New Pharmacist, Practical Advice?

[chibipinkneko]

So I just started work as a retail pharmacist, and needless to say, I could use some advice. I tend to be an overcautious person, which I realize can make it hard to do things fast. So I wondered if anyone could help me with a few situations that come up. Part of the problem is that I'm working per diem, so I have gotten essentially no training, and I'm going into these different pharmacies where I don't know the doctors or the patients. I've worked retail before, but only as a pharmacy intern, so my first two days as a retail pharmacist were pretty rocky. I had 3 hours of training with another pharmacist before I was on my own.

1. One of the things slowing me down are the DUR's. I realize for serious drug interactions I need to call the doctor (and on a weekend, leave a note for the pharmacist to call the MD). But what about the not so serious drug interactions on refills. Here is a fictitious example, a patient is on Spironolactone, Furosemide, and Lisinopril, and Potassium Chloride. Obviously they have a risk of hyperkalemia or hypokalemia. If this is a refill, should I make a note to counsel the patient about this, or should I just assume that the patient understands and was counseled on this before. Another example is someone on Beta blockers and Insulin. Assuming this is a refill, do I make a note to counsel them about closely monitoring their glucose, and to watch for signs of hypoglycemia (sweating), or do I just authorize the DUR as is and assume someone has already spoken to the patient about this.

2. Now what if these mild interactions are on prescriptions that need to be faxed to the doctor. Do I just authorize it and assume the pharmacist will look it over once it goes through? I was making a note of it and leaving it for the pharmacist, but perhaps this is overkill? After I authorize the DUR for the medication to be faxed to the doctor, does the DUR pop up again when the refills come in?

3. How do you handle the questions about over the counter products you know little about? As an example, someone asks you detailed questions about probiotics. Without spending some time, I can't comment on it. If I don't have the time, what do I say? Should I get their phone number and call them back after work?

4. What about the serious drug interactions, like someone with asthma on albuterol taking a non-selective beta-blocker, both are refills. If it's the weekend I can't call the doctor. Should I authorize this DUR and make a note to call the MD for the other pharmacist? Should I not authorize the DUR? Is that even an option? I'm so scared someone is going to get hurt. Although if it was a refill I'm not sure why the pharmacist and doctor authorized it :/

5. Am I allowed to stay after work to finish up verifying scripts? Does the staff have to stay with me? I'm trying to be fast, but after only 2 days, I'm not as fast as someone that has been practicing for weeks, months, or even years. I don't care if I don't get paid for that extra hour. I just really want to do a good job. I don't have to log in my hours in an electronic time card.

Any other advice you could offer would be most appreciative 🙂 I'm trying to do a good job. I may not be in retail forever, but for now this fits my lifestyle. By that I mean that I have health problems with lots of doctors visits, and I will probably need surgery in the near future. *sigh* It is what it is unfortunately :/ I may be back on here to ask more questions.

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[wucool33]

You are essentially asking us how you should be a pharmacist. When I was training, my trainer told me "no one can 'teach' you how to verify rxs." Now that I think back on it, this is so true. I mean everything you let go has YOUR name on it, so what you want to let go should be your decision alone.

However, I think you are being a little too cautious. If it's not a serious DUR and the patient has been taking it for years with good results/no side effects, then why are you worried about it? just because an interaction thing popped up on your computer screen? If you fax on every single "mild" interactions, both you, your coworkers and doctors will go crazy lol

Never "assume" anything. I have fixed plenty of refill problems and I'm sure others have fixed mine as well.

if there was an OTC product you don't know too much about, then just ask them what the problem is and see if you can recommend an alternative. I mean if it's something an OTC product can take care of, chances are it's not very serious. If they are really set on a certain product that you have never heard of, then just be honest and tell them you are not sure. I don't think they'll expect you to call them after work unless you guys are friends.

ALWAYS log your hours. I think we had a discussion about this before on this forum. You are not protected if you work off the clock... you'll be in serious trouble if you actually make a mistake while working off the clock. Your staff members don't "have to" stay with you, but if they like you, they might stay a little bit and help you out.

You'll be okay. People usually find out within the first couple months if they can do retail or not. Don't worry about being "fast" right now. Just do the best you can and I'm sure your coworkers will understand (if they are not complete dbags).

 

[farmadiazepine]

You have to figure out what works for you.

Alot of what you are asking about DUR's are not serious at all. Even the one you mentioned as being serious (using non-selective beta blocker in an asthma patient) is really not a serious DUR.

Instead of analyzing everything, you need to actually know what serious drugs are. Drugs with narrow therapeutic indexes (warfarin, digoxin, carbamazepine) and toxic drugs (methotrexate, mercaptopurine, azathioprine, thioguanine) are drugs that you want to make interventions with if something comes up, and are scripts you want to spend more time on.

