Discharge Scripts
Do they even look at these damn things?
I have a hospital near me that generates discharge scripts via computer. It's all based on what meds the patient was on during the stay in-house. I know the process there because I called and spoke with their pharmacist on duty one night. We hate our jobs equally.
It goes like this. The Ward Clerk generates a list of all current meds on the MAR (Medication Administration Record). This sheet includes PRNs, parenterals, orals, rectals -- the works. The doctor then goes down the list and circles YES or NO. This sheet is then sent to the pharmacist who removes the NO drugs from the profile (by D/C'ing them). Then, the pharmacist prints these sheets directly on the floor and they are reviewed by the patient's nurse based on what was said and what s/he expected. There is a space for the doctor to sign. My pharmacy will fill these w/o the docs signature because we deal with the hospital so much and these sheets are not "fake able." I will admit though, that only 1 out of every 50 are unsigned. So, for the most part, the doctor has the OPPORTUNITY to review these sheets again. A quantity is written in on the bottom as well -- usually it's ONE MONTH.
So I can say, without a doubt then, that at least THREE sets of eyes see (or should see) these damn things before being given to a patient -- Pharmacist, [Ward Clerk perhaps?], Nurse, and Doctor.
Why in the fuck did I get a sheet today that listed:
1. Fentanyl PCA 10mcg/hr Basal with 10mcg on Demand Every 10 Minutes.
2. D5NS 100mL/hr
3. Naloxone
- This was obviously in a 'set' with the Fentanyl to pull from a Pyxis if needed.
4. Heparin Lock Flush 100 Units prn
5. Ancef 1g one hour pre-op
How did this shit get by? It was fucking signed by the doctor. He even wrote in *his* DEA number to cover the fentanyl...the only Narc on the script.
There was more on the script of course - they always leave OTC/PRN stuff and we just use our professional judgment on how to get those things to the patients (Ibuprofen, Docusate, Baby ASA). Usually we just grab it off the shelf if they want it.
But seriously? Dextrose in Normal Saline? Would you like me to educate the patient on how to start a line on himself? Should I also work through with him on how to operate the PCA Pump he has in his bedroom - making sure he sets it for MICROgrams rather than MILLIgrams since it's fentanyl? [End Sarcasm]
I'm expected to review my work before it leaves my pharmacy. Why is this healthcare team not expected to do the same? I could get in serious trouble for not checking my final product prepared by my technicians.
If you care about the outcome I reached - I just scratched the bullshit out. Later in the night when it slowed down, I called the pharmacist on duty there and let him know that that stuff snuck through. He attributed it to "a student screwing around on the computer." I attributed it to his laziness or lackadaisical demeanor. He did not like my analysis -- nor did he apologize for the actions of himself or his student. If his lame-ass excuse was valid/true -- it's still his fault for not staring over the student's shoulder...which would be the law for the student entering orders in my state of residence.
Just Questions
Every day I ask myself questions. Most are rhetorical...but they are pertinent questions. I will share these with you now. Feel free to comment with some of your own. OR Check Out Pharmacy Chick's version of this same exact thing from February 2008.
Why do old, toothless people always appear to be chewing on something?
Why is it than if someone is walking to my pharmacy, I can predict with 99% accuracy that they want to buy 12-hour Pseudoephedrine?
Why is it that someone that wants a script filled 10 minutes before closing will have had that prescription for no less than 7 days?
Why does the person wanting a rare, expensive C-II drug come to my pharmacy each month wanting it only to find out that I still don't have it and won't order it for them unless they fill it with me once and wait for the order to come in?
Why does someone on Medicaid give me their card only to ask me to "just fill it for cash" -- knowing full well that I'm going to bill it to Medicaid FIRST?
Why is it that people think they need Watson brand Hydrocodone/APAP? Nevermind - I know the answer to this one...more street value cause it can be identified by pill-heads.
Why does every person that I would idenfity as a drug seeker use "I have fibromyalgia" as the excuse for their early refill or other behavior?
Why does every complaint go to a non-pharmacist store manager rather than to me?
Why does every doctor's voicemail message have the same bullshit message that I can't skip over (they can press ZERO to get to me!)? "Leave the patient's name, date of birth, drug name with spelling, strength, quantity, last fill and pharmacy call back number."
Why do people have to ask for the pharmacist to give a refill number?
Why will people have pizza delivered to their home in an hour and be happy with that wait time but want their prescription in 15 minutes or less?
Why do people want name brand drugs then be completely happy with store brand soda, chips, water, clothes, and everything else?
Why would someone present a prescription for a child then refuse it when the copayment is anything more than free?
