decision making- case study

1

The professional decision-making process

Case Study

2

CASE STUDY Two pharmacists were reprimanded (rebuked ) by the

Statutory Committee in 1991 following convictions for the supply to a 17-year-old youth of sodium cyanide in one case and strychnine hydrochloride, potassium permanganate (a strong oxidizing agent) and glycerol (Sugar alcohols) in another.

6

CASE STUDY, CONT… Why were such supplies considered wrong? What thought processes should have been gone through

in reaching a decision as to whether to supply? Pharmacists are permitted to supply all these substances

from a pharmacy, so why were convictions as well as a reprimand given?

Would it have been right to supply in other circumstances?

If so, on what knowledge would you have based your decision?

7

STAGE 1: GATHER RELEVANT FACTS

What is needed before any decision can be taken is collect as many facts as possible. We shall call this:

Gather relevant facts1- What criminal law applies here? First, you want to know what the criminal law

says. Ask yourself, ‘will I be breaking the law if I supply?’

8

STAGE 1: GATHER RELEVANT FACTS CONT

In the case of potassium permanganate, you may supply, but there are packaging and labelling regulations to consider. You may supply glycerol; indeed, you can buy glycerol (or glycerine) from the food shelves of a supermarket.

Neither of these substances is controlled as a medicine or a poison. Sodium cyanide and strychnine are both Part I, Schedule 1 poisons with special conditions attaching to their supply.

9

GATHER RELEVANT FACTS CONT

Most of the criminal law that applies to pharmacy practice will be in the Medicines Act, the Misuse of Drugs Act or the Poisons Act, although there is a whole range of other criminal legislation that may apply, e.g. the Environmental Protection Act, the Health and Safety at Work, etc. Act, the Customs and Excise (taxation) Management Act.

10

GATHER RELEVANT FACTS , CONT

What NHS law applies here? In this example, you do not have to consider national

health service (NHS) law because the supply is a ‘private’ one and not within the terms of the NHS contract.

11


What civil law applies here? In this example, the young man managed to cause an explosion by

using glycerol and potassium permanganate together. Would the supplying pharmacist have been partly to blame for any damage that may have resulted? To some extent, yes, because pharmacists are expected, by virtue of their expertise and training, to exercise a greater duty of care than other retailers over the supplies they make.

In the case of strychnine and cyanide, sales are restricted to pharmacies precisely because pharmacists are expected to know the dangers inherent in their use and only to supply responsibly after due enquiries have been made.

12


What guidance does the Code of Ethics give here? As a pharmacist, you have to meet standards that are in

excess of the minimum that the law requires. At the time of this case, the Code of Ethics said ‘A pharmacist must take steps to ensure that all chemicals supplied will be used for a proper purpose and in appropriate circumstances’.

13


The Code went on to give guidance that all oxidising agents, such as potassium permanganate, may be used for the preparation of explosives. (Such requirements are now implicit in the legal requirement to exercise ‘due diligence (careful and persistent work or effort)’ when supplying any chemicals.) . What enquiries should you make? What facts will you need to show that you made reasonable enquiries to satisfy these requirements?

14


5- What professional knowledge do I have that applies here?

In spite of all the legal and ethical constraints or guidance that you are aware of, you will also be applying your technical and clinical knowledge to the situation.

You probably learned in chemistry classes that certain chemicals make explosive combinations.

15

You would know that cyanide and strychnine are very potent poisons.

Many of the problems you encounter in pharmacy practice will require the use of your knowledge of therapeutics, pharmaceutics, good pharmacy practice, etc., as well as knowledge of law and ethics.


16

Where can I look or whom can I ask for help?Finally, but just as important as any of the above, is

whether there is any precedent you can follow, any policy that covers this situation, any other ‘rule book’ or senior pharmacist that perhaps you should consult.

Many pharmacists are employees who will have corporate protocols and procedures to follow and, most valuable at the start of a career, a range of experienced pharmacists who can be asked for advice.


17

STAGE 2: PRIORITISE AND ASCRIBE VALUES

In this example, the fact that the purchaser in the above example is male is interesting but not important; his age, however, may influence your eventual decision.

Even if the purchaser were a middle-aged respectable-looking individual, you might still consider the nature of the substances or combination of substances to be of overriding importance. You are prioritizing the facts.

18

STAGE 2: PRIORITISE AND ASCRIBE VALUES ,CONT

Moreover, you want to weigh up the consequences for yourself, perhaps for your employer, for the young man, for his parents and neighbors and for the reputation of pharmacy of making these supplies or not.

