Random Retail Questions...

[rxfx09]

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So yesterday after being refused an auto transfer for Amoxicillin from a neighboring store (Rx supposedly invalid, baby crying in the background when it was called in, unable to call back/validate the script) it led me to a few questions and other random 'what would you do if..' scenarios..

DISCLAIMER: (In case I ask any DUH! questions) I've only been licensed for a week and have very little retail experience. MY BAD! 😎

1. So after the Amoxil incident, I am really starting to question the validity of ALL scripts that are called in.. Apparently anyone with a pulse can call in a Rx regardless to medical background or training. The errors that can be made, let alone validity of the scripts scares me! How is this legal?? Is there anything I can do to verify or screen these things? Even calling back is a little since all of the nurses and staff are access granted when it comes to the doc's info... Hmm. *sigh*

Other Random Scenarios
2. Thankfully I overlapped yesterday so I didn't quite panic when the CIIer's came in 🙄.. But the one lady that really stood out was the cop who had the Ritalin rx, new patient, paying cash.. Now according to the RPh's I've floated with as an intern, that the "big RED flag", but if everything looks valid (and after calling, sounds valid, but wait there's scenario #1) how am I supposed to police these people?? I take down her address from her license and she tells me the address stated is her actual work address.. Eh? But she'd provide me her home address on the new pt fill in sheet... *Sigh* I guess.

3. Drug Interactions and DURs galore! Boy, so many severe's and moderate's popping up and just "override em" (via other RPh's advice) seems ridiculous! Of course with time and after being yelled at a few dozen, I'll learn to recognize the OKAYs but right now I'm completely second guessing myself and EVERYTHING I've learned for the past 4 years! 🙁

4. Vacation Supplies..*Long Sigh* Lady comes in yelling because we were still unable to get the prior auth for her albuterol and she's out... She's going out of town, doc's office is closed and she needs something to carry her thru the weekend.. Geez. The other RPh (who was also a floater) out of pure frustration ended up approving the fill, making a copy of her driver license and filling it anyway.. 😕

All you retail goons, I know you can probably think of worse scenarios, but for the above mentioned-- what would you do???!

Signed,
Desperately Trying To Stay Out Of Prison and Keep My Job

 

[stevephhs016]

Desperately Trying To Stay Out Of Prison and Keep My Job

haha win!

 

[Old Timer]

Dear Desperately Trying To Stay Out Of Prison and Keep My Job:

1. So after the Amoxil incident, I am really starting to question the validity of ALL scripts that are called in.. Apparently anyone with a pulse can call in a Rx regardless to medical background or training. The errors that can be made, let alone validity of the scripts scares me! How is this legal?? Is there anything I can do to verify or screen these things? Even calling back is a little since all of the nurses and staff are access granted when it comes to the doc's info... Hmm. *sigh*

This varies from state to state. In PA, anyone with a pulse is allowed to call in a prescription. Only a pharmacist may receive the order. Many of these people are barely literate so it's an adventure. It's better than the doctor who IV's some meth and dictates 10 RX's in under a minute. I usually call back and leave a sarcastic message. With a phone in and I can ask them to back & ask the doctor.

2. Thankfully I overlapped yesterday so I didn't quite panic when the CIIer's came in 🙄.. But the one lady that really stood out was the cop who had the Ritalin rx, new patient, paying cash.. Now according to the RPh's I've floated with as an intern, that the "big RED flag", but if everything looks valid (and after calling, sounds valid, but wait there's scenario #1) how am I supposed to police these people?? I take down her address from her license and she tells me the address stated is her actual work address.. Eh? But she'd provide me her home address on the new pt fill in sheet... *Sigh* I guess.

C-II's are not that difficult. If you don't know the patient or the doctor, you call and verify the RX. Sooner or later you learn who the real doctors are and who are the croakers.

