Case studies learnings

These case studies have been published by the Pharmacy Board of Australia to help practitioners understand and meet their professional and legal obligations as a registered pharmacist.

Additional case studies can be found in past newsletter issues published by the Board.

The allegation

A notifier alleged that inappropriate comments published on a pharmacist’s personal Facebook page concerned the practitioner’s personal views on abortion. Although the Facebook page was a closed group, pharmacy patients were members of the group. The pharmacist’s Facebook page included photos of the practitioner at work as a pharmacist. The notifier was concerned that pharmacy patients may be subject to judgement in certain circumstances and may not receive unbiased or timely healthcare.

The issues

The allegation raised issues concerning the practitioner’s responsibilities when using social media as outlined in the Social media policy developed by the National Boards. When using social media, pharmacists should remember that the National Law, the Pharmacy Board’s Code of conduct for pharmacists, and the Guidelines for advertising regulated health services (the advertising guidelines) apply. Whether or not an online activity can be viewed by the public or is limited to a specific group of people, registered health practitioners need to maintain professional standards and be aware of the implications of their actions, as in all professional circumstances.

Registered health practitioners should only post information that is not in breach of these obligations by:

  • complying with professional obligations
  • complying with confidentiality and privacy obligations
  • presenting information in an unbiased, evidence-based context, and
  • not making unsubstantiated claims.

The Board’s Code of conduct states that good practice includes being aware that differences such as gender, sexuality, age, belief systems and other anti-discrimination grounds in relevant legislation may influence care needs and avoiding discrimination based on these differences. While individual practitioners have their own personal beliefs and values, there are certain professional values on which all practitioners are expected to base their practice. These professional values apply to the practitioner’s conduct regardless of the setting, including in person and electronically, e.g. social media, e-health etc.

The outcomes

The Board formed a reasonable belief that the practitioner displayed unprofessional conduct, with respect to inappropriate comments on social media and that the behaviour was below the standard reasonably expected of a pharmacist by the public or their professional peers.

When using social media, it is an individual's right to express their personal views. However, in this case, the Board considered the pharmacist’s use of social media to be in breach of the National Boards’ Social media policy and the Pharmacy Board's Code of conduct for pharmacists in that the practitioner:

  • failed to present information in an unbiased, evidence-based context
  • failed to demonstrate awareness of their own beliefs and how they may impact on the practitioner-patient relationship
  • failed to demonstrate awareness that differences in belief systems may inform the care needs of persons receiving healthcare, and
  • failed to demonstrate awareness of the cultural needs of patients, who might be privy to the Facebook posts, in the context of providing good health outcomes.

In this case, the Board formed a reasonable belief that the pharmacist’s conduct was unsatisfactory and proposed to caution the practitioner.

Lessons to be learnt

Pharmacists who use social media need to remember that their professional obligations continue when they are active online.

The Board’s Social media policy and Code of conduct for pharmacists both apply to all digital activity, including public forums and in closed groups.

The Social media policy provides guidance on pharmacists’ responsibilities and obligations when using and communicating on social media. Anyone using social media to advertise a regulated health service needs to meet the advertising requirements of the National Law. This includes removing any testimonials from a pharmacist’s social media page.

The Code of conduct for pharmacists sets out the required standards of professional behaviour, which apply to interactions in person and online.

Some of the principles that are useful to remember when active online include:

  • maintain professional standards and be aware of the implications of your actions, as in all professional circumstances
  • be aware of your ethical and regulatory responsibilities when you are interacting online – they are the same as when you interact in person
  • ensure that you protect the privacy and confidentiality of patient information, and
  • comply with the advertising provisions in the National Law and with the Board’s advertising guidelines.

The Social media policyCode of conduct for pharmacists and advertising guidelines are available on the Board’s website.

The allegation

A notifier alleged that a pharmacist failed to ensure patient privacy by affixing the pharmacy dispensing label to the primary container over the top of another label showing another patient’s details. The second label was easy to remove, and as a result the first patient’s details were accessible, resulting in a breach of confidentiality.

The issues

The allegation raised issues concerning privacy of patients as outlined in the Board’s Code of conduct for pharmacists and Guidelines for dispensing of medicines, which requires the practitioner to ensure the privacy of patients is assured and that the information about a person obtained through the course of professional practice is only disclosed with the patient's permission.

