24 Mar 2021
The Pharmacy Board of Australia (the Board) has published a summary report of an analysis of notifications involving oral methotrexate.
The report can be found on the Professional practice issues webpage.
Several notifications about oral methotrexate have been recorded since inception of the National Registration and Accreditation Scheme and establishment of the Board in 2010. The Board commissioned the Research Unit of the Australian Health Practitioner Regulation Agency (Ahpra) to undertake an analysis of notifications involving oral methotrexate. The published report provides a summary of findings from this analysis.
The analysis found that:
The summary report concluded that:
Pharmacists are reminded that they need to ensure their own processes, and those of the pharmacy where they are practising, support them to exercise their professional responsibilities in the safest way possible. Pharmacists should ensure they are guided by relevant professional practice standards and can also refer to the following Board guidelines for further information to support professional practice:
The Board and other stakeholders publish case studies from time to time, including about errors involving methotrexate. We encourage all pharmacists to read these case studies and be aware of the issues that may lead to a dispensing error.
The Board will continue to engage with key stakeholders about the risk of errors involving methotrexate and share the details of any developments to ensure that these risks remain in the forefront of the minds of all pharmacists and their support staff.
To date, changes have been made to methotrexate packaging and product information, however, the available proprietary packs of methotrexate tablets include more than one month’s supply and therefore, extra care must be taken to ensure that the correct quantity, directions and counselling are provided when supplying this medication to patients.
The Board will also consider any necessary changes to its guidelines for pharmacists when it begins a review this year and will undertake wide-ranging public consultation on any revised proposals.
We will provide further updates on this work in the coming months.