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Medical Forum / General / Pharmacy / October 2003

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dispensing error, but could be worse

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Hillary Israeli - 23 Oct 2003 01:49 GMT
OK, this isn't the biggest deal, and certainly it could be worse, but it
is incredibly annoying in light of the crap I've been dealing with lately
(my 3 yr old son ill with pneumonia, reactive airway disease, and a sinus
infection x 1 month and counting, 4 doctor visits, 2 hospital visits in
that time;  10 days into this illness I diagnose my 6 yr old cat with
renal failure; 3 days ago my 1 year old daughter starts a fever of 102
which is continuing and will require a doctor visit tomorrow...)

At the hospital yesterday the doctor prescribed clindamycin 10 mL TID x 21
days. My husband went to pick up the medicine after the kids were in bed.
He brought it home and put it away. Tonight when I was giving my son his
4th dose I was looking at the label and I noticed we'd only been given a
total of 200 mL (I had assumed improperly that we'd gotten more bottles
than we actually had. We were only given 2 x 100 mL bottles!). I called
the pharmacy and said "Hi, I'm calling about prescription number XXX, it's
labelled to give 2 teaspoons 3 times a day for 3 weeks, but you only gave
us 200 mL." I was met with a long silence. "Hello?" I said. "What?" said
the voice on the phone. I repeated my original statement, minus the "hi."
"You think you need more?" said the voice on the phone. "Of course," I
said. "Are you the pharmacist?" I asked. "No, I'm a student. You want the
pharmacist?" said the voice on the phone. "Well, yes, that would in fact
be why I chose to press 4 to speak to a pharmacist," I answered (I was
sort of annoyed at this point!)

So I was placed on hold and eventually a woman picked up the phone and
said hello. I said "Hi. Did you student explain why I called?" and she
said yes. So I asked "when can I pick up the other 430 mL we need to
finish treating my son? No emergency of course, but we need it relatively
soon if we're using 30 mL a day." She went into this whole song and dance
about how she was going to have to contact the pharmacist who was in the
night before and find out what went wrong (like I care at this point? I
just want my son's medicine) and she'd have to call the insurance company
and make sure they would cover the "extra" amount (which is IMO just plain
wrong) and she'd have to call the prescribing physician to make sure she
prescribed 630 mL instead of 200 mL (huh? it's right there on the script!
can she not read? or did someone throw away the original?). Not having the
patience to stay on the phone without blowing my top, I just told her we'd
be coming in for the remainder Friday afternoon at the latest, and to
please have it ready. She said she'd call me if there was a problem and I
said fine. End of discussion.

It kind of made me long for the days when my mom got all my prescriptions
filled for me at the local pharmacy, and the pharmacist who would go in to
his pharmacy in the middle of the night to get medicine for me and drop it
by our house since it was on the way home for him. Those were the days!

-h.
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    hillary israeli vmd  http://www.hillary.net  info@hillary.net
               "uber vaccae in quattuor partes divisum est."
                not-so-newly minted veterinarian-at-large :)

Eppefour - 23 Oct 2003 03:46 GMT
First the quick answer would be Cleocin will not last 21 days when mixed so
the prescription would have to be refilled once to finish the course of
medication. Someone should have explained this to your husband, However your
insurance company will require a 2nd copay for the other half of the RX.
They will treat each half as a separate prescription, requiring a copay on
each half.
Hillary Israeli - 23 Oct 2003 16:37 GMT
*First the quick answer would be Cleocin will not last 21 days when mixed so
*the prescription would have to be refilled once to finish the course of

I realize that; however, they could have dispensed me the bottle of
granules and a measured supply of water and told me to mix it as needed.
Or they could have simply said "come back and get the rest when this is
done." They did neither. Of course, the followup to my original post is
that I've been instructed to come pick up the balance of the medication on
Friday, and it will not be premixed but they will be dispensing measured
water (which I think is hilarious - like I can't measure water? But I
guess most people can't be trusted to do it) so I can mix it.

*medication. Someone should have explained this to your husband, However your
*insurance company will require a 2nd copay for the other half of the RX.
*They will treat each half as a separate prescription, requiring a copay on
*each half.