Why would someone call me a 'stupid fucking cocksucker' during one trip to the pharmacy then yell at me during their next trip when I use the word 'shit' in front of their child?
Why do I have to concern myself with HIPAA when any patient would be willing to yell, "Yeah my name is Fred Jones...3-14-51. Doctor Smith called in my Viagra refill this morning"?
"Sir, are you taking any other medications?" No.
"No OTC meds?" No.
"No Vitamins?" No.
"Any herbals?" Nope.
"No other medicines at all?" Well, I've been taking this Saint John's Wort for depression.
Why is the answer always, 'NO' to "Do you have any questions for the pharmacist" only to have the patient call the pharmacy back in 10 minutes later?
There are 24 hours in the day. Why does everyone have to spend their 30 minutes in the pharmacy on the cell phone?
Why does every patient with a new insurance card present that card at the cash register rather than the pharmacy drop off window when the read the sign that says "Please present your insurance card when you drop off your prescription"?
Why is it that 1 out of every 100 patients feel the need to poor their pills out on the counter and count them right there in front of all of us?
Why do Americans have the words, "I want to talk to your supervisor" into their brains for use at the first sign of a problem, dissent, friction, or trouble?
Why is there a direct correlation between the number of items in a person's shopping cart and the likelihood they will want them rung up in the pharmacy?
Why is there a direct correlation between the number of scripts filled in my pharmacy and the amount of alcohol I ingest every evening? Nevermind -- I know the answer to this one too...
Why is there a direct correlation between a patient's lack of teeth and oral hygiene and the likelihood they will present a medicaid card?
Why do I have to be the person to explain to some people that BEER cannot be paid for with Food Stamps?
I have a feeling this post has instant classic written all over it...
I Feel Cheap – Very Cheap
I'm back. Sorry for the lapse. I've been busy and somewhat injured making it hard to type.
Has any pharmacist out there ever sucked up their pride and done something they normally wouldn't do for a patient because that patient brings in a lot of scripts (and income) into the pharmacy? I did that today, and it made me feel sick.
A *long* time patient came in today. My keystone tech took his script. He was just diagnosed with Type II Diabetes Mellitus. He's not overweight, so it was somewhat surprising to me. He already has a meter and lancet device. He didn't get that from me. The script was one of those generic scripts (Glucose Test Strips + Lancets #qs for one month +PRN Refills) Keystone tech had a conversation with him about exactly which meter he had and what kind of lancets he would need.
They settled on the Accuchek Comfort Curve and our store brand lancets which are made to fit pretty much any lancet device. We put the strips on hold -- he still had some of those. So, we merely filled the strips and Metformin 500mg po BID. Easy enough right? Right. He was comfortable with the price -- his insurance knocked off very little, but the cost on the strips was 5 bucks and his metformin was 5 or 6 bucks.
He got home, and pretty much immediately called back. He wanted to speak to a manager. I have gotten to the point where I don't like to handle complaints. I like to let keystone tech handle it -- she's great at it. I'm usually a dick. Go figure. But, he wasn't having it. He wanted to talk to me.
I got on the phone and he was angry. He didn't yell. He didn't curse. Lucky for him, because if he would've gotten hostile, I would have not been as nice as I was. I was shocked I didn't call him a fucking asshole as is...Anyway, he has the nerve to tell us that his lancet device is a Accuchek MULTICLIX (which has some sort of drum-type lancet where one drum has 5 or more lancets in it so there's less handling of sharps). He then tells me that he told this to my keystone tech and the prescription CLEARLY states that -- we screwed it up. He then goes on to tell me that he drives out of his way to get to us because he gets good service from us. Then he started with the "here's what is gonna happen A --- you all are gonna do this. B--- you are gonna do this" bullshit. I was having none of that. I offered to fix it, eat the difference and mail it. That wasn't good enough. He needs the lancets now. He needs to be checking his blood sugar 5 times a day (WHICH IS FUCKING BULLSHIT AS TAP SAYS). Then he tells me I have to pay for his gas to get back out there.
So, I looked at his profile. We fill 10 scripts a month for this guy, and we get pretty good return on his stuff. I also know that he buys a ton of vitamins, assorted OTC vitamins, and other stuff from us. So, he's a pretty valued customer. I sucked up my pride. Rather than tell him I heard the entire conversation and that he told my keystone tech that the store brand lancets would be sufficient AND that the prescription merely says lancets and nothing more, I folded. I told him I would refund the 5 bucks. I also told him I would get the Multiclix ready and edit the price to zero. The difference between the two would cover the cost of his gas and troubles as the Multiclix are much more expensive (They are like 14 bucks per 100 whereas the store brand is 4-5). So, I returned the store lancets (I told him to just pitch them as he refused my offer to GIVE him a lancet device that they would work in -- he wasn't comfortable with that since he's used to the Multiclix...that also pissed me the fuck off). I then filled the Multiclix, billed it to his insurance (to at least cover a little bit of the loss), and I changed the price to zero. My net loss was 18 or so dollars.
