmacy. Pharmacists that aren't making sales for the pharmacy, that result in a patient's death, are a double liability to the pharmacy. Try getting a job after that scenario. I knew a pharmacist 18 years ago. A real pretty girl, smart as a whip. Unfortunately, she had a fight with her husband and was a mess at work. She accidentally made an error, that turned fatal for a patient. She was done. She made an honest error, that resulted in a death. Can you imagine intentionally withholding an epipen in an anaphylactic emergency. Forget all the legal issues (not primary function), how can someone intentionally refuse the life saving measure to a patient's healthcare (primary function) and live with themselves.

Please stop trying to use the law as your defense, it's not there to protect you. It's for the patient's protection. If everything goes wrong, after you give the epipen (not sure how), you may get in trouble. Nowhere near the caliber of trouble for refusing treatment.
If you withhold treatment, knowing that treatment would most likely save the patient, what do you think a judge, jury or pharmacy review board will think of you. Even more importantly, how will you live with yourself. Because in everyone's eyes, that epipen would have saved the life.

Imagine it was one of your family members, in the actual case. Would you thank the pharmacist for following, their interpretation of the law (not primary function), withholding the healthcare (primary function), and watching your loved one die in the consultation waiting area. I wouldn't, but I guess most others would.

 

[xiphoid2010]

As pharmacists, we work for healthcare (primary), law enforcement (not primarily). The law will address your obligation to healthcare first (your primary function as a pharmacist). That is where the problems regarding this issue should be focused upon. Judges and juries will frown on the pharmacist withholding the life saving measures (primary function) first, and most harshly. Using your interpretation of the law (not primary function), to withhold healthcare (primary function), will be at legal issue.

If the pharmacist broke no law or regulations, I'm curious what charges could be brought?

Please stop trying to use the law as your defense, it's not there to protect you. It's for the patient's protection.

Exactly why law bars pharmacists from dispensing without prescriptions -- to protected the people from pharmacists practicing medicine. Epipen isn't 100% successful again severe shock, it can kill someone due to cardiac arrhythmia, and it might not been an allergic reaction (we only know it is for certain in hindsight).

We all know where the moral high ground lies. But when morality runs into legality, the latter tends to hold up better in court.

 

[opinionfree]

First, are you debating on this issue because you are uncertain about how 'you' would respond, or are you debating for some, other reason? Big difference.

If you would give the epipen, why are you doing this? What is your motivation? Mine is quite simple. Preservation of human life. Respondents to this thread, seem to favor withholding the use of an epipen, for a patient experiencing anaphylaxis. Due to ancillary legal concerns. My prayers are that by making simple points, people might reconsider their decision making sensibilities.

If you wouldn't give the epipen, I'm happy to debate this issue with you ad infinitum, in hopes of making valid points upon which you might consider changing your mind.

Your questions, being legal in nature are indicative of your unfamiliarity for the law. Perhaps you should seek legal counsel immediately, to appropriately address your ignorance of the law and prevent any gross infractions of the law. That may lead to patient harm, up to and including, death.

Seems to me your just debating the issue to satisfy some deep seeded need for attention. Sorry. if that sounds harsh. It makes no sense to argue this issue, other than your questionable sense of propriety. You are more than aware of the error, in professional duty, regarding the pharmacist in this real life incident. Instead, you want to argue against me, for an issue, in reality, you agree with me on. Your smart enough to know the pharmacist in the case was wrong. Yet you want to argue against it. I don't understand why?

I refuse to entertain that you personally, wouldn't give the epipen: if the case presented itself at a pharmacy, you were working. Nor, do I not believe you wouldn't instruct a pharmacist, in your charge, to not administer the epipen immediately. Say anything you want against that, I don't believe you. I am concerned, that instead of unifying and helping guide the less experienced, you wish to muddy the waters on an issue dealing with life or death consequences.

 

[xiphoid2010]

Wow, such a long essay, you sure you are not the one seeking attention?

Anyway, you think that you consider to be a moral stance automatically grants legal protection, when it does not. I'm pointed to both the law and board of pharmacy regulation that bars dispensing without a prescription. You haven't been able to do the same.