No, my insurance covers a month's worth of med at a time. I do not have to
pay another copay because the pharmacy made a dispensing error.

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    hillary israeli vmd  http://www.hillary.net  info@hillary.net
               "uber vaccae in quattuor partes divisum est."
                not-so-newly minted veterinarian-at-large :)

James Pinkerton - 23 Oct 2003 18:23 GMT
> *First the quick answer would be Cleocin will not last 21 days when mixed so
> *the prescription would have to be refilled once to finish the course of
[quoted text clipped - 7 lines]
> water (which I think is hilarious - like I can't measure water? But I
> guess most people can't be trusted to do it) so I can mix it.

I believe you could mix the Cleocin and then freeze it. Then thaw it out
when it was needed.  But some people are very uneducated.  If they gave you
the water and power seperately you would be OK.  But Bozo or Bubba  would
probably say, "two bottles of Cleocin"  Give 2 teaspoonfuls of the water
until it was gone and then finish up with 2 teaspoonfuls of the powder.
Eppefour - 23 Oct 2003 19:54 GMT
"No, my insurance covers a month's worth of med at a time. I do not have to
pay another copay because the pharmacy made a dispensing error"
If the pharmacy dispenses 21 days on 1 copay the insurance company has to
right to
reverse the prescription payment on audit because an amount was billed that
the patient cannot use because of expiration.
  Also the water must be distilled.. Most pharmacists that I know would
not dispense unmixed antibiotics simply as a liability issue
Brad - 23 Oct 2003 21:36 GMT
> "No, my insurance covers a month's worth of med at a time. I do not have to
> pay another copay because the pharmacy made a dispensing error"
>  If the pharmacy dispenses 21 days on 1 copay the insurance company has to
> right to
> reverse the prescription payment on audit because an amount was billed that
> the patient cannot use because of expiration.

And extrapolate that payment and deduct an exponential amount from further
reimbursements.
A $60 prescription can cost the pharmacy $600 after adjustment.

>    Also the water must be distilled.. Most pharmacists that I know would
> not dispense unmixed antibiotics simply as a liability issue

I know you would have no problem with it but the general population might.
Heck, I've had patients that didn't know they had to unwrap suppositories
before they insert them.

Brad
Hillary Israeli - 24 Oct 2003 01:37 GMT
* If the pharmacy dispenses 21 days on 1 copay the insurance company has to
*right to
*reverse the prescription payment on audit because an amount was billed that
*the patient cannot use because of expiration.

Well, I didn't bring up the issue of the payment. I just know that when I
spoke to the pharmacist about getting the balance of the prescription, she
told me we should pick it up Friday and it was going to be marked 'paid'
because we already paid our copay and should have recieved the unmixed
bottles at that time.

*   Also the water must be distilled.. Most pharmacists that I know would
*not dispense unmixed antibiotics simply as a liability issue

Well, most pharmacists are covering their a.ses at the expense of their
patients, then, I guess. I don't know. I can't speak for them. I really
wouldn't know their motivation. This particular pharmacist (who works for
a CVS pharmacy) is in fact dispensing the unmixed meds, without any
prompting from me (it was she who said it would be done that way - I would
have been ok with picking it up later on if she'd explained it needed to
be done that way).

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    hillary israeli vmd  http://www.hillary.net  info@hillary.net
               "uber vaccae in quattuor partes divisum est."
                not-so-newly minted veterinarian-at-large :)

rxempress - 23 Oct 2003 06:17 GMT
Ok this is just a hunch.. but here we  go.

Cleocin comes in two size bottles...  50  ml and 100 ml.  Once water is
added to a bottle it is chemically stable for a short time period (either 10
or 14 days... not sure...I am at home).

Cleocin is also not one of the fastest moving drugs on the market... most
stores don't keep more than a couple bottles on the shelf at a time.

