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Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

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Open Access  Full Text Article                                                                                                                                                Research Article 

Assessment of Good Pharmacy Practice among Community Pharmacist and their Perceptions on Ethical Dilemmas

T.T. Muhammed Anwar¹*,   G.R. Rajalakshmi²

¹ Lecturer, Department of Pharmacy Practice, Malik Deenar College of Pharmacy, Kasaragod, Kerala, 671321, India

² Assistant Professor of Pharmacy, College of Pharmaceutical Sciences, Government Medical College, Kozhikode, Kerala, 673008, India

INTRODUCTION

Drugs are the prime member of any disease prevention plans and ailment treatment programmes. Pharmacists are the health professionals appointed by relevant authorities for the safe and efficacious use of drugs since they are the specially upskilled and trained personnel for controlling, organizing and distribution of medicines. Medicine alone does not provide desired treatment output. To achieve the optimal treatment goals, pharmacist must provide enhanced drug related needs and ensure the services are of proper quality.¹ Nowadays community pharmacists providing plenty of services include dispensing, patient counseling and ADR monitoring under the guidance of a registered medical practitioner.²

Good Pharmacy Practice is a practice provided by pharmacists in a pharmacy setting that meet the requirements of the patients who utilize these facilities to attain intact treatment outcome. The intend of GPP is to give drugs and health related services to the public. Pharmacist should provide evidence based services and able to give rational drugs to the patients. The pharmacist must be able to provide quality advice to the society and health care providers and they must keep themselves upgraded about the evolution in the field. They must have good communication skill and should maintain a healthy and close relationship with other professionals. It is helpful in improving the quality of services and mutually shares the knowledge. If there is any doubt in the prescription or in case of any ADRs and drug interactions the pharmacist must contact the prescriber in a friendly manner. Before contacting the prescriber, the pharmacist must ensure there is any mistake that occurred in the prescription and suggest the prescriber with substituted solutions. Through proper interaction between the various professionals, they can mutually upgrade their professional skills and knowledge.¹

Ethics in each field depends on the professionalism of the personnel. There is no universal code of conduct or ethics. Each country has its own guidelines for ethics and code of conduct. These ethical guidelines help the profession and professionals from misconduct and ethical violation.² Prescription drugs, OTC drugs, and other medical devices in the community pharmacy are dispensed by a qualified pharmacist. There are a lot of ethical issues found in the dispensing and administration of these products. Community pharmacists should provide various services like patient counselling, minimizing drug interactions, information about adverse effects, contraindications, administration and storage of drugs along with dispensing the medicines.²

The pharmacist should beware of Ethical dilemmas in the community pharmacy settings. The physicians and pharmaceutical companies are having a greater role in contriving the pharmacist for violating the rules and ethics, since pharmacists are the aqueduct between pharmaceutical firms and prescriber. They are providing management of minor illness and a lot of ethical confusions are arising in these situations. This research was designed to assess the socio-demographic properties and good pharmacy practice among community pharmacists also to find out the dilemma in handling ethical issues, the frequency of ethical dilemma and reasons why community pharmacists may compromise ethical values.²

MATERIALS AND METHODS

The survey was designed to conduct in various community pharmacies of Kozhikode district. The Institutional review committee and institutional ethical committee was approved this study accordingly. 

Study site: Different community pharmacies across Kozhikode district 

Study design: Descriptive cross-sectional study

Study duration: 6 months 

Sample Size: 115 

Study Procedure: About 170 pharmacists who were working in the various community pharmacies in Kozhikode were selected randomly. 120 of them responded by answering these questionnaires and analysed for its outcomes. 

Statistical analysis: The study was analysed by statistics tool (MS OFFICE EXCEL) and interpreted by graphical representations.

RESULTS

170 community pharmacists were approached to participate in this study. Out of this, 120 of them were responded by answering the questionnaire. The demographic characteristics of the pharmacist have been presented in Table 1.

Table 1: Demographic Characteristics of the Pharmacist (N=120)

The response from the participants was analysed question by question.