If there is no legal consequence I think we would all give the epipen, but the reality is it's not that simple. When people are so quick to condemn the pharmacist after reading a news article, I feel there is a failure to fully analyze the situation. So I pointed to the laws and a logic analysis.

Everyone should do what they think is the best course of action, and that involves analyzing all possibilities. That pharmacist was put in a bad situation involuntarily, and he made decision that better protects himself. I for one won't applaud him, but nor would I condemn him.

 

[StellargalS]

The comments on that article are crazy. I know I wouldn't have given the epipen w/o a prescription unless it was legal to do so. Sorry that you forgot your daughter's epipen and decided to eat at a nut-heavy Chinese buffet, but expecting the pharmacist to break the law and possibly face both a job loss and legal action because of your negligence is insane.

Ok 2017.

 

[zelman]

While I honestly applaud you for your idea, I think it still needs a little work.
So will the person in the midst of anaphylaxis, need to fill out the paperwork, wait till it's processed through the computer and sit patiently while you prepare to vaccinate them. Then afterwards, you will administer the life saving EpiPen injection. This seems like much more of a legal and medical ethics quagmire, then just administering the life saving, EpiPen...

Depends on the state. Massachusetts doesn't require a patient signature on the form to administer a vaccine. I could give both injections in about 30-60 seconds and process all paperwork afterward.

As stated above, if I am following a physician ordered vaccine protocol and the EpiPen exacerbates a preexisting cardiac condition with fatal results, I haven't broken any laws.

Also, to restate my original post, if I had any documented history of EpiPen prescription, I would just give it to them and get the refill authorization later. This is only for people for whom I have no documentation of a diagnosed potentially fatal allergy.

 

[StellargalS]

That is one shoddy piece of journalism. IMO. Those people are *****s or it's fake. I mean how did the kid live that long anyway? Yes I know anaphylaxis can progressively develop from a mild allergy. None of the PMH was disclosed to the pharmacist because? There are holes shot through the whole story. I appreciate healthy debate but not over an article from the Dublin Enquirer. Just wanted to say:

 

[GatorPharm]

Ok 2017.

Your maturity is overwhelming.

 

[StellargalS]

Your maturity is overwhelming.

We are on the cusp of the year 2014. I understand your enthusiasm and I think it is great that you contribute. However you should approach these topics as a student and not as licensed professional. Keep up this attitude and you many not pass the board. This is not a popularity contest. There are lives at steak. I will say no more.

 

[Dalteparin]

I think we can agree that dispensing without a valid prescription is illegal. The pharmacist was in a tough situation, there are basically 4 outcomes and their likely effects:

(1) give the meds, breaking the law, the girl lives --> minor or no punishment, ~25% chance of getting fired
(2) give the meds, breaking the law, the girl dies --> heavy punishment, 100% fired and may lose license
(3) not give the meds, obey the law, the girl lives --> no punishment, no effect on the job
(4) not give the meds, obey the law, the girl dies --> no punishment, ~50% chance of getting fired

So (3) is the best and (2) the worst outcome. Faced with a no upside and only downside choice, the logic would be to minimize the probability and severity of the downside. Since the pharmacist can't actually know if the girl is going to live or die, he only has the choice of 2 pairs of outcomes (1)+(2) or (3)+(4). Which pair is the logical choice?

Limitation of this analysis is estimating probability, other laws may apply, intangibles such as morality, public popularity are not factored in.

You're leaving one factor out of this analysis, and that's the probability of getting hired somewhere else after getting fired. I'd say your chances of getting future employment would be a hell of a lot better under option 1 than option 4. If they ask why you left your last job, "I gave an Epi-Pen to somebody who didn't have an Rx" is a better story than "I did nothing while a kid was having anaphylaxis and she died."

As for option 2… still the worst of all outcomes, but I'd feel a lot better about losing my license than watching a kid die. That's just me, though.

