Random Text Fun

Do you ever get a random text from someone who is texting the wrong number... but instead of texting back “Hey wrong number,” you go ahead and keep the conversation going as long as possible?

I did, recently. I couldn't help myself. The potential for comedy was just too enticing. Sadly, it didn't last long, but it still ended up funny.

It was quiet on my side for a little while... maybe 30 minutes or so... then finally I received a response:

Sadly, my trolling for some of the real wedding pictures was left unanswered.

When you're a pharmacist and you get beat down, every single day by patients, physicians, and the company you work for, you seek out these outrageous moments to decompress. 

Hopefully my little bit of fun made you laugh.

Why We NEED Pharmacists

Our job as pharmacists is to dispense the right medication to the right patient and make sure it is correct and appropriate. It's also our job to protect the patient, sometimes from the prescriber or doctor who wrote the prescription.

Above is an example. A careless pharmacist would just type this up as:

Dissolve one and one-half tablet under tongue twice daily as needed for pain.

But a good pharmacist would see the conflicting notes and if he or she didn't know the patient and history, he or she would call the doctor. This careless doctor actually wants the patient to take one tablet in the morning and one-half tablet in the pm.

What would happen if this patient was given incorrect instructions? Probably not much. But with a different drug this could be catastrophic.

Think about that the next time you're pressuring your pharmacist to hurry with your prescription.

Prescription Errors

In the United States, on average there are four billion prescriptions filled every year. (See LINK).

That's a lot of prescriptions.

But the average patient has no idea what's involved at the pharmacy. People only see the pharmacy from the outside, much like we only see my son's head poking out from the sand in the picture... and have no idea that there's so much involved in the filling of their prescription.

When you drop off your prescription, first it is typed into the computer. If you're new to the pharmacy, we have to get all your personal information first, including your pharmacy prescription insurance. Most of the time this is fairly smooth, but at least 10-15% of people have no idea their prescription coverage might be different from their health coverage.

Sometimes we have to call your prescription insurance to get the billing information. This is odd -- it's YOUR insurance, not ours. If you didn't have your Visa card with you, we wouldn't call Visa for this information, right? So that can add time to the process.

Next we make sure the medication is correct. We check the dosage, instructions, and quantity. We make sure your medication doesn't interfere with any of your other medications or allergies. 

If it does, we may call the doctor to get it resolved or find a way to tell you how to manage it. All of this takes time. You'd be surprised how many doctors write for medications that you're allergic to or conflict with something else you're taking even though you told the doctor.

We make sure we fill your medication with the correct medication. This is where a lot of pharmacists take heat in the media when a mistake is made, but in actuality, this rarely happens. I read a figure that pharmacists are 99.98% accurate when filling. That sounds great, but it's not 100% which we all strive for. Suppose your local neighborhood pharmacy fills 50,000 prescriptions a year. That calculates to 10 mistakes a year. That's less than one mistake a month. 

Most of those mistakes are something completely harmless or caught before it ever gets to the patient. But there's always one or two prescriptions that are ingested before the error is discovered. Fortunately most of those situations are harmless too.

We always do our best. We're always 100% focused on our job and there's a lot of checks and balances in the process to stay accurate, but it is not perfect. Mistakes do happen.

But YOU can help. The next time you drop off a prescription at the window, remember... you're only seeing the head of a boy buried in sand. There's a lot that goes on behind the scenes. Demanding that we hurry never helps the situation and increases our likelihood of error and nobody wants that.

Feeling Uncomfortable about Filling Prescriptions

"Dr. RxMan, my name is Detective Daniels. I'm with the Snootyville Police Department. We'd like to ask you some questions."

"Certainly, how may I be of assistance?"

"On November 22, did you fill a prescription for the generic Norco 5/325 to a Mrs. White?"

"Yes, I did."

"Are you aware that the quantity you filled was for 180 tablets?"

"Yes, I know."

"Didn't that seem like a high amount of tablets?"

"Yes, of course. I verified the quantity with the prescriber."

"Are you aware that you filled this prescription 20 days AFTER you filled the same quantity for the same patient?"

"Yes, of course. Mrs. White indicated that she was going on vacation 'somewhere in the middle of Nevada' where 'there are no pharmacies.' When I called the doctor, he approved filling the medication early."