QUESTIONS REGARDING GOOD PHARMACY PRACTICE

Question 1 is about the duration of training and the results obtained are as follows:

Figure 1

Question 2 is concerned with the designation of the pharmacist and the results obtained are:

Table 2: Designation of the Pharmacist In Pharmacy (N=120)

Question 3 is about whether the pharmacist wearing an apron at the time of dispensing, the results attained are:

Figure 2

Question 4 is concerned with the purchase of the drugs, the results attained are:

Table 3: Purchase Of The Drugs (N=120)

Question 5 is concerned the arrangement of medicines, the results attained are:

Table 4: Arrangement of the Medicines in Pharmacy (N=120)

Question 6 is concerned with the storage system of insulin, the results attained are:

Figure 3

Question 7 is concerned whether the pharmacist following temperature controlled system for storing vaccines, the results attained are:

Figure 4

Question 8 is concerned whether the pharmacists recognize any medicine associated problems, the results attained are:

Table 5: Medical or Drug Related Problem (N=120)

Question 9 is concerned with the response of pharmacist when finds out any drugs prescribed without indication at the time of dispensing, the results attained are:

Figure 5

Question 10 is about the response of pharmacist when finds out any prescription error at the time of dispensing, the results attained are:

Figure 6

Question 11 is concerned with the response of pharmacist when finds out any potential ADRs at the time of dispensing, the results attained are:

Figure 7

Question 12 is concerned with whether the pharmacist had any reported events of adverse drug reactions from the patient, the results attained are:

Figure 8

Question 13 is about whether the pharmacist counsel the patients, the results attained are:

Figure 9

If the pharmacist does patient counselling, then the time taken for the activity is reported as:

Table 6: Time Taken for Patient Counselling (N=120)

Question 14 is concerned with finest method for providing instructions regarding usage of drugs, the results attained are:

Figure 10

Question 15 is concerned whether the pharmacists notify the recipient while recognizing potential adverse drug reactions or drug-drug interactions, the results attained are:

Figure 11

Question 16 is concerned does the pharmacist counsel the recipient regarding lifestyle remoulding, the results attained are:

Figure 12

Question 17 is concerned does the pharmacist enquires lactating or pregnant women before dispensing OTC drugs, the results attained are:

Figure 13

Question 18 is concerned does the pharmacist enquires the recipient regarding medication allergy, the results attained are:

Figure 14

Question 19 is concerned does the pharmacist diagnose the ailments on the basis of recipients conditions, the results attained are:

Figure 15

Question 20 is concerned does the pharmacists keep antidotes in the pharmacy, the results attained are:

Figure 16

Question 21 is concerned does the pharmacist follow - up later dispensing an OTC medicines, the results attained are:

Figure 17

Question 22 is about whether the pharmacist inquires about the antibiotic the patient has previously taken while dispensing the same, the results attained are:

Figure 18

Question 23 is concerned with handling of expired medicaments by the pharmacist, the results attained are:

Figure 19

Question 24 is concerned does the pharmacist provides precautions on seasonal ailments, the results attained are:

Figure 20

Question 25 is concerned with the working time of pharmacists, the results attained are:

Figure 21

Question 26 is concerned with the dispensing of schedule G drugs, the results attained are:

Figure 22

Question 27 is concerned with the dispensing of schedule H drugs, the results attained are:

Figure 23

Questions Regarding ethical Dilemma

Question 28 is about whether the pharmacist prevented from dispensing a medicine why because the patient can’t afford the cost of drug therapy, the results attained are:

Figure 24

Question 29 is about whether the pharmacist dispenses a generic drug instead of an original branded medicine, the results attained are:

Figure 25

Question 30 is about whether the pharmacist has to dispense a drug therapy which he/she believes non beneficial to the patient, the results attained are:

Figure 26

Question 31 is about whether the pharmacist is under pressure to achieve daily sales targets for the pharmacy, the results attained are:

Figure 27

Question 32 is about whether the patient is unable to understand health information and advice provided by the pharmacist, the results attained are:

Figure 28

Question 33 is about whether the pharmacist cannot give required information regarding the drug due to insufficient knowledge, the results attained are:

                                                                     Figure 29

Question 34 is about whether the pharmacist is prevented from dispensing medicine due to illegible prescription, the results attained are:

Figure 30

Question 35 is about does the pharmacists dispense schedule X drugs without prescription, the results attained are:

Figure 31

Question 36 is about does the pharmacist dispense schedule X drugs more than those prescribed, the results attained are:

Figure 32

Question 37 is about the reasons why community pharmacists may compromise on ethical values, the results attained are:

Table 7: Reasons Why Community Pharmacists may Compromise on Ethical Values (N=120)

Question 38 is about the Frequency of community pharmacists involved in ethical dilemma situations, the results attained are:

Figure 33

DISCUSSION

Good Pharmacy Practice is a practice provided by pharmacists in a pharmacy setting that meet the requirements of the patients who utilize these facilities to attain intact treatment outcome. The GPP indicator studies have a great role in finding the problems of services provided by pharmacist to the recipients. The major drawback of the research was the lower response rate by the participants and was obtained to be 70.58%.

