Completion fill, which rph is at fault?

[Curiousone1111]

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Hey,
I’m not sure how every pharmacy software operates, but I was just wondering if Rph 1 processes a script and overrides the DDIs, and ends up not having the full quantity in stock... if Rph 2 fills the remainder tomorrow, is Rph 2 just responsible for making sure that the correct drug, remaining quantity, and correct patient label are bagged? Or is Rph 2 also liable for whatever lawsuit might arise from DDI, assuming Rph1 just did an override without any annotation?

I would think Rph 1 is responsible for typing the rx properly and any other therapeutic issues, while Rph 2 is just responsible for making sure that the correct drug is bagged (without having to double check for ddi, etc).

****EDIT:talking about an independent setting where completion fills don’t require your initials. You merely bag the remainder with the initials of whichever rph billed/approved this refill***

 

[M0df]

To me, both. Unless you want to argue that the software didn't have a hardstop on the completion. That may or may not be hard to prove as far as liability issues. I don't think you are ever in 'making sure the right drug bagged' territory even if you are filling refill #10. It still can be your problem. When CVS tells you that you don't need to look at the image or DDI, it doesn't mean you don't have any liability.

 

[Curiousone1111]

To me, both. Unless you want to argue that the software didn't have a hardstop on the completion. That may or may not be hard to prove as far as liability issues. I don't think you are ever in 'making sure the right drug bagged' territory even if you are filling refill #10. It still can be your problem. When CVS tells you that you don't need to look at the image or DDI, it doesn't mean you don't have any liability.

How is that feasible though? Some rphs are really careless or “carefree” and in the end the next day rph has to clean that mess up or deny a pt who was promised to get the med the next day, since the MD won’t pick up the call and the previous rph wasn’t thorough?

 

[Curiousone1111]

To me, both. Unless you want to argue that the software didn't have a hardstop on the completion. That may or may not be hard to prove as far as liability issues. I don't think you are ever in 'making sure the right drug bagged' territory even if you are filling refill #10. It still can be your problem. When CVS tells you that you don't need to look at the image or DDI, it doesn't mean you don't have any liability.

I agree with the refill #10 example, I treat refills the same way I would a new rx. This scenario is just annoying because the pt was promised the remainder the next day.

 

[Pronounce Doxazosin]

How is that feasible though? Some rphs are really careless or “carefree” and in the end the next day rph has to clean that mess up or deny a pt who was promised to get the med the next day, since the MD won’t pick up the call and the previous rph wasn’t thorough?

so if somebody dispensed an incorrect medication and partially filled it, would you complete the order without correcting the issue?

 

[Curiousone1111]

so if somebody dispensed an incorrect medication and partially filled it, would you complete the order without correcting the issue?

I would definitely fix it if the drug they typed up didn’t match the ordered drug. My question is whether I have to be diligent about DDIs too or just focus on correct pt, correct drug/strength/qty in bag. Some rphs just process everything and override all ddis without any notes, then the next day rph has to complete those partials.

 

[M0df]

So, you can view notes on DDI, if you feel they are insufficient, you don't complete the completion. Your job is to see if documentation is sufficient. If it comes down to a lawsuit, you have an argument but if you bypassed insufficient documentation, what's your defense?

 

[Curiousone1111]

So, you can view notes on DDI, if you feel they are insufficient, you don't complete the completion. Your job is to see if documentation is sufficient. If it comes down to a lawsuit, you have an argument but if you bypassed insufficient documentation, what's your defense?

You’re right, what would you consider sufficient documentation? That md was aware and ok with this, or do you expect a full blown explanation of what the md’s theory is and why it should be filled? I’m always seeing md ok and I don’t know what the standards are.

Guess i need to toughen up around pts.

 

[M0df]

Honestly, I have no idea. The more documentation, the better. Some of the MD charts are pretty detailed, some are not. Same with us. I am sure every company has an extensive training module on what they consider a good documentation.

 

[Curiousone1111]

@johnpharm01 what do you think about this?

 

[owlegrad]

In what way is a partial completion fill different than a refill? Legally I do not think you would be able to absolve yourself of liability on the basis that the previous pharmacist approved it.