 

[xiphoid2010]

You're leaving one factor out of this analysis, and that's the probability of getting hired somewhere else after getting fired. I'd say your chances of getting future employment would be a hell of a lot better under option 1 than option 4. If they ask why you left your last job, "I gave an Epi-Pen to somebody who didn't have an Rx" is a better story than "I did nothing while a kid was having anaphylaxis and she died."

As for option 2… still the worst of all outcomes, but I'd feel a lot better about losing my license than watching a kid die. That's just me, though.

That's true. The question then how much of an effect it would be. This could range widely as it involves unknowns such as: if there are laws that require him /her to disclose, if not then would the pharmacist disclose, and if not then would employer call around and if the other party is allowed to disclose.

Option 2 is the worst by far since it conceivably can lead to a charge of man-slaughter.

 

[eagles22]

"Any in all of the cases, you practice within the scope of your knowledge which is to provide basic first aid and then call 911. You don't give pain meds to the gunshot victim. You don't start antibiotics on the cut off finger. Medical emergencies are not meant to be dealt with at the community pharmacy. People know this and they should not expect anything but a quick call to the ambulance."


What the public knows and how they react in an emergency, will become much more clear when you start working, after you finish in medical school. The old, 'any port in a storm', mentality kicks in fast. The examples listed, are ACTUALY events that have occurred during the 2+ decades I've experienced while working in a community pharmacy. Nowhere did I indicate the pharmacist should initiate antibiotics or pain medication. The inclusion of my experiences were to demonstrate the reality of what happens while working in the community pharmacy.
25 years ago, people didn't have cell phones or ambivalence about paying medical bills. They ran into pharmacies because it was access to cheap, immediate medical triage. They did it then and to this day, run into pharmacies with medical emergencies. I certainly don't wish to foster this in happenstance. I agree with you, medical emergencies shouldn't wind up in the pharmacy, they just do. Thinking otherwise and not expecting them to occur, is preposterous. Shared experiences will lend confidence in dealing with medical emergencies when they present themselves. Shrieking and vomiting weren't really included to be exemplary of good emergency response. Perhaps they will impart knowledge to others and prevent the same from happening to them.

My point was that you shouldn't give drugs without an rx in any of those situations. I'm not expecting them not to occur, but I am expecting the pharmacist to act within the scope of his/her practice. So are you saying it's ok for a pharmacist to practice medicine when there's an emergency? Where do you draw the line at what's an emergency that allows you to give a drug? How do you even know that the patient is having an asthma attack/allergic reactions/etc.? Just because someone behaves stupidly doesn't mean the pharmacist has a duty to also behave stupidly and administer medication that may or may not work and also open you up to a ****load of legal liability. You call 911, keep the patient as calm as possible and make sure he/she gets in the ambulance. It's easy to claim it's a moral high ground, but you really don't have all the data about what's happened of the facilities in a community pharmacy to safely start treatment.

 

[BeLikeBueller]

It's interesting to see the different opinions on here. It seems to me to be an issue of conscience - would you still be able to sleep at night based on your actions? For me personally, I wouldn't want to withhold potentially life-saving treatment. If the patient claims to have an epi-pen for a peanut allergy, the patient would be using their own judgement to administer it at that time (if they had remembered to bring it). In addition, a pharmacist should be competent enough to identify anaphylaxis based on the ability to administer epi in situations of vaccine reactions per protocol (you have a blood pressure cuff - use it). For me, the only question is whether or not you believe that someone is lying to you about having been given a prescription for epinephrine. And the question would be - why would they? It's not like someone is running into your pharmacy saying, "Help! I'm having a life- threatening allergic reaction. I need #180 norco stat. Oh, by the way, can you make sure it's the round ones? I don't like the oval ones."

Obviously professional judgement would play a huge part in the decision - how serious does it appear to be? Can they wait for EMS personnel to arrive? Are they passed out on my floor? Etc., etc. But would I force someone to "run" [per the article] to the nearest ED? Probably not.

I would think of it as more of a "good-faith" emergency supply.

Or, perhaps as one poster stated (and I paraphrase) - "I'm not going to give it to you, but I'm not going to stop you from taking it."

 

[xiphoid2010]

Or, perhaps as one poster stated (and I paraphrase) - "I'm not going to give it to you, but I'm not going to stop you from taking it."