The outcomes of the study revealed that out of 120 pharmacists, 65% of them are between the age of 18 to 30 and thus more than 70% of them having less than 10 years of experience. 11.6% of the pharmacist from senior category (more than 50 years of age) were participated in the study and 6 of them having more than 30 years of experience. Most of the pharmacists who are working in community pharmacy settings were with D.Pharm (51.66%), or with B.Pharm (46.66%) degree. Only 2 of them were completed post-graduation in the pharmacy field.

Questions regarding good pharmacy practice:

The first question regarding good pharmacy practice was about the training period of the pharmacist. 67.5% of them completed 3 months of training in dispensing after the course. 38 pharmacists completed 1 month training period and only one of them did not attend training after the course. The educational qualification data indicated that most of them were Diploma holders in pharmacy and thereby completed 3 months training period according to their curriculum. The pharmacists who have completed 1 month training period were mostly degree holders in pharmacy. This data indicates the importance of training and most of the pharmacists are attending training in dispensing after their course.

From this present survey, it was found about 85% of the participants were employee pharmacists and 7.5% of them were pharmacist managers. Only 9 of them were owners of the community pharmacy. Owners of the pharmacy are mostly experienced personnel in this field and they are compelling their employees to provide better health care services. Employee pharmacists are mainly with lesser experience when compared with pharmacy managers and they are providing services of good quality and they are more conscious about the quality of services.

73.3% of the participants were wearing an apron while dispensing and most of them were lady pharmacists. Compared to lady pharmacists only a few gents were wearing an apron while dispensing. It indicated that most of them were aware of their appearance in pharmacy settings and making them more professionally competent. The apron increases the confidence of the pharmacist and helps the patient to distinguish between the pharmacist and a sales assistant.About 77.5% of them were following ABC analysis and 11.7% following VED analysis for the procurement of drugs. But 13 of them did not use any procurement methods for purchasing. Some of the participants especially aged ones did not know about ABC and VED analysis and they were purchasing drugs according to their needs in the pharmacy. They were using their experience for their procurement. Most of the younger pharmacists were aware of these different procurement methods. But they were mostly employees and no voice in the procurement of drugs. Owners of the pharmacy were involved in purchasing and procuring drugs based on their experience in sales.

According to survey 65.8% of them were following alphabetical order for the arrangement of drugs. Very few of them were using therapeutic category, manufacturer wise and fast moving - slow moving methods. 18.3% of them were using all of the above methods for the arrangement of drugs. Alphabetical order is the simplest and easiest method for arrangement of drugs in the pharmacy. Because everyone can understand this method. Arrangement based on therapeutic category is very difficult for the sales assistant to find out drugs as he is not aware of these therapeutic uses of drugs. Some of the pharmacies were following all the methods like an alphabetical method is using inside a “manufacturer wise” model. Fast moving-slow moving methods were mainly used for OTC drugs and they were all placed in a position where the buyer could easily see them.

98.3% of the participants were following optimal storage conditions for the storage of insulin. But 2 of them were not following these conditions. So majority of the dispensing pharmacists were aware of storage condition of insulin. Insulin should store between 2-8 degree Celsius. If it gets colder than that, it can freeze and if it gets warmer than the specified temperature eventually it will start to break down.

Based on the survey 97.5% of participants were following cold chain storage conditions for the storage of vaccines. But few of them required thorough education on the importance of cold storage conditions. The pharmacist curriculum should give more importance to the storage of parenteral preparations and vaccines. Drug inspectors should check whether the pharmacies follow these conditions in order to reduce the chances of dispensing deteriorated products to the patients.

More than 93% of the community pharmacists could identify drug related problems in their day to day life. 75% of them faced prescription errors including errors in the dose, frequency or administration. 34.2% of them found drugs without indication and 6.7% of them confronted with contraindicated drugs in the prescription. It shows that physicians were very careless about prescribing and majority of the pharmacist were aware of these drug related problems. But some of the pharmacists (6.7%) were not aware of these drug related problems. The pharmacy syllabus should give more importance to the drug related problems, common drug interactions and ADRs in the prescription. It will help the pharmacist to find out these problems, reduce drug related errors and prevent the recipient’s life from becoming catastrophic.

More than 80% of the pharmacists were reporting to the physician if there was any prescription error, drug interaction and ADRs in the prescription. It indicates the services of the participants are of high quality and most of them were conscious of these problems. Some of the pharmacists are ignoring these kinds of errors and it endangers the life of patients. Some of the pharmacists were unaware of these problems and some of them were ignoring in order to maintain a good relationship with the physician. They are thinking that, pointing out errors in the prescription will damage the relationship with the prescriber.