3. Drug Interactions and DURs galore! Boy, so many severe's and moderate's popping up and just "override em" (via other RPh's advice) seems ridiculous! Of course with time and after being yelled at a few dozen, I'll learn to recognize the OKAYs but right now I'm completely second guessing myself and EVERYTHING I've learned for the past 4 years! 🙁

This is the most difficult thing to figure out. When to blow it off, when to ask the patient and when to refuse to dispense until you speak to the doctor. Read the interaction and look at the monograph. Look at the patient's history. Speak to the patient. It's not that difficult. You went to school to learn how to make these judgments.

4. Vacation Supplies..*Long Sigh* Lady comes in yelling because we were still unable to get the prior auth for her albuterol and she's out... She's going out of town, doc's office is closed and she needs something to carry her thru the weekend.. Geez. The other RPh (who was also a floater) out of pure frustration ended up approving the fill, making a copy of her driver license and filling it anyway.. 😕

I am a real hardcore a-hole with albuterol. I know someone who died from asthma and I refuse to dispense a Albuterol with less than a 25 day supply. If they are constantly filling rescue inhalers every month with no controller medication or non compliance with their controller medication, I am on the phone with the doctor. This is a violation of the NHLBPI guidelines. I am not getting sued for this crap. The doctor is on call. If not, there is always the ER. If it's a vacation supply, they should not be out????

All you retail goons, I know you can probably think of worse scenarios, but for the above mentioned-- what would you do???!

Signed,
Desperately Trying To Stay Out Of Prison and Keep My Job[/QUOTE]

 

[Actinomycin]

Thanks oldtimer! That really helps.

 

[Pharmavixen]

At my last retail job, I was completely hard-nosed about opioid and benzo scripts. If I couldn't verify it I wouldn't fill it. You can't go wrong with this policy; nobody will die if they don't get their Oxycontin. You will get verbally abused, though that beats getting supoenaed to testify at the trial of a script-forger (been there done that).

And don't get me started about albuterol inhalers. The number of people exhibiting drug-seeking behaviour (screaming abuse, wheedling, faking asthma attacks) convinces me albuterol has (modest) abuse potential; I'm an asthmatic, and albuterol's sympathomimetic effects give you a bit of a high (I hate using albuterol for that reason - can't sleep). I've never had people freak out about their, say, anti-hypertensives, as they do about their albuterol inhalers.

In the jail, they use the actuators from inhalers as crack pipes, fyi.

 

[Sparda29]

At my last retail job, I was completely hard-nosed about opioid and benzo scripts. If I couldn't verify it I wouldn't fill it. You can't go wrong with this policy; nobody will die if they don't get their Oxycontin. You will get verbally abused, though that beats getting supoenaed to testify at the trial of a script-forger (been there done that).

And don't get me started about albuterol inhalers. The number of people exhibiting drug-seeking behaviour (screaming abuse, wheedling, faking asthma attacks) convinces me albuterol has (modest) abuse potential; I'm an asthmatic, and albuterol's sympathomimetic effects give you a bit of a high (I hate using albuterol for that reason - can't sleep). I've never had people freak out about their, say, anti-hypertensives, as they do about their albuterol inhalers.

In the jail, they use the actuators from inhalers as crack pipes, fyi.

Yeah, I was given an albuterol inhaler last year simply because the doctor couldn't figure out if I had asthma or an infection 🙄

So they gave me both, I went without the inhaler and just the antibiotics, the antibiotics worked. So what do I use the inhaler for? I use it before playing paintball. I generally start hyperventilating when I'm running around playing paintball and that wreaks havoc on the helmet by fogging it up, so I take a couple of puffs and I'm good to go in terms of calming down my breathing, however then I have a heart rate of 190 when I'm playing. 😱

 

[rxfx09]

😍 Thanks you guys!! Really helps. Being new and literally just thrown out there you really don't know your options for every scenario. This is why work experience prior to grad is absolutely essential. If not you're like a puppet unsure of yourself and unable to make confident decisions on your own...

Oops and I meant advancing 3 day supplies.. I'm used to them calling it vacation supply based on how we document them in our system.

