what would you do?

[icekitsune]

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I don't have enough experience on this but I wanted to know what other Rph would do. I was talked to by my boss about my decision on these similar situation
First: Friday at night, got an rx from a md with a sig that was written pretty messy.

Rx: hydrocodone/apap
#40
sig: take 1 tab (something that looks like a 12,maybe its a q) then something that looks like an 8, maybe...hrs
mdd:6
Couldn't get a hold of the MD. Recently out of surgery, couldn't get pt's chart or a nurse.
Q: what would you do? Would you dispense it? Do you think its ok or not ok to dispense it despite not know what the sig was but had a absolute MDD?

2) Rx: Drug X ( a CS level 4)
#40
sig: take 1 tab q E hrs (the E looks like a loopy cursive E)
MDD: 3
again, couldn't get a hold of the MD and oncall has no chart.
Q: would you dispense it or not? Do you think its ok to dispense it and then verify the next day despite not sure what the sig says completely?

 

[maria1oh]

What is MDD? Max daily dose?
The hydro/apap could be take 1-2 tabs every 8 hours max daily dose of 6.
The other was likely take 1 tab every 8 hours max daily dose 3 tablets.
You need to get better at reading handwriting. Also check the patients profile to see if they have been on it before. Also try to type in the prescription while they are at drop off so you can catch this before they walk away and come back expecting it ready. Or get their phone number when they drop off to alert them of any issues. Tell the patient you can't read the handwriting and you need to clarify. Tell them you can't reach the doctor (sometimes they have an cell number for their doctor or after hours number) Recommend an OTC alternative (Tylenol extra strength in place of norco). If the patient does not know the directions either and they act like a jerk you could tell a lie and say you are out of stock and send them elsewhere(24/7 pharmacies).
Nearly all the big chains now support pharmacists turning away control substances.

 

[Rockinacoustic]

You need to get better at reading handwriting. If you can not do this then tell the patient you can't read the handwriting and you need to clarify. Recommend an OTC alternative (Tylenol extra strength in place of norco). If the patient does not know the directions and they act like a jerk just lie and say you are out of stock and send them elsewhere(24/7 pharmacies).
Nearly all the big chains now support pharmacists turning away control substances.

What the hell does this solve other than turning away legitimate prescriptions? I'd love to see you counsel a patient in serious pain that Extra Strength Tylenol will hold them over.

A technician can read chicken scratch and fill it as written.... you went to school for at least 6 years to learn what a therapeutic dosage of a drug is- use that knowledge. I would've first asked the patient is they were told how to take it. If not, I'd fill it to the best of my knowledge and counsel the patient on what the usual dosage and schedule is, and mind them not to take more than the MDD. I'd also tell them I'd be calling the prescriber the next day, and if the correct instructions are any different I'd alert them ASAP and rebill their Rx to reflect it.

 

[icekitsune]

What the hell does this solve other than turning away legitimate prescriptions? I'd love to see you counsel a patient in serious pain that Extra Strength Tylenol will hold them over.

A technician can read chicken scratch and fill it as written.... you went to school for at least 6 years to learn what a therapeutic dosage of a drug is- use that knowledge. I would've first asked the patient is they were told how to take it. If not, I'd fill it to the best of my knowledge and counsel the patient on what the usual dosage and schedule is, and mind them not to take more than the MDD. I'd also tell them I'd be calling the prescriber the next day, and if the correct instructions are any different I'd alert them ASAP and rebill their Rx to reflect it.

Well actually I did fill it regarding both situation which was both new and not in the chart. In the first, I called them and explained about the mdd. Cause I didn't want them to go without. For the second, I filled it and verified it with md the next day. My pic told me I shouldnt fill unless I was sure of the rx and the sig, even though the MDD says "3".

 

[HouTX]

half of the rphs will agree with your PIC and the other half would've done what you did. ask yourself these 2 questions whenever you get into a tricky situation

am I breaking the law?
can I justify what I did with the state board?

remember, it's your license. not your PIC's

 

[maria1oh]

The PIC is the responsible pharmacist so they are responsible for everything even when the problem is caused by the other pharmacist. If you guess on filling the script and it ends up causing a problem your PIC is the one who will be ultimately resolving the problem. that's why the PIC could have wrote you up for not verifying it before you filled it.