I think there is probably an even more legal and safer course of action than that. Call 911. If the 911 dispatcher or EMS personnel assesses the situation and give you an order for an Epi-pen, then everyone gets what they want. Sounds simple with some forethought, but may not be something an unsuspecting pharmacist could have thought of during an emergency.

 

[BeLikeBueller]

I think there is probably an even more legal and safer course of action than that. Call 911. If the 911 dispatcher or EMS personnel assesses the situation and give you a verbal order for an Epi-pen, then follow the order. Sounds simple with some forethought, but may not an solution an unexpecting pharmacist could have thought of during an emergency.

I don't know that an EMS dispatcher would have any kind of "prescriptive authority" in this situation. In any case, what you suggest is clearly the best course of action in a generalized sense, but I could imagine a situation where immediacy of action could be required. I think everyone here would probably call EMS first, but what happens after that call would involve one's best professional judgement. We're really playing a giant game of "what-if" here, it seems, while simultaneously hoping and praying that we never have to answer that question.

 

[Dalteparin]

I think there is probably an even more legal and safer course of action than that. Call 911. If the 911 dispatcher or EMS personnel assesses the situation and give you an order for an Epi-pen, then everyone gets what they want. Sounds simple with some forethought, but may not be something an unsuspecting pharmacist could have thought of during an emergency.

You should call 911 even if you do give an Epi-Pen. The patient will need to be evaluated by an MD (and most likely admitted to a hospital) even after receiving an Epi-Pen.

 

[xiphoid2010]

You should call 911 even if you do give an Epi-Pen. The patient will need to be evaluated by an MD (and most likely admitted to a hospital) even after receiving an Epi-Pen.

True. Ah, the fun retail pharmacy scenarios that working in a hospital has spared me of. But if I was in retail, I would call 911 first before start poking people with epipens.

(1) You would want EMS to be on their way STAT
(2) Like someone mentioned, diagnosing and practicing medicine isn't exactly a pharmacist's cup of tea. e.g they might realize it's an asthma attack and order you to give albuterol instead.

 

[Ref]

In my pharmacy, a technician with type 1 diabetes had an insulin pump malfunction and was going into shock, eyes rolling back etc... Their blood sugar when checked was registering 16 and severe brain damage or death was very likely so we wanted to inject this person with a glucagon injection but the pharmacist kept saying no they have no prescription for one so we can't administer one.

Well we were determined to give it anyway before it was too late while the pharmacist was ringing the person's physician. When the physician finally got on the phone he was screaming at the pharmacist why are you calling me just give the shot and save the person's life and worry about a script later... Well we gave it, and my coworker recovered and is forever grateful that we didn't all end up as a headline similar to this Daily Mail story.

I think if I was the pharmacist in the Daily Mail story I'd have given the epipen to the girl's mother after a couple of very quick questions to determine that yes she has a prescription for an epipen for just this situation.

I think what is best for the patient should trump any legal issues in a possible life death situation.

So yeah I'd have to judge that the mother knows what she's talking about regarding an epipen injection and most likely is being honest with me about leaving her epipen at home. I'd be deciding that she would only know these things if she was telling the truth. I'd hand the epipen to the mother for her to administer and dial 911 and be prepared to defend my actions no matter the outcome.

I'd explain I had reason to believe that the girl's life was in fact in danger based on a reasonable assumption that the mother is telling me the truth.

Or... I could say I only handed it over for her to look at and to my shock and surprise she used it on her daughter. I had no idea she'd do that!

Didn't a patient die in a waiting area of a pharmacy begging for an inhaler during an asthma attack? They didn't have a script or were a couple of bucks short or something...

So always follow the law or if not, act in the best interest of the patient and be able to readily explain your thinking your actions in court or before a board. If I feel I'm making the best decision for the patient in the circumstances I'm given I'll just have to trust that I can make others see it that way as well.

A law cannot take into account every single situation that might arise and that's where common sense and training must prevail. It's not a perfect world...