The doctor prescribed a 21 day supply.  That is impossible to dispense
because the drug only lasts 14 days.  The pharmacist gave you a 7 day supply
which makes sense.  You'll have to return to the store to pick up the remain
14 day supply.  At that time they will reconstitute the rest of it and
you'll be able to finish the prescribed course,

Why did they dispense a 7 day supply.  If a store doesn't have enough drug
in stock... or it's a case like this where the full amount cannot be
dispensed at one time..  insurance companies require us to dispense a 5 day
supply (7  in this case is close).  This assures that the patient will come
back and pick up the rest of the drug within 10 days of the original fill.
If they come back after 10 days the pharmacy must return the drug to stock
and credit the insurance company.

The other possibility is that they only had 200 mls on the shelf.

The pharmacist who counseled you should have told you that this is only part
of the medication you need... and that you will need to return after 7 days
to get the rest of the medication.  This way the second set of bottles can
will last 14 days and you will have the  correct days supply.

If you called during a busy time the pharmacist may not have had the time to
research the prescription.  Instead of you calling back the pharmacist
should have gotten your name and phone number and during a less busy time
pulled out the original piece of paper and see what the logic was.  They
should have called you back with an explanation.

hope this helps
James Pinkerton - 23 Oct 2003 15:34 GMT
> The pharmacist who counseled you should have told you that this is only part
> of the medication you need... and that you will need to return after 7 days
> to get the rest of the medication.  This way the second set of bottles can
> will last 14 days and you will have the  correct days supply.

Counseling is pretty much of a joke!  Ezpecially for those filling 300 or
more Rxs a shift with a single Pharmacist on duty. I have yet to see a
pharmacy with an isolated private counseling room.  In the State of MS they
generally ask you to initial part of the Rx label and stick it in a book to
please the State Board of Pharrmacy.  They do offer a printed drug
information sheet, so I guess that is counseling.  The federal government
mandated the Pharmacist to counsel but did not mandate the insurance
companies to pay for it!

It remines me of the MS State car inspection law.  You have to have your car
safety inspected once a year.  The fee is five dollars!  So it is just take
the money and place a sticker on the windscreen. A mechanic is not going to
inspect your car unless he gets $100 or $200 for his time.

The pharmacist had no excuse not to counsel you to return to the pharmacy,
pick up the rest of your prescription and make sure you continued the
theraphy for three weeks. I used to charge for the whole amount with one
co-pay and dispense the rest of the rx "free" when the patient returned.
This legally can no longer be done as if the patient does not bother to get
the balance of the Rx then the insurance company calls it fraud! God forbid
they should have to pay a cent more for my trouble and counseling.
Anonymous - 23 Oct 2003 16:02 GMT
Counselling shouldn't be a joke. No pharmacist should work under
those conditions. That's the joke. Find another job where you can
interact with patients...it must be done or our profession will disappear.

I work at an independent that does that kind of volume and we
have a semi private area in the pharmacy that is soundproof and we
use it and a private room which we use for programs or
for more counselling

jp  rph
Hillary Israeli - 24 Oct 2003 01:44 GMT
*> The pharmacist who counseled you should have told you that this is only
*part
*> of the medication you need... and that you will need to return after 7
*days
*> to get the rest of the medication.  This way the second set of bottles can
*> will last 14 days and you will have the  correct days supply.
*
*Counseling is pretty much of a joke!  Ezpecially for those filling 300 or
*more Rxs a shift with a single Pharmacist on duty. I have yet to see a

Here's what bugs me - the pharmacy I usually go to (not the one where this
problem happened; I was getting this particular antibiotic late at night
when my regular pharmacy was closed) recently got this new electronic
checkout thingy. Now, when you pay, you have to sign this electronic
thing. Basically it displays some kind of disclaimer, some kind of HIPAA
thing, and then it gives you the option to select "accept" or "decline"
counselling. Even when I have just stood there and asked the pharmacist to
explain stuff about the medicine to me, or asked detailed questions about
pharmacokinetics or drug interactions, the checkout person ALWAYS clicks
"decline" counseling before giving me the pen to sign my name. It really
really bugs me, but when I have stated that I would rather not sign under
those circumstances, they give me a whole song and dance about how the
machine won't let you go backwards in the process and yada yada yada. So,
I don't know. If someone is doing any kind of statistical analysis trying
to figure out how the pharmacist's time is used, and comparing pharmacist
man-hours to the number of people counselled, or whatever, it is going to
be way off, because the lay staff ALWAYS automatically clicks "decline" on
the thing. Just a personal pet peeve of mine.