"Were you not concerned for the health and welfare of Mrs. White? Did it not occur to you that so many tablets of Norco might endanger her if taken incorrectly?"

"I'm always concerned about all the medications we dispense. We counsel every patient about the dangers of these medications."

"Are you aware that Mrs. White was found dead in a motel room here in Snootyville? She left a suicide note indicating her intentions. The forensic team is still working on the case, but it appears Mrs. White died from an overdose of Norco."

"Oh my gosh! That's horrible!"

"Our concern is that you ignored a clear and present danger to Mrs. White and YOU are partly responsible for her death. We will be taking evidence to the grand jury for an indictment. Please do not leave the state, Mr. RxMan..."

NO, this didn't really happen...

but could it?

Recently I've seen blog posts ranting and raving about chronic pain sufferers being "mistreated" by pharmacists and pharmacies all over the country. Some encourage the patient to hire a lawyer if they feel like the pharmacist has somehow mistreated them by "keeping them" from their pain meds. They also encourage patients to invoke a clause in the American Disabilities Act to pressure pharmacies to fill without questioning quantities or timing.

Another comment talks about how pharmacists should never say they're "not comfortable" with filling a prescription... the author suggests that no matter what the situation, simply presenting a prescription to a pharmacist FORCES them to fill it without question. 

Mind you, we're only hearing the disgruntled rants of the "mistreated patients," but lets consider the point of the blog: You should never turn down filling a prescription because you feel uncomfortable about it. Is that the correct thing to do? No, it's not. Let me tell you why:

If you're a pharmacist, YOU have EVERY RIGHT to question ANY PRESCRIPTION presented to you, and YOU have EVERY RIGHT to NOT FILL IT for WHATEVER REASON if it makes YOU feel UNCOMFORTABLE. 

If it doesn't feel right, then don't fill it. Are there some people that will feel "mistreated" because you don't fill it? Maybe. Are there some people who are chronic pain sufferers who might slip through the cracks? Possibly. Should we just give out medication to anyone that asks for it and take the risk upon ourselves that people might do what Mrs. White did? Hell no.

No pharmacist anywhere wants people to suffer! But we will NOT be extorted into filling anything and everything because some people, including retired pharmacists, feel like its not our business to assess situations and deny filling. It is our job, and we will do our job.

And in case you don't think scenarios like the one I suggest above with Mrs. White isn't possible... think again. I personally had a very similar situation actually happen to me. It DOES happen. I did not fill a prescription for a large quantity of generic Ambien because I did not feel comfortable doing so, despite having prescriber approval. As it turns out, the man (and his wife) who wanted the large quantity of Ambien were planning on using it to commit suicide! Read that story here. 

I was NOT comfortable filling the prescription as stated in that blog story... and as it turned out, it was for a good reason. If I had ignored my "uncomfortable feelings," I would have had to explain to the police and the victims' families why I filled the medication. And who knows? Maybe I would have been implicated and/or sued by the surviving family? And/or lost my license? Above all else, I would have known forever that I played a part in their suicide. What would that do for your "comfort" zone, pharmacist?

So if you're a pharmacist that feels uncomfortable filling a medication, you go right on feeling uncomfortable and don't fill it. There's a reason why you're feeling that way. Don't feel bullied or pressured into filling anything that you're not comfortable with filling! Period.

We're Spoiling Them

We get e-Scripts all the time. We fill them. That's what we do.

It's kind of like someone calling in an order for a pizza to pick up, except it all comes electronically. On our end an e-Script is like a pizza order. "One medium size pizza with mushrooms" pops up on the computer, so we make the pizza. 

Except there's one prescriber here in Snootyville that doesn't get it. A few days ago she sent over several e-Scripts for herself. As is customary, we process and fill her prescriptions. She's ordered several pizzas, so to speak, and we're going to have them ready for her!

Today she came in to the pharmacy and I pulled all the prescriptions off the shelf that she e-prescribed for herself. I set them on the counter and starting ringing them into the register.

"Oh, I don't want these," she says.

WHAT?! WHAT?!?!?!?!? is going through my mind.