 

[lorain]

it has to be a major drug interaction for me to even look at the DUR, even then most of those i override

-QT prolongation with levaquin and pacerone? override
-ppi and plavix? tried numerous md offices, they wont switch to H2RA, so i dont bother and just tell the pt of interaction and to talk to md to switch if any concern
-serotonin syndrome with tramadol and ssri? most overrated interaction of all time, ive talked to numerous neuro guys within my time in retail whove told me how sick they get of hearing it, the chance of that interaction is really low

-on the inhalers, i counsel them how many puffs to use, and if they are using more, then need to see md...no way i can call on all of these doing 586 a day

- control meds? if it looks good i fill it....except tussionex, i wont fill more than 120ml supply

 

[MountainPharmD]

it has to be a major drug interaction for me to even look at the DUR, even then most of those i override

-QT prolongation with levaquin and pacerone? override
-ppi and plavix? tried numerous md offices, they wont switch to H2RA, so i dont bother and just tell the pt of interaction and to talk to md to switch if any concern
-serotonin syndrome with tramadol and ssri? most overrated interaction of all time, ive talked to numerous neuro guys within my time in retail whove told me how sick they get of hearing it, the chance of that interaction is really low

-on the inhalers, i counsel them how many puffs to use, and if they are using more, then need to see md...no way i can call on all of these doing 586 a day

- control meds? if it looks good i fill it....except tussionex, i wont fill more than 120ml supply

Good luck. I hope you have some good personal liability insurance.

 

[Pharmavixen]

QT prolongation: I'm pretty leery of any of those and would encourage a therapeutic change (unless you're sure it's a rare one, and have documentation proving same).

PPI and Plavix: maybe get them to change it to Pantoprazole; is the FDA recommending that? (Health Canada is).

Inhalers: gotta be careful handing out too many beta-agonists willy nilly in the wake of the SMART trial.

Serotonin syndrome: yeah; I agree that's overstated. Anybody ever seen that?

 

[lorain]

just today, i tried counseling a pt who takes 12 darvocets a day, he didnt want to hear it, at that point, why should i try to help him more if he doesnt want it? i was like hey its your liver... * in my experience* most pts dont care about these kinda things, all they care is about 2 things: how much and how long

 

[BavarianMWE46]

most pts dont care about these kinda things, all they care is about 2 things: how much and how long

Which is why I think the whole phamacists as counselors idea doesn't work. Everyone wants to hit "deny counsel", sign, and get on their way. The pharmacy is just an inconvenience.

 

[Old Timer]

just today, i tried counseling a pt who takes 12 darvocets a day, he didnt want to hear it, at that point, why should i try to help him more if he doesnt want it? i was like hey its your liver... * in my experience* most pts dont care about these kinda things, all they care is about 2 things: how much and how long

This is such a simple problem. I want you to look carefully st what you do as a pharmacist. You simply pour and label. You are going to make yourself extinct. You provide no value to justify your salary.

When you dispense a prescription for Darvocet, you DO NOT allow the days supply to be reported for more than 6 per day. You counsel the patient and inform the patient you will not be filling the prescription at a rate greater than 6 per day. You contact the physician and inform him of the problem and you document what you did and why. That's being professional.

 

[lorain]

This is such a simple problem. I want you to look carefully st what you do as a pharmacist. You simply pour and label. You are going to make yourself extinct. You provide no value to justify your salary.

When you dispense a prescription for Darvocet, you DO NOT allow the days supply to be reported for more than 6 per day. You counsel the patient and inform the patient you will not be filling the prescription at a rate greater than 6 per day. You contact the physician and inform him of the problem and you document what you did and why. That's being professional.

i think he pays cash and md told him its ok to take more than 6

 

[Doctor M]

Which is why I think the whole phamacists as counselors idea doesn't work. Everyone wants to hit "deny counsel", sign, and get on their way. The pharmacy is just an inconvenience.

its all what you make of it...We have had many counseling sessions...the setting thta pharmacy is in also does not help...

