What were they thinking? (This is why it takes "forever" to fill your prescription)

The last few days I was away on a small trip so I was unable to post anything. As soon as I got back to the pharmacy, my boss informed me that she had a "dumb prescription" to contribute to my blog. My boss is hilarious. I then received a prescription also which was dosed incorrectly, so I will post that too. As pharmacists, we know what the dosing SHOULD be which is how we catch these problems, but we do not have the authority to correct the prescriptions. This leads us to have to contact the doctors to verify and clarify, and therefore waste everybody's time (and sometimes get yelled at by patients).

RX #1:

Apparently a seasoned doctor wrote this, and not just a new one who hasn't figured out the art of prescription-writing. So in this image, the doctor wrote: cloxacillin 500mg every 6 to 8 hours for 5 days. This is an antibiotic. How do you ask the patient to take it every 6 to 8 hours? Which one is it? Every 6 hours or every 8 hours? What would the quantity be then if it's 5 days? Is it 20 capsules or 15 capsules? Haha. SO DUMB! Wasting the pharmacy's time to clarify with the hospital. 

RX #2:

The above prescription is for Biaxin 500mg 2 tablets once daily for 7 days.

So anyway, there are two kinds of Biaxin: Biaxin regular-release tablets are dosed twice daily in 250mg and 500mg strengths, and Biaxin XL 500mg extended release tablets are dosed once daily. 

In the above prescription, because no "XL" was written, it indicates the usage of regular-release tablets. If the patient takes the two tablets together, they are getting a huge dose right away which only lasts for about 12 hours, and then once the medication starts to excrete out of the body, they will have a large number of hours where there is no medication in their system and bacteria starts developing resistance. HM. To correct this rx, either, the doctor could write XL behind the Biaxin, or change the directions to BID (twice daily). 

The annoying part is that it's after office hours, and the patient is sick. I cannot NOT dispense this medication, but to change it would be against the law. It's so annoying that even though I know the correct rx, I still need to clarify with the doctor tomorrow. THIS is why it takes "FOREVER" to fill your prescription. (For those curious people, I just gave the patient regular 500mg tablets and told her to disregard directions on the label and take it twice daily.) 

Scientifically Unproven Things That People Do

I have decided to compile a list of scientifically unproven things that people do, just beacuse of their interesting or amusing nature. Note that all of these events are true.

1. Some of our Asian customers like to give their newborns/infants dextrose powder. I have stressed that this is pure sugar with no nutritional value, but yet they often cannot be convinced otherwise and continue this activity.

I would imagine that this would probably predispose the child to diabetes in the future as well, due to the lack of maturity of their organs to process this sugar, but noone wants to listen.

2. Some of our Asian customers also ask for rubbing alcohol to help reduce fever. This is to be wiped over specific parts of the child's body (eg. underarms and forehead, I think), and this is to "evaporate away" the heat.

I have stressed that this isn't very effective, and is quite drying to a baby's sensitive skin. Rather, a lukewarm towel wet with a bit of water would do the trick to cool down their baby too, but ultimately fever-reducing medication like acetaminophen/ibuprofen would be best.

3. Some of our Asian customers also ask for rubbing alcohol for any skin ailment that you can think of. If it hurts, itches, burns, weeps, it's an infection, and they must put alcohol on it to disinfect it.

A lot of the time, when you put alchol on eczema it gets worse due to the drying nature of the alcohol. Strong products like alcohol and hydrogen peroxide can also impair wound healing.

4. Some of our Asian customers request for these "cool patches" to reduce fever that you stick to the forehead of their child. Apparently these are quite common overseas.

We have similar patches in the store, but they say clearly on the box that it is for "soothing" the child, rather than for fever reducing. I don't think a tiny patch on the forehead would be effective at reducing the internal temperature of a child.

5. I have had customers request for Dettol liquid. This can be used as a disinfectant for floors, bathrooms, etc. THESE people are using it for various ailments, including itchy or stinky feet.