Having said that, is this a hypothetical or do you have an example of a completion you didn’t want to fill?

I must be on the negligent end of the spectrum because there has never an instance where I was uncomfortable completing a fill.

 

[Curiousone1111]

In what way is a partial completion fill different than a refill? Legally I do not think you would be able to absolve yourself of liability on the basis that the previous pharmacist approved it.

Having said that, is this a hypothetical or do you have an example of a completion you didn’t want to fill?

I must be on the negligent end of the spectrum because there has never an instance where I was uncomfortable completing a fill.

This is a hypothetical, I’ve been in it before but can’t recall the scenario. If you’re always ok completing that either means your coworkers are awesome and thorough, or that you’re probably chill and I’m just ocd/by the books, haha

do you focus more on pt safety or on everything such as quantity? Insulin qty sometimes doesn’t even make sense and my coworkers just fill for a month supply without any annotation (our state requires getting md auth before changing qty). Would you refuse a completion for something like that or only if it’s an actual safety situation like DDI? I’d probably refuse if the DDI has no notes, and if the qty is off for actual pills (since that quantity is more clear), but especially for controls

 

[grumpyRph]

Just make a quick call or fax to the doctor , document, and move on with your life

 

[Curiousone1111]

Just make a quick call or fax to the doctor , document, and move on with your life

I don’t mind calling, the issue is if the MD doesn’t answer and the pt is screaming their lungs out demanding the med.

 

[mentos]

Hypothetically, the lawyers will go after everyone's name who touched the prescription. So both Rphs would be responsible. That's why I always checked the scripts even for refills before giving them out. I'm still the pharmacist giving it out, even if it's been checked before. CVS could give a rat's ass about your liability and tells you that only product check is necessary.

 

[owlegrad]

So much to unpack here.

Are you holding up scripts because the quantity doesn’t make sense? If so...why? Just dispense a quantity that makes sense and move on with your day. You can notate a clarification if that makes you feel better.

Would you let a screaming patient dictate how you practice pharmacy? Hopefully you are speaking in hyperbole because if someone is screaming at you because you have a concern for their safety either you have done a poor job explaining that concern to them or they are a nut case. Don’t get me wrong I have been yelled at by plenty of customers but I can’t think of a single time that I was yelled at after I explained a concern for their health (except for controlled substances of course when I refused to fill over safety reasons).

Basically what I am saying is either you need to work on your communication skills or you just have the worst possible customer base. I can’t even imagine saying like “there was an unexpected delay in filling this script because I had to contact the doctor due to a concern I had about the effect it would have on your health. I am waiting on a reply from your doctor” and having a customer scream at me about it. I would probably give the script back at that point. Who cares what the pharmacist yesterday said? Hence the “unexpected” part of my statement. It also helps to be proactive - call the patient and tell them not to come back today because of the “unexpected” development.

Take my comments with a grain of salt though, I am certainly on the chill end of the spectrum. You do you.

 

[Curiousone1111]

Hypothetically, the lawyers will go after everyone's name who touched the prescription. So both Rphs would be responsible. That's why I always checked the scripts even for refills before giving them out. I'm still the pharmacist giving it out, even if it's been checked before. CVS could give a rat's ass about your liability and tells you that only product check is necessary.

Gotcha, that makes sense. If you’re able to do it at CVS which is hell, guess we should all be able to. If the hard stops still pop up then they should be looked at. There should be a note somewhere at some point in fill history.

 

[Curiousone1111]

No

So much to unpack here.

Are you holding up scripts because the quantity doesn’t make sense? If so...why? Just dispense a quantity that makes sense and move on with your day. You can notate a clarification if that makes you feel better.

Would you let a screaming patient dictate how you practice pharmacy? Hopefully you are speaking in hyperbole because if someone is screaming at you because you have a concern for their safety either you have done a poor job explaining that concern to them or they are a nut case. Don’t get me wrong I have been yelled at by plenty of customers but I can’t think of a single time that I was yelled at after I explained a concern for their health (except for controlled substances of course when I refused to fill over safety reasons).

