How do you verify a prescription in retail pharmacy

[tompharm]

I was wondering if anyone can explain to me what I need to know for verifying a prescription in a retail pharmacy.
I know the typical dose range for most drugs I suppose. Would I be frowned upon or considered slow if I take a drug reference book to work and verified each prescription by looking it up until I got the hang of the job?

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[rph3664]

Is this a real question?

 

[pinipig523]

Hmmm... not sure if serious...

 

[Sparda29]

Most retail pharmacy computer systems and insurance systems warn you if a dosage is not correct or if there is an interaction. I'd just carry a smartphone with Lexi or Micromedex.

 

[farmadiazepine]

Yes you will be frowned upon and considered slow. I am surprised you are a pharmacist and have never had exposure to prescriptions before and dosages and frequency and all? Whatever you do, do not bring a book. You are taking a step backwards. Pay for Lexi-comp for your phone and use that to verify whatever you need.

But really, you never worked in a pharmacy before? What did you do during school? Or rotations? You didn't think this would catch up to you? Now that it did, you better hope you work in a slow a** pharmacy with an owner who doesn't know jack sh** about drugs lol .. You can find em, they exist

 

[tompharm]

I did all my rotations in a hospital . I did take a community pharmacy rotation but I did not get to verify. All we did was tech work and a journal club.

So what is it? Will it all be computerized or will I need to verify everything with a reference guide? Like I said I have a bunch of tables with dose ranges for things but I don't know the exact dose and I can't hardly memorize it for the life of me.

I'm really just scared I'm gonna get fired from a job because I am slow. I had tendency to doubt myself and double check things so I dunno. I guess I'm gonna keep working at those tables and hopefully I'll be ok in a few weeks.

 

[pharmd201389]

There's nothing to look up. I don't understand your question. 99% of drugs will be the same thing. Plavix once a day, metoprolol tartrate twice a day, metformin twice a day, etc etc etc. what exactly are you looking up?

And even for pediatrics, there's absolutely nothing to look up. Doctors don't write the patients weight on scripts for antibiotics, so there's nothing you can really do.

Please don't be that pharmacist who slows down the entire workflow because he/she looks up if it's ok to give omeprazole 20 mg BID. Please.

 

[tompharm]

There's nothing to look up. I don't understand your question. 99% of drugs will be the same thing. Plavix once a day, metoprolol tartrate twice a day, metformin twice a day, etc etc etc. what exactly are you looking up?

And even for pediatrics, there's absolutely nothing to look up. Doctors don't write the patients weight on scripts for antibiotics, so there's nothing you can really do.

Please don't be that pharmacist who slows down the entire workflow because he/she looks up if it's ok to give omeprazole 20 mg BID. Please.

So what am I verifying? I don't understand
I guess your right but Im still confused as to what I am verifying. And will the computer let me know if something is not correct?.
Say for instance someone gets levothyroxine .112 mcg per day and the doctor accidently writes .112 mg per day ... will the computer let me know that its not the right dose?

 

[pharmd201389]

LOL. Stop trolling.

"Can I speak to dr jones? I'm calling from the pharmacy. Thanks.

Hi Dr. Jones, you wrote a script for John Smith for levothyroxine .112 mcg. Did you mean 112 mcg? Because, you know, if you meant .112 mcg, I'm more than willing to compound this prescription for you by taking these 112 mcg tablets and smashing them to make 1/1000th of the dose. What is that, you meant 112 mcg? Oh ok! I just wanted to be sure."

I really hope you are trolling.

 

[tompharm]

LOL. Stop trolling.

"Can I speak to dr jones? I'm calling from the pharmacy. Thanks.

Hi Dr. Jones, you wrote a script for John Smith for levothyroxine .112 mcg. Did you mean 112 mcg? Because, you know, if you meant .112 mcg, I'm more than willing to compound this prescription for you by taking these 112 mcg tablets and smashing them to make 1/1000th of the dose. What is that, you meant 112 mcg? Oh ok! I just wanted to be sure."

I really hope you are trolling.

Nope I'm absolutely serious... I have a lot of anxiety and I really want to be sure I am going to be ready

 

[pharmd201389]

Then go to a doctor. If you pulled this crap at any busy store, they'd flame you to hell and be justified in doing so.

 

[tompharm]

Then go to a doctor. If you pulled this crap at any busy store, they'd flame you to hell and be justified in doing so.

Anyways I just want to know if the computer system helps out with that kind of stuff...

 

[owlegrad]

Yes the computer knows when the script is not typed correctly. No one even needs a pharmacist for checking prescriptions at all. Please don't let it become widely known.

