The Pharmacy Chick

Flying the coup in retail

Ask for X, get Y.

Filed under: Uncategorized — pharmacychick at 8:21 pm on Sunday, June 14, 2009

You know its happened to you. You fax a refill request for A to a doctor’s office and they send back something different than what you asked for….and no explanatory note.  Then  the guessing game begins. 

This has become especially prevalent once the e-prescribing started.

 Did the Dr intend to change the prescription?  Did we fill it wrong to begin with? (pull the hard copy…check…whew, we did it right). Whether its asking for L-thyroxine 0.1mg and they fax back 0.125, or asking for Trivora and they send back Tri-nessa, its frustrating.  Would it kill them to include a note?  What if we didnt’ notice the change and just forwarded the previous rx with new number?  It’s happened before when we didn’t catch the change…we asked for X , expected X, refilled X and didn’t notice the change…a change that was supposed to be made.  After all, not ALL of them are mistakes.

Almost without exception, it requires a call back to clarify.  If there is one thing that the Chick does not like to do is GUESS on  the intent of a prescription.  I like to know without any doubt what the Dr wants. Sometimes it defies reason.

We sent a refill to a Dr for syringes for Mr K.  We have to have a signed RX because its Medicare-D.  A day later we get a fax from his Dr’s office for (and I kid you not)  “undetermined drug” 1 po qd.”  At the bottom it said Cinnamon capsules 200mg”.  First of all, cinnamon is an otc supplement.  We aren’t filling a prescription for it. Second we asked for syringes and got no response. and 3rd, the Cinnamon was unsolicited; we didn’t ask for it and as far as I know, the Mr K didn’t ask any member of the pharmacy for it.

I gave the project to the intern.  “Get an ok for this (handing him the refill request for the needles) and find out if he is supposed to get the cinnamon or not.”  He called the office and got the syringes ok’d (ok, thats half the battle) but hung up confused about the cinnamon and asked me for advice.  I told him ” Call them back..Its your job as the pharmacist  to not hang up from a conversation until you have the answers you need or are assured of what you are supposed to give the patient. If the nurse isn’t sure, ask her to check”. (sorry interns, but sometimes you guys can drive us nuts…)

Communication is a major component of what we have to do to provide health care to patients.  It really annoys me when I ask for specific information in a clear and concise format and I either get no reply or something completely different than what I asked.

For example: I sent a prior auth request for a patient prescribed Lipitor and it wasn’t covered.  3 faxes and 2 weeks later, I get a human on the phone and they said “oh, we gave her a prescription for Simvastatin…” (That the patient didn’t fill at my pharmacy….) yea thanks for letting me know…NOT.

or: I sent a refill request for Lantus and got  a rx back for Humulin 70/30.  I called the patient. “No, we haven’t changed anything…I need Lantus” Back to square 1…send the refill back to the office with notes that we do not want Humulin.

Almost missed this one:  We requested Fluoxetine 20mg refill.  The rx came back paroxetine 20mg.  since all these are electronic/faxed hardcopies sent instead of signing off on OUR refill request, the tech had just written the old rx number on this fax and I reassigned it.  It was finished and filled as fluoxetine before I noticed Paroxetine.  I called the office “Oops!,  sorry pharmacy, my bad, refill fluoxetine as before…”

These are like the equivalent of a prescription booby trap.   Ask for X, get Y back and hope you notice there is a problem, when there is a severe lack of notes.

I am just saying that if you are a prescriber and you are responding to a refill with something DIFFERENT than what we asked for, include a note: “new strength” “changed med” “dc old rx, fill new drug”, ANYTHING…



Comment by rxkerber

June 14, 2009 @ 11:43 pm

I had an erx come over for verapamil SR 120mg 1 tab qd #90……easy enough……but in the comment field was written….verapamil regular release (not SR) 120mg 2 tabs qam and 1 tab qpm. WHAT?????? I barely saw that. Now, I had to call the office and clarify. And I sent the fax back with a big not-so-nice note explaining how this is a giant mistake begging to happen. If their computer system does not have the correct drug then call the rx in or fax a written copy. Do not pick the wrong drug and fix it in the comment field!!!!!!!!!!!

Comment by Mike

June 15, 2009 @ 3:33 am

I don’t have any real data to back my opinion, but I’d be willing to bet that providers only see a small percentage of their faxed refill requests beforehand, and that the provider’s staff is making guesses on their own end.