Also in cases where you are unsure but don't want the patient to go without their medication you could dispense just a 1 day supply instead of the full amount. Then after verifying it as correct the next day you can dispense the rest or get a new script. That way if you did screw up the patient would only have a 1 day supply instead of the full amount. Either fill them as two separate prescriptions or fill it as a partial fill and dispense remainder after verification if correct.
But this again could cause problems and your PIC could write you up for dispensing without full verification. If you work for a laid back PIC they would support your professional judgment but some PICs like to play politics and would write you up for doing this.

 

[ancienbon]

The PIC is the responsible pharmacist so they are responsible for everything even when the problem is caused by the other pharmacist. If you guess on filling the script and it ends up causing a problem your PIC is the one who will be ultimately resolving the problem. that's why the PIC could have wrote you up for not verifying it before you filled it.

Also in cases where you are unsure but don't want the patient to go without their medication you could dispense just a 1 day supply instead of the full amount. Then after verifying it as correct the next day you can dispense the rest or get a new script. That way if you did screw up the patient would only have a 1 day supply instead of the full amount. Either fill them as two separate prescriptions or fill it as a partial fill and dispense remainder after verification if correct.
But this again could cause problems and your PIC could write you up for dispensing without full verification. If you work for a laid back PIC they would support your professional judgment but some PICs like to play politics and would write you up for doing this.

Really? A staff pharmacist who executes his professional judgement could have been written up by the pic. I thought it was his or her license on the line

 

[HouTX]

don't get caught up on being written up because you can get written up for all kind of stupid sh1t. if I ever have a PIC or pharmacy supervisor write me up for something stupid, I'll be job hunting that same evening.

thank goodness I have always worked with some great bosses. but at the same time, I built up a good reputation with them. as long as I can justify why I did something the way I did, they were cool about it.

 

[BidingMyTime]

Lots of good advice here. To sumerize, it is your license ultimately that is at stake if you give out a prescription wrong & harm occurs to the patient. The state board won't buy that you did a "best guess" of the writing as a defense.
Steps I would try:
Ask a technician if available, if they can read the doctors writing--once you learn a doctors writing it is usually obvious what they mean, even when it doesn't look like that, so they may have more experience with that doctors writing. It is still your license, so make sure you trust the technician.
Ask the patient if the doctor told them how to take, many times patients will have written discharge instructions from the hospital, if so, I would annotate that on the RX and dispense.
Check the patients profile to see if they have had this before (or if they have had other scripts from this doctor that you can look at to see how the doctors writing matches up with a sig.
Ask the on-call doctor if he will give a new prescription under his name for the patient.
I wouldn't dispense a one day supply if I had any questions about the drug or directions (I would for questions concerning quantity or duration of therapy)--I have called doctors concerning questions about directions vs the drug, and it turns out that drug was supposed to be something completely different, so I wouldn't dispense until I was sure of both drug & directions.
If patient is unhappy about your concern for their health, then they have the right to take their script to another pharmacy. Or call the on-call doctor to discuss their situation. While I am sympathetic that they really do need their medicine now, they need their CORRECT medicine with CORRECT directions, and if I am not sure of that, then I can't dispense.

 

[Pharmpills]

"Guessing" on directions is never a good thing especially a control substance, it's not like a zpack where you can prob. just put as directed. Either you can read it or you can't, if you can't then call the MD and leave a message. If the patient want they can take it to another pharmacy. It's that simple bc why put yourself at risk by guessing what you think a sig might be in order to please a patient. People to try to sue for anything today so protect yourself and remember no one can ever write you up if an rx is illegible and you don't dispense it until clarified.

 

[icekitsune]

"Guessing" on directions is never a good thing especially a control substance, it's not like a zpack where you can prob. just put as directed. Either you can read it or you can't, if you can't then call the MD and leave a message. If the patient want they can take it to another pharmacy. It's that simple bc why put yourself at risk by guessing what you think a sig might be in order to please a patient. People to try to sue for anything today so protect yourself and remember no one can ever write you up if an rx is illegible and you don't dispense it until clarified.

Thanks for your comments. I guess its too late to do anything now, though some of the comments are making me nervous about being sued. I'll learn from this mistake and think about what I should do next time if the situation happens again. Hopefully nothing bad will come out of this situation. I don't want to be sued this early in my career.