 

[zelman]

...A law cannot take into account every single situation that might arise and that's where common sense and training must prevail. It's not a perfect world...

You don't think a law granting prescriptive authority would account for every situation?

 

[molyhelp]

Hello everyone I just read a sad article: http://www.dailymail.co.uk/news/art...-adrenaline-injection-didnt-prescription.html, and was wondering what protection if any pharmacists have under the law to administer epinephrine without a prescription. Personally I would administer it regardless even at the risk of my license but I was wondering if such a thing would be covered under a good Samaritan law?

Edited to add this line: Sadly, after reading the law sentences, I am sad to share that this law is not about giving pharmacist immunity to inject EPIPEN in emergency to non-vaccinated patient; please see updates at a few posts below this post.

Lucky find: law of 2014: We are protected in California (please update for your state if you find law, thanks):
Source: Pharmacy Board's Newsletter "The Script" (PDF file and link included here so you don't have to find, please see page 9
http://www.pharmacy.ca.gov/publications/14_spring_script.pdf

Civil Code Added Section 1714.23
to define “anaphylaxis” and
“epinephrine auto-injector;” grant
immunity to an individual who
administers epinephrine to another
in good faith, at the scene of an
emergency situation, in accordance
with the provisions of the bill; and
provides immunity from alleged civil
damages those organizations or others
who provide or develop standards for
training programs or standards.



H&SC Added Section 1797.197(a)
to establish definitions, to also
include “anaphylaxis” and
“epinephrine auto-injector” and
others; authorize a health care
provider to issue a prescription
for an epinephrine auto-injector
to a person, who presents current
certification demonstrating that the
person is trained and qualified to
administer the auto-injector; authorize
specified (defined) persons to render
emergency care, so long as specified
requirements are met; and specify
minimum training requirements for
the use of epinephrine autoinjectors
by the California Emergency Medical
Services Authority.

 

[Old Timer]

Lucky find: law of 2014: We are protected in California (please update for your state if you find law, thanks):
Source: Pharmacy Board's Newsletter "The Script" (PDF file and link included here so you don't have to find, please see page 9
http://www.pharmacy.ca.gov/publications/14_spring_script.pdf

Civil Code Added Section 1714.23
to define “anaphylaxis” and
“epinephrine auto-injector;” grant
immunity to an individual who
administers epinephrine to another
in good faith, at the scene of an
emergency situation, in accordance
with the provisions of the bill; and
provides immunity from alleged civil
damages those organizations or others
who provide or develop standards for
training programs or standards.



H&SC Added Section 1797.197(a)
to establish definitions, to also
include “anaphylaxis” and
“epinephrine auto-injector” and
others; authorize a health care
provider to issue a prescription
for an epinephrine auto-injector
to a person, who presents current
certification demonstrating that the
person is trained and qualified to
administer the auto-injector; authorize
specified (defined) persons to render
emergency care, so long as specified
requirements are met; and specify
minimum training requirements for
the use of epinephrine autoinjectors
by the California Emergency Medical
Services Authority.

You are only protected if your organization has developed standards and has trained you in these standards.

and provides immunity from alleged civil damages those organizations or others
who provide or develop standards for training programs or standards.

There are several issues here.

The first is are you qualified to diagnose a person with anaphylaxis? If you are not, you are clearly and unequivocally practicing medicine without a license. If you are sure the patient is having an MI, would you give them an aspiring tablet? Your moral and legal responsibility as a community pharmacist is to get the patient to the proper person who is qualified to make the diagnosis and provide the appropriate treatment.

 

[molyhelp]

Edited to add this line: Sadly, after reading the law sentences, I am sad to share that this law is not about giving pharmacist immunity to inject EPIPEN in emergency to non-vaccinated patient; please see updates at a few posts below this post.

UPDATES after analyzing the actual law sentences:
Basically, the law still SADLY required WRITTEN ORDER from someone like physician and PHARMACY LABEL....(in emergency anaphylaxis, we don't have time for that.)

