Onymnomycin
Got an Rx from a dentist today:
Onymnomycin 300mg
1 qid until finished
#40
0 refills
I love it when prescribers make shit up.
"Oops, I picked the wrong one."
That's not a phrase you want to hear a doctor say when you call up and ask if he really wanted $random-obscure-drug-that-no-one-has-ever-heard-of after he's sent an e-prescription over to you from his fancy-schmancy new EMR. You know, the EMR that lists every single drug ever made from the beginning of time up until now, regardless of whether or not that drug still exists, and doesn't use any sort of Bayesian analysis — yes, the same technology that sorts your email — to suggest your drug of choice based on past prescribing habits, or to sort drugs based on their probability of usage or (Heaven forbid!) to suggest that just MAYBE, doctor, you really wanted something else when you picked that whacko drug from the drop-down box.
So anyway, the bogus prescription was for extended-release lovastatin. Yeah, it really does exist, but hilariously enough, the prescribing doctor had never heard of it. And neither had the pharmacist, thankfully, because she might have ordered it, and then the patient would have gotten the wrong medication.
Christ, people. Proofread your goddamn prescriptions. To make sure that gibberish that your EMR spits out is REALLY what you want. And that you've actually heard of the drug you are prescribing. It ain't rocket science, and even if it were, I'm sure you'd be equal to the task.
Yeah, yeah. We all make mistakes. Proofreading a friggin' prescription shouldn't be one of them. But yet, somehow, I see anywhere from 4-20 crap prescriptions Every. Single. Day. All because they weren't proof-read before they were handed to the patient or sent to the pharmacy.
What's the most fun part of all this is that when you get the doctor on the line, he cops an attitude because he thinks he's the Second Coming of Christ even though he's the bonehead who made the mistake. Get over yourself, dude. <Internet toughguy>I swear, one of these days, I'm going to drive to a doctor's office and put my foot up someone's ass.</Internet toughguy>
No, I don't hate my job, but I do hate people sometimes. It gets tiresome saving other people's bacon when all you get is grief for your troubles. Grief from the patient because the prescription took more than 30 seconds to fill ("Well, can you just fill it anyway?"), and grief from the doctor because you deigned to bother him.
And no, not all doctors are like this. Many of them are awesome, nice people. But just as the vocal minority often gives the silent majority a bad name, the types of doctors that are most likely to come to the phone themselves are the ones who want to pick a fight. And they often do everything in their power to make you feel like a piece of shit, even when they are in the wrong. Needless to say, that does neither themselves, nor their profession any favors. The same holds true for bad behavior no matter who you are, or what you do.
What does "2 qd" actually mean?
Last night I had a prescription that said "2 qd" — it was a phoned-in prescription. I filled it, thinking nothing of it, and low and behold I see it has been edited to some different directions. "WTF?" I say to myself, pulling out the hard copy. Nope, it definitely says "Π qd" (That's as close to a Unicode approximation to the symbol for 2 that I can come up with.)
"Um, so why did you change this?" I ask, handing the QA pharmacist the hard copy and the edited label.
"Because it was wrong," she says.
"No, it wasn't," I say, handing over the script written by her hand. "2 qd means '2 tablets once daily'."
"You don't know that," she says. "What if the doctor means take 1 tablet in the morning and 1 tablet 4 hours later, or 1 tablet twice a day?"
"Well then the doctor should write that."
"Sometimes they don't."
"I see. *pause* I was always taught that 2 qd means '2 tablets once daily' and if the doctor wants twice daily dosing, the script should say 'BID' otherwise the doctor — not the pharmacist — has made a mistake. And that 2 qd absolutely means 2 tablets/capsules/whatever once daily, with no ambiguity."
"Well, I like to put 'Take 2 tablets every day as directed.'"
We argued a bit after that, but the trouble with sticking "as directed" on there is a nifty way of a pharmacist doing a little CYA, which isn't necessarily a bad thing. The script technically doesn't say it, and generally speaking, the patient hasn't been "directed" in how to do anything, so it's actually not correct to do that. What if the script is for meloxicam or nabumetone?
To aid in the discussion, here's a brief Latin recap for those that have forgotten it, or never learned what the abbreviations actually meant in the first place. Unfortunately, they're not much help, either:
- q: quaque: "every"
- qd: quaque die: "every day" which is generally understood to be "once a day" or "once daily"
- qX°: every X hours
- po: per os: "by mouth"
- od/os/ou: oculus dexter ("right eye"); oculus sinister ("left eye"); oculus uterque ("both eyes")
And so on.
For me, I will continue to write "Take 2 tablets once daily" when I see "2 qd". But to others, that means something different, and I think it's important that prescribers know that that it means something different to each pharmacist. I mentioned this phenomenon in my Chantix prescribing tutorial, and it applies here as well. There is indeed ambiguity, where there should ideally be none.
And it so happens that this presents the perfect opportunity to test out my new polling toy. So I've included 2(!) polls for finer-grained results. We'll pretend we're dealing with tablets for the sake of simplicity. If you are not in the medical field, please vote "Other medical personnel". The poll will open a new window for each poll which is annoying, but there doesn't seem to be a way around this. And feel free to elaborate in the comments — I really had no idea until yesterday that this was something not everyone agreed on.