Basically what I am saying is either you need to work on your communication skills or you just have the worst possible customer base. I can’t even imagine saying like “there was an unexpected delay in filling this script because I had to contact the doctor due to a concern I had about the effect it would have on your health. I am waiting on a reply from your doctor” and having a customer scream at me about it. I would probably give the script back at that point. Who cares what the pharmacist yesterday said? Hence the “unexpected” part of my statement. It also helps to be proactive - call the patient and tell them not to come back today because of the “unexpected” development.

Take my comments with a grain of salt though, I am certainly on the chill end of the spectrum. You do you.

I actually admire you, I like your responses. Thanks for being helpful always. I think I’m just a timid and shy person, but you’re right I need to speak up and not give a crap about the nut case’s reaction lol.

I haven’t held up over a quantity issue but a colleague was saying how the board is going after any rph who “strays” from what the rx order says, even in quantity. Apparently it’s considered misconduct lol. It just gave me another thing to worry about. What would you annotate, our state doesn’t let us change qty without md’s authorization

 

[mentos]

Gotcha, that makes sense. If you’re able to do it at CVS which is hell, guess we should all be able to. If the hard stops still pop up then they should be looked at. There should be a note somewhere at some point in fill history.

Product check has only been around for a couple years at CVS. Before, all pharmacists had to read every script when verifying. Or they would blow past it and hit enter, but they were hard stops.

Between this thread and your CYA thread, is there something that happened that you're worried about? If these are really hypothetical situations that you made up, you need to relax and think about something else.

 

[WorthlessOxygen]

What would you annotate, our state doesn’t let us change qty without md’s authorization

My go-to is "Qty clarification: qs 30 days ok per md" or for insulin/other high audit risk sub whatever specific quantity makes sense instead of qs.

 

[Sine Cura]

asically what I am saying is either you need to work on your communication skills or you just have the worst possible customer base. I can’t even imagine saying like “there was an unexpected delay in filling this script because I had to contact the doctor due to a concern I had about the effect it would have on your health. I am waiting on a reply from your doctor” and having a customer scream at me about it. I would probably give the script back at that point. Who cares what the pharmacist yesterday said? Hence the “unexpected” part of my statement. It also helps to be proactive - call the patient and tell them not to come back today because of the “unexpected” development.

You can't give e-scripts back.

And to be proactive you have to be fast and prioritize work. Now, "prioritizing work" may mean cutting corners to some, but a lot of pharmacists complain but they don't call pt ahead of time for questionable e-script narcs and they get hung up on the literalness of **** that doesn't even matter because of ins limitations (like the name of test strips MUST MATCH WHAT IS PRESCRIBED OMGLOLZ, i.e., rx for True Merix despite only Freestyle Lite being covered, or even better holding up a Freestyle lancet order because the prescribed item is "lancet 33g" and you'll never get the FQHC prescriber to change it, or even mo' better holding up a script for basal insulin because it said 8640 mL written qty but you can't even dispense that much... who.... cares...)

 

[owlegrad]

My go-to is "Qty clarification: qs 30 days ok per md" or for insulin/other high audit risk sub whatever specific quantity makes sense instead of qs.

This times infinity. No prescriber will EVER object to a pharmacist changing a quantity to something that makes sense and annotating that the MD approved it, except for controls I wouldn’t do that.

 

[Curiousone1111]

You can't give e-scripts back.

And to be proactive you have to be fast and prioritize work. Now, "prioritizing work" may mean cutting corners to some, but a lot of pharmacists complain but they don't call pt ahead of time for questionable e-script narcs and they get hung up on the literalness of **** that doesn't even matter because of ins limitations (like the name of test strips MUST MATCH WHAT IS PRESCRIBED OMGLOLZ, i.e., rx for True Merix despite only Freestyle Lite being covered, or even better holding up a Freestyle lancet order because the prescribed item is "lancet 33g" and you'll never get the FQHC prescriber to change it, or even mo' better holding up a script for basal insulin because it said 8640 mL written qty but you can't even dispense that much... who.... cares...)

