Anyone who has worked in a pharmacy knows what the title to this entry refers to. For those who don't know... When a customer calls for a refill on his/her medication and there are no refills remaining, we usually will fax a form over to the doctor's office asking for authorization to refill the prescription.
This usually works very well. However, as you'll see, this can lead to major problems...
Today, CVS called our pharmacy asking for a transfer. They didn't have our prescription bottle, but the patient told them that we needed to transfer his prescription for gabapentin 100mg. I looked in our computer and couldn't find a script for gabapentin 100mg. The patient had always gotten gabapentin 400mg. I didn't think much about the mix up at first. A lot of patients generally have no idea what they're taking and at what dose. I was sure the patient had just made a mistake and told CVS his dose was 100mg instead of 400mg.
I started to give the other pharmacist the info on the script, but once I got down to the directions, both of us kind of paused for a second. The prescription: Gabapentin 400mg, 2 capsules 4 times a day. That's a whopping 3,200 mg of gabapentin per day. It's not unheard of, but it is a pretty large dose. Both the CVS pharmacist and I started to wonder if this was some sort of mistake, so I tried going back to pull the original script. Unfortunately, our software is behind the times, and I was unable to bring up an image of the original RX on my computer. Furthermore, the first fill with those directions was from a couple years ago, and the script was no longer in the pharmacy. The only thing I had was the refill request form that had those directions on it that was approved by the doctor's office.
The CVS pharmacist said that he'd call the doctor's office to double check the dose, and then he hung up. 10 minutes later, he called back to tell me that the office told him the patient should be on Gabapentin 100mg, 2 capsules twice daily. That's a 400mg daily dose.... FAR different than the 3,200 mg dose he'd been getting for years.
I had to know what the hell was going on, so I called the doctor's office looking for an explanation. What I got was some receptionist who couldn't possibly be a nurse considering just how stupid she was. She looked at the chart and told me that since January his dose of Gabapentin has been 400mg per day. I explained to her how shocking this was to me considering the office had approved the refill request for the 3,200 mg per dose in April.
This was her explanation: When we send refill request forms to the office, she looks at the drug, looks at the patient's name, and just signs off on them without the doctor ever looking at them. Thefore, she wasn't at all surprised that she had been approving a dose that was 8 times larger than the one the doctor wanted the patient to be on. She also couldn't understand why we were just a little concerned that the patient had been taking 3,200 mg of gabapentin all along and was now going to be dropped down to 400mg once he picks up the prescription at CVS.
This whole scenario might sound shocking, but I'm willing to bet it happens a lot more often than we'd like to think it does. You can tell just by looking at what's written on the replies that the doctor (or whoever is approving these refills) is just signing off on the refills without even looking at the prescription or the patient's chart. We'll often write notes on the fax forms asking whether a dose or directions haver changed, and we'll just receive a fax back for #30 with 5 refills and absolutely no response to our question. Moreover, you can fax over a request for some kind of cream that the patient hasn't used in 5 years, and we get approval on it. I often wonder if we faxed over a bunch of refill requests for Percocets how many would get approved? I bet if we faxed over 10 requests, at least 4 or 5 would get signed off on.
In any case, after about 5 minutes of explaining to that stupid receptionist why it was very important to me to know whether we screwed up the first time the script was called in or whether it was their mistake that they kept approving these refills, she finally looked back 2 years ago and told me that the patient was, indeed, on 3,200 mg per day at one point. Everything after that was a chain of fuckups on their part. She didn't care though. She still didn't understand what the problem was.
The take away message: If you work in a doctor's office, and are in charge of approving refills, LOOK AT THE FUCKING REFILL REQUEST AND CHECK THE DAMN CHART BEFORE APPROVING IT!!!