Dealing with forged prescriptions
Everyone has their own preferred method of dealing with forged prescriptions. Ryan at EclecticEsoteric recently asked what I would do. It so happens that Andrew at PharmCountry has a related post, so it seems an opportune time…
When you've got a forged or altered prescription, there are two basic things you SHOULD do.
1) Contact the prescriber. Verify that it has been forged or altered.
2) Initiate a PharmAlert, the details of which can be obtained by contacting your state's board of pharmacy. I believe this is how such an alert is usually initiated anyway — I'd say "always" but I haven't worked in every state, so that's impossible for me to know.
PharmAlerts start a cascading reaction. A notice is typically faxed to the pharmacy at the top of the list in your area, and they, in turn, fax to other pharmacies who fax to other pharmacies. You are also supposed to pick up the telephone, and notify the pharmacist at the receiving pharmacy as well, but we rarely do. I should take a picture of the PharmAlert notification map for my area. It's kind of nifty because one of my stores is #1 on the list. If I had to guess, I would say that the seed pharmacies at the top of the lists are probably chosen that way because they are lower volume, and it's thought that they have more time to seed the word along? I have nothing to back this up, I'm only guessing. We are responsible for notifying three pharmacies, whereas everyone lower on the list than us is only responsible for one.
Doctors' offices can also initiate pharmalerts, and often do if a prescription pad is stolen.
There are a couple of things you COULD do beyond these two steps, depending on how crazy you want to be. These include contacting the police, the DEA, and anyone else you might want to contact. It all depends on how zealous you want to be. Me? I don't bother because I don't particularly want to be a law enforcement officer. If I did, I'd work for the DEA. Some pharmacists also take the opportunity to lecture the person about altering a prescription. That's not really my style either. The person already knows they did it, and they know it's wrong. I don't need to beat it into their head, or threaten to call the police on them.
All this changes, though, if you're a habitual offender and/or I suspect there might be organized crime involved. In that case, I verify the script, call the police very quietly, and keep you waiting until the officer arrives, at which point you are arrested. And yes, it always does seem to fall on me to keep the person waiting and so on. I have no idea why. Apparently my poker face is pretty good.
Assuming no drastic measures are taken, I would also say that you shouldn't give the prescription back to the person, but I have seen it done. (An act which never ceases to boggle my mind!) By doing this, you are giving the person another chance to take the script elsewhere. This is unacceptable!
Regardless, I believe it's important to keep whatever action you decide to take low-key and professional. You are not this person's parent. You aren't the police. You are the medication gatekeeper. Politely deny them, do what you must do, and keep the ball rolling.
[tags]Pharmacy, pharmalerts, pharmacy practice[/tags]
The ins and outs of prescribing Chantix (varenicline): an illustrated How-To guide
Chantix is pretty popular these days, and with good reason. It works pretty well. In fact, of all of the people I've talked to, there's not one that's not had success with it. Anecdotal, but nifty. I was dead wrong in my guess that insurers would balk at paying for it. Even medicaid is paying for it in my area, which is truly mind-blowing given how tight they are with their formulary. Even when it's not covered, it's still usually cheaper than buying a month's worth of cigarettes.
What's not so nifty about Chantix are the horrific prescriptions we see for it. Directions that make no sense. Or make sense within a certain context, but probably not the context the prescriber was thinking of. This will become clear shortly.
This is a short post, but it's big because of all of the pictures.
Table of Contents:
- How does Chantix come?
- Normal Chantix Use: prescribing a course of Chantix
- Normal Chantix Use: the first month (photos begin)
- Normal Chantix Use: Month 2 and beyond
- Abnormal Chantix Use and common missteps
Can you read these prescriptions? (Round 2)
Update: Thanks to Kevin, MD, The Consumerist, and The Wall Street Journal Health blog, this entry is getting a lot of traffic. If you enjoy it, please take the time to Digg it. 
The first round was popular, so I thought I would share another round of Bad Prescriptions. Answers will be posted tomorrow (Thursday) night around midnight.
Remember there's more to a prescription than the drug. You need to get:
- Drug name
- strength
- directions
- quantity
- number of refills
The last prescription is totally legible. I have included it so you can cringe along with me. It was for a 6 year old child. And the folks in the Ivory Tower think MinuteClinics are bad…
Exhibit A:
Exhibit B:
Exhibit C:
(Standard disclaimer about electronic prescribing not being the perfect answer applies.)
[tags]Medicine, pharmacy, prescriptions, bad handwriting, doctor's handwriting[/tags]
Can you read these prescriptions?
These three prescriptions were handed to me two days ago. Can you read them? (Click each for a larger image.)
Answers will be posted tomorrow night. Reply in the comments! (Directions, too!)
Exhibit A:
Exhibit B:
Exhibit C:
I should remind you, however, that electronic prescriptions are not a magic bullet, either, though they certainly mitigate problems like these.
[tags]Medicine, pharmacy, prescriptions, bad handwriting, doctor's handwriting[/tags]