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So lately I've been getting a few extra hours in another pharmacy, because their weekday person doesn't want to come in for short days on Fridays and Sundays. (It's a Jewish store, so we close early on Fridays, 2 hours before sundown; this time of year that's around 2 PM.; Sundays we're there until 4.) In just two half days, I've gotten at least three episodes which I shall call . . .
Learn to use your &*()*% software!
Sometimes we get e-prescriptions that just don't make sense, because they're internally contradictory.
Episode One: Doctor sends in a prescription for "Ocean Saline Nasal Spray" for a young child. Now the signatura ("sig", meaning "Write this:" or less literally, "directions for use") you'd expect to see might be something like "1 spray in each nostril qid" or similar, but then I get to the sig field and see "Inhale 3 ml in nebulizer q4h prn".
OK, this is weird. One or the other of those items is wrong, because that sig doesn't match the product, but which one is it?
Now this doctor is at a Health Center, which is notoriously hard to get through to anyone at, but I give it a shot. Get the secretary, then the pediatric department secretary, then the pediatric nurse, and finally the doctor herself.
She says, "I just want them to use that in the nebulizer, for a little moisturization."
I said "OK, but they do make saline for nebulization; it comes in 3 ml vials, but it's a different strength." (0.9%, vs. 0.65% for the spray)
She says, "But I couldn't find that product in my computer. I tried to change it, but it wouldn't let me."
Right, like I'm supposed to read your mind. Sorry, they don't teach that in pharmacy school. (Although I've picked up a bit here and there, true.)
Episode Two: (Warning, this gets a little technical.)
Patient is a 5-month-old child, gets e-script for "Children's Motrin, 50mg/1.25ml". Direction for use is 2 ml every 6 hours.
Problem is, "Children's Motrin" is actually 100mg/5ml, which is exactly half as strong (50mg per 2.5 ml). What he's describing is "Infant Motrin Drops". I don't actually have that product in my dispensing computer; not all OTC items are in there. I do some research to find an NDC that's covered, even looking it up on the ordering website of my regular store's wholesaler (this store doesn't even have an account there). I get it entered, the insurance pays, I fill it, label it, bag it, and as I'm about to drop it in the delivery box, something occurs to me.
For this patient, 2ml would be an appropriate dose of the Children's strength (40mg), but in the Infant's strength, it's maybe a little too heavy (80mg). Did he really mean to prescribe this product, or did he want the regular suspension? The above episode with the nasal spray is still fresh in my mind here. I've seen where doctors just picked the first product that shows up on the drop-down list, regardless of whether it's exactly what they wanted or not.
Tried to call the doctor. Office is closed. Look up doc's cell phone. Cell phone goes to voice mail. Try to call parent to get the patient's weight, so I can calculate the dose for myself and see if it's at least within the realm of reasonableness. Patient's phone goes to answering machine. I'm not comfortable dispensing this without confirmation, so it's gonna have to wait until I hear back from someone.
Then, shortly before we close, I get a call from another doctor: he wants to call in a medication for the first doctor! Says the doc's on his way over. How's that for coincidence. I figure that when he gets here to pick up his own stuff, I can ask him about the e-script for the Motrin, right? Maybe even show him the two products and point out the difference?
Two o'clock comes and goes. Doctor still hasn't shown up, and I gotta leave. Shabbos is in a bit over two hours, I have to be in synagogue, in my nice suit and fedora hat, by 4:46, and I live 40 minutes away from this store.
So I hit the road. Boss closes the place down and skedaddles a few minutes later. When we get back there on Sunday morning, I ask him if the doc ever showed up. Nope.
Episode three: a comedy in four acts.
Act Ⅰ: Sunday morning, 10:03 AM, there's an e-script for Omnicef 300 mg, two capsules daily for 10 days, dispense #18. Now that doesn't add up to ten days, but whatever. Maybe they gave her two capsules in the office as a sample, who knows.
10:05 AM, before I get a chance to fill the first, here comes another script, same patient and doctor, for Duricef 1000 mg, one tablet daily for 10 days, dispense #10.
