Legal/ethics..overreacting?

Started by rxcatlady
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rxcatlady

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Overreaction?

A MD writes an RX for say Tenex with 90 tablets and 3 refills. My pharmacy gets Tenex in 100 count bottles. Instead of counting out 90, we label the 100 count bottle (with all 100 inside) with the RX label that says 90, and we send it with the patient. Does this sit wrong with anyone else? I'm being told that this is a reasonable quantity, so it doesn't fit the FDA misbranding definition, and supposedly they have emailed the FDA to ask, and they say it is ok. (Also note, where I work "abides" by federal law only, no state law).

From my perspective, the physician authorized 360 tablets total and we dispense 400. That seems like a big deal. A month delay in labwork and returning to the MD. At first, I just had them count 90, but now I'm being told that we all need to uniformly do this because a tech complained about me making them count. Granted, I had made exceptions for Allegra (100 dispensed for 90) and Aspirin 81 (120 dispensed for 90) since they were over the counter, but I am thinking that I should not have let that slide either.

I am being told that since the FDA has said it doesn't fit their definition of misbranding that it is ok. But I still think it is an ethical issue at the very least. This is now "policy" and I am not allowed to have them count it. Debating on going to another job. Management thinks I am just overreacting, but I honestly feel like it is wrong to intentionally dispense more than what is authorized by the prescriber. The other pharmacists don't care for it, but consider it an organizational issue. I am assured that I can't have legal action against me for this, so many pharmacists just abide even though they don't like it.

Now you know where all government money goes to as I'm told all government facilities are ran this way...
There are more issues than that above which may contribute to my strong reaction, such as not breaking Tussionex bottles and dispensing 120 mL rather than what is written for (30mL) without calling, not requiring DEA or federal ID numbers on CII-V RXs, and "rounding" of a Vyvanse RX that was written for #20 with 3RF (we just dispensed 90..)
 
I always do the stock bottle if I have to waste my time grabbing something off the OTC shelf. I had ASA 325 #45 and I have the cheap 88 cent bottle OTC ASA 325, but the bottle size is 175 so I gave the whole bottle and just changed the directions to take 1 daily for 45 days. There were no refills so that's how I handled that. But I would absolutely never round up for C2s. That's absolutely crazy and I wouldn't do it for Tenex either. I just do it on a case for case basis, nothing major. We get a lot of Cheratussin for 120 ml and I dispense 118 because we order the small 118 bottles to make filling easier.
 
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rxcatlady said:
"rounding" of a Vyvanse RX that was written for #20 with 3RF (we just dispensed 90..)
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No refills on C2s like Vyvanse.

You should not 'consolidate' refills on C3-5 either. By definition, all controls have potential for abuse so you must not dispense more than the quantity prescribed at one time.
 
I understand that the last 3 issues are the big issues. I can blatantly say no to those, though. Since it's a military facility, there really aren't inspections. I feel like this makes them feel like they can't get in trouble and push the envelope. I am really trying to decide how big of a stand to take on the dispensing legend drugs in a quantity other than what was prescribed and what is on the label. Since the FDA says this isn't misbranding, I have no federal law (that I know of) to support me not participating in this policy. I still feel like it's a wrong practice though.
 
pezdispenser said:
No refills on C2s like Vyvanse.

You should not 'consolidate' refills on C3-5 either. By definition, all controls have potential for abuse so you must not dispense more than the quantity prescribed at one time.
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Exactly. I threw a fit over this, but they just had someone else check it since I refused!
 
Inventory would be way off. Oh and I'd never do any of those things.
 
You say you're at a military facility, are you a federal employee under a scope of practice? At the VA this is common practice-- in fact, it is national VA policy to round up for certain, limited drugs. And pharmacists certainly have the right to change quantities of non-controlled substances around in the VA as well. If I were working at a CVS, I could see feeling uncomfortable, but working within a federal facility I believe adds a bit more protection.

rxcatlady said:
I understand that the last 3 issues are the big issues. I can blatantly say no to those, though. Since it's a military facility, there really aren't inspections. I feel like this makes them feel like they can't get in trouble and push the envelope. I am really trying to decide how big of a stand to take on the dispensing legend drugs in a quantity other than what was prescribed and what is on the label. Since the FDA says this isn't misbranding, I have no federal law (that I know of) to support me not participating in this policy. I still feel like it's a wrong practice though.
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Are your techs really that lazy? And the upper management sided with them???