 

[Sparda29]

So what am I verifying? I don't understand
I guess your right but Im still confused as to what I am verifying. And will the computer let me know if something is not correct?.
Say for instance someone gets levothyroxine .112 mcg per day and the doctor accidently writes .112 mg per day ... will the computer let me know that its not the right dose?

Huh? Isn't .112 mg the same thing as 112 mcg? Either way, most retail computer systems do not allow you to freetext enter an order like that. You go to the drug field, type in levothyroxine and it'll pop up a bunch of different NDCs of levothyroxine with different doses and you pick the correct one. You won't be able to pick a strength that doesn't exist.

Now we've had mistakes happen in the hospital where the dose strength and unit of measure field are kept separate and in a rush you might miss that the doctor incorrectly picked mg instead of grams or viceversa. (I've seen orders written for Vancomycin 1mg and Vancomycin 1000 grams before.)

 

[tompharm]

Huh? Isn't .112 mg the same thing as 112 mcg? Either way, most retail computer systems do not allow you to freetext enter an order like that. You go to the drug field, type in levothyroxine and it'll pop up a bunch of different NDCs of levothyroxine with different doses and you pick the correct one. You won't be able to pick a strength that doesn't exist.

Now we've had mistakes happen in the hospital where the dose strength and unit of measure field are kept separate and in a rush you might miss that the doctor incorrectly picked mg instead of grams or viceversa. (I've seen orders written for Vancomycin 1mg and Vancomycin 1000 grams before.)

.112 mcg is a very small dose...............what you wrote is not what I typed

 

[tompharm]

Thanks for the help I'm just going to memorize dose ranges so that I can feel comfortable with recognizing a mistake.

 

[ptsome110]

The topic stirred my curiosity as I am still a student. I was hoping someone could seriously answer the question: "what are all the different things a pharmacists checks for before verifying a prescription in the retail setting".

Of the top of my head I'm thinking: indication (did the MD not know what he was prescribing), dosing (is it too high?), and contraindications. The PC acts as a second check point by helping to screen for drug drug interactions / contraindications, abnormal dosing, and look a like sound a like sound a like drugs. The PC is just a second barrier where as the pharmacist is the all inclusive barrier who is aware of a lot more things regarding the patient due to customer interactions.

I've shadowed a staff pharmacist at a hospital and they have clinical notes as well as lab values on the patient. In that setting since you have more information I see how a pharmacist might research more in depth; howeve even in that scenario the people I shadowed were highly experienced and as such rarely looked up anything (mostly peds medications due to the sensitivity of that patient population).

To the original poster: I would suggest doing a residency if you feel you have not been adequately prepared. You will not only gain confidence but will also be a lot more adept.

 

[thephoenician88]

I was wondering if anyone can explain to me what I need to know for verifying a prescription in a retail pharmacy.
I know the typical dose range for most drugs I suppose. Would I be frowned upon or considered slow if I take a drug reference book to work and verified each prescription by looking it up until I got the hang of the job?

.....
LOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOL

guys in retail, if you want to be sure of what you do, you have to know your **** enough to get by

In other words, you should know lisinopril 10mg qday is OK, you should know lisinopril 10mg bid is less ok but still OK by retail standards, you should know lisinopril 100mg is NOT OK
if you have to check the dosage for each rx, you've done something wrong.

I check dosage if i see something excessive (i've seen some high labetalol doses) and i'll check if the system flags something major. Otherwise, you should know. It's usually basic stuff...

 

[pezdispenser]

Say for instance someone gets levothyroxine .112 mcg per day and the doctor accidently writes .112 mg per day ... will the computer let me know that its not the right dose?

You wrote it wrong as well. Levothyroxine 0.112 mg per day is the correct dosage.

You are also not thinking practically. In retail, most of the tablets are made to correspond with the usual dosage range. There is no ".112 mcg" or even "112 mg", so you should immediately know that they are wrong. You won't even be able to type them into your computer system, and definitely do not try to 'free type' it in as a compound or something. However, doctors do write these things all the time, and the key to being a good pharmacist is to know when to question them, and when to just fix it yourself. I would fix both ".112 mcg" and 112 mg myself, to levothyroxine 0.112 mg. But I would call to verify things like "levothyroxine .25 mg", because the doctor may have meant 0.025 mg or did indeed want 0.25 mg, in which case you would have to make that dose with multiple tablets because it is not made in 0.25 mg.