I reminded them that there's a poison symbol on the bottle for a reason; it's quite possible that this is getting absorbed through the skin, and to just be cautious when using these products. Perhaps a better-studied Western medicine product would be more effective for their skin problem.

6. I had a 20-something year old female customer ask me for a refillable/reusable enema. After I asked a bunch of questions, I realized that she was not constipated. She actually wanted to refill this enema with organic coffee. I wondered what in the world for, and she told me that apparently it made your skin beautiful. LOL. I should've taken down her information and asked her if she ended up being successful.

7. I have a bunch of customers who have cold symptoms for 1 day like runny nose, stuffy nose, sneezing, and perhaps a sore throat and they immediately go to their doctor for antibiotics. They don't understand (or refuse to) that colds are caused by viruses which are not killed by antibiotics. The first doctor (hopefully) tells them that they don't need any drugs. After wasting the government's money to see the doctor the first time, they continue to have symptoms for another 2 days, which is normal, as colds usually last around a week, and are worst around the 3rd to 4th day. They then waste more of the government's money going to another doctor to get a second opinion. At this point in time, perhaps they have gone to a doctor who easily prescribes antibiotics, even when the patient has a dry non-productive (non-chunky/phlegmy) cough, and the sore throat has gone away.Now the patient will come to the pharmacy gloating about their first doctor being wrong and not giving them drugs in the first place, because look, the second doctor thought they needed drugs.

This is what I say to myself and my loved ones:
A) ***SUCK IT UP***. It's a cold. Fighting it will make you stronger.
B) If you take antibiotics at the start of a cold, by the time you're almost done your 5-7 days of antibiotics, even if you did NOT take them in the first place, your cold symptoms will have still typically resolved. Now you have created some bacterial resistance. Good job.

The worst part is that some doctors WILL prescribe antibiotics for patients who have been sick for two days! Often these symptoms have partially resolved by the time the patient gets to the pharmacy, lol.

8. Lots of Asian customers believe that it is bad for you to "take so many days of antibiotics". The more you take the worse it will be for your body, thus, only taking them until you feel better ie. 2-3 days is the best! I had a guy come to the pharmacy asking for something to treat his tooth pain. I found out from him that he had already taken some clindamycin from his previous bout of tooth pain, about.2 days worth until he got better. THEN, the tooth pain returned, and he had been taking another two days of clindamycin, but now it was not working.

HELLO bacterial resistance. The duration of treatment has been studied to be whatever it's supposed to be, in order to kill all/most of the bacteria causing that particular bacterial infection. When you only take 2-3 days of antibiotics, you end up killing the bacteria that are easily killed, leaving behind all the strong ones that survived. These strong bacteria now end up reproducing and you have an infection that returns, and the antibiotics you just used is ineffective. Oh wait, so are all the OTHER antibiotics that are related to that one.


More and more of these scenarios occur daily. I hope you enjoyed this post. =)

What is Worse? Newbie Doctor or Annoying Patient?

A patient of mine came in during a busy time and said "I know that the newest Bayer blood glucose machine is out, so I want it now. I brought in a prescription last month and it's on my file". For those who don't know, some of the blood glucose machines are free with a purchase of 100 strips, and some have a cost regardless of whether you buy strips.

I told this customer "Because this machine is very new, I don't think the rep has come by to show me anything about the machine yet. I also do not know if it's free with a strip purchase, so let me call him and ask". I make the phone call and the rep tells me that it is in fact free with purchase. He also informs me that he hasn't been by any stores yet because he himself had only received the demo kit the week before. I asked him what the differences between this one and the old one were. Apparently this machine is more accurate compared to the other ones, and eventually all the meters will be upgraded to these new test strips. I told the customer that I had located this information and that the machine was free and I would now process his test strips. I also mentioned that because these strips were so new, there was no entry in my computer system so I had to manually enter this into the system and figure out how to bill it. I then entered it and had to call his insurance company for a pseudodin # in order to bill the strips, and finally I got it working.