Some sentences of the law is here:
http://leginfo.legislature.ca.gov/faces/billVotesClient.xhtml

4119.3.
(a) Notwithstanding any other law, a pharmacy may dispense epinephrine auto-injectors to a prehospital emergency medical care person or lay rescuer for the purpose of rendering emergency care in accordance with Section 1797.197a of the Health and Safety Code, if both of the following requirements are met:
(1) A physician and surgeon provides a written order that specifies the quantity of epinephrine auto-injectors to be dispensed to a person described in subdivision (b) of Section 1797.197a of the Health and Safety Code. The physician and surgeon may issue the prescription only upon presentation of a current certificate demonstrating that the person is trained and qualified under Section 1797.197a of the Health and Safety Code to administer an epinephrine auto-injector to another person in an emergency situation. The prescription shall specify that the dispensed epinephrine auto-injector is for “First Aid Purposes Only” and that the named recipient is a “Section 1797.197a Responder.” A new prescription shall be written for any additional epinephrine auto-injectors required.
(2) (A) The pharmacy shall label each epinephrine auto-injector dispensed with all of the following:

I swore to Do No Harm BUT the law is still not supporting community pharmacist as EPIPEN injector for non-vaccinated patient in EMERGENCY situation yet....SAD....

 

[zelman]

UPDATES after analyzing the actual law sentences:
Basically, the law still SADLY required WRITTEN ORDER from someone like physician and PHARMACY LABEL....(in emergency anaphylaxis, we don't have time for that.)

Some sentences of the law is here:
http://leginfo.legislature.ca.gov/faces/billVotesClient.xhtml

4119.3.
(a) Notwithstanding any other law, a pharmacy may dispense epinephrine auto-injectors to a prehospital emergency medical care person or lay rescuer for the purpose of rendering emergency care in accordance with Section 1797.197a of the Health and Safety Code, if both of the following requirements are met:
(1) A physician and surgeon provides a written order that specifies the quantity of epinephrine auto-injectors to be dispensed to a person described in subdivision (b) of Section 1797.197a of the Health and Safety Code. The physician and surgeon may issue the prescription only upon presentation of a current certificate demonstrating that the person is trained and qualified under Section 1797.197a of the Health and Safety Code to administer an epinephrine auto-injector to another person in an emergency situation. The prescription shall specify that the dispensed epinephrine auto-injector is for “First Aid Purposes Only” and that the named recipient is a “Section 1797.197a Responder.” A new prescription shall be written for any additional epinephrine auto-injectors required.
(2) (A) The pharmacy shall label each epinephrine auto-injector dispensed with all of the following:

I swore to Do No Harm BUT the law is still not supporting community pharmacist as EPIPEN injector for non-vaccinated patient in EMERGENCY situation yet....SAD....

That law is about dispensing EpiPens to EMTs or Paramedics for use as first responders.

You should have looked at...

4052.8. (a) In addition to the authority provided in paragraph
(9) of subdivision (a) of Section 4052, a pharmacist may
independently initiate and administer vaccines listed on the routine
immunization schedules recommended by the federal Advisory Committee
on Immunization Practices (ACIP), in compliance with individual ACIP
vaccine recommendations, and published by the federal Centers for
Disease Control and Prevention (CDC) for persons three years of age
and older.
(b) In order to initiate and administer an immunization described
in subdivision (a), a pharmacist shall do all of the following:
(1) Complete an immunization training program endorsed by the CDC
or the Accreditation Council for Pharmacy Education that, at a
minimum, includes hands-on injection technique, clinical evaluation
of indications and contraindications of vaccines, and the recognition
and treatment of emergency reactions to vaccines, and shall maintain
that training.
(2) Be certified in basic life support.
(3) Comply with all state and federal recordkeeping and reporting
requirements, including providing documentation to the patient's
primary care provider and entering information in the appropriate
immunization registry designated by the immunization branch of the
State Department of Public Health.
(c) A pharmacist administering immunizations pursuant to this
section, or paragraph (9) of subdivision (a) of Section 4052, may
also initiate and administer epinephrine or diphenhydramine by
injection for the treatment of a severe allergic reaction.