Please also watch out for pediatric doses and liquids. There was a case where a pharmacist made a mistake on digoxin 0.05 mg/mL and the baby died. Others to be careful with include:

Morphine 20 mg/mL oral solution or 20 mg/5 mL
Ibuprofen Infants' Drops 50 mg/1.25 mL and "1 dropperful" = 1.25 mL, whereas the other solution is ibuprofen 100 mg/5 mL.

 

[pezdispenser]

The topic stirred my curiosity as I am still a student. I was hoping someone could seriously answer the question: "what are all the different things a pharmacists checks for before verifying a prescription in the retail setting".

Of the top of my head I'm thinking: indication (did the MD not know what he was prescribing), dosing (is it too high?), and contraindications. The PC acts as a second check point by helping to screen for drug drug interactions / contraindications, abnormal dosing, and look a like sound a like sound a like drugs. The PC is just a second barrier where as the pharmacist is the all inclusive barrier who is aware of a lot more things regarding the patient due to customer interactions.

I think you are talking about what is officially called the "prospective drug use review". It's in OBRA 90 as a requirement to receive reimbursement under Medicaid, so the state Boards of Pharmacy incorporated it into their pharmacy practice standards, and thus it is part of what pharmacists are required to do. So, copy and paste from the Florida Board of Pharmacy rules:

64B16-27.810 Prospective Drug Use Review.

(1) A pharmacist shall review the patient record and each new and refill prescription presented for dispensing in order to promote therapeutic appropriateness by identifying:

(a) Over-utilization or under-utilization;

(b) Therapeutic duplication;

(c) Drug-disease contraindications;

(d) Drug-drug interactions;

(e) Incorrect drug dosage or duration of drug treatment;

(f) Drug-allergy interactions;

(g) Clinical abuse/misuse.

(2) Upon recognizing any of the above, the pharmacist shall take appropriate steps to avoid or resolve the potential problems which shall, if necessary, include consultation with the prescriber.

----------------
Yes, most computer systems are setup to check all of these automatically, and it will pop up a list of warnings that you can either override or consult with the prescriber to resolve.

 

[Tonyg89]

If you work for a major retail chain the computer systems are made so anyone can use them.If you were to type in Synthroid under the drug search there would be no options to choose any strength in mg only in mcg. It will also automatically switch it to the generic. Also most systems will bring up a medication error by comparing the drugs in the persons profile and any allergies they may have on profile. Only thing there is you have to make sure their profiles are up to date every time they come in and the only problem people are new customers that are not in your system. At that point it falls on you and your knowledge to make judgements.

 

[BidingMyTime]

Are you actually graduated? Did you pass NABLEX? As a trained pharmacist you will (or should) already know dosing for common drugs, common drug/drug interactions, common drug/disease interactions, etc. You shouldn't have to look up *everything*, you are the pharmacist. Of course, you can't know everything, you will get prescription for seldom used drugs, or questionable dosages or indications, and you may have to look up things in those cases. Your employer will undoubtedly have a computer system that flags interactions/allergies etc (many of which will be a nuisance, but you will have to use your knowledge to know which ones to override, and which ones to seek further clarification on.) Your employer will undoubtedly have an electronic system you can use (Facts & Comparisions, Micromedix, Lexicomp, etc.)--having reference guides is required by many state laws. You can always have your own system on your smart phone to have a look-up program (you may prefer this if your employer is using a reference that is not one you are as familiar with.) I would say I don't have to look things up more than an average of once a day. You may be looking things up more once you first start as a pharmacist, but doctors tend to write for the same things, so once you are familiar with the doctors in your area, its going to be rare to see anything unusual from them (the unusual scripts would be more likely to come from a teaching hospital that the pt may have traveled to, to get a different opinion.) If you still have concerns about consulting a reference, than you call the doctor. Your first day as a pharmacist in any practice setting will be a bit scary, but if you are a properly trained pharmacist, its not going to be that overwhelming.

 

[Ackj]

Something I find myself wondering about is dose titration/re-titration. Obviously stuff like beta blockers you're starting therapy at a lower dose and working your way up to a target dose, as tolerated. So a patient has made their way up, and then a few months go by that they haven't had it. The doc sends over an e-rx for that same high dose. Should they be re-titrated first? Same thing for like Aricept 23, the PI has pretty clear directions for how long you should be on the lower doses before using the higher ones (3 months of 10mg). If they've worked their way up to the high dose in the past, but had a period of not taking the drug, should they jump right back on that high dose?

 

[WhiteSnows]

This is a valid question. To answer yourself without adding any judging, you need to verify the followings:

1. Is the patient's name matching the prescription?
2. Is the dispensed drug in the bottle what has been written?
3. Is the direction correct what has been written?
4. Are quantity and # of RF correct?
5. Any significant drug interraction?