The man also asked to see another blood glucose machine by the same company and started asking more questions like "what is the difference"? (My response: They're practically the same...the newest one that you're getting is supposed to be more accurate.) He then keeps looking at the other machine. I asked him "So which machine do you want? If I give you this one and I open it, you cannot change your mind. I cannot give an open one to someone else". He goes "Okay, I'll take the newest one." I said "Are you 150% sure?" and he says "Yes." After a few more minutes, he's STILL looking at the other machine and I ask him the same thing again. Then this happens one more time, and he looks VERY indecisive. Finally I said "Look sir...are you getting the newest one or not? You need to be 200% sure because once I do it, I'm not changing it. Decide right NOW. If you decide on the newest one, stop looking at the old one." He decided he wanted the newest one. Finally.

At this point in time, it was quite busy, but the most pressing matter on hand was the prescription for an elderly gentleman who had just come out of surgery to remove a lung, for which his daughter had already waited a while. He had a prescription for docusate sodium and Tylenol #3. As soon as I saw the prescription I was like "OMG. This doctor does not know how to write prescriptions." See the following:

What was a huge pain?
1) Any prescription (especially narcotic prescriptions) require a definite quantity if the direction is "as needed". If the patient takes max 2 tablets every 4 hours around the clock for 30 days, assuming his pain is not reduced, then "30 days/1month supply" = 360 tablets which is a pretty huge quantity
2) Narcotic prescriptions cannot be repeated (you must do a part fill - ie. write a large quantity and say to dispense a smaller quantity every X number of days). This means that the repeats are void.
3) This is coming out of a frickin' hospital where you can barely get a response from a doctor especially if they're a resident, or not on call, don't answer pages, or no longer works on the unit that they were on when they wrote that prescription. If you get a call back, it also frequently is not on the same day within a reasonable time. This doctor had the newest license number I'd ever seen. Oh no.

I decided to call the hospital to page the doctor. Thank God they called back within 15 mins. I asked the doctor if they were familiar with writing narcotic prescriptions, and the answer I get was "Well, I guess I'm learning how to do that today!" WHAT. I then proceeded to teach the doctor how to write a prescription, and then to change my prescription. Okay then. I get the quantity verified...so apparently this doctor didn't really care and 360 was fine, haha. I counted and double-counted it by hand. The patient's daughter is pacing like crazy and is saying that she's going to leave soon because she needs to take care of her dad, but she also really needs his medicine as he just got cut open. I run the prescription to the counter. She goes "OMG, why are there SO MANY PILLS?! Last time he got a small amount he threw them out because he was mad at his cancer!". Okay then...now I had to change the number of pills into half.

Cut back into scene 1 with glucometer patient. He apparently walked away and walked back with the merchandiser from the front store after making a huge complaint! So now I was informed that I was mistreating this guy. WHAT?!
Man: You are supposed to be helping me! I GOT HERE FIRST. Why are you helping this woman?! How can you just start helping me and then switch over to someone else?
Me: This woman was here way before you...I think it's possible that she has been waiting for an hour.
Man: She was NOT here for an hour!
Me: Were YOU here for an hour? How would you know?
Man: Well, you should be helping me!
Me: Look, this woman has been waiting for much longer than you, and her father just came out of the hospital after getting cut open and removing an organ and she needs to get this medication to him as soon as possible. I am helping you with your things now.
Man: You're being ridiculous! How can you say you've been helping me when you're wasting your time doing this here and that there and talking to this person on the phone and that person on the phone? You should be working on MY prescription. I SWEAR THAT YOU'RE MAKING ME WAIT ON PURPOSE!
Me: Sir, you have to understand that I WAS working on your prescription! ONE phone call was to the manufacturer of your blood glucose machine to make sure I can give it to you, and to get you the proper details because it's so new that nobody knows. The OTHER phone call was to YOUR insurance company to make sure that it would go through your insurance so that you don't have to pay! I was calling people for YOUR sake! (Thinking: Shouldn't talk to me like that.)
Man: Oh.

