Tuesday, June 23, 2009

The Best Way to Get Prescribers to Write Prescriptions Correctly

I'm dead serious when I suggest this. I also know that it will never happen. However, it will stop prescribers from making stupid mistakes on prescriptions pretty damn quickly.

There should be a law mandating that every single prescription must be written correctly in order for pharmacies to legally fill it. That means every time a doctor doesn't write a quantity, doesn't include directions, doesn't sign his name, doesn't write the patient's full name, writes illegibly or makes any other stupid mistake, pharmacists send the patient right back to the office to get a new prescription. After a dozen or so patients return to the office by lunch to get their scripts rewritten, the prescribers will quickly learn to write them correctly.

I'm so sick of calling to clarify every other prescription I get. The percentage is even higher on e-prescribed scripts. Really... How hard is it to write a fucking prescription correctly? More importantly, how can you just laugh it off when I call to clarify it?

Today, I called the office because I couldn't read whether the doctor wrote felodipine or amlodipine on a prescription. It looked a lot like felodipine, but the patient had amlodipine in the past, so we had to call to clarify it. For one, they couldn't tell me right away. They had to call me back... 6 hours later. Then, the woman on the phone said, "It's for amlodipine, but I have no idea what the rest of the prescription says."

That's great! It's a good thing I could read the rest of his chicken scratch because otherwise, I might have had to wait another day to get the directions clarified.

Then, there was the e-script that came through just like this:

Valtrex 500mg
Quantity: 426
Sig: 2 tabs (1,000mg) three times a day for 7 days

426 Valtrex, huh? So, I called to clarify the quantity just to make sure she really meant 42. Yes, the nurse meant 42 tablets. However, she suddenly realized she made another mistake, saying it was supposed to be for 500 mg, 1 tab 3 times a day for 7 days.

"So, the quantity should be 21 then, right?" I queried with the feeling that she just screwed up.

"No... It's for 42 tablets. She's taking it 3 times a day for 7 days," she answered.

"Three times daily for 7 days would be 21 tablets. Seven times 3 is 21," I informed her.

"Oh.... Well, that's weird because the doctor quite clearly wrote for 42," she responded confused.

I was done playing games with her. "Listen, the original prescription came through for 1,000 mg TID. That's the usual dose for treating shingles (which this patient had). I'm pretty sure the doctor meant her to take two 500 mg tablets or one 1,000 mg tablet TID."

"No... the doctor quite clearly wrote 500mg, 1 tablet TID," she insisted.

I told her that I would feel much more comfortable if she asked the doctor to clarify the dose and get back to me. She begrudgingly agreed.

Ten minutes later, the prescription was e-prescribed again to us with the original directions of 2 tablets TID. She never called to tell me if she got clarification on the script, so I had to call her back. It turned out I had been right. Had I not been insistent about getting the proper directions on the script, it would have been filled incorrectly and those incorrect directions would have been verified with a member of the office staff.

Isn't it comforting to know that often times the doctor's office staff is guessing on prescriptions when they call them in to us? I go through this same speil every freaking day. And are the patients happy that I took the time to make sure the prescription was correct? NO!! They're pissed at me for making them wait.

When they're not pissed, they think it's a big joke. "Oh.. Dr. Whathisname's writing is so terrible. HAHA."

You know... It isn't fucking funny. It wastes my time. It wastes the patient's time. Most importantly, it's DANGEROUS. People get killed because of poor handwriting. People get killed by incorrectly written prescriptions. Pharmacists are fucking awesome at correcting 99.9999% of the mistakes that prescribers make on scripts, but while we just might be the most accurate and obsessive compulsive perfectionists outside of NASA, we do occasionally miss these mistakes. Many of us are working long hours, under high prescriptions volumes, and with little help, so it's hard enough for us to make sure that the right pills go in the right patient's bottle. We don't need the added pressure that comes from poorly written prescriptions... especially when those errors are so freaking easy to eliminate if prescribers would just take 2 extra seconds.