There is more stuffs to look at if it is a control. Ex, DEA#, Valid prescription?, so on.

 

[farmadiazepine]

Checking a script for me personally differs when I work at a chain versus when I work at an independent. No matter where you are, always just start with the same 1 basic thing: The script is typed up for the right name AND right DATE OF BIRTH.

 

[PharmacyGirl7]

If you need to look stuff up, epocrates is also free online if they dont have anything else. You can use it on your phone too or micromedex

Also make sure the right drugs were pulled/counted. A few times the wrong drugs were counted and good thing I caught it

 

[BenJammin]

The big three you should always spend a bit more time on in the verification process are

1. Warfarin
2. Insulin
3. Anything given to a child under the age of 18

 

[farmadiazepine]

I agree with the poster above. There are some Rx's you just stop everything and only focus on them. But I'm going to add a few more to the list.
Warfarin. Methotrexate. Azathioprine, Thioguanine. Carbamazepine. Phenytoin. Digoxin. Add in any narrow therapeutic index drug and any seizure drug. Any drug for someone less than 18 years old. Insulins. If you don't know what the drug is or how it should be prescribed, stop and look it up. I can't believe there are pharmacists out there who dispense prescriptions without knowing what they are even dispensing.

 

[LearnerSharer]

This is a valid question. To answer yourself without adding any judging, you need to verify the followings:

1. Is the patient's name matching the prescription?
2. Is the dispensed drug in the bottle what has been written?
3. Is the direction correct what has been written?
4. Are quantity and # of RF correct?
5. Any significant drug interraction?

There is more stuffs to look at if it is a control. Ex, DEA#, Valid prescription?, so on.

Agreed, and here is my List of 7 steps that I Must Check:
1. (Letter) Name of patient: Must match. Why? If that is wrong, the patient can die and I can lose my license.
2. (Number) Date of Birth: Must match. Why? If that is wrong, the patient can die and I can lose my license.
3. (Letter) Name of med: Must match. Why? If that is wrong, the patient can die and I can lose my license.
4. (Number) Strength (milligrams, grams, mEq, percent, ratio (250 mg / 5 ml), Bactrim DS, Bactrim SS...): Must match. Why? If that is wrong, the patient can die and I can lose my license.
5. (Letter) Instruction: Must match. Why? If that is wrong, the patient can die and I can lose my license.
6. (Number) Imprint on pill (or NDC of liquid): Must match. Why? If that is wrong, the patient can die and I can lose my license.
7. Of course, must check Drug Interactions. Why? If that is wrong, the patient can die and I can lose my license.

I MUST ALWAYS check the 7 items above. Why? Life is very important, theirs or yours.

The rest, I may check or no, depending on situation.
Why? May have trouble later but NOT deadly.

Date of script? May check or no. If that is wrong, the patient WILL NOT die and I WILL NOT lose my license.
Name of doctor? May check or no. If that is wrong, the patient WILL NOT die and I WILL NOT lose my license.
Signature of doctor? May check or no. If that is wrong, the patient WILL NOT die and I WILL NOT lose my license.

Quantity written? May check or no. If that is wrong, the patient WILL NOT die and I WILL NOT lose my license.
Quantity counted by my tech? May check or no. If that is wrong, the patient WILL NOT die and I WILL NOT lose my license.
Refills? May check or no. If that is wrong, the patient WILL NOT die and I WILL NOT lose my license.

Day supply? (Fear insurance audit) May check or no. If that is wrong, the patient WILL NOT die and I WILL NOT lose my license.

Flu shot covered by insurance? This is a waste of our time. My chain should employ high school students to remotely do this, not a tech at 15 dollars an hour or a pharmacist at 60 dollars an hour.
Zostavax covered by insurance? Again, vaccine billing is a waste of our time. Let's be clear. If vaccine billing can be done remotely, outsourced to another group of people, chain should invest into outsourcing the lengthy task of vaccine billing to other workers.

Money Secret:
Any one with talent to open a company?
This is your key to money:
Contract with chain and other pharmacies to try to bill vaccine remotely (be sure to protect privacy and follow HIPPA rules.)

The key to secure the contract? Vaccine billing cost time. When you add up the minutes you spend on thousands and thousands of patient, total time will be in hundreds of hour a flu season of 6 months.