These are stupid laws though that require everything to match. Technically strips aren’t drugs so if it doesn’t say DAW can’t you just change to whatever brand without any annotation lol.

I always changed insulin quantity without thinking twice about it til some people started saying that it’s considered misconduct and you could lose your license lol

also the only reason I get iffy about changing quantity is because pts will swear left and right that it was supposed to be xyz amount and you gave the wrong amount. Some doctors or providers end up complaining like the scenario with proair and proventil, “why’d you switch it out.” Lmao

 

[Curiousone1111]

Product check has only been around for a couple years at CVS. Before, all pharmacists had to read every script when verifying. Or they would blow past it and hit enter, but they were hard stops.

Between this thread and your CYA thread, is there something that happened that you're worried about? If these are really hypothetical situations that you made up, you need to relax and think about something else.

Just had a series of bad life experiences, a bit traumatized and paranoid as hell. Lmao

 

[Curiousone1111]

This times infinity. No prescriber will EVER object to a pharmacist changing a quantity to something that makes sense and annotating that the MD approved it, except for controls I wouldn’t do that.

Yes definitely don’t mess with controls quantity for sure

 

[panicatthepharmacy]

Some doctors or providers end up complaining like the scenario with proair and proventil, “why’d you switch it out.” Lmao

That's super unlikely, it seems to me.

 

[grumpyRph]

doctors think they are being so helpful by stating "just switch to any covered ppi" like hey um, just say a couple concrete alternatives with concrete strengths. "just switch to any covered ppi" they could just write instead "or prilosec 20mg same sig" like...just as much typing. lol. UGHGHGHH!!GHG!HGH!H!

when do u think they'll get rid of phone trees? it kills my soul SO much.

 

[Curiousone1111]

That's super unlikely, it seems to me.

I’ve heard of it before, silly though!

 

[Curiousone1111]

doctors think they are being so helpful by stating "just switch to any covered ppi" like hey um, just say a couple concrete alternatives with concrete strengths. "just switch to any covered ppi" they could just write instead "or prilosec 20mg same sig" like...just as much typing. lol. UGHGHGHH!!GHG!HGH!H!

when do u think they'll get rid of phone trees? it kills my soul SO much.

LOL, right?!? Just provide the alternatives Do you still get clarification if they sent an rx with “switch to anything covered”? You could probably just switch and annotate md ok since they literally gave u permission to switch to anything lmao

 

[grumpyRph]

LOL, right?!? Just provide the alternatives Do you still get clarification if they sent an rx with “switch to anything covered”? You could probably just switch and annotate md ok since they literally gave u permission to switch to anything lmao

i guess i like to get clarification because this lets them know that you can't just say that. they think they're being helpful, but if you call and fax 10,000x maybe they'll get the hint ever to not operate like that.

 

[Sine Cura]

Today I got a bunch of scripts from pain management that were "take 1 capsule by mouth." "take 1 tablet by mouth." Even the tramadol. come on now

 

[Curiousone1111]

No frequency?! Lmao. What was the quantity maybe they really wanted it once a day, rofl

Today I got a bunch of scripts from pain management that were "take 1 capsule by mouth." "take 1 tablet by mouth." Even the tramadol. come on now

 

[Curiousone1111]

i guess i like to get clarification because this lets them know that you can't just say that. they think they're being helpful, but if you call and fax 10,000x maybe they'll get the hint ever to not operate like that.

That’s true. Maybe they’re afraid the alternative they provide won’t be covered too so they keep it general lol

 

[Rockinacoustic]

doctors think they are being so helpful by stating "just switch to any covered ppi" like hey um, just say a couple concrete alternatives with concrete strengths. "just switch to any covered ppi" they could just write instead "or prilosec 20mg same sig" like...just as much typing. lol. UGHGHGHH!!GHG!HGH!H!

when do u think they'll get rid of phone trees? it kills my soul SO much.

You don't feel confident substituting a therapeutic equivalent PPI and need to be told what to dispense?

 

[Sine Cura]

A prescription is literally telling a pharmacist what to dispense, so yeah that is just a minimum expectation, the simplest courtesy, etc.