About 66.7% of the participants had reported cases of ADR from the patient and major drugs causing ADR include NSAIDs, analgesics, antibiotics, immunosuppressants, anti-depressants, anti-psychotics, and anti-hypertensives. But most of the pharmacists were not reporting these ADRs to the physician. They do not know the benefits of reporting ADRs. Similarly, the lives of patients are not valued by many. All these indicate indifference to their responsibility.

Majority of the community pharmacist (97.5%) were counselling the patient for less than 5 minutes (51.3%) and 5-10 minutes (46.2%). Very few of them were providing counselling for more than 10 minutes. The main reason behind this less counselling time is lack of time and interest. Some of the patients were not interested in counselling and they rush on their own.

About 63.3% of pharmacists were using oral method for giving instructions to the patient. 32.5% of them were interested in written methods and very few of them were using pictograms or leaflets. It indicates that the oral method is the simplest method to provide instructions regarding drug utilization. It is also useful when the patient is illiterate and cannot read instructions written by the pharmacist. But the written method is also used with every drug along with the oral method. The written method is useful for a patient with memory loss.

Almost 90% of the participants were warning patients about drug interactions and 79.2% of them were counselling the patients about lifestyle modifications for diseases like diabetes mellitus, hyperlipidemia and hypertension. But most of them have less knowledge about other diseases. Some of the pharmacists were less aware of drug interactions and ADRs.

89.9% of them were asking female patients whether they are pregnant or lactating before dispensing OTC drugs. Pregnant and lactating women need special attention before dispensing drugs. Because some drugs may seriously affect the fetus or newborn babies. It is a good sign that about 90% of the participants were well aware of these problems.

Only 63.3% of the participants were asked about drug allergies to the patients. It indicates that some of the pharmacists were not aware of drug allergies. Some patients show serious allergic reactions towards some of the drugs. Before dispensing the pharmacist should ensure that if there were any drug allergies.

About 30% of the pharmacist could diagnose diseases based on patient complaints. They were well experienced and they were dispensing OTC drugs for minor ailments based on complaints of the patient. Only experienced campaigners can diagnose diseases based on patient complaints. Younger pharmacists did not have an idea about providing OTC drugs otherwise the patients name the specific drugs for their use. Majority of the pharmacies did not maintain antidotes in the pharmacy. Only 20% of them were procuring antidotes, mainly activated charcoal. This shows that the importance of keeping antidotes in the pharmacy could not understand by these participants. 

OTC drugs have an important role in increasing the sales of the pharmacy. Most of the patients are not consulting the doctor for their minor ailments. They are depending on community pharmacists for these minor illnesses. But 79.2% of community pharmacists were not concerned with follow up after dispensing an OTC drug. It indicates that most of the patients do not take these drugs properly due to lack of supervision by the pharmacist. It may cause serious side effects to the patients.

Only 76% of the participants were inquiring about the patients before dispensing antibiotics. It indicates that most of them are aware of one of the serious problems in modern medicine, antibiotic resistance. The unwanted use of antibiotics and discontinuation of antibiotic intake before completing the course are the main reasons for antibiotic resistance.

Most of the participants (61.7%) take back the expired medication to the manufacturer for recycling. 38.3% were following garbage disposal for expired medications. Some of them were using both these methods. 75% of them were giving precautions on seasonal ailments like skin diseases, viral infections and allergies. It is one of the major duties of community pharmacists to the society. They can provide preventive measures by placing various charts and flexes near the pharmacy and also provide knowledge orally or using leaflets.

According to the present survey, most of the community pharmacists (60%) were working for 8 hours in a day. 23.3% were working for 7 hours per day. The maximum duration spent by participants in pharmacy is for 12 hours (only 0.8%). It indicates that most of the pharmacists are working for an optimum time period. So they can provide quality services to society. Overtime work may badly affect their efficiency.

Schedule G drugs should be given only under medical supervision. But 35% of the community pharmacists were dispensing it as an OTC drug. Schedule H drugs should be sold under the prescription of a physician. But 16.7% of the participants were dispensing it as an OTC drug. These are examples of breaching the laws without any hesitation and the authority should give special attention to these problems.

Questions regarding frequency of ethical dilemmas:

Community pharmacists were facing many of the ethical scenarios in their day to day life. Sometimes the patient cannot afford the cost of the drug therapy. 37.5% of the pharmacists were facing this problem once in few months and 7.5% were facing once in a day. In such situation pharmacists undergo ethical confusion whether to dispense the medication entirely as per the prescription or as per the affordability of the patient. 33.3% of the participants were dispensing generic drug instead of branded medicine once in a day. Some of the patients are interested in generic drugs due to its low cost. So patients approach these stores for their purchase.