OK, that's mathematically more sensible, but it's still odd. I've seen two antibiotics from different classes used in the same patient, for resistant organisms (MRSA, etc.), but these are both cephalosporins. Really doesn't make therapeutic sense to use them together.
So I call the doctor. Same health center as the nasal saline, different doctor, same rigamarole to get through. Finally talk to the doctor. She says, "No, cancel the first prescription. The second one replaces it."
So maybe I can get a note on the script saying so? Pretty please?
Anyway, I fill the second, delete the first, bag it up , it's waiting for the delivery man. Just in time for:
Act Ⅱ: 11:15 AM, I get a call from another doctor at that office, telling me to cancel Prescription #2. He's just seen the patient, and now he wants me to give her the Duricef, 1000 mg, one tablet twice a day, dispense #20. That's a pretty high dose, but not unreasonable in more severe infections. I write it down on an ℞ pad as usual, and ask if he wants me to fill this prescription. That's OK, says he, I've already e-prescribed the new dosage, just fill it from that.
OK. Pull the bag from the delivery box, thankfully it hasn't left yet. Reverse that claim, then pull up the e-script on my screen preparatory to filling it. Which leads to:
Act Ⅲ: 11:20 AM. Duricef 1000mg, sig: two tablets twice a day, dispense #40.
OK, that dose is not within the realm of reasonability. I call the doctor back, again. He's in with a patient and can't talk to me. That's funny, when I'm talking to a patient and a doctor calls, I tell the patient "just a minute" and take the doctor. I guess I'm not as important as a doctor is. Leave a message with the secretary for him to call me back, with all the details. Meanwhile the patient's parent is on the other phone in my other ear, wanting to know where her daughter's medicine is. I give her a summary of the above 20 lines.
After a while, MD calls me back. I ask him whether he wants me to do what he told me, or what he wrote me?
He looks at what his computer sent me. No, he says, the e-script is wrong, dispense it the way I told you on the phone.
Good thing I didn't throw that paper out.
Also, it occurs to me. I work at independent pharmacies with comparatively low volume. I can see in a busy chain pharmacy, doing 500 or more a day, if they got all these e-scripts one after the other, that they might just fill all of them without even noticing. Yeah, the computer will throw up a DUR warning, but how many times do the techs blast right past those without even reading them?
Act Ⅳ: Parent calls back, I tell them the medicine is done and ready for the delivery. She says "Oh, what about my other daughter's prescription? She was also supposed to have gotten one."
Episode 4: I'll leave this one in summary form. All the same patient.
11:58 AM: Clindamycin lotion, apply once daily in the evening.
11:59 AM: Clindamycin pledgets, use twice daily.
12:00 N: Clindamycin lotion, apply twice daily.
12:01 PM: Clindamycin pledgets, use once daily.
Naturally the doctor's not in, even though these scripts seem to have just emanated from his office. I just printed out all four of them and left them on the desk for the regular pharmacist to deal with today.
Starting next March, e-prescribing is gonna be mandatory in New York State. If they can't figure it out now, I shudder to think what it's going to be like then.
And one bonus episode, not dealing with a doctor but a failure of software nevertheless:
Episode 5: 1:35 PM, our internet goes down hard. Since our phones are VoIP, so do our phones. Bad enough we can't process prescriptions (well we can print labels and dispense meds, but without online adjudication who knows if we'll get paid), but if we can't even answer the phone, people are going to think we're closed.
Boss calls Pessimum Offline from his cell phone; the opening recorded spiel mumbles something about "outages in our area". He finally gets through to a human being, they tell him "Back online in 2 to 4 hours."
We'll be closed by then.
I holler across the store at him to ask them to forward the lines to his cell, so he can at least answer the phones, even if it's only to tell the patients that we're down. He agrees that this is a good idea and passes it along to the rep, who sets it up. For the next hour and a half, the whole pharmacy business was conducted through the boss's iFruit, which is not the most ergonomic shape for sticking under your ear whilst you type prescriptions. I also call another store around the corner, where I sometimes also work, and ask them if they're down? They also have Pessimum, but they must be on a different trunk because they're still up. Finally the lines start lighting back up at 3, and we're back in business.
