Clinical decisions & documentation logs

[1800callsaul]

Okay guys I need your help. I'm a brand new pharmacist, just got my license, and am working for a big box chain. I've worked 2 shifts already and have come across a couple drug interactions that make me down right uncomfortable:

1. Pt taking remeron, buproprion and parnate. I saw that he had been refilling for years, nonetheless I still kinda freaked out inside so I spoke to the PIC (who was there). She said she spoke with the doctor numerous times about this combo.

2. New statin added on to stable gemfibrozil. The other staff rph called the day before my shift and had this OK'ed by the doctor even after warning him of risk of myopathy/ relative contraindication.

There has been somewhat less serious stuff as well. By way of example: a patient picked up a 20 days supply of Ultracet a week ago and dropped off a new script for Percocet the week later (this did NOT look like any sort of drug diversion, old old old lady + not crazy large quantities). I made sure I told the patient to stop taking the ultracet if she was going to take percocet. She admitted that she had no idea that they both had tylenol and also thanked me for telling her this because she would've continued to take both. Unfortunately I never documented any of this because it was a crazy zoo atmosphere that day (nonstop phones, my first day at a higher volume, truck day, yikes). I'm worried that there are going to be days when these sorts of conversations do not happen because of the crazy atmosphere.

Where/how do you guys document these sorts of things? Would a daily notebook dedicated to documenting these sorts of things suffice? I was thinking of jotting down my notes for the most severe interactions/clinical concerns and how/why I handled the situation. I just don't know if that would hold up in a court of law/ lawsuit.

Any input is greatly appreciated.

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[Hic]

is there a scanner at your pharmacy? document on the RX and then scan it

 

[doublehh03]

Can't you document in in the patient's profile under "notes?"

At CVS, we use the notes to document any DDI with the MD, early refills on controlled substances, and any other important stuff.

Its very difficult to pull every single hard copy and document it on there.

 

[owlegrad]

I have so many patients on amlodapine+simvastatin, statin+gemfibrozil, etc. I am not saying it is ok, but it is more common than I would have thought.

 

[zelman]

A lot of psych meds get pushed beyond recommendations. Don't fill clozaril over 900mg/day or wellbutrin over 450mg/day (aplenzin 522mg). Everything else, just document, counsel if you have time, and move on. I was very uneasy the first time I filled an effexor XR 450mg/day. Now, every high dose effexor I see makes me think "450mg didn't kill that lady, so this should be okay."

 

[pharmalt82]

Okay guys I need your help. I'm a brand new pharmacist, just got my license, and am working for a big box chain. I've worked 2 shifts already and have come across a couple drug interactions that make me down right uncomfortable:

1. Pt taking remeron, buproprion and parnate. I saw that he had been refilling for years, nonetheless I still kinda freaked out inside so I spoke to the PIC (who was there). She said she spoke with the doctor numerous times about this combo.

2. New statin added on to stable gemfibrozil. The other staff rph called the day before my shift and had this OK'ed by the doctor even after warning him of risk of myopathy/ relative contraindication.

There has been somewhat less serious stuff as well. By way of example: a patient picked up a 20 days supply of Ultracet a week ago and dropped off a new script for Percocet the week later (this did NOT look like any sort of drug diversion, old old old lady + not crazy large quantities). I made sure I told the patient to stop taking the ultracet if she was going to take percocet. She admitted that she had no idea that they both had tylenol and also thanked me for telling her this because she would've continued to take both. Unfortunately I never documented any of this because it was a crazy zoo atmosphere that day (nonstop phones, my first day at a higher volume, truck day, yikes). I'm worried that there are going to be days when these sorts of conversations do not happen because of the crazy atmosphere.

Where/how do you guys document these sorts of things? Would a daily notebook dedicated to documenting these sorts of things suffice? I was thinking of jotting down my notes for the most severe interactions/clinical concerns and how/why I handled the situation. I just don't know if that would hold up in a court of law/ lawsuit.

Any input is greatly appreciated.

For the Percocet and Ultracet, consults will pop-up at WAGS and you can just let the ptn know and it will be documented in the system, so you're legally safe.

HOWEVER: The bigger question is this - what happens if you don't tell a patient? Can you be held liable? For what? How much?

 

[PharmdA07]

I have so many patients on amlodapine+simvastatin, statin+gemfibrozil, etc. I am not saying it is ok, but it is more common than I would have thought.

I've seen numerous issues interaction and issues in retail. I still remember my very first few months fresh out of school and just got licensed being shocked by a pt with a stent and hx of MI being given Voltaren XR 75mg QD, and when I called and asked, I was told "Because she needs it!" (?!), and this is from a family MD (???!!!). There are other things that I've sees, so many to list here but things such as Celexa 40mg given with Prilosec, Haldol with Ranexa, Cheratussin AC given to a true-morphine-allergic pt, etc.

The things about these is that you do your best and push yourself to the limit but not OVER it! Remember that you are still responsible for the wellness of your patients; so, if you need to say NO, then do so. I've done that multiple times with Celebrex 100mg QID eek, Levaquin 750 mg TID (Yes, it's the letter T that was written), etc.