The initial dispensing label had not been removed from the medication when it had been labelled in error for an earlier patient. Because the medication had not left the pharmacy it was able to be reused. However, the initial dispensing label with the patient’s details should have been removed before dispensing the medicine to the next patient.

The outcome

The Board formed a reasonable belief that the pharmacist’s conduct was unsatisfactory and cautioned the practitioner.

Lessons to be learnt

Pharmacists must ensure that all pharmacy services are provided in a manner that respects and upholds a patient's privacy requirements in accordance with the Board’s codes and guidelines, as well as relevant privacy laws applicable to health providers.


The allegation

A notifer alleged that the practitioner allowed a pharmacy student to prepare and dispense a patient’s methadone dose without direct supervision and failed to check the dose before it was provided to the patient. As a result, the patient received a dose that was significantly higher than prescribed as the student had provided the dosage milligrams as millilitres.

The issues

The allegation raised issues concerning the roles and responsibilities of pharmacy staff. The Board’s Code of conduct for pharmacists outlines that good practice involves making the scope of the student’s role in patient or client care clear to the student, to patients or clients and to other members of the healthcare team. The code also states that the onus of supervision cannot be transferred and that any practitioner or student under supervision must receive adequate oversight.

The allegation also raised issues concerning proprietor responsibilities as outlined in the Board’s Guidelines for proprietor pharmacists, which includes maintaining an awareness of and responsibility for the services being provided, ensuring that the practice of pharmacy is conducted in accordance with applicable laws, standards and guidelines, that appropriate risk management procedures are in place for the operation of the pharmacy, and that business procedures, policies and protocols are routinely followed.

The outcomes

The practitioner demonstrated poor insight into his roles and responsibility as a supervising pharmacist. As a consequence, the Board considered it necessary to restrict the pharmacist from acting as a preceptor or supervisor of interns or students. In addition, the practitioner was required to undertake formal education and provide a reflective report demonstrating how the practitioner had incorporated the lessons learnt in this education into the practitioners practice as a pharmacist.

Lessons to be learnt

The dispensing of methadone for opioid replacement therapy (ORT) is an inherently high-risk area of pharmacy practice. The Board considered the supervision to be irresponsible, unprofessional and in the absence of safeguards (i.e. direct supervision) extremely dangerous.

Careful management of all aspects of supply of ORT is required by pharmacists in accordance with the jurisdictional legislative requirements including any policies and guidelines issued by local authorities. Pharmacists must also ensure compliance with pharmacy practice standards and codes and guidelines published by the Board.

The allegation

It was alleged that a practitioner dispensed a medication to the incorrect patient. When collecting the prescription, the patient was provided with a medication belonging to another patient with the same surname but different first name by a pharmacy assistant. As a result of this error the patient took a medication that was not prescribed for them and suffered adverse effects.

The issues

The allegation raised issues about patient counselling when supplying a medicine. The Board’s Guidelines for dispensing of medicines outline that patient counselling is part of the process of dispensing medicines and provides an opportunity to elicit the necessary information from a patient, and to provide the required information to enable safe and effective use of medicines. Counselling is also the final checking process to ensure the correct medicine is supplied to the correct patient.

The outcome

The practitioner's performance was considered to be unsatisfactory and the practitioner was cautioned.

Lessons to be learnt

The Board notes that there have been numerous similar cases like this in the last year. In this instance, the practitioner acknowledged the importance of checking that the first name and surname are correct at all times. Supply of medications to the incorrect patient can have significant health consequences. The pharmacist should make every effort to counsel, or to offer to counsel the patient whenever a medicine is supplied. Lack of counselling can be a significant contributor in failing to detect dispensing errors.

A notifier alleged that a patient was issued a repeat authorisation by a pharmacy for two additional supplies of a prescribed medicine without the authority or direction of the prescriber. For more information, please read the newsletter.

A notifier alleged that a pharmacist purchased OxyElite Pro capsules from a supplier in the United States and supplied the product to patients of the practitioner’s pharmacy. For more information, please read the newsletter.

A recent notification highlighted the importance of giving appropriate advice about medicines used during pregnancy or while breastfeeding. For more information, please read the newsletter.

Page reviewed 21/03/2019