 

[Old Timer]

i think he pays cash and md told him its ok to take more than 6

First, I see you edited your post to take out the "he threatened me" crap. Did someone take your lunch money when you were in second grade? Here is the deal:

I'm sorry Mr. Smith. I cannot and will not dispense Darvocet with directions that indicate more than six per day. Taking more than six tablets per day on a regular basis can harm your liver. In fact, over use of acetaminophen is the largest cause of liver transplant in the United States. I will be happy to consult with your physician so we can device an appropriate regiment that will relieve your pain and safeguard your health. What is your phone number? I will call you back just as soon as I check with your doctor.

Should the doctor insist on dosing more than 4gm/day, I personally would decline to fill the prescription and inform him to try to fill it elsewhere after you once again inform him of the risks. Document all of your conversations.

I don't give a rat's a** whether he pays cash or has insurance. This is an over dose and I will not set myself up to be sued and then reprimanded by the State Board.

You are just dead wrong here....

 

[lorain]

First, I see you edited your post to take out the "he threatened me" crap. Did someone take your lunch money when you were in second grade? Here is the deal:



Should the doctor insist on dosing more than 4gm/day, I personally would decline to fill the prescription and inform him to try to fill it elsewhere after you once again inform him of the risks. Document all of your conversations.

I don't give a rat's a** whether he pays cash or has insurance. This is an over dose and I will not set myself up to be sued and then reprimanded by the State Board.

You are just dead wrong here....

i actually shouldve left it in and expanded on the things he said, but thats not imp right now

i asked the pharm manager and she said they have talked to the md and hes ok with it and that i guess they do frequent lfts on him, this is documented on the hard copy, so i dont see any problems

 

[aelephant]

I located a good article about fluoroquinolone QTc prolongation. I remember learning about this during school, but don't recall what was said aside from, "They cause it."

The citation is:

Arrhythmias associated with fluoroquinolone therapy
International Journal of Antimicrobial Agents
Volume 29, Issue 4, April 2007, Pages 374-379

What I got out of it:

- moxifloxacin (Avelox) is associated with the most profound QTc prolongation in research studies
- levofloxacin 500mg once daily and ciprofloxacin 500mg twice daily did not prolong the QTc interval, higher doses did
- that being said, from 1996 to 2001 there were 25 cases of TdP associated c FQ use
- 13 cases associated c levofloxacin
- 2 cases with ciprofloxacin and 2 with ofloxacin (Floxin)
- there have been several case reports of levofloxacin leading to QTc prolongation and/or TdP when used concomittantly with other drugs known to prolong the QTc interval - none of these cases included amiodarone as far as I can tell, but that doesn't mean the interaction isn't possible.

Seems like it is documented well enough that I'd avoid the combination. Just because no one has died from amiodarone + Levaquin doesn't mean it won't happen. I certainly wouldn't want to be the first pharmacist to see it and to bear responsibility for it. Particularly when the caution is clearly spelled out on the package insert.

 

[Old Timer]

i actually shouldve left it in and expanded on the things he said, but thats not imp right now

i asked the pharm manager and she said they have talked to the md and hes ok with it and that i guess they do frequent lfts on him, this is documented on the hard copy, so i dont see any problems

Keep up your malpractice insurance. Be ready for a good answer for the lawyer.

Attorney: So Mr. Lorain, what is the daily maximum recommended dose of acetaminophen?

Lorain: 4 GM

Attorney: Can you repeat that sir?

Lorain: Yes, 4 GM.

Attorney: So can you explain to the jury why you would knowingly dispense multiple prescriptions to the decedent with doses of 7.8 grams of acetaminophen per day?

Do you see where this is going? This is outside the standard of care. How much is too much 10 per day, 20 per day, 30 per day? What drug do you stop for an over dosage?

 

[Vitamin K]

Keep up your malpractice insurance. Be ready for a good answer for the lawyer.

Attorney: So Mr. Lorain, what is the daily maximum recommended dose of acetaminophen?

Lorain: 4 GM

Attorney: Can you repeat that sir?

Lorain: Yes, 4 GM.