I can almost count on one hand how many times I’ve actually spoken to the provider directly about a clarification.

Comment by chris

June 15, 2009 @ 5:20 am

I hate it when doctors/nurses just say, oops, sorry about that, change it and send it back for us to sign.

As far as they were aware, that prescription has left them CORRECT and they have signed it to say so.
If I gave a patient a script that I had initialled as dispensed correctly, but it wasnt. I would have to
1. deal with angry/upset/scared/agressive patient
2. apologise to the patient and hope they don’t sue me
3. contact the patient’s doctor if they have taken any, and try to resolve the situation with the doctor
4. report error fully and completely to head office
5. investigate why the error happened
6. put in place systems to stop the error happening again
7. document that all of the above has been carried out, even if there was no systematic fault, just a one off slip

I understand why i do all of this (most of the time) and am happy to do it, it’s my job after all. but wouldnt it save time if i could just say, oops! and get someone else to fix my mistake for me.
thats because its technically not an error until the patient gets it. Its too bad, because I’d rather not be a their filter. Judges hold us accountable for filling a prescription correctly “as written” even if the dr wrote it wrong. Sad, but true.

Comment by Phat

June 15, 2009 @ 8:45 am

I have become a real asshole about this the last few months. A couple of the offices are aware of what I’m doing, so they seem to be working on it.

That sorta thing happens, at our pharmacy, about a dozen times a day. Once I check to make sure we filled it correctly, I call the office back to clarify. Of course they are always stupefied, so they have to call me back. Meanwhile I circle the problems on the hard copy, make a note on what and why it’s wrong and fax it back to the office.

Sure I’ll get a phone call in ten minutes saying, never mind we really meant to sent what you asked for, but that’s not the point. When they give you that clarification, they can just brush you off in a way and not consider the problem.

If you fax it to them, and send it to them again, you get too benefits.

A) You waste their time just like they wasted your time

B) It either catches their attention or another’s attention and someone goes “Gee, maybe we should look into this problem”

Suffice it to say, it does appear to be working. With certain offices we’re having minimal problems now. Perhaps that’s a route you should try.

Comment by Frantic Pharmacist

June 15, 2009 @ 2:02 pm

This kind of thing makes me totally crazy. What would happen if we just filled whatever the doc’s office sent over (ie., acted like the pour-lick-and-stick automatons that some people think we are?) There would be some mighty wrong prescriptions out there.
and we would be liable because we didnt’ check…and we “should have” noticed.

Comment by Jen

June 15, 2009 @ 3:01 pm

I have some offices that send back the fax I sent them with NOTHING written on it. Our faxes have these nice little boxes to check and numbers to circle but they send it back blank. Some of my co-workers take that to mean one refill but I always call back and tell them that I don’t know what that means. They never seem to understand my confusion!
This happens to us all the time. A blank sheet is exactly that, BLANK. we do not fill it blank we send it back and ask them to complete it. sharpies come in really handy here to BOLD our notes.

Comment by Filet

June 16, 2009 @ 12:55 am

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Comment by Pharmer Jane

July 5, 2009 @ 12:27 pm

This is a daily battle in my long-term care pharmacy. When I worked retail, I could at least ask the patient if they were expecting a change of dose, drug, or directions. My current population of patients are cared for my others, and they often have NO idea if anything was supposed to change. The rule for my technician staff is that if an order comes over that does not specifically indicate a change using words like increase, decrease, stop, etc, then it lands in the “clarify” bin next to my desk so that I can assess if the change was intentional, or if we faxed for refills and got crap as a response.

Most of our issues come for Acme brand CPOE. I don’t know if they’re used nationally, but the big three health systems in the area use them, and there are SO many opportunities for error. The part that I dislike the most is that an order can be entered by a medical assistant and sent to the pharmacy WITHOUT being explicitly authorized by a physician, PA, or NP. They do batch authorization at the end of the day. I am forever calling about confusion on IR vs ER formulations, because “extended release” in this system shows up as TB24 or TB12 at the very end of the drug name.

I know that my state’s medicaid plan pays for interventions like this, if I would take the time to document. Most of my patients are dual Medicare D and Medicaid, and the D plans do NOT reimburse for pharmaceutical care. I spend at least 2 hours each day playing phone tag to clarify orders, and for all my interventions I am reimbursed ZERO.

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