What would you do and why?

[bananaface]

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This scenario happened to me today. I think it would be interesting to see how different people would approach the same situation. Plus, I know that the pre-pharm folks appreciate discussions like this.

If you want more information, you can also ask relevant questions about the scenario. I will tell you the answers if I know them. I may ask you questions about your answers and point out issues that are raised. But, I will not offer personal commentary, per se.

So... What would you do/think/feel in this situation and why?

Scenario:

Mr. W. comes to your pharmacy and states that he is there to pick up his prescription. You look in the pickup area and find nothing. You check the computer system and see that nothing was filled. You ask him if this was something he requested or something the doctor was supposed to call in. He says that he dropped the bottle off at the counter yesterday afternoon. You check the refill too soon bin and doctor call bin and still find nothing. He does not remember the name of the medication he dropped off. And, he points out that he does not have the bottle anymore since he gave it to someone in the pharmacy yesterday. He has been waiting patiently at the counter while you investigate. But, he definitely wants to pick up his prescription, even though he has no clue what he asked to be filled. The staff who worked the day before are not available to answer questions.

 

[npp71681]

Hi!
Bananaface,

Here it goes, if I understood correctly.
First, Mr. W is telling that he dropped the bottle of that medication on the counter.
Second, he said that he gave the bottle to someone in the pharmacy.
So, which is true? he dropped the bottle on the counter or he gave it to someone in the pharmacy?
Third, when asked for the medication name, he don't know anything about it. So, then how did he find out that this particuler medicine or bottle needs to be refill?

If I were you in this case, I would'nt give him what he wants without having any correct info b/c of HIPPA. And there is no way that someone can come to your pharmacy and just say I want refill.

I worked in retail for 5 months and whenever someone comes for refill a Pharmacist tell that person to wait few minutes while he/she pull up his/her record and makesure that is right stuff. And a Pharmacist is still confused about something he/she would call the Doctor's office and makesure that the patient is eligible for refill on the particuler medicine.

 

[dgroulx]

We get this situation at work every so often.

Since he dropped off the bottle, it was a refill. There will be a record of the original script in the computer. If it wasn't refilled and I refill is owed, then I'll do it really quick. If it was filled but not picked up, we fill it again and give it to them then figure out where it went later on in the day. Sometimes, I'll type in a refill from the front counter and a tech in the back will throw away my label that comes out on her printer. You have to run back there really quick and say, "I need the label for xxx". But, if you're slammed at the counter, you can't always do that. This shouldn't happen if the techs who do this had common courtesy for other employees. It's only 2 girls who do this, everyone else saves the labels that print out.

I would also check a different computer screen to see if it was put on file for various reasons. For example, it could be a refill too soon, or maybe expired insurance.

If there is nothing on the computer, not even the person's name, then I would assume that the patient has the wrong pharmacy or has some sort of memory impairment. The wrong pharmacy has come up a couple of times for me. When I mention the possibility, they think about it and realize that they are in the wrong place.

 

[baggywrinkle]

Scenario:

Mr. W. comes to your pharmacy and states that he is there to pick up his prescription. You look in the pickup area and find nothing. You check the computer system and see that nothing was filled. You ask him if this was something he requested or something the doctor was supposed to call in. He says that he dropped the bottle off at the counter yesterday afternoon. You check the refill too soon bin and doctor call bin and still find nothing. He does not remember the name of the medication he dropped off. And, he points out that he does not have the bottle anymore since he gave it to someone in the pharmacy yesterday. He has been waiting patiently at the counter while you investigate. But, he definitely wants to pick up his prescription, even though he has no clue what he asked to be filled. The staff who worked the day before are not available to answer questions.

My next question would be do you know what the medication was for? Bloodpressure? Water pill? Simple terms here hoping the guy has a clue
why he puts things in his mouth. If he doesn't know this much he shouldn't
be wandering around without adult supervision. Your last option is to look at
his profile and see what is refillable throwing names out to see if a light clicks on. You could also be mean to him and fill something - anything that has a
refill just to send him away happy, or you can throw your hands up in despair (for dramatic effect) and blame the rascals who worked yesterday apologizing
profusely promising to have them publicly flogged. You don't need to say it, I feel the same way you do about that last technique. It's purpose is to deflect his frustration ANYWHERE else than on you. If you can align yourself with him on his side than you can be frustrated together ( that damned insurance company). He feels like he has an ally and a friend, you don't get stomped on. Whoever isn't there is fair game.