The relative importance you attach to these issues will also depend on your own personal opinions and attitudes. In other words, you are ascribing values to the facts you have assembled.

19

STAGE 3 GENERATE OPTIONS

In other words, ask yourself: ‘What could I do in this situation?’

In this example there will be at least four options: 1. Supply none of the items 2. Supply all of the items 3. Supply some of the items 4. Delay to seek advice.

20

STAGE 3 GENERATE OPTIONS ,CONT You might suggest other variations such as selling some

or all of the items, subject to certain conditions, such as a written request specifying reason for purchase or giving the authority of someone you know to be responsible.

By careful analysis, you will be able to establish the likely consequences of each course of action and then choose which will have the best chance of a good outcome or, in some cases, the least likelihood of causing harm.

21

STAGE 4 CHOOSE AN OPTION

Stage 4 Choose an option In other words ask yourself: ‘What should I do in this

situation?’ Remember that, when making your choice, you may have to be able to justify why you made that one.

22

SUMMARY OF THE FOUR-STAGE DECISION-MAKING PROCESS.

Stage Components1. Gather relevant facts: what applies here?

Criminal, NHS and civil lawThe Code of Ethics Council statements Professional and other knowledge

2. Prioritise and ascribe values: what are the interests of various parties ?

The patientThe PublicCarers Relatives and neighbours Other healthcare professionals The pharmacy profession Your employer Yourself

23

SUMMARY OF THE FOUR-STAGE DECISION-MAKING PROCESS ,CONT

Stage Components3. Generate options What could you do?

What are the possible consequences of each option? How likely are the consequences?

4. Choose an option What should you do? Can you justify the chosen option?

24

THE FIVE-STEP MODEL

There is another model for ethical problem Solving 1. Respond to the “sense” or feeling that something

is wrong. 2. Gather information/make an assessment. 3. Identify the ethical problem/consider a moral

diagnosis. 4. Seek a resolution. 5. Work with others to determine a course of action.

The End

26

CASE STUDY “AN ASSIGNEMNT” Roger Lucas, 70 years old, was admitted to the medical intensive care

unit from the surgical floor of the hospital with what appeared to be a pulmonary embolism. Mr. Lucas had fractured his femur in a fall at the nursing home where he is a patient and was awaiting surgery the next morning when he developed dyspnea, tachypnea, and tachycardia. At almost the same moment that Mr. Lucas arrived in the ICU, another patient, Ronald London, was admitted in the next room under equally emergent conditions. Mr. London was 60 years old and had a history of liver cirrhosis from alcohol abuse. Mr. London had ruptured esophageal varices. Helen Fowler, Pharm.D., was the pharmacy supervisor for the evening shift for the six intensive care units in the hospital. She and two other pharmacists worked frantically to fi ll all the orders for intravenous drugs and parenteral solutions that came from the intensive care units.

27

CASE STUDY ,CONT Later, after the rush had subsided, Dr. Fowler decided to conduct

rounds and learned that Mr. London had died. The code team was still picking up their equipment when Dr. Fowler got to the unit. “That’s a shame,” Dr. Fowler said to the nurse who was straightening up the room and conducting postmortem care so that Mr. London’s family could spend some time with him before his body was sent to the morgue. Then Dr. Fowler noticed the label on the IV bag in the trash, the one that had held the IV the nurse had just removed from Mr. London’s arm. Dr. Fowler was shocked to see that the empty IV bag included heparin, not the octreotide he should have received. A hemorrhaging patient should never receive heparin.

28

CASE STUDY ,CONT Without saying anything to the nurse, Dr. Fowler

stepped next door to see what solution was hanging in Mr. Lucas’s room. Much to her dismay, Mr. Lucas was receiving octreotide when he should have been receiving heparin. And, the two names had been switched on the labels. In the rush and confusion surrounding the admissions and the critical nature of both patients, the IVs were inappropriately labeled. Apparently no one checked the bags for the name of the drug before hanging them since in each case the patient’s name and room number were correct.

29

COMMENTARY

This case is complex but reveals potential ethical concerns. As the pharmacist involved in the case, Dr. Fowler will need to decide what she needs to do and why. The five-step model can help Dr. Fowler work toward a justifiable resolution.

30

1. Respond to the Sense That Something Is Wrong

2. Gather Information3. Seek Resolutions4. Work with Others to Choose a Course

of Action

Follow the following hints to make a good decision?

decision making- case study

Documents