Attorney: So can you explain to the jury why you would knowingly dispense multiple prescriptions to the decedent with doses of 7.8 grams of acetaminophen per day?

Do you see where this is going? This is outside the standard of care. How much is too much 10 per day, 20 per day, 30 per day? What drug do you stop for an over dosage?

100% Correct. C.Y.A.

 

[MountainPharmD]

Keep up your malpractice insurance. Be ready for a good answer for the lawyer.

Attorney: So Mr. Lorain, what is the daily maximum recommended dose of acetaminophen?

Lorain: 4 GM

Attorney: Can you repeat that sir?

Lorain: Yes, 4 GM.

Attorney: So can you explain to the jury why you would knowingly dispense multiple prescriptions to the decedent with doses of 7.8 grams of acetaminophen per day?

Do you see where this is going? This is outside the standard of care. How much is too much 10 per day, 20 per day, 30 per day? What drug do you stop for an over dosage?

Already beat you to it!

Good luck. I hope you have some good personal liability insurance.

 

[Old Timer]

Already beat you to it!

Even a blind squirrel finds an acorn once in a while.

 

[gsinccom]

Even a blind squirrel finds an acorn once in a while.

 

[MountainPharmD]

Even a blind squirrel finds an acorn once in a while.

I'd rather be lucky than good.

 

[Rebel78]

-QT prolongation with levaquin and pacerone? override

why take the chance? get it switched, plenty of choices

-ppi and plavix? tried numerous md offices, they wont switch to H2RA, so i dont bother and just tell the pt of interaction and to talk to md to switch if any concern

all the literature says no. Like you said, I couldn't get an office to switch it when I worked at WAG, but I still wouldn't dispense it. Buy some Pepcid OTC. You ain't getting Prevacid with your Plavix, least not from me. Trying to get the hospital I'm at to set up a protocol for this.

-serotonin syndrome with tramadol and ssri? most overrated interaction of all time, ive talked to numerous neuro guys within my time in retail whove told me how sick they get of hearing it, the chance of that interaction is really low

agreed. Just counsel the pt and let them know what to look for.

no way i can call on all of these doing 586 a day

Tell the board that when there is a problem, I wouldn't advise somebody on a public message board to practice in that manner. The WAG I worked at for 5 years averaged about 4K a week, there's always time 👍

 

[Rebel78]

Keep up your malpractice insurance. Be ready for a good answer for the lawyer.

Attorney: So Mr. Lorain, what is the daily maximum recommended dose of acetaminophen?

Lorain: 4 GM

Attorney: Can you repeat that sir?

Lorain: Yes, 4 GM.

Attorney: So can you explain to the jury why you would knowingly dispense multiple prescriptions to the decedent with doses of 7.8 grams of acetaminophen per day?

Do you see where this is going? This is outside the standard of care. How much is too much 10 per day, 20 per day, 30 per day? What drug do you stop for an over dosage?

Exactly. You can't go by "what the RX manager said" or "well, the doctor said this". Your a professional and you have to make your own decisions. I personally know a pharmacist who had their license suspended for 2 years for causing liver damage to a pt with APAP.

To the original poster, don't go by what anybody on here says is ok, what your other staff pharmacist or even your RXM says is ok to "let go". It's your livelihood, your license, and your conscience if something goes wrong. If that does happen, you can't point your finger and say "they said do this".

 

[Thoughtfulsinner]

Prevacid will be OTC in November so then you won't have to worry about that interaction with Plavix anymore.

 

[MountainPharmD]

Prevacid will be OTC in November so then you won't have to worry about that interaction with Plavix anymore.

So we do not worry about interactions with OTC drugs?

 

[Rebel78]

If someone comes to the counter and sits a box of Prilosec down and is picking up Plavix, would you not say anything? I would, and do all the time on many medications. If somebody is a prescription customer and sits a bottle of St John's Wort down, I'm gonna check their file.

 

[Sparda29]

So we do not worry about interactions with OTC drugs?

