Disciplinary sanctions for lack of file notes: ‘It created unease and fear’

After recent sanctions imposed by the Disciplinary Board of the Ordre des pharmaciens du Québec (OPQ) on two pharmacists for failings in the followup of a vulnerable, non-compliant patient, questions and criticism were rife within the profession.“It's a decision that's not understood,” said Patrick Hemery, president of the Association professionnelle des pharmaciens salariés du Québec (APPSQ). “It has created unease and fear.”Hemery points to several areas of concern raised by pharmacists, both on social networks and in the comments section of the Profession Santé (sister publication of Pharmacy Practice + Business) website: the methods employed by the trustee, the disciplinary process in place and the disproportionality of the sanctions applied. These concerns and criticisms are summarized in an open letter addressed to the Trustee’s Investigations Department and the OPQ, including a number of recommendations and possible solutions (see below).Read: Two pharmacists sanctioned for serious failures in monitoring a patientRead: Message from the OPQ president: Towards a better understanding of disciplinary decisionsTrustees "out of touch”Investigative methods used are often experienced as “a humiliation” for pharmacists, according to Hemery, who believes that, “trustees push for guilty pleas right from the start, which is not normal.”One of the main issues is the length of procedures, he believes. "A simple investigation sometimes takes six months, when it could be settled in 15 days. This generates significant costs and pressure for pharmacists, who must not talk about it."One of the main issues is the length of procedures, he believes. "A simple investigation sometimes takes six months, when it could be settled in 15 days. This generates significant costs and pressure for pharmacists, who must not talk about it."But above all, the APPSQ president criticized trustees who are still too disconnected from the realities on the ground, in his opinion.“Trustees haven't been practicing for years,” he said to Profession Santé. We need to review the way they are recruited, perhaps hiring them on five-year fixed-term contracts, which would oblige them to return to practice afterwards," he suggested.In his open letter, Hemery points to, “a disciplinary regime whose interpretation is sliding towards a theoretical ideal, disconnected from the concrete constraints of professional practice.”He told Profession Santé: “Trustees haven't been practicing for years. We need to review the way they are recruited, perhaps hiring them on five-year fixed-term contracts, which would oblige them to return to practice afterwards," he suggested.Obligation of means, not of resultsAs for the Disciplinary Board's decisions, Hemery points out—as OPQ President Jean-François Desgagné did in a letter to pharmacists published on the Profession Santé website on July 9 (and published here)—that they are based on the “importance of documentation,” the “role of therapeutic surveillance” and “collective responsibility.”Despite this, the main stumbling block remains the message conveyed by the two decisions. “It was perceived as an obligation of result,” explained Hemery. “But we only have an obligation of means.”In his open letter, Hemerey points out that these decisions criticize pharmacists, “for failing to document certain verbal reminders aimed at supporting treatment adherence.” Importanly, these are reminders that did in fact take place, according to the available evidence, he wrote."What is at stake here is not the absence of intervention, but the absence of explicit documentary evidence. This posture worryingly shifts the disciplinary regime towards a form of implicit result requirement, or at the very least, absolute traceability, regardless of context."The criticisms levelled at pharmacists are, moreover, impossible to realize in everyday community pharmacy practice. “We work in a continuous flow of action and patients, and if we have to be led to record all our verbal orders, it's endless,” said Hemery. “We'll end up taking 15 patients a day instead of 50."This vagueness adds concern to that engendered by the new practice framework set out in Bill 67, which is due to come into force imminently.“Even responsible, repeated and relevant practice could now be deemed insufficient if it is not recorded according to high standards of formalism, often unrealistic in today's clinical workload,” he said, warning that file notes may now be a way of protecting oneself from potential legal action by the trustee, rather than an action aimed at improving patient care.Moreover, as things stand, there is no evidence of a causal link between the lack of notes in the patient's file and his stroke, who has since been institutionalized in a vegetative state. "I'm aware that a patient ends up in a (long-term-care facility), but is it because he didn't take his apixaban? There is no expert report to prove this."Question of interprofessional equityFinally, the APPSQ president denounces a decision that, “seems to depart from the guidelines of proportionality, nuance and clinical realism.”At issue is the proportionality of the penalties applied to the two pharmacists—fines of $5,000 and $4,500 respectively—which is questionable, even shocking, when, “no element of wrongful intent or gross negligence has been demonstrated,” writes Hemery."How many other healthcare professionals in Quebec receive such a severe sanction for an omission of this nature, with no obvious fault or serious triggering event? This severity raises a real question of interprofessional fairness."On the strength of all these findings, the APPSQ president is calling for swift, concrete action on the part of the trustee’s Investigations Department to “bring about change,” so as not to end up undermining confidence in the supervisory mechanisms. “I'm confident that things will change quickly.” This article has been translated from its original French and first appeared on our sister site Profession Santé.

Disciplinary sanctions for lack of file notes: ‘It created unease and fear’

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