In some situations, pharmacist believes that some medications are not beneficial to the patient.18.3% of the participants were facing this problem once in 3 months and 19.2% once a week. It produces a serious ethical dilemma situation, whether to dispense or not. Some of the community pharmacists were pressurised to achieve their daily sales targets. 22.5% of them were facing this problem few months once and 5% of them facing once in a day. So the community pharmacist was forced to dispense costly drugs and more OTC drugs to the patient. 

In some situations, patients cannot understand the information provided by the community pharmacist. These occur mainly to pharmacists with lesser experience. 17.5% of them are facing this problem once in few months. Sometimes the pharmacist cannot provide the required information regarding the drug due to insufficient knowledge. It mainly occurs for newer drugs available in the market. Some pharmacists were not aware of newly available drugs in the market. But experienced campaigners do not have this problem. They can handle these situations easily. However, 26% of them were facing this problem once in few months.

The most common ethical problem in community pharmacy settings is illegible prescriptions. Nowadays some of the physicians have converted to electronic prescriptions. But most of them were following conventional method. Illegible prescription causes serious ethical dilemma situation among pharmacists either to dispense by guessing or avoid it by making a way for the patient to another pharmacy. Experienced pharmacists have lesser chances for these kinds of situations. 44.2% of the pharmacists were facing this problem once in few months and 26.7% of them were facing once in a week.

One of the most serious ethical dilemma situations in community pharmacy settings is related to schedule X drugs. Some patients force the pharmacist to dispense these classes of drugs without prescription or to dispense more number than those prescribed. But only a very minute percentage of pharmacists that is 0.8% of pharmacists were dispensing schedule X drug without prescription. The probable reason for this act may be the patient is a regular customer and the pharmacist has thorough knowledge about his condition and previously the patient was prescribed with the same drug. Only 2 pharmacists had dispensed schedule X drug more than those prescribed. It may be due to COVID 19 situation. Due to the pandemic situation patient cannot consult the doctor. Sometimes phone call requests from the prescriber tend to dispense these drugs more than those prescribed.

The main reason for compromising ethical values in the community pharmacy settings include to protect their jobs (44.2%), to carry out physician’s order or request (25%), to meet employer’s order (20.8%) and to carry out patient’s request (20%). But still some community pharmacists are there, who do not want to compromise on these ethical situations. Mainly younger pharmacists in the field are well aware of ethical concerns whereas experienced pharmacists are less aware of ethics in the pharmacy settings. Pharmacists in the community settings are facing a lot of dilemma situations in their day to day life. The frequency of ethical dilemma situations experienced by the community pharmacists was found to be once in three months (19.2%), once in six months (20%), once in a month (12.5%), once in a week (7.5%) and 22.5% of the pharmacist never had an ethical problem in their career.

CONCLUSION

Pharmacists working in the community pharmacies of Kozhikode district are providing services of proper quality. Most of them are completed their training period in dispensing. Most of the pharmacists are employee pharmacists and they are arranging drugs in alphabetical order. Most pharmacies providing temperature - controlled measures for keeping vaccines and other parenteral preparations. They are counselling the patients with oral or written method and mostly taking less than 10 minutes with each patient. Most of the pharmacists are reporting the physician about ADRs, contraindicated drugs and other prescription errors. Some of them are giving schedule H, G and X drugs without supervision of doctor or without valid prescription.

Community pharmacists are faced with various ethical dilemma situations in their day to day life. Most of them are facing ethical dilemma situation at least once in three months. Community pharmacist compromise on ethical values and ethical issues mainly for protecting their jobs. The physician’s request and employer’s invasion into their activities have a great role in creating ethical dilemma situations and thus violating the laws. Some of the patients are compelling the pharmacist for providing drugs without valid prescription and also for breaching the rules. The most common ethical dilemma situation faced by community pharmacists are with illegible prescriptions.

The authorities should be vigilant about the education, training and licensing of pharmacist and include the guidelines of good pharmacy practice in their syllabus. At institutional level the student must be taught about drug interactions, ADRs and they should be motivated by attending continuous educational programmes by pharmacy council and other authorities. It will be helpful to reduce the errors while dispensing and improve the quality of the services by the pharmacist. The authorities should be keen-eyed about exploitation of the pharmacist by employers and should strictly warn the pharmacist to avoid breaching the laws.

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