...where it says "A pharmacist administering immunizations pursuant to this section, or paragraph (9) of subdivision (a) of Section 4052, may also initiate and administer epinephrine or diphenhydramine by injection for the treatment of a severe allergic reaction."

So, it seems that any immunizing pharmacist can administer epinephrine and IM diphenhydramine in California.

 

[Old Timer]

...where it says "A pharmacist administering immunizations pursuant to this section, or paragraph (9) of subdivision (a) of Section 4052, may also initiate and administer epinephrine or diphenhydramine by injection for the treatment of a severe allergic reaction."

So, it seems that any immunizing pharmacist can administer epinephrine and IM diphenhydramine in California.

Only if you gave a patient an immunization and they had a severe allergic reaction. This does not apply to a patient who presents to the pharmacist with an allergic reaction not directly due to the immunization given.

 

[zelman]

Only if you gave a patient an immunization and they had a severe allergic reaction. This does not apply to a patient who presents to the pharmacist with an allergic reaction not directly due to the immunization given.

That's your intetpretation.

When I read the law, the pharmacist is described as an immunizer. The patient is described as having an allergic reaction. There is no stated correlation. I'm sure you think one is implied, but that's not how laws work. Implied ones don't count.

 

[swatchgirl]

Only if you gave a patient an immunization and they had a severe allergic reaction. This does not apply to a patient who presents to the pharmacist with an allergic reaction not directly due to the immunization given.

But the law only says "for the treatment of a severe allergic reaction". It didn't say "for the treatment of a severe allergic reaction brought on by the immunization."
Or is that part implied?

 

[swatchgirl]

That's your intetpretation.

When I read the law, the pharmacist is described as an immunizer. The patient is described as having an allergic reaction. There is no stated correlation. I'm sure you think one is implied, but that's not how laws work. Implied ones don't count.

But you and the patient or the patient's caregiver will still need to fill out immunization paperwork and consent forms BEFORE you can give the vaccination, right? Or can you do all that afterwards so you can save time? What if the patient dies anyway and the mother blames you for giving both the epi-pen without a rx AND what she thinks was an uncalled for immunization shot given to her daughter without proper consent? How would you defend yourself then?

 

[zelman]

But you and the patient or the patient's caregiver will still need to fill out immunization paperwork and consent forms BEFORE you can give the vaccination, right? Or can you do all that afterwards so you can save time? What if the patient dies anyway and the mother blames you for giving both the epi-pen without a rx AND what she thinks was an uncalled for immunization shot given to her daughter without proper consent? How would you defend yourself then?

If you administer one vaccine during your shift, you are "A pharmacist administering immunizations pursuant to this section, or paragraph (9) of subdivision (a) of Section 4052"

If you are an such an agent you are able to "initiate and administer epinephrine or diphenhydramine by injection for the treatment of a severe allergic reaction."

You don't need to immunize that particular patient. You just need to be an immunizer.

 

[swatchgirl]

If you administer one vaccine during your shift, you are "A pharmacist administering immunizations pursuant to this section, or paragraph (9) of subdivision (a) of Section 4052"

If you are an such an agent you are able to "initiate and administer epinephrine or diphenhydramine by injection for the treatment of a severe allergic reaction."

You don't need to immunize that particular patient. You just need to be an immunizer.

It would be nice if the law does protect the immunizing pharmacist to that extent. Assuming the statute you cited CAN be liberally interpreted to mean what you wrote, the pharmacist still has to have the proper training to quickly and correctly diagnose an anaphylactic reaction, and be able to recognize and assess the severity of the reaction to correctly classify it as an emergency situation that necessitates him to be the "stand-in" doctor. All that can basically be summarized as "exercising the pharmacist's professional judgement". So then why would so many pharmacists be reluctant to dispense an epi-pen in an emergency without a prescription? Does it have to do with the confidence level of making a correct diagnosis? Or is it simply because diagnosing a patient and prescribing a treatment is still outside of the scope of practice for a pharmacist?