Idk how to feel about the rounding thing. I would say that giving 100 is okay, but the last refill they would only get 60 tablets (if the script was 90 + 3Rf). To me dispensing more than what was authorized is a dispensing error but I don't have any laws to back that up.

Now if this was a real retail pharmacy, absolutely no rounding. Last thing you need is an audit from a PBM or drug control.
 
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Don't the prescribers get upset that you didn't give them what they wanted? I can see the FDA being more interested in misbranding cases where a pharmacy would be shorting someone and ripping them off. I can also see that without insurance or state laws, you have fewer limitations there. But you still have to answer to the doc who wanted to give X and you gave Y.
 
So most don't think I'm overreacting. Good deal. We don't keep track when 100 is dispensed instead of 90 because we don't label it that way. Therefore, at the end of the 3 refills, they get a total of 400.

I work at a pharmacy on a military base. It's easier this way as my husband is military and I won't have to continually get licenses in new states when we move. I just started a few months ago, though. If all army or military facilities are ran this way, I'm not sure I want to be a part of it.

And yes, the tech really was that lazy. And yes, management (the lt. colonel and major) sided with them, thus creating this policy that I have to use 100 count bottles when dispensing 90 if that's how it is supplied.

I have not seen the email from the FDA and have asked to do so. In the actual act, it says "an accurate statement of the quantity of the contents in terms of weight, measure, or numerical count, except that under clause (2) of this paragraph reasonable variations shall be permitted, and exemptions as to small packages shall be established, by regulations prescribed by the Secretary. " So they say this is a reasonable variation.

I just feel like my ethics are being stretched, and I do not like it. I think I would rather take more MPJEs and search for jobs rather than work for the military at this point. Just because I likely won't get in trouble for something since it's common practice and federal facility (FDA doesn't exactly inspect and not subject to state boards), doesn't mean that I'm willing to compromise on what I think is right. It has been a long weekend weighing this.
 
Silvermist said:
You say you're at a military facility, are you a federal employee under a scope of practice? At the VA this is common practice-- in fact, it is national VA policy to round up for certain, limited drugs. And pharmacists certainly have the right to change quantities of non-controlled substances around in the VA as well. If I were working at a CVS, I could see feeling uncomfortable, but working within a federal facility I believe adds a bit more protection.
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I work on an army post. I am not a provider and we do scripts from the community as well as inside the facility. Are these policies you are talking about referring to just VA providers that have agreed to this? No such contract exists here. I honestly don't think I would get in trouble for it, but the principle seems wrong to me. We could at least document dispensing more and label it correctly instead of putting it in the computer as 90/3rf and labeling it as such when the bottle actually has 100 in it.
 
Ackj said:
Don't the prescribers get upset that you didn't give them what they wanted? I can see the FDA being more interested in misbranding cases where a pharmacy would be shorting someone and ripping them off. I can also see that without insurance or state laws, you have fewer limitations there. But you still have to answer to the doc who wanted to give X and you gave Y.
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I did have one physician call and ask why we did this. Unfortunately it was my second day and I passed the phone call off. That's when I just told the techs that I wanted the label to match. It only became a problem this week because I was told I couldn't do that anymore.
 
I don't see any problem with this. Tenex is cheap for us. I do the same thing.

When I was at CVS, everything for 90, if it came in 100 count bottles then I either just labeled the bottled, or I took it out and just put all 100 into a vial and labeled it. It was too much work to take out 10, save it, and put it back on the shelf.
 
WTF all of you smoking? How is this making you or your employer any money? Stupid to give 10 free pills for every rx written for 90. With just 10 customers, you lose out 1 bottle inventory wow. No wonder our government has no money all the time. Fncking lazy ass.
 
