Pharmacists are expected to take reasonable steps to satisfy themselves that a prescription has been issued by an authorised prescriber. Prescriptions for Schedule 4 and Schedule 8 medicines subject to abuse, such as such benzodiazepines and opioids, are most likely to be forged. However pharmacists should also consider other medications such as anabolic steroids which may be abused and medications such as Catapres that can be used to mask the symptoms of withdrawal from drugs of dependence (if, for example, a patient has sold their prescribed takeaway dose of an opioid substitute). The supply of such medicines in the absence of a legal prescription results in unacceptable risks to the public.
Each State and Territory has its own drugs and poisons legislation which outlines the requirements for valid prescriptions and pharmacists’ statutory obligations if a forged prescription is received or detected[1]. Pharmacists should also ensure that they check the requirements of the state that the prescription originates from, for example if a patient reports they are on holidays or if the pharmacy is located close to a state border.
Generally, pharmacists have an obligation to notify the state health department and in some jurisdictions, the police if they reasonably believe a prescription has been forged or fraudulently altered. Some states also have specific processes for medical practitioners to follow if their prescription pad has been lost or stolen. This information is published online and can be checked by pharmacists.
Could this be a forged prescription? – Consider and ask yourself the following:
The Patient
- Do you know the patient?
- Is there a patient medication history?
- Is the medication consistent with the patient’s known dispensing history?
- Is it reasonable for the patient to be visiting the pharmacy, given their home address?
- Is the patient on holidays or visiting a friend or relative?
The Prescriber
- Do you know the prescriber, including their practice or speciality?
- Is it reasonable for the patient to be seeing this prescriber?
- Is the prescriber from out of town?
- Are the drugs prescribed tailored to the individual or do all the prescribers’ patients all seem to receive the same drug(s)?
The Situation
- Is the patient in a hurry and unable to return later?
- Has the patient presented the prescription late in the evening, or on the weekend, when it is difficult to confirm treatment with a doctor?
- Is the date of the prescription consistent with a patient’s urgency to fill it?
- Is a diversion used to distract the pharmacist and/or is pressure applied to make them fill the prescription quickly (e.g. crying baby or feigned illness)?
- Is the Pharmacy particularly busy?
The Prescription
- Does it look ‘too good to be true’ (that is, handwriting, format and patient information; are the directions fully written out)?
- Do the quantities or directions differ from the usual prescribing pattern?
- Are the symbols, terminology or abbreviations unusual?
- Has white-out been used, is there any smudging or different colour ink on the prescription?
- Does it look like previous dispensing stickers have been removed or are there too many ‘staple holes’ in the repeat authorisation?
It cannot be assumed that an electronic prescription is genuine. Forged and fraudulent computer-generated prescriptions are as prevalent as handwritten ones and they can be more difficult to identify. In the often fast paced environment of many community pharmacies, key points to check to ascertain that an electronic prescription is genuine include:
- Are there perforated edges on the edges of the script? These are often lacking on scanned or coloured photocopies of genuine prescriptions.
- Does the prescriber’s information on the prescription match the pre-printed information on the back of the prescription?
- Is the font size different from normal?
- Are there any spelling errors? Dispensing software does not usually spell the name of medicines incorrectly. Individuals who fraudulently copy information from a genuine prescription may inadvertently use incorrect spelling for the name of a medicine or incorrect abbreviations for the prescriber’s instructions.
- Does the quantity or number of repeats seem to have been manually altered? Medical practitioners are not authorised to make manual alterations to computer-generated prescriptions.
The above is not an exhaustive list of factors that may indicate a forged or fraudulent prescription. Also, one or more of these factors may be present, but the prescription could still be genuine. Above all, trust your own professional judgment. If the prescription seems wrong, it probably is and you should not dispense it. If a decision is made to refuse to supply, a detailed note of the reasons why should be recorded in the patient’s history.
I think this prescription may be forged – what should I do?
- Ask the patient for further information to clarify their clinical need for the prescribed medication and general health status – this will also provide more time to critically appraise the prescription.
- Contact the prescriber to confirm that they wrote the prescription but obtain the doctor’s phone number from a source other than the prescription. The prescriber’s name can be checked on the Australian Health Practitioner Regulation Agency Register of Practitioners. Some states in Australia allow for an emergency supply to be provided if the prescriber is unavailable. Two days’ supply can be made and the prescription must be retained until verification is possible.
- Ask for identification – exercise your professional judgment to establish that the patient is who say they are and that they have a genuine therapeutic need for the medication.
- Record the details of all intervention communications with prescribers to ensure your colleagues are aware of relevant matters. Do not assume that one of your colleagues has confirmed that a prescription is genuine unless there is evidence to support that belief.
If may be difficult for a pharmacist to justify dispensing a forged prescription if they:
- failed to contact prescribers in circumstances where they might otherwise be expected to do so (for example, excessive prescribing);
- failed to contact the relevant department to report ‘excessive supply’;
- relied upon the fact that the handwriting on one forged prescription is consistent with an earlier prescription, which was also forged; or
- failed to discover that a prescriber’s details had already been added to a published list of stolen prescriptions.
This article was written by Principal Scott Ames. Please contact Scott Ames if you have any questions or if you would like further information.
This article was originally published as a Practice Alert by Pharmaceutical Defence Limited.
[1] Health (Drugs and Poisons) Regulation 1996 (Qld); Poisons and Therapeutic Goods Regulation 2008 (NSW); Drugs, Poisons and Controlled Substances Regulations 2017 (Vic); Poisons Regulations 2008 (Tas); Medicines, Poisons and Therapeutic Goods Regulation 2008 (ACT); Controlled Substances (Poisons) Regulations 2011 (SA); Medicines and Poisons Regulations 2016 (WA); Poisons & Dangerous Drugs Act (NT)