Does annotating actually CYA?

[Chrish]

Entresto to/from ACEI < 36 hrs

Thanks! Didn’t know this one

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[owlegrad]

I can imagine a scenario where an office is upset about modifying the quantity when it is unclear but I personally never experienced it. I suspect >99% won’t care and in the vary rare instance one does just explain you were doing what you felt was best for the patient without realizing the office had a reason for an unusual quantity. This is where soft skills help. I personally wouldn’t try to turn it around on the office but it could be helpful to remind them that units exist for a reason.

Try something like this: “I thought the 3 meant 3 pens. I did it that way to save the patient money and because it made sense. Next time it is unclear would you like me to call the office to clarify?” Because I am a beta male I would also throw in an “I’m sorry” to smooth things over but I know some alpha types are allergic to insincere apologies (and sincere ones?). I find most people are quite reasonable and if you explain it in simple terms without being defensive they will usually get it.

The odds of being reported to the board over that are probably astronomical.

 

[Curiousone1111]

OP, you need to have the mindset that prescribers don't know **** about what's stocked in the pharmacy or how dispensing works so turn it around on them in the rare event they try to stir **** up.

"I'm not a ****ing mind-reader"
"Don't put a DAW 1 if you didn't mean it"
etc etc.

Very true, some are stupid and end up saying “you should’ve called to clarify then” lmao. Yes, you shouldn’t be clear but we should call on everything. Excellent.

to CYA does it suffice that the doctor or his agent says that the doc wants to continue pt on this combo because pt has been on it for a while and can tolerate it? Just because they tolerate it now doesn’t mean they always will though? I’m saying this with regards to combos that are listed as contraindicated and pop up red in the system or on micromedex, lexicomp, etc as well as being listed as so in the package insert. I just have a hard time justifying dispensing contraindicated combinations because I always wonder what would happen if a pt ended up suing. Wouldn’t the package insert end up working against you since it clearly says not to give it together?

 

[johnpharm01]

Very true, some are stupid and end up saying “you should’ve called to clarify then” lmao. Yes, you shouldn’t be clear but we should call on everything. Excellent.

to CYA does it suffice that the doctor or his agent says that the doc wants to continue pt on this combo because pt has been on it for a while and can tolerate it? Just because they tolerate it now doesn’t mean they always will though? I’m saying this with regards to combos that are listed as contraindicated and pop up red in the system or on micromedex, lexicomp, etc as well as being listed as so in the package insert. I just have a hard time justifying dispensing contraindicated combinations because I always wonder what would happen if a pt ended up suing. Wouldn’t the package insert end up working against you since it clearly says not to give it together?

I don't think you "get it" You have use good judgement with the well being of the customer the focus not preventing yourself from getting sued. What's good judgement? Applying your education, training, and experience to ensure outcomes. If a therapeutic issue arises it, assess it and decide a course of action to take i.e counsel, call me for alternative, or monitor. The above ACE and entresto example. Your computer flags the di because the customer had been getting lisinopril in the past and now shows up with entree to. This one is likely a consult asking the patient when the last took lisinopril. Or take warfarin. A warfarin patient starts an antibiotic. If it's macrobid or keflex the issue can likely be solved with counseling. Cipro, maybe maybe not. Bactrim is an all likelihood a phone call and hold on dispensing till it's resolved. Patients can provide some info in the last two examples like their next inr date. In other words you have to think.

Worried about liability? Have good practices, carry insurance and study case law. Patients get hurt from errors but also when the Dr writes for an unfamiliar med andthe pharmacist fills a bad rx. Know what you are doing and have backbone. Welcome to the big leagues.

 

[johnpharm01]

Fill an rx for penicillin and the customer has an anaphylactic reaction is bad. Do it without trying to record allergies, worse. Do it AFTER knowing about the allergy and NOT assessing risk horrible.

Fill a fentanyl patch rx for an opiate naive patient very bad.

Fill an new rxs for atovastation 80 and gemfibrozil 600mg bid for an elderly patient very bad.

Fill prometh with codeine for a 2 year old very bad

On the other hand, fill rx for penicillin for a customer after asking for allergies and none reported, then the patient developes anaphylaxis, bad for the patient and you still might get sued but you did your job.

Fill clozaril or isotretinoin rxs without checking appropriate databases very bad.