 

[bananaface]

For npp71681:

1) (further info) This is a known individual for HIPPAA purposes. You waited on him last week and realized while looking for the prescripion that even though he goes by "John W." he is listed on file as "C. John W." since John is technically his middle name. You definitely know that he has a legitimate purpose at your pharmacy.

2) (clarification) He dropped the bottle off AT the counter TO a pharmacy employee.

3) (question) Is it realistic to expect that all patients know the names of all of their medicatons?

The information above may or may not change your answer. It is ok to rethink things given new information/ideas. That is what this is all about. 🙂

******************

For dgroulx:

(further information) When you checked his profile you saw two fills from 3 weeks ago, one 5 weeks ago, and one 6 weeks ago. All were for 30 day supplies. None are for controlled substances.

The patient is a cash customer.

There are no prescriptions on hold in the patient's profile.

It is a slow day.

The patient uses your pharmacy exclusively.

********************

For baggywrinkle:

He does not remember what the medication is for.

None of the names of medications on the profile mean anything to him.

After he tells you that the names are not familiar, he volunteers that it is a little green pill that he takes two of.

Since he no longer has his bottle for reference, he appears to feel removed of all responsibility. It is pretty clear that he thinks that the pharmacy staff misplaced his bottle, but that they can be counted on to figure out what he dropped off.

He is intently watching you try to figure out what was dropped off the day before. If you just fill something from his profile, he might ask you how you knew that was the medication he needed. Since there are 4 possible medications (see above), your changes of filling the correct med are 1 in 4. (question) Is this a feasable solution for this case?

(question) If the staff member from the day before were publicly blamed, how would that reflect on your staff in general? Does it have any repercussions for you personally/profesionally? (Please spell it out for the sake of the pre-Pharm folks. Let's give them something to ponder.)

***************

You can use scenario information directed to other people. It is all the same scenario.

 

[baggywrinkle]

He doesn't know why he is taking the medication - that worries me and is an opportunity for patient education. We aren't expecting rocket science here, just that folks take some responsibility for their lives where they are able. In fact, this should be part of patient counseling under ideal conditions - even refills. Open the bottle pour a tablet into the cap. It is an opportunity for a last check on the medication. THIS IS YOUR WATER TABLET. YOU SHOULD BE TAKING IT ONCE DAILY IN THE MORNING. Yes, it is peach colored and most likely really is HCTZ 25mg. Move on to the next medication. This is the ideal. How you do this when you are short handed and the printer is jammed I don't have a clue.

Two green tablets a day is quite enough to work with and you should be able to find it on his profile....unless of course he is taking his wife's estradiol by mistake. I refer you back to the patient's responsibility. How often has a medication gotten in to the wrong patients bag and the patient took the medication for a WEEK before noticing that isn't his name on the label? If the fellow is impaired in some way he is excused. A caregiver (adult supervision) is warranted. The folks who are just lazy get no slack whatsoever. This is the essence of patient education. They are responsible adults. It is not our job to follow them home to administer the medication, stroking their throats to make sure they swallow it. This is why God invented Mothers.

Yes we are professionals. We are also human and variation happens. Accepting responsibility for errors on behalf of the pharmacy is part of the package. How you do this can indeed have repercussions so it requires finesse. Sympathy and humor WORKS. (They were short handed yesterday and it was very busy, I'll bet the new guy who is just learning has your bottle in his pocket and took it home with him. We shall have him publicly flogged. How can we resolve this issue to your satisfaction NOW. Bottom line. Do whatever it takes to end the conversation quickly and peacefully. This includes pulling rank if they get in your face. (I got the drugs, you need em, we do it my way or no way at all) Rule with a velvet covered iron fist

Your goal is to send him away happy. It may require bending the law. For example, if the two green tablets had no refills GIVE him some to keep him going while you backtrack to get a new prescription. A little water under your keel makes this difficult situation easier (not a rugrat). You might recognize two green tablets from a scan of the profile. Otherwise it costs you time as you open each bottle on his profile to find the correct tablet. A waiting customer is a cranky customer. Learn to sweat on one side of your face 🙂

 

[bananaface]

for baggywrinkle:
(more info)
on his profile you see the following....
filled 3 weeks ago: white, round tablet #30
filled 3 weeks ago: white oval tablet #30
filled 5 weeks ago: light blue capsule #60
filled 6 weeks ago: round, pink tablet #30

 

[jemc2000]

So if it is a little green pill that he takes, and you don't have it in the system, then it isn't a refill from you? But you said he only gets his prescriptions from you? Hmmm, now I am really confused. I guess I will sit here quietly and watch how this plays out.