"Why did you send them to us?" I ask. I'm not happy, and it is showing. I personally filled all these medications and maybe I'm just an idiot for thinking this, but I feel like my time is valuable and she wasted a lot of it.

"So you could have them on record when I needed them," she says, defiantly, completely unaware of how it works on our end... I assume.

"You know, when you send over an e-Script, we're going to fill it, right? That's what we do."

She looks at me and doesn't say anything. I'm not sure if she's embarrassed for wasting my time or just doesn't give a damn. I'm leaning toward the latter.

I undo what I've done at the register and ask her why she's at the pharmacy today. She asks about getting a refill for a medication she didn't e-Script to us, nor bothered to even let us know ahead of time that she needed. In her head it is completely reasonable to just show up at the PICK UP window and ask us to refill a prescription on the fly, right during the busy dinner hour, without any idea or concern about the issues this creates for us.

I fill her prescription. As I'm ringing it into the register, three people in line are now staring at me. As politely as I can, I tell her we need to know 24 hours in advance what she needs filled, and if she's going to send over a prescription electronically, it would be nice if she added a note to "do not fill ~ place on hold" if she doesn't want it filled.

Her puzzling reply: "Oh, but I'm used to you spoiling me."

Euthanize me.

One Doc at a Time

Recently the Crazy RxMan went to see the doctor. It was time once again to see the doctor for a routine matter. It's not like retail pharmacy is killing me or anything. No, it was all routine, I tell you. Routine. The appointment was for 10am.

This is not my usual doctor. The "If you like your doctor you can keep him" didn't seem to apply to me, so this is a new doctor for me. I can't see my old doctor because he's not on my new health plan that I didn't want to change.

9:55am ~ I show up and announce myself to the receptionist. She tells me to take a seat.

10:10am ~ My name is called and I'm led to the examination room.

10:45am ~ Finally the doctor comes in and performs the examination.

"Well, we're going to keep your medications the same."

He fiddles on the computer, using the e-Script system to send off refills to my pharmacy.

"Ok, I sent them off. They'll be ready when you get there."

My eyes squint. My lips curled. The demon inside me is rising within me.

"How could you possibly know that?" I asked. You see, I've kept my mouth shut about my job and where I work because I wanted to see what he would say after submitting my refill prescriptions.

"Well, uh..."

Obviously he's never had this question before.

"I'm a pharmacist," I said, "And I actually work at the pharmacy you just sent those prescriptions to. When you say that to people, they come to the pharmacy expecting their medications to be ready for them. It doesn't work that way. Sometimes the e-Script system is delayed up to an hour from the time you hit <submit> to the time we actually get it on our end. Plus we need time to enter it on our computer, print a label, fill it, and check it. That takes time too. And if we're busy at the pharmacy, that takes even more time."

The doctor was silent. No one has ever explained this to him before. And that's why us pharmacists have such a hard time with this system. It sure looks great on their end, and after making the patient wait almost an hour before they are ever seen, they're either ignorantly or intentionally sending people to the pharmacy with the idea their prescription will be ready for them when they get there.

Well, that's one down, 893,850 to go.

Why Flu Shots are so Disruptive

It's that time of year. People want a flu shot. People need a flu shot. People think they WILL DIE if they don't get a flu shot RIGHT FRICKIN' NOW. So let's go on down to the pharmacy and get one!

I'm all for vaccinations. I think everyone should get a flu shot. I vaccinate my children. I really do think you're much better off statistically speaking getting the flu shot. I just wish that my retail pharmacy wasn't so completely rabid about it. It's a cash cow for retail pharmacy, or at least it has been in the past few years. Now that everyone and their pet hamster is giving flu shots, we just don't know how the cash cow will do this year.

I even like the idea of pharmacists giving flu shots... under the right circumstances. But when The Authorities at corporate stick up big signs which say "Flu Shots Today" and "Get your flu shot anytime," there's where I have the problem. Call it bad luck, a twist of fate, or voodoo, but I'll be danged if people don't show up for a flu shot at the WORST POSSIBLE TIME.

Here's some examples: 

Time: Monday

Why: It's Monday, the pharmacy day of hell. Everything happens on Monday. New scripts, refill requests, orders not filled over the weekend, a huge inventory order to handle... this all happens on MONDAY.