Lol..wouldn't want to handle the inventory at your store. I dispense everything correct quantity. Only exception are non controlled liquids, I'll round up a few mls if it means I don't have to open a bottle.
 
rxcatlady said:
I work on an army post. I am not a provider and we do scripts from the community as well as inside the facility. Are these policies you are talking about referring to just VA providers that have agreed to this? No such contract exists here. I honestly don't think I would get in trouble for it, but the principle seems wrong to me. We could at least document dispensing more and label it correctly instead of putting it in the computer as 90/3rf and labeling it as such when the bottle actually has 100 in it.
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At the VA, we round up for things that have to be dispensed in stock bottles per what CMOP stocks (e.g. aspirin--can only be dispensed in bottles of 120, so we give #120 for a 90 day supply even if MD writes for #90). I think as long as it's not a controlled substance, it's OK to give more, just not less. Not sure what exactly the policy states though. I do agree that if you dispense more, it should be labeled as such. You should not dispense #100 with a #90 label.
 
who do I or we need to contact to get this corrected? taxpayers footing the bill for these lazy asses techs that don't want to count
 
farmadiazepine said:
I don't see any problem with this. Tenex is cheap for us. I do the same thing.

When I was at CVS, everything for 90, if it came in 100 count bottles then I either just labeled the bottled, or I took it out and just put all 100 into a vial and labeled it. It was too much work to take out 10, save it, and put it back on the shelf.
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I highly doubt you did that at cvs, you'd be fired if anyone found out, at least at Walgreens.
 
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There's no way this is a serious discussion. No way in hell. Pharmacies are becoming so lazy that we're giving patients 100 tablets for a 90 day supply just because we don't have time to remove 10 tablets?
 
wagrxm2000 said:
I highly doubt you did that at cvs, you'd be fired if anyone found out, at least at Walgreens.
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Of course I did that at CVS, why else would I say that? Nobody knew, that's all. Why would I say that to people I work with? I did it for 4 years, no problem at all.
 
I would at least want a written policy. You will take the fall for this if someone goes sniffing. I could live with this policy if it was just for crap like aspirin and Claritin.

Never on the controlled medications. Vyvanse? Are you ****ing serious. It may as well be Oxycontin. Literally.
 
Anyone who has ever worked for the federal government, regardless of the capacity (i.e.., military, contractor, or civil servant) knows it is rife with complacency and entitlement that leads to sort of behavior. Sadly, I don't find this story too shocking.
 
rxcatlady said:
I work on an army post. I am not a provider and we do scripts from the community as well as inside the facility. Are these policies you are talking about referring to just VA providers that have agreed to this? No such contract exists here. I honestly don't think I would get in trouble for it, but the principle seems wrong to me. We could at least document dispensing more and label it correctly instead of putting it in the computer as 90/3rf and labeling it as such when the bottle actually has 100 in it.
Click to expand...

... what bacillus said.

No, we don't ask what the providers want and they don't need to agree to anything. If they order for a 90 day supply but our policy is to only give a 30 day supply, we give a 30 day supply. If they order for window but our policy is to mail it, we mail it. Conversely if they say to mail it but our policy is to hold it at the window until the patient picks it up, we hold it at the window.

If they order for 100 tablets but our stock supplies have 120 tablets, we give 120 tablets. If they order for something that is nonformulary or needs additional paperwork filed and didn't go through the motions to submit the proper paperwork, we deny it all together. Under certain circumstances we even cancel the order outright, or put it on permanent hold.

I think it would be nice if the system allowed us to say we were dispensing 120 tabs instead of 90, but there are limitations and that is not always possible.
 
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BenJammin said:
There's no way this is a serious discussion. No way in hell. Pharmacies are becoming so lazy that we're giving patients 100 tablets for a 90 day supply just because we don't have time to remove 10 tablets?
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HouTX said:
who do I or we need to contact to get this corrected? taxpayers footing the bill for these lazy asses techs that don't want to count
Click to expand...

The CMOP here does 45,000 prescriptions a day, it is probably cheaper and more efficient to not count out the 10 tablets each and every time.
 
Anyone who disagrees with this on a financial basis has no familiarity with VA pricing.

If #120 ASA 81mg costs $0.30 and it takes a tech (earning $10/hr) 1 minute to remove 30 tablets, doing so wastes $0.09.

salary cost = $10/60min * 1 min = $0.166667
savings in ASA = $0.30 * 30/120 = $0.075

Neither of these numbers are accurate, but I assure you, the math works out with the real numbers, too.
 
the problem with giving 100 pills full bottle instead of giving 90 as prescribed is with readyfill... when u fill it few days in advance, and the customer has 10 days of pills remaining, they not gonna come pick it up.. that means u end up having a ton of Return to Stock.. and what happens after its returned to stock? they gonna come and get u to refill it for them! if you're a floater its not a big deal. but if you're a staff, you're just sticking candies up your candy a/sses.
 
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