More irritations from the night from hell on call.
I called in an order for a patient to the local Walgreen’s pharmacy. We contract with them for after hours pharmacy supply.
The order I received was:
Ativan 0.5mg – 1mg every 4-6 hours as needed
Easy enough, yes?
The Pharmacist says “Which is it? 0.5mg or 1mg?”
I say, “Either – - the doc wants the patient to have the option of both, if needed”
Pharmacist: “Well you can only do one or the other — the med comes in 1mg tabs. So I can either fill it with 1mg tabs – - or break them in half and fill it with 0.5mg tabs?”
Me: “Well, the patient either breaks the 1mg tab in half…or take two of the 0.5mg tablets — either way – - the order reads 0.5mg – 1mg. Fill it however you want to – - but the 1/2 tabs would probably be easier for him to manage”
Pharmacist: “What kind of order is this? Are you a nurse?”
Me: (at 1:45 a.m. in the morning) “Well, yes – are you a Pharmacist?”
Pharmacist: “I’ll call the doctor and clarify the order to read “0.5mg – one to two tabs”
Me: “Actually – you don’t have to call him to clarify – - that’s the order he gave me.”
Pharmacist: “You said he gave you 0.5mg – 1mg”
Me: “Yes, and if you fill 0.5mg tabs – - then common sense would dictate that you’d advise the patient to take one or two, right?”
Round and round we went until I finally just told him to go ahead and call the doc for a clarification order. Hell, what do I care if the Pharmacist calls and makes an ass out of himself asking whether he should fill it with whole tabs or half tabs. Either way, it doesn’t matter which one – - as long as the patient gets the right med at the right dose.
I really should sleep, hey? I’m pretty wired.
Your line of “Well, yes – are you a Pharmacist?” cracked me up. My friend just finished school last summer and became an RN – she was telling me about a simular story not long ago and how some other nurse could not seem to get that concept about the 1/2 and the whole for meds.
Oh. My. Gosh.
I usually am more apprehensive of the Medical Dummies (MDs) than the pharmacists. It’s the pharmacists that usually know more about what’s being prescribed.
Scary!
The doctor who wrote the script didn’t pay attention in medical school. Lesson #1 in prescription writing for dummies is: Medication, strength and formulation. Only THEN do you specify how many tablets you can take. So sadly, the pharmacist was correct in his hassling you, and the doctor who gave you the script wasted your time and should have called it in himself.
Thanks, Doc S. – although, I still contend that it’s not much of a leap to make the decision to fill it with half tabs and advise the patient to take one-two tabs. To me, 0.5mg is the same as a 1mg tab broken in half. But then, I don’t write scripts and realize you guys have reasons for rules. Thanks for the input
No—Actually the pharmacist was an ass. It doesn’t matter what some precribers are taught in their respective schools—a large amount of prescribing presumably based on what prescribers were taught is bunk anyway. As well, the format that many prescribers use is directly responsible for a significant number of prescribing errors. It really should not be up to a referring provider (prescriber) what strength of medicine is used to treat the patient; lots and lots of errors are made in this function (strengths that either do not exist or are poor choices for other reasons), managed care and the pharmacist’s judgment trump whatever the presciber thought up, cost can be a huge factor, etc. You were absolutely correct in requesting the therapy as 0.5mg to 1mg per dose—any PharmD that obssesses about this kind of minutae instead of evaluating diagnosis, appropriateness of care based on dosing, other medicines, gender, age, other disease states, economics, etc. and cannot figure out what to do should think about possibly sitting for the CPhT exam as an alternate career choice.
I am a pharmacist and would agree that the pharmacist had the right and the DUTY to question the source of the rx order called in during the wee hours of the morning. You did not say whether you specified the quantity, if you offered the source of the rx (this is nurse XYZ), or even if you gave all the critical identifiers of the physician such as state license number, address, DEA number, etc. Please be aware that it is the legal responsibility of the pharmacist to verify that it is an authentic order, lest he/she be questioned by both state and federal authorities. The pharmacist should have been able to clarify the directions of the order if you indeed indicated the proper number of dosage units that the patient should have received. Doctors, nurses, pharmacists—be respective of fellow professionals and follow proper procedure and medication errors and illegal drug diversion will be prevented.