For issues that are in the gray area such as Nexium + Plavix, Vicodin 5/500 2tabs po q4-6h PRN, Diprolene given to 14 months yo girl, etc. just call to let prescriber know and counsel to your best ability and document in the system or on the hard Rx copy, whichever is best. The pt will sign to acknowledge the counseling and the fact that you call the prescriber and documented everything will cover you.

 

[zelman]

I've seen numerous issues interaction and issues in retail. I still remember my very first few months fresh out of school and just got licensed being shocked by a pt with a stent and hx of MI being given Voltaren XR 75mg QD, and when I called and asked, I was told "Because she needs it!" (?!), and this is from a family MD (???!!!). There are other things that I've sees, so many to list here but things such as Celexa 40mg given with Prilosec, Haldol with Ranexa, Cheratussin AC given to a true-morphine-allergic pt, etc.

The things about these is that you do your best and push yourself to the limit but not OVER it! Remember that you are still responsible for the wellness of your patients; so, if you need to say NO, then do so. I've done that multiple times with Celebrex 100mg QID eek, Levaquin 750 mg TID (Yes, it's the letter T that was written), etc.

For issues that are in the gray area such as Nexium + Plavix, Vicodin 5/500 2tabs po q4-6h PRN, Diprolene given to 14 months yo girl, etc. just call to let prescriber know and counsel to your best ability and document in the system or on the hard Rx copy, whichever is best. The pt will sign to acknowledge the counseling and the fact that you call the prescriber and documented everything will cover you.

Agreed with your points.

But one of your examples was Celebrex 100 qid. If there is a 400mg capsule, why not 100 qid?

 

[PharmdA07]

Agreed with your points.

But one of your examples was Celebrex 100 qid. If there is a 400mg capsule, why not 100 qid?[/QUOT

Sorry I meant Celebrex 200 mg QID, I was typing too fast (Still at work ...) and I think I just verified about 5 celebrex 100mg scripts--that's probably why LOL

But it was for the back pain and I still remember refusing that script but he got it filled somewhere else I think. And then I haven't heard from that pt anymore (wonder if that kind of dosing harmed him in any way)

 

[farmadiazepine]

A lot of psych meds get pushed beyond recommendations. Don't fill clozaril over 900mg/day or wellbutrin over 450mg/day (aplenzin 522mg). Everything else, just document, counsel if you have time, and move on. I was very uneasy the first time I filled an effexor XR 450mg/day. Now, every high dose effexor I see makes me think "450mg didn't kill that lady, so this should be okay."

aplenzin 522 is the equivalent of wellbutrin xl 450.

ingesting an entire bottle of effexor will never kill a patient or do any hard. it will probably just give them a stomach ache. ssri's and effexor are some of the safest drugs thats why they are so often used for depression because if anyone wants to kill themselves, they can't overdose on these meds.

 

[zelman]

aplenzin 522 is the equivalent of wellbutrin xl 450.

ingesting an entire bottle of effexor will never kill a patient or do any hard. it will probably just give them a stomach ache. ssri's and effexor are some of the safest drugs thats why they are so often used for depression because if anyone wants to kill themselves, they can't overdose on these meds.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1188857/?page=1

 

[WhiteSnows]

Okay guys I need your help. I'm a brand new pharmacist, just got my license, and am working for a big box chain. I've worked 2 shifts already and have come across a couple drug interactions that make me down right uncomfortable:

1. Pt taking remeron, buproprion and parnate. I saw that he had been refilling for years, nonetheless I still kinda freaked out inside so I spoke to the PIC (who was there). She said she spoke with the doctor numerous times about this combo.

I wonder how many people actually die from this combination. However, it is always good to document that you have spoken to the physician and the patient about potential adverse effect of these drugs and advise the patient what to do if he/she experiences sign and symptom.

Serotonin Syndrome occurs rarely and the symptoms are actually quite bothersome that prompts the patient to D/C the drugs or seek emergency help.

 

[1800callsaul]

Thanks for all your input guys.

Working as a student/intern/ tech is one thing but once that role changes, boy o boy does the stress level ever rise. I really hope I can adapt fast because I don't know how long I'll last.

 

[farmadiazepine]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1188857/?page=1

case report

 

[MIRPh]

I see the same situation at my pharmacy too. For eg. Elderly patients on scary combo of meds or some patients on a combo of Soma,Xanax,VicodinES , some pts on Soma since months!!!! 95% of the time ,I am told either by the Dr that it is fine or by the more experienced RPhs - not to worry,pt has been on these since ages!

When doing refills on some of the above kind scripts, would you just go ahead and fill them or would you still call the Dr and document them in order to keep ur self safe??
Every time I come across these,it makes me queasy !

 

[spacecowgirl]

If I had a dollar for every duplicate serotonergic RX, I'd have...lots of dollars.

I look back and some of the interactions that concerned me so much as a new grad and laugh at myself. Now it's the terrible abx prescribing I see that scares me.

 

[spacecowgirl]

And to be more helpful - just document.

 

[zelman]

case report

Of course. You think there's an IRB out there that will allow a double blind placebo controlled study of 15g venlafaxine?

 

[knight on horse]

OP you are right to question those drug interactions, always do. Nevertheless, patients can take those drugs together sometimes, it is just that special caution is necessary