 

[Rockinacoustic]

A prescription is literally telling a pharmacist what to dispense, so yeah that is just a minimum expectation, the simplest courtesy, etc.

I would think the courtesy is not having to play phone tag with the prescriber and keep the patient waiting. If you determine pantoprazole is a proper substitute is not writing "MD ok Protonix 40 mg daily" adequate for any legal or insurance audits?

I guess I just have a different mindset working in a hospital where I have a bounty of information and providers who trust us to "change it to what you think is best"

 

[Sine Cura]

I could switch DOACs, insulins, inhalers easily. I could also add on a spacer for every inhaler, add on a meter and lancets for every script for test strips that's missing the other supplies. There are limits to the amount of fraud I'm willing to commit especially that which isn't backed up by the PCP's EHR for that pt.

 

[Rockinacoustic]

I could switch DOACs, insulins, inhalers easily. I could also add on a spacer for every inhaler, add on a meter and lancets for every script for test strips that's missing the other supplies. There are limits to the amount of fraud I'm willing to commit especially that which isn't backed up by the PCP's EHR for that pt.

That's a nice straw man

 

[Sine Cura]

That's a nice straw man

Actually no because the whole thread is about retail pharmacy conditions of excessive microdocumentation and who gonna get dinged for what, and there is no conceptual difference between switching DOACs and switching PPIs or switching insulins and switching PPIs.

 

[Old Timer]

You don't feel confident substituting a therapeutic equivalent PPI and need to be told what to dispense?

If you do that in a retail pharmacy in Pennsylvania, you will have violated the Pharmacy Act, The Generic Substitution Act and on audit the claim would be reversed and you would have to pay it back.....

 

[Pronounce Doxazosin]

You don't feel confident substituting a therapeutic equivalent PPI and need to be told what to dispense?

I have no problem switching literal therapeutic equivalents. (eg ProAir vs Ventolin), but switching PPI sounds like a potentially dangerous proposition (at least in retail setting). If a doctor is prescribing Dexilant, I’m going to assume to that you are choosing that over other PPIs for medical reasons

 

[PharFromNormal]

I have no problem switching literal therapeutic equivalents. (eg ProAir vs Ventolin), but switching PPI sounds like a potentially dangerous proposition (at least in retail setting). If a doctor is prescribing Dexilant, I’m going to assume to that you are choosing that over other PPIs for medical reasons

I think your key words here are potentially and assume. Switching a ppi might also be harmless and your assumption may be wrong. If I keep your same logic I’d also never want to proactively want to try to even see if I could save a patient some $$$ by seeing if the doctor would entertain or consider a cheaper one. Reality is it may be specific for medical reasons or not because that’s the one that’s on the top of their mind or the one they are used to but not oppose the others.

it’s fair to say each pharmacist is gonna have their own opinion, which may vary on each specific scenario, on whether they should call or not. These opinions may be more liberal or conservative than what any laws, regulations or contractual agreements demand or permit.

if you are a practicing pharmacist and you think everything is black or white, please go back to school/academia. Rules get bent or broken and in some instances it’s the right thing to do, in others people can get burned badly. That’s what comes with the turf. Know the risks of your actions and make the determination of what you think is ok. The risk may mean not only patient impact but also employment impact.

 

[Curiousone1111]

In what way is a partial completion fill different than a refill? Legally I do not think you would be able to absolve yourself of liability on the basis that the previous pharmacist approved it.

Having said that, is this a hypothetical or do you have an example of a completion you didn’t want to fill?

I must be on the negligent end of the spectrum because there has never an instance where I was uncomfortable completing a fill.