Signature

    hillary israeli vmd  http://www.hillary.net  info@hillary.net
               "uber vaccae in quattuor partes divisum est."
                not-so-newly minted veterinarian-at-large :)

Bob - 25 Oct 2003 03:57 GMT
e
> theraphy for three weeks. I used to charge for the whole amount with one
> co-pay and dispense the rest of the rx "free" when the patient returned.
> This legally can no longer be done as if the patient does not bother to get
> the balance of the Rx then the insurance company calls it fraud! God forbid
> they should have to pay a cent more for my trouble and counseling.

==================
I NEVER gave away my services...not once in 30 years behind the
counter...IF I have to fill the Rx 3 times because the drug is only good
for 10 days and they need a 30 day supply then I charge 3 Copays...

It has nothing to do with Insurance companies... I just feel that if I
provide a service (filling an Rx)   I am not about to do it for free...

I do however take the time (personally..no matter how busy I am) to
explain to the patient WHY I can only dispense a 10 or a 14 day
supply... and That they WILL have to have the Rx refilled and they WILL
have to pay another copay...

In those 30 years I have had maybe 2 customers really complain about
that and they shut up pretty fast when I asked what will they give me
FOR FREE...

Bob Griffiths
Wally - 25 Oct 2003 04:21 GMT
>IF I have to fill the Rx 3 times because the drug is only good
>for 10 days and they need a 30 day supply then I charge 3 Copays...

I just go a step further and state thate insurance allows one bottle per
dispensing (unless cash, then I will give the patient/parent/guardian what they
want to pay for). If there are amy objections, I happily let them use the
pharmacy phone to call their 3rd party. And since I now work overnights, most
of the time the complainants don't get a reply.

>It has nothing to do with Insurance companies... I just feel that if I
>provide a service (filling an Rx)   I am not about to do it for free...

I also agree with Bob, we already give away too much of our services. I go as
far as I am willing to please the customer; enough to keep that customer from
going across the street to Walgreens.

>In those 30 years I have had maybe 2 customers really complain about
>that and they shut up pretty fast when I asked what will they give me
>FOR FREE...

Good onya, Bob.

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Eppefour - 25 Oct 2003 13:20 GMT
>IF I have to fill the Rx 3 times because the drug is only good
>for 10 days and they need a 30 day supply then I charge 3 Copays...

I just go a step further and state thate insurance allows one bottle per
dispensing (unless cash, then I will give the patient/parent/guardian what
they
want to pay for). If there are amy objections, I happily let them use the
pharmacy phone to call their 3rd party. And since I now work overnights,
most
of the time the complainants don't get a reply.

If you dispense only 1 bottle per copay, you are violating the terms of
insurance agreements. If a patient should get 400cc for a 10 day supply
i.e.: 2 teaspoonfuls qid on cephalexin 250mg you must mix 2 bottles for 1
copay. Insurance audit will charge back the whole rx for short filling. On
federal programs like Medicaid it  can be considered fraud. If the rx lasts
longer than the expiration date of the mixed liquid then the cut should be
documented on the RX so the auditor understands.

One reason I sold my store was that I was tired of dealing with auditors. I
still try to comply with all standards even though  I work for a chain and
am no longer fiscally responsible to the third parties
Nobody Special - 26 Oct 2003 01:44 GMT
> > The pharmacist who counseled you should have told you that this is only
> part
[quoted text clipped - 11 lines]
> mandated the Pharmacist to counsel but did not mandate the insurance
> companies to pay for it!

That federal mandate doesn't apply to all prescriptions, you realize.
James Pinkerton - 26 Oct 2003 14:08 GMT
> That federal mandate doesn't apply to all prescriptions, you realize.

I believe the Pharmacy Board in MS decided that if the RPh. has to do it for
all Medicaid Rxs then we might as well require it for all prescriptions. It
might not be required but can you give Medicaid patients a higher standard
of care than you can cash patients, or patients with health insurance?
 
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