It is the loss of the safety net. Access is not the same as safety, and a quicker consultation is not necessarily a safer one.
Matilda was only about two hours old. My attention was elsewhere; the world had narrowed to her tiny face.
A nurse walked over to give her the routine newborn hepatitis B vaccination. Out of the corner of my eye, I noticed something that did not look quite right.
I stopped her before it was administered.
The vaccine in the nurse’s hand was Boostrix. It was not hepatitis B.
No harm occurred. The nurse was not careless. She was not incompetent. She was a trained professional working in a busy healthcare system.
But the moment has stayed with me ever since, because it captured something every clinician knows and every health system must be built around: good people make mistakes.
Medication errors are not rare aberrations. They are one of the most recognised, reported and preventable sources of harm in healthcare. The World Health Organization has described unsafe medication practices and medication errors as a leading cause of avoidable injury and harm worldwide.
In Australia, medication safety has its own national safety standard because the prescribing, dispensing, administering and monitoring of medicines are all points at which things can go wrong.
This is the reason modern healthcare has moved away from the old idea that safety is achieved by simply training individuals better. Training matters enormously. Competence matters. But the lesson of patient safety over the past few decades is that training alone is not enough.
The modern patient-safety approach assumes that humans are fallible. It assumes that fatigue, pressure, distraction, system design, workload, and interruptions all matter. It assumes that even careful clinicians will make errors. So we build systems around them.
I understand this much better now than I did earlier in my career.
When I was a paramedic, before I became a doctor, I had a very different view of general practice. In my small bubble of pre-hospital emergency medicine, where the work was visible, urgent and sometimes dramatic, I thought of GPs as office-bound referral monkeys.
I saw the adrenaline and immediacy of emergency care and, with more bravado than wisdom, assumed general practice sat somewhere lower on the medical hierarchy.
Then I walked the walk.
I went to medical school. I worked in hospitals. I entered general practice. And I realised just how very wrong I had been.
The amount of knowledge required to practise medicine safely is vast. The training is long, because the stakes are high. And the learning does not end at graduation, internship, residency, fellowship or the first year of independent practice. It continues for the rest of your career.
General practice is not easy medicine. It is undifferentiated medicine. It is the place where chest pain, fatigue, abdominal pain, rash, headache, anxiety, dizziness, a child with fever, a new mole, a request for antibiotics, a missed cancer, a hidden safeguarding issue and a medication interaction can all present in the same morning.
The work can look deceptively simple from the outside. That is part of the danger.
In hospitals and general practices across the country, every vaccination should be double-checked before administration. We do this not because nurses are poorly trained, but because they are human.
The same principle applies to prescribing.
In primary care, a GP often prescribes alone in a consulting room. A good GP checks the diagnosis, considers differentials, weighs contraindications, checks allergies, looks at interactions, adjusts for age, pregnancy, renal function and other comorbidities, and often double-checks doses against guidelines.
But even then, the system does not simply trust the doctor.
The patient takes the prescription to a pharmacist. The pharmacist checks the medication, the dose, the instructions, the interactions and the appropriateness of supply. Sometimes pharmacists catch our errors. Sometimes they clarify ambiguous instructions. Sometimes they identify interactions or duplication. Sometimes they simply provide another layer of patient education.
That is not an insult to doctors. It is a safety net. And it is a safety net I value deeply.
I count myself as a careful doctor. My patients probably use the word “thorough” to describe me more than any other word. I check guidelines. I think about edge cases. I worry about missing things. I have built multiple safety mechanisms into my own workflow.
And still, I have made medication errors before. I will make medication errors again.
That is not a confession of negligence. It is an acknowledgement of reality. Every honest clinician knows this. The goal is not to pretend errors can be eliminated by confidence, training or professional pride. The goal is to build systems where errors are more likely to be caught before they reach the patient.
This is why I will always advocate for the role of my pharmacist colleagues in checking my work before medication is dispensed.
Pharmacists are exceptionally well-trained professionals. They are essential to the Australian healthcare system. They understand medicines, pharmacology, interactions, formulations, storage, dispensing and medication counselling in depth. Every day, pharmacists improve care and prevent harm.
But that is not the same as saying pharmacists should be turned into substitute diagnosticians for increasingly broad areas of primary care.
A pharmacy degree is not a medical degree. Pharmacy training is not founded on years of clinical diagnosis, physical examination, undifferentiated presentations, longitudinal care and supervised decision-making across the full breadth of human illness.
Pharmacists are not trained in the same way to examine abdomens, listen to chests, assess rashes in the context of systemic illness, identify red flags, perform opportunistic preventive care, or notice the unrelated but important finding the patient did not come in for.
The concern with pharmacy prescribing is not that pharmacists are not intelligent. They are. It is not that pharmacists are not valuable. They are. It is not that pharmacists do not prevent harm. They do.