Time: Right when the pharmacy opens

Why: We have a bunch of crap to get down right when we open the door. Computers need booting with a bunch of passwords, the automatic refill is staring at us with that come hither look, and reports need signatures and filing. First thing in the morning is a nightmare for most pharmacies. Add a flu shot into the mix and chaos ensues.

Time: Lunchtime

Why: People get this great idea in their head ~ "I'll go get my new script filled at my pharmacy during lunch! It will be easy because no one will be there. I'm so smart!" ~ Unfortunately, everyone else has the same idea, including people that think they'll stop by the pharmacy during lunchtime and get a flu shot. It's also when doctors (who actually get a lunch) clear out their refill requests that pile up on our fax machine and e-script queue.

Time: Right after work

Why: See above. EVERYONE is picking up their prescriptions on the way home from work. Sure, I'll just pop in for a quick jab, right? All they have to do is poke me in the arm, right?

Time: Right after the last tech leaves for the day

Why: Now everything is left for the pharmacist to take care of. New scripts, prescription pick ups, the phone ringing, people with questions, end of day reports... all kinds of crap that we take care of at the end of the day, all alone, with no help. 

Time: Just before closing

Why: The pharmacist is tired. We've had enough. We want to go home. The LAST thing we want to see is someone come by 15 minutes before closing and ask, "Got time to do a flu shot?"

But what is it about the flu shot that makes pharmacists cringe? Here's some possibilities:

1. Most people that want a flu shot are first time patients at the pharmacy. That means we have to add them into the system, get their insurance, have them fill out the paper work, run a claim, and print a label. This process takes much more time. The Authorities want you to believe that it is isn't any different than a new prescription drop off. Oh, that's so wrong. You don't ask patients to fill out a consent and release form every time they drop off a new prescription. 

2. And then there's the slow patient that takes FOREVER to fill out the paperwork. We try to streamline it as much as possible. "Sign, date, and answer 1-8." I even highlight the portions in red. Almost every time they don't listen ~ almost every single time.

3. THEN we have to give them all the paperwork, get payment, or have them sign out the "prescription." If someone is at the pick up window (because it took the flu shot patron FOREVER to fill out the form) we have to kindly ask them to move. They never want to move and roll their eyes.

4. THEN we need to get them into the waiting area, try to finish up anything else pressing in the pharmacy (like the person that was waiting with their eyes permanently rolled into the back of their skull), and head to the waiting area to do the flu shot.

5. THEN there's always the questions about the flu shot after we've already given it. Oh they could have asked anywhere along the way, but no, let's save that question until after it is too late.

It doesn't really take that long to do the actual flu shot part. It's the people part that gums the whole thing up. New patients, people who don't have their insurance with them and want to call their spouse to get it, people who get mad if they have to wait a few minutes, people who insist it should be free when we're getting a co-pay on our end, people who can't line up in the correct place, people who yell at us because their insurance wants them to get the flu shot at their doctor's office... it goes on and on. Add to that a corporate attitude of distrust, and we're all just screwed.

What would be the best way to handle it? Let each pharmacy manager decide when is the best time to give flu shots for his/her store and arrange to have all flu shots given during this time. Overlap time of pharmacists, 1pm to 5pm, or whatever works for that particular pharmacy, NOT "anytime."

"Anytime" is just bad.

Pharmacy Robbery: What do you do?

Recently there have been a bunch of #Pharmacy robberies!

Here's some tips and advice for the pharmacist and technicians:

SAFETY is your number one concern.

To ensure everyone's safety, do this:

1. Give the robber whatever they want!
2. Do NOT try to be a hero. Do NOT try to disarm the robber. Do NOT try to stop him/her.
3. Do NOT make quick motions that could startle the robber. Tell the robber what you are doing as you're doing it as to not cause any confusion. Example: "I am reaching over to get you a bag for your oxycodone."
4. Follow the directions of the robber until they leave.
5. Do NOT chase after the subject(s) committing the robbery. Instead, call 9-1-1. Tell them you were ROBBED (this is different than a burglary). If a weapon was displayed, tell the 9-1-1 operator what you saw immediately. This will speed the police's arrival.