WHAT WAS THIS PATIENTS HX? THIS IS IMPORTANT TO CONSIDER ALSO.IF YOU GIVE AN ELDERLY PATIENT A DIFFERENT STRENGTH,SHE POSSIBLY WOULD BE UNAWARE OR UNABLE TO BREAK THE TABS IN HALF.THEY ARE VERY SMALL.THIS RPH COULD HAVE HELPED WITH THE DECSION TO SAY,”WELL IT WOULD BE EASIER TO TAKE THE 0.5MG TABS AND TAKE 1 OR 2 TABS.OVERALL I THINK THIS RPH WAS A JERK AND JUST ANOTHER “OH I’M SCARED I MIGHT GET SUED” AND THIS MAY BE LEGIT FROM HIS PERSPECTIVE.MY MESSAGE TO NURSES AND DOCS. PLEASE BE PRECISE WHEN ORDERING YOUR SCRIPTS. IE; ATIVAN 0.5MG #100 TAKE 1 OR 2 TABS Q6H PRN END OF STORY
From my work with oncellrx.com and ontimerx.com I know that errors in taking medications (taking the right amount, at the right times, not skipping, or doing the right thing after accidentally skipping a dosage) is critically important. It seems the patient is the one responsible for getting it right or getting hurt. Nice to see a caregiver taking care of the patient!
frankly speaking most nurses who call in rx’s to my pharmacy, can barely even pronounce the medication name. Most of the time we play a guessing game. So I suggest as long as a pharmacist has to put their lisence number on an order ask as many questions as possible. These nurses act like asses with us, because the MDs don’t give them any respect to begin with.
Sado Pharm.D
To clarify – this patient was a terminal hospice patient suffering from periods of restlessness and anxiety due to his terminal cancer diagnosis – I was taking care of in his own home. Yes, I did indicate the quantity in the phone call.
Again, I still say that filling the script with 1/2 tabs and instructing the patient (or his caregivers) to dose him with one or two tabs, as needed is easier for this patients situation.
And again, if a pharmacist really wants to call the MD at 2 in the morning to clarify the ’0.5mg – 1mg as needed’ order – and how it should be filled (full tabs or half tabs).. is wasting the MDs (and the patients) time. But, hey – I did my part of the job… my terminally ill patient now, unfortunately, had to wait until the pharmacist got over his case of semantics.
In my experience as a pharmacist, any health care professional can be a “MD (medical dummy)” at any time. Beware!!! I can sympathize with the 2 a.m. call though…most definitely makes a night from hell. Hopefully all of us have the knowledge and common sense to take care of our patients. In the meantime, we have to learn how to survive and get along with one another in the sometimes hostile & less-than-ideal world of medicine.
Anyone who calls in a cs at 2am should not be surprised that their identity is questioned. Thanks to NYS for having the sense not to allow that – benzos/cs’s can’t be called/faxed. FYI – I would be willing to put money on the fact that the rph wasn’t calling to clarify 0.5 or 1mg tabs, but he wanted to make sure that it was a legit rx…especially after you told him/her that it really wasn’t necessary to call. Next time, make it easier on everyone and call in Ativan 0.5mg 1-2tabs Q4-6 PRN. End of story.
I’m Irish and provide a 24 hour service in an English hospital!!!
Has anyone queried the PO dose! That’s more an IV dose to be honest! Doh!!!
It doesn’t matter how many letters you have after your name! Common sense indeed dictates that you give out 0.5mg lorazepam tablets and write ‘one or two’ on the label. Shame on all you pedantic people out there!
And I still contend that unless you have worked at the bedside of a home patient who is terminally ill, in their last few hours of life – - it doesn’t matter what the script is written for, at that point. The priority is the patient comfort… by the time the damn script gets sorted out at 2am with a pendantic pharmacist… the patient will have died… uncomfortably.
I understand the semantics when it comes to just a regular script, for regular patients. Dying, terminially ill patients are a different story – in my opinion, the pharmacist in this situation should recognize the dynamics at play. That’s just my personal.