Drugs for pediatric patients is what you want to spend more time on.

Everything else is really not that serious.

Whatever the computer stops you for being LEVEL 1 or CATEGORY X or what ever your most serious interaction is, is what you want to contact the MD for.

Here is a hint to help speed you up. Some people agree with this, others don't like it, but this is what I do: When it comes time to check a refill, you simply assume everything is correct on the prescription, because really the first pharmacist was the one who should have checked the prescription. All you do for refills is make sure the pill matches up with what is on the label of the bottle. Hate it or love it, that's what I do. Of course, when you get those narrow TI drugs, you always double check if you can.

Good luck. No one can tell you how to be a pharmacist. You just have to get experience.

 

[Bier9999]

Not being cynical but you should have asked these question during your 6th year when they placed you at a retail rotation. Those pharmacists are experienced enough to be qualified as a preceptor and they have an ideal knowledge about the location, the customer base, the workflow of the pharmacy, etc. Keep in mind that you pay them to ask questions. While there are honest pharmacists on the internet who will answer your questions, some will give you wrong advice and jeopardize your license.
I’ll try to pitch in and offer sound advice. Working in NY, you have to be fast but you have to know your own limits. There is no ‘textbook’ way of verifying orders or else pharmacy wouldn’t pay $100k/year. With regards to DUR’s, like farmadiazepine stated, the ones that you should focus on are the narrow therapeutic window drugs like seizure drugs 😛henytoin, depakote, etc. Anticoagulation drugs like warfarin, heparin, etc. Drugs/Allergy interactions like penicillin and Suprax.
You will see a lot of simple interactions that pop up on refills but do a quick check on the profile. If the patients have been on them before, it is probably safe. So don’t speed dial the MD unless you check the entire profile first cause they will raise hell on you. Stay alert on pediatric medications. Most of the drugs are weight based so don’t be shy to ask the caregiver how much the child weighs. Don’t assume most of the drugs are in milligrams. Some will be in units, cc, etc.
If you want more advice, PM me.

 

[chibipinkneko]

Thank you everyone for your help 🙂 Yes, I realize now is not the best time to be asking questions. To be honest, the past few years have been really rocky. I have had multiple surgeries for serious health problems and I was so fixated on that during school, it was hard to focus on pharmacy. I actually may need another one soon where they break my hip, reorient the hip socket, and secure it with pins. Think THR, but worse. And I'm in my 20s. It's called a PAO and there are very few surgeons in the country that even perform this surgery. I actually graduated from a prestigious school with a high GPA, but that doesn't always translate to the real world. I'm not saying this to garner sympathy, but it is what it is. It did influence some of the choices I made in the past.

Due to my health problems, I completed my internship hours, but no more than I was required to do. And the retail internship that I did during school was nothing like this. The pharmacist would not let me even look at the DUR's. I was lucky she even let me count the pills as she sent my friend behind the cash register and she just rang up prescriptions for most of the day. And all of their techs took vacation time while I was there, so the pharmacist didn't have any extra time to teach me much. I was basically an unpaid intern. So I didn't get a chance to see patient's profiles and deal with the interactions. Most all of my intern hours are in the 1st and 2nd year, which happened before my injuries.

I also realize that working per diem as a pharmacist for my first job is not ideal at all. But no one wants to hire someone with very little experience. I understand this NOW. I entered pharmacy school when the market was still good, and I graduated when it was pretty bad. I can't change the past. I'm smart, kind, and a hard worker, but inexperienced, so no one wants to hire me in a saturated market.

My grandma is a pharmacist as well, and I trust her a lot, so I've asked her some of these questions. And to be honest, asking random pharmacists for advice on the internet doesn't seem much different than asking the random pharmacists I meet while working as I work at many different stores. I mean is it? At the stores I'm assured of their license to practice, so I guess it's better? The problem is that I'm often alone on assignments, so I don't have any pharmacist to ask.

Yes, I calculate the dosage for pediatric patients. I have an average weight chart with me that I use. If it were my pharmacy I would ask the techs to write down the weight of every child, but these aren't my pharmacies, and I don't want the techs to hate me :$ One thing that does bother me is that the doctor writes, "Take 1 teaspoonful three times a day." When I was an intern we always had to write, "Take 1 teaspoonful (5 mL) three times a day." It's hard because these aren't my pharmacies, so I just write a note on the bag, and mark the syringe for the patient. I could make them rewrite the sig, but again, I don't want the techs to hate me. Seems like all of the other pharmacists are okay with this. I'm not, so I make a note on the bag and mark the syringe.