The concern is that pharmacy prescribing collapses two separate safety roles into one transaction.
The rollout of pharmacy prescribing is often defended on the grounds of convenience and access. I understand those arguments. Patients are struggling to get appointments. General practice is underfunded. Emergency departments are overloaded. Pharmacists are accessible, trusted and distributed across communities.
But access is not the same as safety, and a quicker consultation is not necessarily a safer one. A more convenient prescription is not necessarily better care. And if a policy improves access by removing diagnostic depth, fragmenting records, creating conflicts between prescribing and dispensing, and weakening the independent medication check, then we need to ask whether the apparent efficiency is being purchased by shifting risk onto patients.
This is not a theoretical concern.
I have already seen a patient who presented with what they reported to the pharmacist was likely shingles. According to the patient, the pharmacist dismissed their concern for shingles and told them it was eczema. They were supplied a steroid cream. A week later, after no improvement, they came to me with a textbook case of shingles. By then, the window for effective antiviral treatment had passed.
At a recent education evening, I discussed that case with another GP, who described a near-identical scenario with another patient.
These are anecdotes, not population-level evidence. They should be treated as such. But anecdotes are often a signal that a system is failing.
A “simple UTI” is often not a simple UTI.
A simple UTI can rapidly progress to pyelonephritis. A simple UTI may actually be a sexually transmitted infection. A simple UTI may be the first sign of an ectopic pregnancy.
This is why diagnosis matters.
In general practice, even the apparently simple presentations are approached with a question that John Murtagh drilled into generations of Australian GPs: what is the worst-case scenario, and how do I rule it out?
That question sits in the background of every consultation. It is there when a patient presents with dysuria. It is there when a child has a fever. It is there when a rash looks benign. It is there when someone requests “just antibiotics”.
The task is not simply to match a symptom to a medication. The task is to decide what else this could be, what must not be missed, what needs examination, what requires investigation, what needs follow-up, and what needs escalation.
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That requires training in clinical assessment. It requires experience in undifferentiated presentations. It requires the ability to take a sensitive history, ask personal and sometimes uncomfortable questions, perform an examination, generate a differential diagnosis and decide on the safest management plan.
General practice is designed for that work.
We have private rooms. We have examination couches. We have diagnostic equipment. We have access to the medical record. We can ask about sexual history, pregnancy risk, domestic safety, pelvic pain, vaginal discharge, and testicular pain.
We can examine. We can arrange urine testing, pregnancy testing, STI testing, blood tests, imaging, follow-up and escalation when required.
That cannot be replicated safely by standing at the counter of a public pharmacy.
Even where pharmacies have consultation rooms, the broader issue remains: pharmacists, though highly trained in medicines, are not trained to the same depth in clinical examination, differential diagnosis and the management of undifferentiated community presentations. Their training is different because their role has historically been different.
The risk is not that every pharmacy UTI consultation will go wrong. Most will not. The risk is that the system encourages everyone to treat “simple” symptoms as simple, until the day they are not.
Social media is full of stories of doctors making medication errors. To this I say: yes. That is exactly the point.
Doctors make errors despite extensive training. Nurses make errors. Pharmacists make errors. Paramedics make errors. Specialists make errors.
The solution is not to pretend one profession is immune from error. The solution is to build systems that assume error will happen and reduce the chance that it reaches a patient.
Aviation learned this lesson at terrible cost.
The deadliest aviation accident in history occurred on 27 March 1977, when two Boeing 747s collided on the runway at Los Rodeos Airport in Tenerife. KLM Flight 4805, a Boeing 747-206B, collided with Pan Am Flight 1736, a Boeing 747-121. Five hundred and eighty-three people died.
The KLM aircraft was captained by Jacob Veldhuyzen van Zanten, one of KLM’s most senior and experienced pilots, and the airline’s chief flight instructor. He was not an amateur. He was not poorly trained. He was not someone who lacked expertise. Yet in a high-pressure, foggy, congested, communication-impaired environment, a catastrophic error occurred.
The lesson aviation drew from disasters like Tenerife was not that experience and training is worthless. It was that safety cannot depend on one expert individual being perfect.
Healthcare learned this same lesson, and now we must not let our politicians forget it.
The rollout of pharmacy prescribing is dangerous because, in one fell swoop, we are taking a system with a separation between prescribing and dispensing and replacing it with a model where a less clinically trained prescriber may assess, diagnose, prescribe and dispense in the same encounter.
The answer to GP access is not to create a parallel, fragmented diagnostic system inside retail pharmacies. The answer is to properly fund general practice, expand team-based care, improve integration, and use pharmacists as the medication-safety experts they are.
When Matilda was two hours old, a medication error almost reached her. It was stopped because someone noticed before administration.
Dr Patrick Gough is a GP registrar and medical director of Medibetter.
