Jason Poquette, RPh, is a 1993 graduate of the University of Connecticut School of Pharmacy. For most of his career, he has held retail pharmacy management positions. He also spent 7 years working in health plan formulary analysis and research. He currently works for Pharmacy Healthcare Solutions (PHS) as manager of an outpatient hospital pharmacy, developing programs to improve utilization of the pharmacy and transitional care for patients.

Jason Poquette

, nothing is more critical to patient safety, and the success of medication therapy than an accurately verified prescription. However, in my opinion, too little time is spent teaching the next generation of pharmacists this vital skill. As such, I am sharing my personal approach to the verification step in prescription fulfillment.

There are 6 steps I go through for each patient. We discussed steps 1-3 in the previous article. Now I would like to discuss steps 4-6.

 It is now time to hold the prescription in your hand, and compare it to what was written by the prescriber, and what we can know about the patient through the computer profile. You will sometimes be reading an electronic prescription, sometimes a handwritten prescription, sometimes a printed or faxed prescription, and sometimes a phoned-in prescription. The information will not always be easily found. Your eyes will have to jump around and scan the document. But 1 by 1, every piece of information on the written prescription must be accurately replicated on the filled prescription. This includes the correct patient, drug, directions, prescribing physician, refills and much more.

This is also the point at which you can determine if the prescription is reasonable, given what you now know about the patient’s gender, allergies, comorbidities, and age. You are asking yourself: “Is this the right medication, and right dose for THIS specific patient, based upon what I know.” As pharmacists verifying a prescription, we often do not know the ICD-10 code for the condition, but we can make reasonable assumptions based on their profile and draw conclusions.

 Having confirmed that the prescription was accurately interpreted by the inputting technician, it is now time to consider any relevant drug or therapy interactions or duplications. Your software will probably help you a little with this, but don’t depend on it!

You must think about the clinically significant interactions or duplications that might be going on. Some may be significant enough to merit a phone call. Others might just require a consultation with the patient. At times, you may have to review previously filled prescriptions and notes written by a pharmacist on a previous fill. Was an unusually high dose dispensed before? Was a call already made, and documented? Look over the profile.   

You must also take into consideration any warnings or information transmitted back to the pharmacy by the insurance plan. How, exactly, do you handle the many dozens of potential interactions and duplication warnings that you get when verifying a prescription? This is maybe the hardest thing to teach because every pharmacist is a bit different. The bottom line is this: you are making a professional judgment, and you will have to be accountable for it. If you believe it merits a call to the prescriber, then call. Is it something to talk to the patient about? Then do so. And document all your actions.

Your decision to fill the prescription will also be based on what you can know about the patient from their profile. Review previously filled medications, and determine if the current prescription makes sense based on their history.

 Finally, we have to check to make sure that the actual drug in the vial is the one prescribed. The label may be perfect, and the directions superb, but it could be the wrong tablets or capsules inside. Most computer systems today allow the pharmacist to see an actual image of the medication to compare to what is in the bottle. In fast-paced pharmacies where stock bottles may not get returned to the shelf immediately, the potential for this error is significant. I recently read a report of a patient who was supposed to get Gabapentin 600mg, but the pharmacy accidentally put Gemfibrozil 600mg in the bottle.

Also, I also take a quick peek at the billing. Is the copay reasonable? Was an insurance billed at all? If anything looks abnormal, it may prompt the need for a call to the patient to prepare them for steps they may need to take.

To err is human. But when it comes to dispensing prescriptions we must do all we can to minimize and eliminate mistakes that could harm our patients. 

Articles

This is Part II in a 2-part series on Verifying Prescriptions.

How To Verify A Prescription, Part II

There is no step in the prescription filling process more critical than the final verification performed by a pharmacist. And yet, as important as it is, I am often surprised how little exposure to this step students have before they graduate. To be fair, pharmacy schools simply cannot duplicate the setting in which most retail pharmacists must conduct this important function. The 'lab' is, at best, an anemic attempt to reflect the real pressures and distractions that go on in the real world. 

I remember having two APPE students standing side by side with me as we talked through my thought process when verifying a prescription. We did this for about 30 minutes. When finished, they both remarked that they had never had an experience like that before, and thanked me profusely. This was 3 months prior to graduation.

I am writing this article not because I believe I have developed the world's best approach to flawless prescription verification. I am also not writing to impose my personal approach on seasoned pharmacists who have their own system and method for making sure the prescription is correct. 

Rather, I write this in the spirit of sharing a few hints and suggestions to new pharmacists, and students, from a pharmacist who has been doing this for 25 years. The following are the things I do each time I verify a prescription. This isn’t intended to be exhaustive or comprehensive, but sufficient for most new pharmacists to have a good idea how to conduct this critical function. I also appreciate that software varies, and the steps you engage in will sometimes be dictated by your filling software as well.

The first thing I do is make sure the items I am about to verify are organized in a way that I can easily identify the scope of my job. Is it just 1 prescription? Is it 10? I do a quick check while organizing them to make sure they all belong to the same patient. Once organized, I then proceed to work my way through the order 1 prescription bottle/inhaler/vial/cream, at a time. 