@owlegrad while completing partial fills, you said there has never been an instance where you were uncomfortable completing a fill. If someone got a few pills of a CS friday, and the rest of the order does not arrive til Monday… if you’re working Monday, even if DDIs and everything look good, do you ever check the state registry to see if it was filled too early? The issue I’ve had is that the rph consistently fills the controlled substance early. In my state you’re not supposed to fill a CS until they have less than a 7 day supply OVERALL of all previous supplies (meaning they need to get each fill on the exact due date, and if you fill it 2 days early this month, 2 days the previous month, 3 days the previous)…. Going forward you have to fill everything on the exact due date of when they run out. If both rph are responsible for the fill even though friday’s rph filled a few pills and promised the rest of it on monday, am i expected to check the state registry? Rph already gave a few so does it really matter if I fill the rest or not? It’s not really a therapeutic/safety issue but more of a legal one that I don’t know how to explain to the pt without pissing them off especially since they think the other rph gave a few so what difference does it make? If I deny it, the original rph already billed the full quantity and the state registry thinks the full amount was dispensed but in reality now the patient will lose the remainder, md has to be contacted for a new script, and not sure about what has to be done about the wrong info on registry and whether you can unbill and rebill for correct amount? (For CS that are out of stock and you fill a few pills, the rest must be dispensed within 72 hrs or else it’s void. So if I deny it, technically the rph can’t give the rest out tomorrow).

 

[owlegrad]

Does that apply to all controlled substances or just C2s? If your partner is doing partials on Friday with the promise of getting the remainder on Monday you are already screwed and I can’t really offer any advice expect that you could ask them to stop doing that.

When I was in retail if we partialled a C2 we just told the patient they would lose the rest. There was no mention of getting the rest within 72 hours. It was just a simple “we have 20, you can have them if you want but you will lose the rest of the script”. I suggest you and your partner do it that way to avoid unpleasant surprises or impossible to keep promises.

 

[Curiousone1111]

Does that apply to all controlled substances or just C2s? If your partner is doing partials on Friday with the promise of getting the remainder on Monday you are already screwed and I can’t really offer any advice expect that you could ask them to stop doing that.

When I was in retail if we partialled a C2 we just told the patient they would lose the rest. There was no mention of getting the rest within 72 hours. It was just a simple “we have 20, you can have them if you want but you will lose the rest of the script”. I suggest you and your partner do it that way to avoid unpleasant surprises or impossible to keep promises.

This applies to all controls, if you’re low on stock you can give whatever and the remainder within 72 hours. But if you have the full quantity and the patient wants a lesser amount for whatever reason, for C2 the balance is void.

yeah partners can decide not to partial controls but it’s just an issue when I cover/float. Never know if I should just fill the rest even if they’re too early since previous rph started it, or not.

 

[owlegrad]

This applies to all controls, if you’re low on stock you can give whatever and the remainder within 72 hours.

Is this some weird state specific law? Because partials for C3-5 are not an issue and have no 72 hour limit. You could even adjust the quantity to being lower and just let the patient refill it when it is due.

 

[Curiousone1111]

Is this some weird state specific law? Because partials for C3-5 are not an issue and have no 72 hour limit. You could even adjust the quantity to being lower and just let the patient refill it when it is due.

Right, c3-c5 if someone just wants a few pills that’s fine they can get the rest whenever (before it expires in 6 months). It’s only if you’re low on stock of a c2 where you have to give the rest in 72 hrs. Otherwise, if a pt just wants to be picky and get a few c2 and pick the rest up next week, they can’t do that. They lose the balance if they partial a c2. Sorry I mistakenly stated it for all controls low on stock.

 

[BidingMyTime]

If you do that in a retail pharmacy in Pennsylvania, you will have violated the Pharmacy Act, The Generic Substitution Act and on audit the claim would be reversed and you would have to pay it back.....

Seriously? If the doctor wrote "may sub any other PPI", does that not count as an order in your states?
I'd just write up the order/annotate it as "clarified with prescriber to change to Prilosec 20mg QD", and then fax or call the doctor and let him/her know what you changed it to for their records.

 

[BenJammin]

Rph 2 bears no responsibility. Ridiculous to suggest otherwise.

 

[Sabril]

Rph 2 bears no responsibility. Ridiculous to suggest otherwise.

I never really feel like it is a matter of who did what. It's more like who is lower on the totem pole. As long as I know that I am the low hanging fruit, I'll be extra vigilant on anything that even remotely has my name on it.