Here is where I see an advantage to having a CVS card. Since it record the transactions, the computer should be able to keep track of the OTC products they purchase. When you're ringing up a prescription and then scan their CVS card, the computer should have the ability to pull up the OTC drug record and give you a DUR warning.

So even if it's a clerk doing the check-out, the DUR warning should be made so that only a pharmacist can override it, hence pharmacist comes over, checks it out, and informs the patient about the interaction. Ask some questions, find out if they are still taking the OTC medication.

 

[Vitamin K]

Here is where I see an advantage to having a CVS card. Since it record the transactions, the computer should be able to keep track of the OTC products they purchase. When you're ringing up a prescription and then scan their CVS card, the computer should have the ability to pull up the OTC drug record and give you a DUR warning.

So even if it's a clerk doing the check-out, the DUR warning should be made so that only a pharmacist can override it, hence pharmacist comes over, checks it out, and informs the patient about the interaction. Ask some questions, find out if they are still taking the OTC medication.

Just because someone's buying an OTC doesn't mean they're taking it...plus a lot of the herbals aren't in the DUR system.

 

[Sparda29]

Just because someone's buying an OTC doesn't mean they're taking it...plus a lot of the herbals aren't in the DUR system.

You can ask them that when the DUR comes up.

 

[Aznfarmerboi]

I personally think the QT prolongation crap is bs unless the patient is at risk such as underlying heart diseases, heart failure, etc. A lot of times, QT prolongation while putting you at risk will never be realized. Without a baseline QT that you do not have access to.. there is no point in switching drugs that work. There are a gazillion drugs out there that are commonly dispensed together such as antipsychotics, levaquin, etc.

 

[Aznfarmerboi]

Of course... medications like tri cyclics itself carry more QT prolongation than SSRIs, but in general QT or not, they have more cardio problems than SSRIs.

 

[Pharmavixen]

I personally think the QT prolongation crap is bs unless the patient is at risk such as underlying heart diseases, heart failure, etc. A lot of times, QT prolongation while putting you at risk will never be realized. Without a baseline QT that you do not have access to.. there is no point in switching drugs that work. There are a gazillion drugs out there that are commonly dispensed together such as antipsychotics, levaquin, etc.

QT prolongation is one of those rare AEs that's potentially devastating and impossible to predict. You could dispense ciprofloxacin 10,000 times without incident and then the 10,001st person has previously-unrecognized congenital long QT syndrome and develops Tdp. Lawyers make lots of money off these sorts of rare, idiosyncratic reactions.

 

[Rebel78]

QT prolongation is one of those rare AEs that's potentially devastating and impossible to predict. You could dispense ciprofloxacin 10,000 times without incident and then the 10,001st person has previously-unrecognized congenital long QT syndrome and develops Tdp. Lawyers make lots of money off these sorts of rare, idiosyncratic reactions.

Those aren't the ones the original poster was speaking of, I think they were unsure about the DUR that comes up when they are taking an antiarrhythmic such as Cordarone. I don't think the pharmacist would have liability if the preexisting condition wasn't diagnosed, but they would if they were being treated and the pharmacist just "let it go" as was stated as above.

 

[bacillus1]

For #1, I always like asking for the Dr.'s DEA# when taking a called in Rx. Though I haven't been doing that for the past week or so because it really throws people off and it takes them like 5 mins to find the DEA.

 

[Sparda29]

For #1, I always like asking for the Dr.'s DEA# when taking a called in Rx. Though I haven't been doing that for the past week or so because it really throws people off and it takes them like 5 mins to find the DEA.

Even for non-controlleds?

 

[bacillus1]

Even for non-controlleds?

Yeah I decided to give it a try, out of my own initiative, actually mostly so I could look up the Dr. if I accidentally got the name wrong...People got annoyed but gave it to me. Now I just settle for phone #.

Though there was that one time where I didn't know I had to get DEA for a controlled. I asked for a DEA and the secretary couldn't find it. Then I said it's alright and then she proceded to ask for my name. I gave the pharmacist's name and said that I do want the DEA after all after the pharmacist told me that I need DEAs for controlleds.