GPhC Patient Safety 2 — Questions and Answers
Question 1: A patient presents with a prescription for co-trimoxazole. They mention they are also taking warfarin. What is the key safety concern?
- Co-trimoxazole reduces warfarin absorption
- Co-trimoxazole enhances the anticoagulant effect of warfarin, increasing bleeding risk (Correct answer)
- Warfarin reduces the antibacterial efficacy of co-trimoxazole
- There is no clinically significant interaction
Correct answer: Co-trimoxazole enhances the anticoagulant effect of warfarin, increasing bleeding risk
Co-trimoxazole significantly potentiates the anticoagulant effect of warfarin through multiple mechanisms: the trimethoprim component inhibits CYP2C9 (the main enzyme metabolising S-warfarin), and the sulfamethoxazole component may displace warfarin from protein binding. This can cause dangerously elevated INR and serious bleeding.
Question 2: When performing a medicines use review (MUR) or the New Medicine Service (NMS), the pharmacist identifies that an elderly patient is taking a benzodiazepine long-term. What patient safety advice should be prioritised?
- Advise the patient to stop the benzodiazepine immediately
- Discuss the increased risk of falls, cognitive impairment, and dependence, and suggest a GP review for a planned gradual withdrawal (Correct answer)
- Tell the patient benzodiazepines are safe for long-term use in the elderly
- Switch the patient to a different benzodiazepine without GP input
Correct answer: Discuss the increased risk of falls, cognitive impairment, and dependence, and suggest a GP review for a planned gradual withdrawal
Long-term benzodiazepine use in elderly patients significantly increases the risk of falls, fractures, cognitive impairment, and dependence. NICE recommends planned gradual withdrawal. Abrupt cessation is dangerous and can cause seizures. The pharmacist should advise a GP review for a structured dose reduction plan.
Question 3: A patient with a documented penicillin allergy (anaphylaxis) is prescribed cefalexin. What should the pharmacist do?
- Dispense cefalexin as it is not a penicillin
- Contact the prescriber — patients with penicillin anaphylaxis have a higher risk of cross-reactivity with cephalosporins (Correct answer)
- Tell the patient cefalexin is completely safe despite their allergy
- Substitute with a different cephalosporin without consulting the prescriber
Correct answer: Contact the prescriber — patients with penicillin anaphylaxis have a higher risk of cross-reactivity with cephalosporins
While the overall cross-reactivity between penicillins and cephalosporins is low (1-2%), patients with a history of penicillin anaphylaxis have a higher risk and should generally avoid cephalosporins, particularly first-generation ones like cefalexin. The pharmacist should contact the prescriber to discuss alternative antibiotics.
Question 4: Which of the following scenarios would require the pharmacist to intervene under the NHS safeguarding framework?
- A young adult requesting the morning-after pill
- An elderly patient with unexplained bruising who appears fearful and is accompanied by an aggressive relative (Correct answer)
- A parent buying paracetamol suspension for their child with a fever
- A teenager buying acne treatment
Correct answer: An elderly patient with unexplained bruising who appears fearful and is accompanied by an aggressive relative
Pharmacists have a duty of care under safeguarding legislation to recognise and report concerns about vulnerable adults and children. Unexplained bruising combined with fearful behaviour and an aggressive companion are recognised indicators of potential abuse or coercion. The pharmacist should follow local safeguarding procedures.
Question 5: A prescription for a child specifies a dose that exceeds the maximum recommended in the BNF for Children. The prescriber states this is intentional for the patient's specific condition. What should the pharmacist do?
- Dispense as the prescriber has confirmed the dose
- Request the prescriber endorse the prescription to confirm the higher dose is intended, document the conversation, and dispense with appropriate counselling (Correct answer)
- Refuse to dispense under any circumstances
- Reduce the dose to the BNF maximum without telling the prescriber
Correct answer: Request the prescriber endorse the prescription to confirm the higher dose is intended, document the conversation, and dispense with appropriate counselling
When a prescriber intentionally prescribes above BNF-recommended doses, the pharmacist should request written confirmation (endorsement) that the dose is intentional, document the clinical conversation, and then dispense with appropriate patient/carer counselling. This creates an audit trail and ensures patient safety without blocking appropriate clinical decisions.
Question 6: What is the primary purpose of the Falsified Medicines Directive (FMD) safety features system implemented in UK pharmacies?
- To track how many medicines each patient uses
- To verify the authenticity of prescription medicines and prevent counterfeit products entering the supply chain (Correct answer)
- To monitor pharmacist dispensing speed
- To enable automatic reordering of stock
Correct answer: To verify the authenticity of prescription medicines and prevent counterfeit products entering the supply chain
The FMD requires unique identifiers and anti-tampering devices on prescription medicine packs. Pharmacies must verify and decommission these unique identifiers at the point of dispensing to confirm authenticity. This protects patients from counterfeit, stolen, or recalled medicines entering the legitimate supply chain.
GPhC Patient Safety 2
A patient presents with a prescription for co-trimoxazole.
They mention they are also taking warfarin.
What is the key safety concern?