Responsibility

Is it just me or are people nowadays babied through life?

When I grew up, my parents always stressed the importance of school and education, of working hard to achieve our goals and dreams in life. The more effort you put into something, the greater the output, usually. While I was enrolled in many extra-curricular activities throughout the school year and the summers in-between and was signed up for lessons in various things, there were other kids who got to "go outside and play" all the time. Generally if I talk to most of my friends of my age (or older), they had similar upbringings. It was just a normal part of life to work hard to earn something.

Now we hear in the news that it's demeaning to kids and impairing their ability to "fit in" if they don't finish an assignment on time and a teacher gives them a poor grade in school. The answer to this is apparently to be extremely lenient, give the student an extension, and encourage them. If they don't do an assignment, it's fine, just mark them on the work that they have done. All students should pass their grade; how much trauma would it be if they got held back in school and all of their friends graduated?!

Seriously, real life does NOT work that way and I have no idea what the education system is thinking. If you're in the real-world and you're consistently late for your job, your boss will find someone else to do it. If you were supposed to do an "assignment" for a large construction company and you were slacking off and no work was done, you just cost someone thousands of dollars, so they'll find someone else to do it.

In the pharmacy, we see these poor attitudes trickling in year after year, consistently getting worse, and people are feeling an increased sense of entitlement. It's not even just in the young people anymore! We have older people (with grey hair) who are doing the same thing!

Conversation #1
Lady: I need to refill my birth control
Me: Oh, unfortunately you don't have any more repeats on it.
Lady: That is ridiculous! How can I NOT have any more repeats?
Me: You are just out of repeats because you used up everything the doctor gave you.
Lady: WHY DID YOU NOT CALL ME TO TELL ME I HAD NO MORE REPEATS? YOU ALSO DID NOT CALL ME TO TELL ME TO REFILL MY MEDICATION!!
Me: YOU are responsible for your own medication. You can see on your label how many repeats are remaining, and also you can see EVERY DAY when you take your pill how many pills are remaining. If you realize that you're coming down to only 1 week left of pills you should have either checked with the pharmacy to see if you had any more repeats, or made an appointment with your doctor.
Lady: Well, what am I supposed to do now, I have no more medication! You HAVE to give me more medication!
Me: Well, I could try to fax your doctor for repeats, you can make an appointment with them, or you can go to a walk in clinic.
Lady: That is ridiculous!
Me: Sorry, those are your only options. (In my mind I'm thinking that SHE is ridiculous!)

Conversation #2
Lady: I need my pills, but I have no more repeats. You need to fax my doctor as soon as possible. I AM LEAVING FOR VACATION TOMORROW. I HAVE to have my pills and you MUST give them to me.
Pharmacy team member: We will try our best to fax the doctor and ensure you get everything in the original bottles, with expiry dates on them, and in brand names after being specific to the doctor to write "no substitution" on the renewal. Hopefully they reply.
Lady: Well, I don't care how you do it, just make sure I get my pills!!

Why is it that people always come last minute to the pharmacy to get their things? You take your pills every day. You see how many pills are remaining. EVERY DAY. Every day the number decreases so the urgency increases! WHY WAIT UNTIL THERE IS ONE LEFT?!

Frosty Reception

Surprisingly the last few days have been pretty short on ridiculous incidences at work. It makes it so much more relaxing, but that means I have less to post, so I'm posting about an incident that occurred a few weeks ago.

I was checking a prescription prepared for a patient, and I noticed that it read as follows:

Estrace 1gm - 1 tablet daily

Prometrium 100 - 1 capsule twice daily

For those non-pharmacy people, these are hormone medications (an estrogen and a progesterone). 

Knowing that the doctor probably meant 1mg (1/1000th of 1gram), I signed it and hoped that the patient wouldn't show up until the next day so at least all the documentation would be proper, and faxed the doctor's office with a quick note asking for clarification. When I asked "Do you mean Estrace 1mg instead of 1gm" I pretty much expected the doctor to just write "YES!" and fax back, making it completely easy for them. 