Thanks again for the advice 🙂 I want to be a really good pharmacist. I think I'm being overzealous about the interactions. I'm just so freaked out that someone is going to get hurt and sue me :$ You're right, it is my name on the prescriptions, and that's why I've been so super cautious. But it's really slowing me down, and it sounds like it is not always necessary. I'll pay due diligence to the drugs with a narrow therapeutic index.

Oh, I did have a question about warfarin. So warfarin interacts with many many drugs. If a patient was on an antibiotic (like Septra) two months ago, that's not something to worry about is it? I was thinking that if the patient was titrated by an unknowing doctor while on the septra then their INR would be titrated with the antibiotic, which would mean they are being undermedicated currently. I mean my gut is telling me that I don't need to worry about it, but maybe I'm wrong? It's a totally different issue if someone on warfarin starts an antibiotics.

 

[Ackj]

Oh, I did have a question about warfarin. So warfarin interacts with many many drugs. If a patient was on an antibiotic (like Septra) two months ago, that's not something to worry about is it? I was thinking that if the patient was titrated by an unknowing doctor while on the septra then their INR would be titrated with the antibiotic, which would mean they are being undermedicated currently. I mean my gut is telling me that I don't need to worry about it, but maybe I'm wrong? It's a totally different issue if someone on warfarin starts an antibiotics.

Your INR reflects your last 3 or so doses. INR is monitored at least monthly, and going that far out is only for very stable patients. With something interacting for a short while, they probably did a few additional INRs, or went back to weekly draws for a whille. A full 2 months out, it is no longer an issue.

 

[waiter]

Thanks for making this thread. I am wondering the same things. Looking forward to hearing more suggestions. While interning I could see what pharmacists decided to require consultation for. There is such variety in what rph's decide to intervene on.

 

[knight on horse]

Part of the problem is that I'm working per diem, so I have gotten essentially no training, and I'm going into these different pharmacies where I don't know the doctors or the patients. I've worked retail before, but only as a pharmacy intern, so my first two days as a retail pharmacist were pretty rocky. I had 3 hours of training with another pharmacist before I was on my own.

Sounds awesome

1. One of the things slowing me down are the DUR's. I realize for serious drug interactions I need to call the doctor (and on a weekend, leave a note for the pharmacist to call the MD). But what about the not so serious drug interactions on refills. Here is a fictitious example, a patient is on Spironolactone, Furosemide, and Lisinopril, and Potassium Chloride. Obviously they have a risk of hyperkalemia or hypokalemia. If this is a refill, should I make a note to counsel the patient about this, or should I just assume that the patient understands and was counseled on this before. Another example is someone on Beta blockers and Insulin. Assuming this is a refill, do I make a note to counsel them about closely monitoring their glucose, and to watch for signs of hypoglycemia (sweating), or do I just authorize the DUR as is and assume someone has already spoken to the patient about this.

2. Now what if these mild interactions are on prescriptions that need to be faxed to the doctor. Do I just authorize it and assume the pharmacist will look it over once it goes through? I was making a note of it and leaving it for the pharmacist, but perhaps this is overkill? After I authorize the DUR for the medication to be faxed to the doctor, does the DUR pop up again when the refills come in?

3. How do you handle the questions about over the counter products you know little about? As an example, someone asks you detailed questions about probiotics. Without spending some time, I can't comment on it. If I don't have the time, what do I say? Should I get their phone number and call them back after work?

4. What about the serious drug interactions, like someone with asthma on albuterol taking a non-selective beta-blocker, both are refills. If it's the weekend I can't call the doctor. Should I authorize this DUR and make a note to call the MD for the other pharmacist? Should I not authorize the DUR? Is that even an option? I'm so scared someone is going to get hurt. Although if it was a refill I'm not sure why the pharmacist and doctor authorized it :/

Err on the side of caution. Make note of and inform people of all these things. At the least, people, both patients and doctor, will know that they've got someone who knows their stuff working with them, even if it's currently more book than street knowledge. In the best case, you will really have helped someone with a serious situation. And who knows? Maybe there was some lingering symptom or complication that was the result of an interaction or side effect.

You will get the rhythm of things after time.

5. Am I allowed to stay after work to finish up verifying scripts? Does the staff have to stay with me? I'm trying to be fast, but after only 2 days, I'm not as fast as someone that has been practicing for weeks, months, or even years. I don't care if I don't get paid for that extra hour. I just really want to do a good job. I don't have to log in my hours in an electronic time card.

Your time is done, leave, unless there are special mitigating circumstances in the patient's situation. The danger is you will be worked for free, with the acquired expectation of management that everyone, including yourself, should work for less