Therefore, I call for pharmacists to revolt and refuse to fill prescriptions unless they are written correctly. We need to stop wasting our precious time bickering and bargaining with the office staff, and let them realize just how often they screw up. Let them waste their OWN time correcting their OWN mistakes.


The Ole' Apothecary said...

Mike, we can pass all the laws and regulations we want, but we can't change the tide of human behavior.

Years ago, Massachusetts passed a rule requiring doctors to PRINT their name below their signature on each presciption. They did---illegibly!

I think the only thing that will force them to write clearly is the medium they have use to write it. Two years ago, the hospital I work for eliminated prescription pads for discharge or emergency medications, and required prescribers to used the computerized printout that is part of our information system. Oh, joy! The entire prescription is legible, including the doctor's identity, succeeding where the stupid old Massachusetts rule failed. sure, sometimes the details need to be clarified, but the body of the script, including the prescriber's name, are arelegible. Our local retail pharmacies must be overjoyed to have the bugaboo of the E.R. prescription removed.

Anonymous said...

Why are pharmacists relegated to leaving messages with receptionists or nurses when verifying prescriptions (and then waiting 4, 5, 6 hours)? How is it not possible to take two seconds between patients to call the pharmacy back?

Whenever the phone tree gives the option of "if you are a physician and would like to speak to one of our physicians, press 5" I am tempted to press 5 and see where that gets me.

RxKerBer said...

I press '5' or whatever the button is for md to talk to md. I don't care. My time is as valuable as theirs.

My main point is after all this time spent correcting, when you do happen to make a mistake, the patient acts like you are trying to kill him. I typed 10mg instead of 5mg and didn't catch it at verification. He asked how often mistakes were made at my pharm. My other pharmacist told him in the past year since we've worked together maybe 2 or 3 mistakes. That is 'unacceptable" We are simply too human.

Shalom said...

There's one pediatrician here in town who is notorious for his handwriting. I mean, I've been a floater for several chains over the past fifteen years, I have worked in well over 100 stores in two states, I've seen some real winners in my time, but I have never seen anything like this guy. He's so bad that the state stepped in and ordered him to use pre-printed blanks for his most-prescribed meds (per a pharmacy board inspector), and he still manages to screw them up occasionally by circling the blank space between two medications.

I have his fax number on speed dial. I will not fill a single one of his hand-scribbled scripts without verification from the office, and even then I can hear them in the background asking each other what they think it says. This is just plain unprofessional, in my humble opinion, and arrogant besides, because he's saying the two and a half seconds he saves per script is worth more than the fifteen minutes each he wastes for us, his staff, and his patients.

What bugs me the most is when the patients ask, "Whatsamatter, can't you read?" My reply is inevitably, "Sure I can read, Dr ------ can't write." I've actually sent prescriptions back to him to be re-written (it was for Concerta or some such, and I'm not filling a C-II that looks like what my grandma used to call "fliegenkakechts", which is Yiddish for what a fly makes) and I've also had parents tell me they asked him to re-write some rx's before they even left his office. He can't seem to write legibly even when he's trying to. How does a man get through twenty-one years of schooling without even knowing how to print?

Keith said...

I think Ole Apothecary is right....more regulation is not the answer. Since it is our responsibility to insure that we are filling rx's correctly, it is our responsibility to "solve" the problem of badly written rx's. As long as we play the same old game of calling the nurse to clarify a rx, we will continue to get badly written rx's. We are the one's that must find a solution. One possible solution is to send patients back to the doc if something is not clear about a rx. Once the docs start getting irrate patients back in their office, they will change their ways. I learned a long time ago that you get whatever you tolerate. As long as we tolerate these bad rx's and as long as we play the same old game, that is just how long we will have this problem.
I have long advocated that pharmacists unite and force change. In the area of badly written rx's, we have the upper hand. There is something we can do. Just send the patient back to the physician. We have tried to be "helpful" to the patient, but we have not been helpful. We have helped perpetuate irresponsibility by physicians and nurses. The "helpful" thing to do is send the patient back to the physician. After a few irrate patients, the physicians will change their ways and this will solve the problem for the patient and us pharmacists.