The Authorities you work for may have their own set of "rules" regarding a robbery, such as YOU trying to remember a description of the robber or remembering what they touched (for fingerprints) or making sure you keep the note if a note is passed to you.

Yeah, that's all great, but YOUR CONCERN is YOU and YOUR TECHNICIANS, so screw that idea. Remember, this is the same brain trust that decided to remodel your pharmacy with ultra low counter tops out in the open making it easy for anyone to jump over... so let the videotape be evidence. 

YOUR concern is your safety and the people you work with, not the multi-million dollar company and a few bottles of oxycodone. Don't jeopardize your safety trying to notice all the moles and tattoos of your robber. This will just piss them off. Never, ever piss anyone off who has a gun.

Your company likely will have a policy and procedure to follow AFTER the robbery. Follow that after dialing 9-1-1.

Here's some links to recent news articles on pharmacy robberies:

LINK 1
LINK 2
LINK 3
LINK 4

Overheard from the Dispensing Bench

"Is that the man giving me my flu shot?"

"Why yes," the technician answered. "He's the pharmacist."

"But he looks so mean!"

Try this at your Restaurant

"That was one delicious meal. Please give my compliments to the chef," I said to the waitress.

She thanked me for the patronage and handed me the bill.

"What's this for?" I ask.

Stunned, she says "That's your bill."

"Oh, it's covered by my Visa," I said.

"Well..." she says, rolling her eyes, "we're going to need to SEE your Visa card."

"I don't have it with me. Just look it up on the computer or call Visa. They can give you my information. Besides, it's the same as last time I was here."

And yet, if this was actually a true story, you'd scoff at the insanity of it all.

BUT this is an every day occurrence in the pharmacy. EVERY SINGLE DAY. People come in with a prescription and do not have their prescription card. Some people can't even tell you what the name of the company is that handles their prescription insurance. Others have a card two or three years old. And no matter how busy you are they expect you to just magically make it appear.

It doesn't work that way in pharmacy, people.

Zithromax is now Controlled?

"Is Zithromax a controlled substance," he asked as I was filling his prescription for a Z-pack.

"No," I replied. "I know lots of people want a Z-pack for the least little thing, but to my knowledge it has no addictive qualities."

At this point, maybe five minutes has passed since the patient first walked in and I'm in the middle of filling his prescription.

"Oh. I'm going to complain! I asked the doctor's office if they wouldn't mind calling this in for me so it would be ready when I got here," he says in a grumpy tone.

"This office calls in medications all the time," I said.

"The lady told me Zithromax is a controlled substance and I had to hand deliver the prescription," he says. "I'm going to call them up and complain!"

We're now at the seven minute mark and I'm heading toward the register with his Rx ready. He's my first patient of the day and there was no wait. I had his prescription ready in less than ten minutes, but he's mad because the office wouldn't call it in ahead of time for him. He must have one damn important job if he can't wait ten minutes.

Who's to say what really happened at the doctor's office, but I wouldn't be surprised if that's exactly what happened. I've had office staff lie to me over the phone. It actually happens all the time. My personal favorite is, "We never received your fax" as I'm hold a fax confirmation in my hand.

Or maybe Zithromax was bumped up to a C-II controlled status and I didn't even know about it?

The Return of Respect Starts with Us

There's no one person to blame. It just kind of happened. Maybe it happened when we stuck a pharmacy inside a grocery store. Or maybe it happened when they opened the first pharmacy with a drive through window. I don't know when it happened exactly. Neither do you. What we do know is that our profession changed somewhere along the way.

Yes, we're one of the most trusted professions, but we're treated with much less respect now than we used to be. When people come into Goofmart Pharmacy, do the script push across the counter, and tell me they're going to be back for their prescription in five minutes (without having any idea of the current situation or how many people are ahead of them in line), it shows the lack of respect people have for our profession. When people tell me that all I have to do is "slap a label on it," it shows the lack of respect people have for our profession. When people come in after having seen the doctor ten minutes ago expect their prescription to be filled and ready to pick up, it shows the lack of respect people have for our profession.