I think it's a joke that the law doesn't allow the pharmacist to diagnose or prescribe, but still puts him in situations that force him to either make a diagnosis quickly and dispense, or watch a patient die, all without adequate liability protection. The law doesn't want to give pharmacists too much power, but it does this by making him powerless and vulnerable in life-and-death situations like these, while the patients are left on their own to hopefully pull through. Are the law makers really looking out for the public? It makes me wonder sometimes.

 

[BidingMyTime]

Reading through this I thought, didn't was already have this discussion? And then I see 2013 as the year.

Please stop trying to use the law as your defense, it's not there to protect you. It's for the patient's protection. If everything goes wrong, after you give the epi-pen (not sure how), you may get in trouble. Nowhere near the caliber of trouble for refusing treatment.

Wrong, wrong, wrong. There is NO law or penalty for not helping someone and Good Samaritan laws ONLY protect someone with a license, as far as their license. Good Samaritan laws also do NOT require that people help, it only protects people who choose to help. Pharmacists can NOT diagnose (in most states and most situations), and WILL be at legal risk giving out a medicine without a prescription.

If you withhold treatment, knowing that treatment would most likely save the patient, what do you think a judge, jury or pharmacy review board will think of you. Even more importantly, how will you live with yourself. Because in everyone's eyes, that epipen would have saved the life.

No way I could know that. I am not trained to diagnose, I have no idea what is happening to the patient, I would be 100% legally at risk for "guessing."

Imagine it was one of your family members, in the actual case. Would you thank the pharmacist for following, their interpretation of the law (not primary function), withholding the healthcare (primary function), and watching your loved one die in the consultation waiting area. I wouldn't, but I guess most others would.

Well, as has been pointed out if, the pharmacist guessed right, I'd probably be happy. If the pharmacist guessed wrong and the epi-pen made the situation worse, I'd be suing that pharmacist, and win, because that pharmacist KNEW s/he wasn't qualified to diagnose, and yet misled me by doing so.

And someone mentioned getting another job......pretty sure future employers would only care about board actions from breaking the law, they would not care about a death that I had NOTHING to do with.

 

[BidingMyTime]

Thinking more about this from the hospital end, what if a visitor to a hospital had an anaphalytic attack? Do you think the triage nurse will go ahead and give them a shot with epi since the doctor is with another patient? Do you think the floor nurse will break open the crash cart and give a shot of epi? No, no, no. 100% liability for the hospital. The visitor on the floor will have to be transported to ER and be evaluated by the doctor who will then order the epi. And the visitor better hope they are inside the hospital, if they have their attack in the parking lot, an ambulance will be called to transport them in, because of liability nobody on staff can go out to them to treat them or transfer them into the hospital. Sound cold and cruel? It protects the hospital, which protects everyone--hospitals that close due to repeated lawsuits can't serve anyone. Same with pharmacies/pharmacists that put themselves at risk by ignoring clear cut law.

 

[ancienbon]

Thinking more about this from the hospital end, what if a visitor to a hospital had an anaphalytic attack? Do you think the triage nurse will go ahead and give them a shot with epi since the doctor is with another patient? Do you think the floor nurse will break open the crash cart and give a shot of epi? No, no, no. 100% liability for the hospital. The visitor on the floor will have to be transported to ER and be evaluated by the doctor who will then order the epi. And the visitor better hope they are inside the hospital, if they have their attack in the parking lot, an ambulance will be called to transport them in, because of liability nobody on staff can go out to them to treat them or transfer them into the hospital. Sound cold and cruel? It protects the hospital, which protects everyone--hospitals that close due to repeated lawsuits can't serve anyone. Same with pharmacies/pharmacists that put themselves at risk by ignoring clear cut law.

Thank you so much for writing this well thought analogy. You hit the nail on the head. As a pharmacist it is very unlikely that i would dispense the epipen without a script. I would direct them to the er.
We are not the (er)

 

[swatchgirl]

So in the end, did this pharmacist ever get let go? He surely followed protocols and did things by the book, which is probably what saved his butt in court. But in the words of "A Few Good Men", did he get "dishonorably discharged" from his station? If he didn't, then it means that when in doubt, follow protocols down to a T is still the best policy, right?

 

[ancienbon]

Just reminding that the incident took place in Ireland not in the us.