 

[Curiousone1111]

Fill an rx for penicillin and the customer has an anaphylactic reaction is bad. Do it without trying to record allergies, worse. Do it AFTER knowing about the allergy and NOT assessing risk horrible.

Fill a fentanyl patch rx for an opiate naive patient very bad.

Fill an new rxs for atovastation 80 and gemfibrozil 600mg bid for an elderly patient very bad.

Fill prometh with codeine for a 2 year old very bad

On the other hand, fill rx for penicillin for a customer after asking for allergies and none reported, then the patient developes anaphylaxis, bad for the patient and you still might get sued but you did your job.

Fill clozaril or isotretinoin rxs without checking appropriate databases very bad.

These are very good examples. I don’t think they can sue you for anaphylaxis to penicillin if they have NKDA listed in their profile. You’re not psychic nor are you responsible for something they weren’t even aware of.

For fentanyl patches it has its own requirement of having to be on a certain dosage of an opioid for at least a week. My rph, when I was an intern, would just check for any history of opioids without paying attention to the dose or whether it was recent or not..

If you get a fentanyl rx and its been a few days since they ran out of the other opioid, or a few weeks.. how do you determine whether they’re still considered tolerant or not? I haven’t found any info on that so it’s a gray area although I’m sure it won’t be likely that an opioid pt would wait for weeks between pick up of other opioid and current pick up of fentanyl.

 

[Rockinacoustic]

These are very good examples. I don’t think they can sue you for anaphylaxis to penicillin if they have NKDA listed in their profile. You’re not psychic nor are you responsible for something they weren’t even aware of.

For fentanyl patches it has its own requirement of having to be on a certain dosage of an opioid for at least a week. My rph, when I was an intern, would just check for any history of opioids without paying attention to the dose or whether it was recent or not..

If you get a fentanyl rx and its been a few days since they ran out of the other opioid, or a few weeks.. how do you determine whether they’re still considered tolerant or not? I haven’t found any info on that so it’s a gray area although I’m sure it won’t be likely that an opioid pt would wait for weeks between pick up of other opioid and current pick up of fentanyl.

If they aren't already withdrawing from being off 60 MME for a few days/weeks, they ain't tolerant

 

[mentos]

Dont just put 'md said it's ok'... md needs relevant and specific clinical reasoning too that you as a pharmacist agree is reasonable... 'md said inx with warfarin is ok' vs 'md aware of inx and told pt to make inr appointment for this week to monitor'... or something

That's funny because at a small hospital where I worked, one of the choices was "MD aware" and most pharmacists didn't type any comments.

 

[Curiousone1111]

That's funny because at a small hospital where I worked, one of the choices was "MD aware" and most pharmacists didn't type any comments.

Are you saying that was considered sufficient? Idk anymore haha

 

[Charcoales]

That's funny because at a small hospital where I worked, one of the choices was "MD aware" and most pharmacists didn't type any comments.

Oh darn you'd think it'd be like 'md aware and ok with X because Z' or something

 

[mentos]

Are you saying that was considered sufficient? Idk anymore haha

No but these DURs would pop up for every little thing. They would type notes for the major ones.

 

[BidingMyTime]

It's always better to annotate. Will it save you in a lawsuit? Maybe, maybe not. But if there is no annotation, then most likely you will be going down. Obviously, the more detailed the annotation, the more likely it is to save you.

ie 30mg Coumadin QD.......1) double check with Dr, he said to OK to fill VS 2) talked with dr and filling as is, pt has factor 5 mutation and has been on 30mg Coumadin QD for past 3 years, current INR is 1.9 drawn 3 weeks ago

Above case is true story, pt came into hospital with order to continue home meds, nurse lists home meds as Coumadin 30mg, and I'm like no possible way. But after getting the pertinent medical info, I OK'd order. Obviously a "yeah, go ahead and give 30mg Coumadin" with no justification would not be an acceptable annotation.

 

[BidingMyTime]

"Don't put a DAW 1 if you didn't mean it"
etc etc.

Years ago, there was an elderly doctor in the community I was working in, who never used DAW-1....except for amoxicillin. And for amoxicillin, he always put DAW-1 (and yes, he wrote the amoxicillin generically, he didn't write Amoxil or Trimox or anything like that.) I never did learn his rational why....