In some cases it might just be a matter of having had enough of waiting. When people go to their doctor, wait fifteen minutes to get taken to an exam room, wait another ten minutes to actually see the doctor, then get only five minutes with the doctor and given a handful of scripts, they've had enough. They don't want to wait anymore, and I can't blame them. But a patient can't go through this routine and then expect things to magically accelerate at the pharmacy. Yes, your doctor did see you and prescribed a medication. BUT we're not only filling your prescription, we're ALSO making sure it is safe for you, is appropriate for you, and making sure you're getting the right medication. That's our job and whether you like it or not, this part takes time too.

The e-Script system reduces a little of the workload in the process. By eliminating some of the issues doctors have with writing clearly (there's so many of them you can't possibly imagine) the e-Script system has introduced a new set of issues. Office staff that are untrained with the system or don't know the medications that well (such as the difference between immediate release and extended release) gum up the process quickly. Unfortunately, because of the way the doctor office works, getting it fixed rapidly is almost impossible. For a patient that thinks we have a magic phone line which instantly connects us to the prescriber, any additional wait time seems ridiculous to him or her.

My biggest complaint with the e-Script system is not the system itself, but the way patients perceive it. In some cases, this perception is created by the doctor. I have had patients tell me, patients who actually know better, that their doctor will fiddle on the computer with their prescription and announce to them, "Ok, I sent it over. It's ready. Go get it." In other cases, patients themselves think that once the doctor hits the SEND button a label prints out on our end and a team of technicians instantly fills the prescriptions. I have had to tell too many people that sometimes it can take up to an hour before we ever see it on our end. "But I saw my doctor send it" they say, not knowing that it's not like email. Even if it was like email, who checks their email every 30 seconds? (Yes, I know there's some people that do check their email every 30 seconds. I'm talking about NORMAL people).

If we're going to return some respect to our profession, we as pharmacists need to stop these incorrect perceptions. I have patients who are also doctors for other patients. I do my part by gently telling them how our side of the process works. If you're a pharmacist, I encourage you to do the same. When you get a patient that runs in expecting a prescription to be ready for them when they walk in and you determine that the doctor has given them the idea that it would be ready for them immediately, take some time to call the office and again, GENTLY tell them how it works. Tell them how much you appreciate the fact that they care for our patients, BUT that you're not running a fast food operation. If you're nice, you'll get a message across eventually.

As for patients, do your part to train them as well. Decide on a wait time with your staff depending on various situations and stick to it. Exceptions can and should be made for crying babies, but don't push yourself and risk patient safety just because they're in a hurry. Patient safety is paramount, and it is what we're all about as pharmacists. Don't let your company bully you. Don't let metrics pressure you. Don't let whiny patients coerce you. Do what is right for the patient by carefully checking each and every prescription. 

Only then will the respect for our profession return. 

We all make mistakes?

This is from a video tutorial on solving equations. It was created and narrated by my 13 year old son's Algebra teacher. Watching her videos is part of his nightly homework assignments.

I think most teachers are a dedicated, hard-working group of underpaid people. Everyone makes mistakes, but I couldn't just let this one go by without making fun of it. I had a lot of teachers in pharmacy school that also made little mistakes here and there, including a chemistry teacher who consistently couldn't figure out the difference between "affect" and "effect."

We're all human and allowed to make mistakes, even doctors, right?

No. The one group not allowed to make a mistake is the pharmacist. We're the last line of defense in patient safety. It's our job to protect the patient and 0% error is expected.

Suppose for a moment that the error rate of your average pharmacist is 0.02%. That's actually a number that's been thrown out there in the past. That means your average pharmacist makes no mistakes 99.98% of the time. That's pretty dang good, right?

Well, further suppose the average pharmacist fills and/or checks 50,000 prescriptions a year. Sounds like a lot? Yes, that's a lot, and that's actually pretty accurate. That means there are 10 prescriptions a year that could be filled incorrectly. Out of that 10, most is just something inconsequential to the patient... but there is always that possibility that there's one or two prescriptions... filled incorrectly, that could cause harm or death to the patient.

Keep that in mind the next time you see your pharmacist. He or she is under a massive amount of stress to help you get better, but more importantly, to keep you alive. Pushing your pharmacist to work faster to get your prescription ready increases that stress and increases the likelihood of mistakes.