So, anyone that is familiar with business knows that 3% net profit is ideal after all is said and done. That's unrealistic in pharmacy, but it's a decent gauge. So, to make back that $18, you have to sell ~33x that amount to cover the loss. So, I have to do close to $600 worth of business to make that back...That's exactly why shrink/theft is such a huge deal and horrible for business. Now, I'm not saying it's theft, but I damn sure bent over backwards here.
I know that I'll make that money back, but I feel like a freaking spineless piece of shit for kissing this guy's ass like I did. But, word of mouth goes a long way in my area -- and I'm sure that he'll let it be known to everyone how nice we are and how we made things right.
Then again -- I did make a note in his profile that he gets no more favors...:-)
My turn…
Just about everybody has taken their shot at "Why does my prescription take so long to fill?" Now, I will end this argument once and for all. For starters, here is the short version: "IF YOU WANT M&M's, BY ALL MEANS - GTFO! KTHX"
Now, I really like PharmacyTales Version (WHERE DID YOU GO, PT?), but the problem with it is that it is much too wordy. A visitor to the normal, American pharmacy would see that, scream TL;DR and run away screaming. The American public wants lists and pictures. I will now provide the perfect document to give to patients explaining WHY THEIR PRESCRIPTION TAKES SO DAMN LONG TO FILL!
==========================
Dear Pharmacy Visitor,
Recently, we've noticed an increase in prescription wait time due to many factors. To ensure all our patients have full knowledge of our policies and procedures, we've developed this list-type document so that each and every person knows the time and effort put into every prescription.
Prescription Filling Process:Â
Drop-off of Prescription(s)Â by Patient [Usually 1 to 15 New Rx's or Refills]
New Patient Addition (OR Existing Patient Information Verification)
New Insurance Addition
Scanning of New Prescription (In some of our locations)
Input of Prescription into Computer System
Pharmacist Verification of Typed Prescription
Computer-Based Drug Utilization Review (DUR)
Pharmacist Acknowledgement, Review and Resolution of DUR Issues
    - These range from wrong/missing drug, dose, route, quantity, to drug interactions, poor doctor handwriting, unsigned prescriptions, and early/late refills.
Billing and Insurance Adjudication via Online Processes
Resolution of Various Insurance Issues (or Lack Thereof)Â via Phone Call to Insurance
Resolution of Other Ins. Issues via Phone Call to Doctor's Office for Info/Change
Selection of Correct Drug/Dose from Shelf
Counting of Correct Quantity
Placement in Bottle/Labelling
Pharmacist Verification of Tablet Dispensed to Original Rx
Printing of Supplemental Patient Drug Information
Bagging of Prescription(s) With Correct Pamphlets
Cashier Verification of Correct Patient
Ringing of Prescription/Additional Store Items
Correction of "Patient Issues" with Billing Amount
Patient Signing for Insurance Payment/HIPAA Policy
Patient Payment for Rx/Other Items
Pharmacist-Patient Private Consultation
Other Pharmacy Related Tasks -- Not *Directly* Related to Your Prescription:
All of the Above Steps for the Person(s) in Front of You in Line
Numbering/Sorting of Older Prescriptions for our Filing System
Shelving of Incoming Drug Orders/Stock Replenishment
Stocking/Straightening of OTC Drug Shelves
Calling of Drs. for Rx Refills for Other Patients [as a Courtesy]
Calling of Drs. for Order Clarification/Prior Authorizations/Etc
Answering of Patient OTC Drug Questions
Answering of Assorted Store-Related Questions
Answering of Phone Calls Concerning ANY Issues
Taking Refill Requests from Pts Refusing to Use Computer-Automated Refill
Taking of NEW Prescriptions from Doctor's Offices
Ringing out of Items Not Related to Rx Sales
Ringing out/Logging of Pseudoephedrine Sales
Printing Rx History Forms for Patients for Tax Purposes
Cleaning of Pharmacy Area
LUNCH - We get one just like you!
Bathroom Breaks - We gotta go sometimes, too!
If you think you can help us optimize any of these steps, feel free to give our toll-free number a call at 1-888-ANG-REST.
Sincerely,
Your Phriendly Pharmacist
Â
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