 

[deleted820760]

Sure, if OP's co-workers are dispensing this and not documenting any intervention then shame on them. I'm just genuinely curious what contraindicated combos their co-workers are dispensing that gives them pause.

Tikosyn and Levaquin came to mind.

 

[deleted820760]

Yeah I once worked with a pharmacist who would not dispense flomax and finasteride together because it is a therapeutic duplication. No joke.

How about linezolid with SSRIs? Personally I don’t usually object unless there are 3+ agents but I know some pharmacists who are significantly more conservative than that.

But I think most interactions are overrated. I mean how many DURs do you blow through in a day? Most of them are fake news.

I do care about the Linezolid and SSRI interaction, and so do the good infectious disease doctors in my experience. They appreciate being called on that.

 

[maria1oh]

It did save us in insurance audits. If you do vacation over ride you should put a note in.

 

[Dred Pirate]

Can you give some examples of "contraindicated combos"

Vanc + zosyn (although not absolute)
IM olanzapine + IM/IV bzd's
Pletal in the setting of heart failure (triggers if they are on entresto, etc)
colchicine + clarithyromycin
Combo's of DOAC (I mean this is obvious but I have seen surgeons order xarelto post op for VTE prophy and continue a patient's eliquis for afib

 

[Sine Cura]

Since I don't like my job THAT much I just blast through all the SCC 13s I can

 

[Rockinacoustic]

Vanc + zosyn (although not absolute)
IM olanzapine + IM/IV bzd's
Pletal in the setting of heart failure (triggers if they are on entresto, etc)
colchicine + clarithyromycin
Combo's of DOAC (I mean this is obvious but I have seen surgeons order xarelto post op for VTE prophy and continue a patient's eliquis for afib

Huh? Your first two examples are appropriate for the right indications/circumstances

 

[Dred Pirate]

Huh? Your first two examples are appropriate for the right indications/circumstances

zosyn + vacn = high risk of AKI, no reason not to change to cefepime +/- flagyl depending on if anerobic coverage required.
IM olanzapine + iv/im bzd's is an absolute contraindication (cat x on lexi) due to high numbers of deaths if given within 1 hour.

 

[Rockinacoustic]

zosyn + vacn = high risk of AKI, no reason not to change to cefepime +/- flagyl depending on if anerobic coverage required.
IM olanzapine + iv/im bzd's is an absolute contraindication (cat x on lexi) due to high numbers of deaths if given within 1 hour.

Disagree...

If your health-system has higher PsA susceptibilities with Zosyn over Cefepime I would favor that empirically for sepsis or risk factors for PsA (If such an antibiogram exists who knows). Monitor renal function closely and hold other nephrotoxic agents untilt he dust settles.

If you actually read into the warning on Lexicomp, the IM Olanzapine and parenteral BZD is based on case reports where a majority had polypharmacy in the background. Is it a first choice of mine for the excited delirium ED patient? No (Ketamine is). Is it more effective and just as safe as a B52? Probably.

Maybe my rhetoric with asking the OP for a "Contraindicated combo" isn't conveying well... my main point is that there are few absolute contraindications in pharmacy and not every drug interaction is black and white. If you don't use clinical judgement then what makes you better than your company's QA software?

 

[Dred Pirate]

Disagree...

If your health-system has higher PsA susceptibilities with Zosyn over Cefepime I would favor that empirically for sepsis or risk factors for PsA (If such an antibiogram exists who knows). Monitor renal function closely and hold other nephrotoxic agents untilt he dust settles.

If you actually read into the warning on Lexicomp, the IM Olanzapine and parenteral BZD is based on case reports where a majority had polypharmacy in the background. Is it a first choice of mine for the excited delirium ED patient? No (Ketamine is). Is it more effective and just as safe as a B52? Probably.

Maybe my rhetoric with asking the OP for a "Contraindicated combo" isn't conveying well... my main point is that there are few absolute contraindications in pharmacy and not every drug interaction is black and white. If you don't use clinical judgement then what makes you better than your company's QA software?

I agree with what you say about clinical judgement - but was just point out examples - but I think we are on the same page. At my institution the PsA susceptibilities are similar with zosyn and cefepime.
In regards to the IM olanzapine - these pt's often have self medicated so to speak on the outside with a mix of unknown substances, and I try to avoid polypharmacy on top of that in the ED- therefore I will never use this combo (without proper spacing)