Too many folks get their panties (undershorts) in a wad , and it’s especially bad if it occurs on night shift. There’s enough freakin’ at the wee hours, wherever. Yea, it sounds like a RN was looking out for best interest of patient, physician, etc., but the pharmacist was covering his/her heinie as well. As was explained later, the quantity was mentioned. Good. Why a hundred in a hospice patient? And, why not lorazepam liquid? And, c’mon, it was controlled after all, it should have made a difference if the physician specified # 100 of the 0.5 or 1 mg tablets. In my dispensing area, we have blue scripts that are not not photocopyable and have little checkboxes for specific quantities. Round and round was ridiculous, though. If I find myself going round and round more than once, I try to rephrase or use other words to get my concern across, and it might make perfect sense to the other person; they might see my point. (A little habit I picked up from my foreign-speaking husband, and later curious children.) If it’s any solace, I’m sure that the pharmacist was thinking it was the night from the netherworld, as well.
Honestly, I think the situation had everything to do with the quantity. Is the pharmacist being instructed to dispense twenty of the 0.5mg tablets or twenty of the 1mg tablets?
However, at 2am, there’s no need to call the physician. Nothing else in the order (as described above) was questionable.
Instead, the pharmacist should have dispensed the equivalent number of 0.5mg tablets indicated, and in this case, in the form of split 1mg tablets. (So, if the quantity was in fact twenty tablets, the pharmacist should have split and dispensed ten 1mg tablets.)
The End.
Actually, not really.
Lisa, I found what you stated above a tad alarming (and you wrote it more than once):
“I still contend that it’s not much of a leap to make the decision to fill it with half tabs and advise the patient to take one-two tabs.” January 2004
“Again, I still say that filling the script with 1/2 tabs and instructing the patient (or his caregivers) to dose him with one or two tabs, as needed is easier for this patients situation.” October 2006
If the order is filled with split 1mg tablets and the order calls for a 0.5mg to 1mg dose, then saying take one to two tabs (1mg to 2mg) is not the same as saying take 1/2 to one tablet (0.5mg to 1mg), the correct dose.
Anyway, if anyone’s interested in listening to a super fine hour of booty-shaking Latin music, go online to http://www.ritmolatino.org or subscribe to the podcast (Ritmo Latino) in iTunes.
Now that’s what I call Web 2.0 spam.
Neil – at least it is considerate spam
Address the post first… spam second. perfect.
Considering that I wrote this post more than three years ago after a very long, exhausting shift with home hospice – I can see and understand the different points of view here. Contrary to popular belief, I respet the hell outta pharamacists (usually.) :-\”
I am a Pharm D and in both states I have practiced in, the order has to be clear on which strength tab to give on controls.Glad to see in the end everyone seems to be on the same page.
On another note…Wow, we must be starved out there for more pharmacist blog lines. 8-|
anybody know the size of a 1mg ativan? try cutting it in half.
I got a kick out of your blog! My father is a pharmacist and deals with the same issues time and time again. On a different topic, I am a meeting planner for a CME company in Boston, MA. I am researching what it is that will get pharmacists excited about coming to our meetings. As a pharmacists you need so many CME’s per year. Do you get them online or do you prefer to go to live meetings? If you were to go to a live meeting, what would entice you to go? Is it the food? Content? Certain people in the industry? Etc. Any insite would be appreciated. Thank you!
Honestly a lot of what that was dealt with the fact that it was a controlled prescription. I have no idea what state you work in, but in one of the ones I have worked in you can get your ass handed to you for a simple dispense mistake like that on a controlled prescription. I understood it, but it wasn’t worded the best.
Then again the pharmacist could have just been a dumbass (which is equally possible), but I think the latter is just as likely.
A pharmacist needs to follow explicit directions with no hint of ambiguity when filling a prescription. If there is something to be concerned about, the prescriber must be contacted, discussion ensued and documentation noted. Judgement calls lead to three types of action: refusal to fill, calling the prescriber to change the script or filling the script following the exact directions. The doctor should have decided on a strength since he knows the patient history well or have discussed the choices with the patient and potentially a pharmacist before writing the prescription (triad relationship).
My mother is a nurse and I know she doesn’t know the legalities behind pharmacy practice. From another perspective, it may seem like the pharmacist is acting irrational, but there are lots of laws (some silly) that can’t be overrided.
My sister was a nurse,and every night she would come home crying.My hats off to all you care givers.