Unless blue looks like green to him...............

 

[bananaface]

For jemc2000:

(further information) He may indeed be colorblind.

(question) How could you find out?

 

[baggywrinkle]

for baggywrinkle:
(more info)
on his profile you see the following....
filled 3 weeks ago: white, round tablet #30
filled 3 weeks ago: white oval tablet #30
filled 5 weeks ago: light blue capsule #60
filled 6 weeks ago: round, pink tablet #30

The key here is two tablets daily. The color is secondary. A quick screen of
his profile for anything matching that sig will narrow the field quickly. You might show him the blue capsule and ask him if that is the one. It would be appropriate for a 30 day supply in a non compliant patient. You can offer to call his physician to see what they have recorded him taking. Could it be that he has been taking physician samples?

If nothing matches that sig than you cannot help him and you should tell him so. At this point he is consuming way too much time and you really need to move on. We are not paid to be psychic! You might ask him who he gave the bottle to and refer him to that person. Based on what you have told us he wouldn't have a clue who he gave it to. He sounds like he couldn't find his way out of a paper bag with a road map. When it is time to close on a deadlocked situation you shrug your shoulders and with your most sincere look ask him what he wants you to do from the available options; door one two, three, or four and be quick about it.

 

[Samoa]

Is one of his medications digoxin?

 

[bananaface]

For baggywrinkle:

When you show him the blue capsule, he says that is the one.

He was indeed color blind.

It took about 90 seconds to figure out what he needed filled.

He is relieved that you figured it out. But, not surprised.

*******************

For Samoa:

Digoxin is not on his profile.

********************

(question) So, what happens next?

 

[GravyRPH]

You pat yourself on the back, go to your computer, and post the experience on SDN.

😀

 

[bananaface]

GravyRPH - You have a PM.

 

[GravyRPH]

Ouch, how come I'm sensing you're giving me that glare my mom used to.

For the record. I wasn't trying to put down Banana, I honestly think anyone should pat themselves on the back for figuring these kinds of puzzles out. Surely, the patient probably won't (he still won't understand why you didn't have it ready in the first place). It takes a common sense that a lot of your co-workers may not have.

 

[bananaface]

I'm sorry, GravyRPH. I can see I took your comment in an unintended way. Will you accept my apology if I send you the lovey smiley? 😍

*******

For anyone:

The scenario does not end until Mr. W is out the door and he is not quite there yet.

You just figured out which medication Mr. W. wants. It is pretty obvious that you will fill it. But there are a still few decisions to make that could affect the outcome of this situation. The answers to these questions depend on the situation. What is right for this particular scenario?

When will you fill the medication? How long will he wait?

Will you or will you not apologize for the prescription not being ready when he arrived?

Will you try to tell him why the medication was not ready?

Will you do anything to compensate him for his inconvenience?

 

[loo]

When will you fill the medication? How long will he wait?

Will you or will you not apologize for the prescription not being ready when he arrived?

Will you try to tell him why the medication was not ready?

Will you do anything to compensate him for his inconvenience?

Immediately. Depends. No, unless he specifically asks. No.

There is no right or wrong--you just try to do right by the patient. 😀

 

[Caverject]

Here is another scenario: What do you do when you have an illiterate patient?


Would you refer them to this:

 

[bananaface]

So we completed the scenario. 🙂

For those of you who are not veterans, you probably noticed that at the beginning, when everyone was trying to figure out what medication was supposed to be filled, there were many questions that we went through. Things which did not pan out in this scenario may work in other situations. Good problem solvers may go through many possibilities before they actually figure out what happened. With experience we start to figure out what is most likely to have happened and you'll tend to ask those questions first. Everything is a possibility, from the pharmacy staff having made a mistake to the patient having walked in to the wrong pharmacy.


Does anyone have any comments to add, or anything they'd like to discuss?

********

South2006:
No! I would send them to you and tell them you would be glad to draw stick figures showing them how to insert their rectal suppositories! I want to see how you handle the "unwrap and insert" part! 😱 HehHehHeh. That was one wasteful billboard. 😀

 

[Caverject]

In that case, I will refer patients with eating disorders to you. When you cure patients, you can give them this nice shirt as a prize!