Which way would smart investor invest? Pay for 100 hours to someone sitting at computer at minimum wage (or lower wage at other country) or pay USA tech at 15 dollars and USA pharmacist at 60 dollars per hour

Seriously, chain now wants the pharmacist to TRY TO BILL VACCINE, just to see if this patient even has coverage by insurance !!! Executives forgot a very important key: Pharmacist costs 60 dollars every hour. That means 60 dollars every 60 minutes. That simply means: 1 minute is 1 dollar. Trying to bill vaccine will cost about 1 to 3 minutes. We waste 3 minutes of the pharmacist, we waste 3 dollars. And then, the patient does not even want to get vaccine. What does it mean? Anyone? Simple, for sure, we wasted 3 dollars already. Multiply that by at least 1000 a season. We waste at least 3000 dollars. Multiply by 10000 pharmacists, we waste 3 million dollars. How much profit do we get from vaccine? We must outsource to third world country and pay 1000 dollars for any contractor that can take the contract.

I am sure some smart person with connections to third world country will jump into this niche and secure a new market segment by escalating this investment chance to tier 1 conversation at stock holder and board meetings to shake up the chains that employ over 20 thousand stores, 60 thousand pharmacists. Every season, the chains are losing money, millions and millions of dollars to wasted time, LOST OPPORTUNITY and LOST PROFITS because we, soldiers at the front line, simply have no time to try to bill insurance just to see if patient has coverage for flu vaccine. Prove to me that you are smarter than your look. Bring this to the table and give me your Action Plan in 2 hours.

Sorry for the rant. I prefer to help sick patient directly at the store.

So,
If you did not sleep well last night,
and
If your boss yelled at you, threatening to write you up,
and
If patient yelled at you for not having medication on time (and they don't care about the reason you explained),
and
If you have painful feet because you have been on your feet over 8 hours a day for 5 days with stiff NEW shoes,
and
If your bladder is painful because you held for 4 hours so far....

Then, be sure you always check 7 items and help the patient have the medication safely.

Cheers!!!!!!!! and DNH, pharmers

 

[RealityRx]

The rest, I may check or no, depending on situation....

For anyone getting started in retail that may be reading this, please pay NO attention to this suggested list of "optional" checks.


Date of script?
-You do not want the reputation as "the pharmacist who will fill two year old norco rxs".

Name of doctor?
-You will get the following phone call only once or twice before you start to care: "This is Mrs. X. I am looking at a bottle you filled for my mother that says Dr. Smith. That is not her doctor. How do I know this is right? Who's prescription is this? I am calling her doctor..."

Signature of doctor?
-If it's not there, and there is a problem later, good luck explaining that.

Quantity written?
-You don't want to be the idiot in the computer who verified #1000 xanax.

Quantity counted by my tech?
-If there's supposed to be #120 percocets in the bottle and you hand out #30, whoever takes that angry phone call will hate you.

Refills?
-Don't make a fool of yourself and let a bottle of morphine go out with your name on it and one refill.

Day supply?
-It will take one insurance audit with your initials all over every "#4 alendronate, 4 day supply" or "nuvaring, 1 day supply" for your rx supervisor to look for a way to get rid of you. You better be able to defend giving out six bottles of lantus with a 30 day supply if you want a long career nowadays.

 

[rxgolfer]

As a retail pharmacist, what kind of publications/apps would you want to subscribe to?

1) ISMP
2) Pharmacist Letter
3) Micromedex app

anymore?

 

[type b pharmD]

Youll be ok man. The computer system catches 95% of errors (such as dose too high, contraindicated age or regimen, and every DDI you can think of)

Its not about memorization.. its about being able to analyze and apply practical clinical reasoning on the fly.. which yeah that is kind of scary at first, but you know more than you think. Go slow at first and youll learn to trust yourself.

As far as resources, seriously only consider prescribers letter, medical letter, whatever NACDS puts out, and then youll have facts and comparisons or clinpharm available at your work computer.. personally I just kept the window open and checked interaction significance or counseling points from time to time. The information you need to dispense will generally be supplied in-line.. you just need to apply judgement. . Or in the case where you dont have enough info, have your staff make a call or fax

 

[npage148]

Just assume it's right depending on the tech inputting and push it along /kiddingnotkidding

With stupid dosing of easy stuff (Norvasc BID). Get use to it, doctors are stupid and don't care and it's a waste of time to try to correct them. Hopefully the patient's insurance is draconian enough to not allow that and the doctor is forced to fix it or try to get a PA for their stupid dosing.

Something I'm always careful on is ml, tsp,mg confusion. My last partner got canned from a situation that started when he QA'd 2tsp instead of 2ml for something for a ped

 

[Ramzy]

I always check for proper dose titration if it is a new rx