Instead, if you see the attached document, I received a fax in return where the doctor clarified it to be 1gm. I think this was one of the rare times I had to clarify a clarification because I knew that I was probably right. 

I called the doctor's office only to be greeted with the frosty receptionist. Our conversation in summary:

Me: Hello! I just received a fax back from your office and I just wanted to clarify the dose again. 

Reception: Well, if the doctor WROTE 1 gram, then it IS 1 gram. WHAT is the problem? 

Me: Well, it's just that the product Estrace only comes in 0.5mg, 1mg, and 2mg, so 1 gram is a pretty huge dose. Can you please ask him to look at it again? 

Reception: WHY? The doctor ALREADY wrote the answer, and we ALREADY faxed back. It IS what it IS. 

Me: Look, if the direction is 1 gram per day, and each tablet is 1mg, then the patient should be taking 1000 tablets per day, or 10 full bottles of 100 tablets per day. Do you understand why I am asking? (ie. Please use your brain and think about it...)

Reception: Oh. Okay, then fax your request again. 

I faxed the request again, making it even clearer and finally I got the answer that I wanted. Thankfully the doctor was courteous and wrote "sorry" on his response; there have been other doctors who have been quite rude in return (I now only WISH I had kept copies of those responses, hahaha). I have also dealt with many types of receptionists in the past and some have also been quite rude for no reason. I hope that this incident showed that sometimes we're not calling just to be annoying and that people should wake up and think for a second before they speak! 

PS. I was just thinking that there's no way that one of those automatic dispensing machines would've been able to do the amount of work/thinking it took to fix this problem.

PPS. This is another reason why it takes "THAT LONG" to fill your prescription. If this incident didn't happen during YOUR prescription, it happened to the person before you. =)

Unnecessary Work

A man came to pick up his prescription today. which came to $9.99. I scanned in the barcode and said "That'll be $9.99 please". He opens his wallet, so the pretty fat stack of bills inside is quite visible, and he hands me a twenty-dollar bill. I ring it in and give him $10.01 change.

Man: Um, can I pay with card?
Me: You just finished paying.
Man: I mean...can I pay with my credit card?
Me: You just paid and I already gave you change. You mean you want me to do a REFUND for you so you can PAY AGAIN with your credit card?
Man: Yeah.
Me: You seriously want me to do a refund so you can pay again with a credit card?
Man: Yes.
Me: WHY?!
Man: Because I want to.

I contemplated the other worse things in life and decided that things could've been a lot worse. At least in this scenario I did not get yelled at for something stupid and not my fault.

I processed this man's refund, asked for a penny, and gave him back change, and then charged his card. What an unnecessary amount of work for something so simple. Craziness.

That's What I Meant!

Customer: I have a pretty stuffy and runny nose. I used Claritin and it didn't work. Can you recommend something else for me?
Me: How long have you been experiencing symptoms?
Customer: It has been maybe 2 weeks I've been trying the Claritin and I haven't  found it very effective for me. Is there anything better than Claritin?
Me: Let me ask you a few questions then. Do you have any allergies to medications, any medical conditions, or are you using any other medications? Have you tried any other medications?
Customer: No to all of the above.
Me: Which symptoms are bothering you the most? The runny nose, stuffy nose, or both?
Customer: All of them.
Me: So you're itchy and sneezy? Any colourful discharge?
Customer: Yes, itchy and sneezy. No discharge.
Me: There's no list of what really works better, but there are quite similar allergy meds and some people find one works better for them than other drugs. It takes trial and error.
Customer: What is that?
Me: Trying it to see if it works better. Let me show you something. *walks to the aisle and selects Aerius Sinus 12 hour*
Customer: WAIT, THAT is what I've been using the whole time!!
Me: You told me that you've been using CLARITIN all along!
Customer: Well, I MEANT that.
Me: So you've been taking AERIUS and NOT CLARITIN?!
Customer: Yes.
Me: Okay, so try Claritin Sinus 12 hour, or you can use Claritin Sinus 24 hour. Keep in mind though, that the decongestant that helps with extra stuffy nose in these can keep you awake maybe.
Customer: Okay, I don't want something so strong, I have trouble sleeping.
Me: Okay, maybe try plain Claritin. It still works for allergy symptoms, just not as well for super stuffy nose, but it won't affect sleeping as much.
Customer: Okay, give me the 12 hour one.
Me: Plain Claritin pills are ALL 24 hours.
Customer: I only want something that's 12 hours.
Me: They're the SAME allergy medication. Claritin in the usual dose lasts 24 hours. When you get Claritin SINUS they cut the dose in half and add another drug, so then you need to take it twice a day, because IT'S ONLY HALF the amount.
Customer: What?! I only want 12 hours, so forget the sleeping. I'll take the Claritin Sinus 12 hours.
Me: Whatever you want. (By this point I had had enough.)