 

[bananaface]

That pic is too friggin wide.

Notice he has Coors LIGHT behind him....

 

[loo]

For those of you who are not veterans, you probably noticed that at the beginning, when everyone was trying to figure out what medication was supposed to be filled, there were many questions that we went through. Things which did not pan out in this scenario may work in other situations. Good problem solvers may go through many possibilities before they actually figure out what happened. With experience we start to figure out what is most likely to have happened and you'll tend to ask those questions first. Everything is a possibility, from the pharmacy staff having made a mistake to the patient having walked in to the wrong pharmacy.

Well put, bananaface. I have one tidbit to add about illiterate patients. Please treat them with respect, courtesy, and dignity. Most patients I've dealt with are embarrassed in some way and have been treated very poorly by the public in the past. They may not be able to read/write, but they are NOT stupid.

 

[bananaface]

According to the National Institute for Literacy, 1 in 8 adults in the US are functionally illiterate with regards to the english language. They now consider speaking, writing, and reading when assessing literacy. People can be illiterate because english is not their first language, because they never had the opportunity to learn to read (more common in older americans), because they have a learning disability and it was not recognized in school, because education was not a high priority for their family, because they dropped out of school prematurely, because are were visually impaired (common in the elderly), etc. Illiteracy is definitely not equivalent to stupidity.

(climbs onto soap box)

The bottom line:
The time that you spend counseling patients is probably the most important time you will spend all day. The value of all of your other job functions can go right out the window if the patient does not take the medication or takes the medication incorrectly because he or she does not understand what to do. Hardly anyone will tell you that they cannot understand/read the instructions on their medication vial, because they are afraid to appear dumb. It is really important to ask patients if they have any questions or concerns about their medication, because most people (including literate people) will not ask questions unless you prompt them. It is also important to speak to patients using words that everyone understands. Using terms "place" instead of "instill" and "by mouth" instead of "orally" really make a difference in patient comprehension, both on the prescription label and while counseling. If you are careful to use regular vocabulary, instead of hairy technical terms, you will find that your patients are more comfortable, and more likely to ask you questions when they have them. The functional literacy level and the functional level of comprehension go down when the difficulty of the terms you use goes up.

(falls backwards off of soap box)

 

[baggywrinkle]

The time that you spend counseling patients is probably the most important time you will spend all day. (falls backwards off of soap box)

Now tell us how you PROPERLY do this job on a consistant basis as mandated by law in an environment where it is a miracle that the five r's
(right drug ,right dose, right patient, right route, right time) are not violated on a daily or even an hourly basis. At the moment I am only able to manage targeted special cases like your fellow who is screaming for the pitch. The rest get a QUICK offer for counsel
(that'llbe29.95doyouhaveanyquestionsaboutyourmedicationsthanks. NEXT!)
keeping in mind that while you are cashiering/counseling/answering questions nothing on the counter is being done, line two wants a transfer and the doc line has a script to phone in.....

How would your day-to-day change if the state inspector was standing at your elbow with his clipboard?

 

[bananaface]

You just make the time to counsel. There is no special answer. If people end up waiting an extra 5 minutes for their prescription, that is how it is. Hell, if they wait an extra 30 minutes, that is how it is. I make no excuses for taking the time to complete the other key steps. There is no reason this step is any different. I'm not saying you have to go all out. But patients need the key points and a chance to ask questions on anything they haven't taken before.

People are generally happier waiting a few minutes longer and getting your personal attention, anyway. They see that there is someone they like and who cares about them on the other side of the counter and usually decide that the wait wasn't so bad, even if they were agitated before. I have had people gush at me and thank me for my time after they waited 45 minutes for a prescription. It is an extreme example - but it shows how quality persona l attention can make a huge difference.

The safety issue is directly related to staffing levels. I am lucky to work for a chain with good tech staffing. To me a good support staff is one of the biggest factors to consider when evaluating a potential job. If a store is chronically understaffed it is important that pharmacists fight for better staffing. Understaffing is not fair to you, patients, or other staff. And it costs the company money by adding additional expenses.

I don?t think a lot would change if an inspector dropped by. Maybe our manager would quit calling people ?dude?.

I think I missed the part about my screaming fellow.