Might be a good idea to see if we can get at least a backup dial-up line, just in case this happens again.
Learn to use your &*()*% software!
Sometimes we get e-prescriptions that just don't make sense, because they're internally contradictory.
Episode One: Doctor sends in a prescription for "Ocean Saline Nasal Spray" for a young child. Now the signatura ("sig", meaning "Write this:" or less literally, "directions for use") you'd expect to see might be something like "1 spray in each nostril qid" or similar, but then I get to the sig field and see "Inhale 3 ml in nebulizer q4h prn".
OK, this is weird. One or the other of those items is wrong, because that sig doesn't match the product, but which one is it?
Now this doctor is at a Health Center, which is notoriously hard to get through to anyone at, but I give it a shot. Get the secretary, then the pediatric department secretary, then the pediatric nurse, and finally the doctor herself.
She says, "I just want them to use that in the nebulizer, for a little moisturization."
I said "OK, but they do make saline for nebulization; it comes in 3 ml vials, but it's a different strength." (0.9%, vs. 0.65% for the spray)
She says, "But I couldn't find that product in my computer. I tried to change it, but it wouldn't let me."
Right, like I'm supposed to read your mind. Sorry, they don't teach that in pharmacy school. (Although I've picked up a bit here and there, true.)
Episode Two: (Warning, this gets a little technical.)
Patient is a 5-month-old child, gets e-script for "Children's Motrin, 50mg/1.25ml". Direction for use is 2 ml every 6 hours.
Problem is, "Children's Motrin" is actually 100mg/5ml, which is exactly half as strong (50mg per 2.5 ml). What he's describing is "Infant Motrin Drops". I don't actually have that product in my dispensing computer; not all OTC items are in there. I do some research to find an NDC that's covered, even looking it up on the ordering website of my regular store's wholesaler (this store doesn't even have an account there). I get it entered, the insurance pays, I fill it, label it, bag it, and as I'm about to drop it in the delivery box, something occurs to me.
For this patient, 2ml would be an appropriate dose of the Children's strength (40mg), but in the Infant's strength, it's maybe a little too heavy (80mg). Did he really mean to prescribe this product, or did he want the regular suspension? The above episode with the nasal spray is still fresh in my mind here. I've seen where doctors just picked the first product that shows up on the drop-down list, regardless of whether it's exactly what they wanted or not.
Tried to call the doctor. Office is closed. Look up doc's cell phone. Cell phone goes to voice mail. Try to call parent to get the patient's weight, so I can calculate the dose for myself and see if it's at least within the realm of reasonableness. Patient's phone goes to answering machine. I'm not comfortable dispensing this without confirmation, so it's gonna have to wait until I hear back from someone.
Then, shortly before we close, I get a call from another doctor: he wants to call in a medication for the first doctor! Says the doc's on his way over. How's that for coincidence. I figure that when he gets here to pick up his own stuff, I can ask him about the e-script for the Motrin, right? Maybe even show him the two products and point out the difference?
Two o'clock comes and goes. Doctor still hasn't shown up, and I gotta leave. Shabbos is in a bit over two hours, I have to be in synagogue, in my nice suit and fedora hat, by 4:46, and I live 40 minutes away from this store.
So I hit the road. Boss closes the place down and skedaddles a few minutes later. When we get back there on Sunday morning, I ask him if the doc ever showed up. Nope.
Episode three: a comedy in four acts.
Act Ⅰ: Sunday morning, 10:03 AM, there's an e-script for Omnicef 300 mg, two capsules daily for 10 days, dispense #18. Now that doesn't add up to ten days, but whatever. Maybe they gave her two capsules in the office as a sample, who knows.
10:05 AM, before I get a chance to fill the first, here comes another script, same patient and doctor, for Duricef 1000 mg, one tablet daily for 10 days, dispense #10.
OK, that's mathematically more sensible, but it's still odd. I've seen two antibiotics from different classes used in the same patient, for resistant organisms (MRSA, etc.), but these are both cephalosporins. Really doesn't make therapeutic sense to use them together.