A Conversation on Being Specific

Recent Conversation

Man: I have this rash on my arms and the thing that the doctor gave me doesn't work. (Note that the rash doesn't look like hives.)

Me: How long have you had the rash? 

Man: 2-3 weeks. The doctor also said that there was something I could take OTC but I cannot remember what it is.

Me: Do you know what medication was initially prescribed to you? Did the doctor tell you what this rash was caused by?

Man: No, I don't remember the name of the medication, and I do not have it with me. I also don't know what this rash is caused by. It's just a rash that's itchy. 

Me: Well, it's hard to help tell you what to do next if a prescription medication wasn't useful, because lots of prescription medications are much stronger than OTC medications, so anything I suggest might not work anyway. 

Man: Well, the doctor said I could use something OTC that was very good. 

Me: Was the rash due to an allergy according to the doctor, and is it spreading?

Man: I don't know. It was just a rash and it is getting worse. 

Me: Unfortunately you aren't giving me enough information about the cream that you used or what caused this rash, so I cannot really recommend something that might be effective for you unless I get more information. If in fact your prescription medication is stronger than anything OTC, then you might have to go back to your doctor for follow-up. Can you call maybe try to call someone at home and ask them the name of this cream?

Man: No, no one is at home. UGH. Nevermind! You are so useless!! 

Me: LOL. Ridiculous.

What does that say?

Reposting some old, but good stuff.

When you first try to read this prescription I think most people are a little dumbfounded. Once you know what it says it's just really obvious. This is from a pediatrician...I am quite concerned that there have been mistakes made elsewhere due to his poor quality handwriting!

The Journey Begins

I've now been a pharmacist for four years. At work we talk about drugs, medical conditions, and patients; at home we talk about what work was like, and whenever we have a chance to step out of our busy lives for a second and can enjoy some time with friends, what do we talk about? We talk about work, drugs, medical conditions and patients.

My husband has always said to his other friends that when I get together with my pharmacist friends it always ends up being a gabfest about the worst patients,  students, and more patients...To tell you the truth, I think that my colleagues and I will never get enough. Nobody understands what the pharmacist has to tolerate except other pharmacists so when there's a giant group of us or even just two of us, it's just everyone letting off steam. "I cannot believe that so and so said and did THAT!" Or, "The doctor really wrote THAT?"

Over the years there have been some pretty good stories in which sharing them elicits some minor sympathy from "outside people" (ie. those who don't spend hundreds of hours behund the counter) but they have slowly faded from my memory. This blog will be the new place to keep my pharmacy "exposures" remembered, and hopefully I will be able to convince you, the reader, that next time you see your pharmacist, be NICE to them - they aren't just pill-counters and free question-answerers (although we do that too). We have lots to offer, and we want to help...just appreciate what we do and don't take us for granted.

With that said, this place is also going to be a place where I and potentially some future guest posters will be letting off steam. Enjoy the stories, laugh, and don't seriously wonder "OMG, did that REALLY happen?" Of course they did. In a not so literal sense, we are kind of like nurses, your other favorite profession - we deal with crap on a daily basis.