So I call the doctor. Same health center as the nasal saline, different doctor, same rigamarole to get through. Finally talk to the doctor. She says, "No, cancel the first prescription. The second one replaces it."
So maybe I can get a note on the script saying so? Pretty please?
Anyway, I fill the second, delete the first, bag it up , it's waiting for the delivery man. Just in time for:
Act Ⅱ: 11:15 AM, I get a call from another doctor at that office, telling me to cancel Prescription #2. He's just seen the patient, and now he wants me to give her the Duricef, 1000 mg, one tablet twice a day, dispense #20. That's a pretty high dose, but not unreasonable in more severe infections. I write it down on an ℞ pad as usual, and ask if he wants me to fill this prescription. That's OK, says he, I've already e-prescribed the new dosage, just fill it from that.
OK. Pull the bag from the delivery box, thankfully it hasn't left yet. Reverse that claim, then pull up the e-script on my screen preparatory to filling it. Which leads to:
Act Ⅲ: 11:20 AM. Duricef 1000mg, sig: two tablets twice a day, dispense #40.
OK, that dose is not within the realm of reasonability. I call the doctor back, again. He's in with a patient and can't talk to me. That's funny, when I'm talking to a patient and a doctor calls, I tell the patient "just a minute" and take the doctor. I guess I'm not as important as a doctor is. Leave a message with the secretary for him to call me back, with all the details. Meanwhile the patient's parent is on the other phone in my other ear, wanting to know where her daughter's medicine is. I give her a summary of the above 20 lines.
After a while, MD calls me back. I ask him whether he wants me to do what he told me, or what he wrote me?
He looks at what his computer sent me. No, he says, the e-script is wrong, dispense it the way I told you on the phone.
Good thing I didn't throw that paper out.
Also, it occurs to me. I work at independent pharmacies with comparatively low volume. I can see in a busy chain pharmacy, doing 500 or more a day, if they got all these e-scripts one after the other, that they might just fill all of them without even noticing. Yeah, the computer will throw up a DUR warning, but how many times do the techs blast right past those without even reading them?
Act Ⅳ: Parent calls back, I tell them the medicine is done and ready for the delivery. She says "Oh, what about my other daughter's prescription? She was also supposed to have gotten one."
Episode 4: I'll leave this one in summary form. All the same patient.
11:58 AM: Clindamycin lotion, apply once daily in the evening.
11:59 AM: Clindamycin pledgets, use twice daily.
12:00 N: Clindamycin lotion, apply twice daily.
12:01 PM: Clindamycin pledgets, use once daily.
Naturally the doctor's not in, even though these scripts seem to have just emanated from his office. I just printed out all four of them and left them on the desk for the regular pharmacist to deal with today.
Starting next March, e-prescribing is gonna be mandatory in New York State. If they can't figure it out now, I shudder to think what it's going to be like then.
And one bonus episode, not dealing with a doctor but a failure of software nevertheless:
Episode 5: 1:35 PM, our internet goes down hard. Since our phones are VoIP, so do our phones. Bad enough we can't process prescriptions (well we can print labels and dispense meds, but without online adjudication who knows if we'll get paid), but if we can't even answer the phone, people are going to think we're closed.
Boss calls Pessimum Offline from his cell phone; the opening recorded spiel mumbles something about "outages in our area". He finally gets through to a human being, they tell him "Back online in 2 to 4 hours."
We'll be closed by then.
I holler across the store at him to ask them to forward the lines to his cell, so he can at least answer the phones, even if it's only to tell the patients that we're down. He agrees that this is a good idea and passes it along to the rep, who sets it up. For the next hour and a half, the whole pharmacy business was conducted through the boss's iFruit, which is not the most ergonomic shape for sticking under your ear whilst you type prescriptions. I also call another store around the corner, where I sometimes also work, and ask them if they're down? They also have Pessimum, but they must be on a different trunk because they're still up. Finally the lines start lighting back up at 3, and we're back in business.
Might be a good idea to see if we can get at least a backup dial-up line, just in case this happens again.
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