2. Check if this is a new prescription or the first refill. 

The very first thing I look at when picking up the first vial (I'm going to say 'vial' even though I know it may be a different type of item) is to see if this is the first fill or a refill. I do this because it prepares my mind for the 'type' of mistake I am likely to catch. The first fill (or even the first refill) will often reveal a different type of error than you expect to see on the 10th refill of a medication. I'm not suggesting you are more careful with the first fill, but only that the type of mistake is usually different,m and you must prepare your eyes to catch it. Basically, for the first fill or first refill I tell myself that "all bets are off" and literally anything could be wrong. Check it all. Carefully. 

3. Ask if the prescription is reasonable.

The next thing I do is very important. Actually, it is what I do not do that is the key. I do not begin comparing the label on the vial to the written prescription image yet. Rather, I simply look at the label, the patient name, the drug and dosage, and I ask myself this simple question: Is it reasonable? Regardless of what the actual prescription says, is what is written on this label reasonable for the patient? It is my experience that more than half of all mistakes that leave a pharmacy could have been caught by simply looking at the label, and thinking about it clinically. For example, levofloxacin 500mg 4 times daily does not make sense...no matter what I am going to find on the prescription itself. You must stop and think. Pause and ponder. 

At this stage, I am also allowing my mind to recall the 'possible' mistakes that are most frequent with the given drug I am verifying based on my experience. For example, is it for Metformin? Then I am thinking something like 'was it written for regular metformin or metformin ER?' Is it for bupropion? Then I'm thinking about the different dosage forms of bupropion that are frequently confused. Is it for amoxicillin, a sulfonamide or codeine? These are all common allergies, so I am thinking about that possibility. Is it for hydroxyzine? Then did they pick the correct form (pamoate vs. hydrochloride)? Is the drug a common 'look alike/sound alike' drug? Like Haldol vs. nadolol. These thoughts are what I am considering before I ever even take a look at the prescription,

Finally, as part of this initial review of the label itself, I am thinking in my mind 'Is this normal?' For example, omeprazole 40mg twice daily is technically 'reasonable' (under certain circumstances and for some diagnoses), but it is definitely not the norm. Ibuprofen 800mg once daily may be reasonable, but it is not the 'normal' way it is dosed. When I see something is not 'normal,' I am preparing my mind to check this closely on the original prescription. 

These, then, are the first 3 steps I take in the prescription verification process. Please check back for Part II of this article where I share the final 3 steps in my own process for verifying prescriptions!

Prescription Verification is a critical step in the filling process. We should talk about it more with our students and colleagues.

How To Verify A Prescription, Part I

It came as shock when I learned that the Editorial Director for

, Kirk McKay, had recently passed away after a 3-year battle with colon cancer. I read this while browsing my copy of the print issue,

where chairman and CEO Mike Hennessy, Sr. described Kirk as a man whose “passion and dedication to his work, and his team did not falter once during his long and courageous journey coping with a vicious disease.”

I, as with many other pharmacy writers, knew Kirk from our interactions with him during the content creation and submission process. I had emailed him back and forth many times. Yet I never knew, until now, that for much of that time which we were pleasantly interacting about articles, he was secretly battling a notoriously difficult form of cancer. Kirk was pleasant, encouraging, and responsive to my many questions. My heart goes out to his family, friends, and co-workers who obviously knew him much better than I ever would. Still, this stranger on the other end of the email exchanges will miss him.

His passing has gotten me thinking about 'editing' in general, and the difficult job of an editor, transforming content into print-ready material. Kirk’s LinkedIn account described him as having “23 years of editorial experience, including managing, editing, and writing print and online content for medical and veterinary professionals, and for consumers.” Kirk was a veteran in the field of editing, a craft and talent that often, in my opinion, goes unnoticed.

I have been personally grateful for the hard work, and patient prodding of editors I have encountered along my rocky road as a pharmacy writer. The work of a good editor is often invisible. You only notice their existence when something goes wrong. You see their handiwork not so much by their appearance as by their hidden strategy to produce well-written and interesting articles for the readers of their journal, blog or magazine. When you visit a website like 

 and browse through hundreds of pages of relevant content, know that behind the scenes is the tireless labors of an effective editor.

If the pen is mightier than the sword, forgive the cliché, then editors are like literary lieutenants leading an army of would-be writers into battle. Speaking of words, someone has said: “handle them carefully, for words have more power than atom bombs.” Words are powerful, and editors must wallow in words every day.

Today’s readers arguably have shorter attention spans than any previous generation. The effective editor must bear this in mind as they oversee the assembly of every syllable of material arranged for their audience. They must turn a clever phrase, and arrest the mind of easily distracted readers, all while watching for mindless misspellings and poor punctuation.

Editors also have to deal with egos. That is, they have to chop out sentences, and paragraphs that writers produce, and deal with the fallout of having messed with their creations. I’m sure many-an-editor has had to endure the furor and frustration of an author who couldn’t believe his writing was so bad that it needed that much correction. It did. And you can thank an editor for doing it. They saved you.

And so, once again, my heart goes out to the loved ones of our friend Kirk McKay. And my heart goes out to all the many editors, editorial directors, and proofreaders out there that make reading a pleasant experience rather than a chore. Your unsung work deserves a chorus of praise. And I, for one, thank you.

The passing of Pharmacy Times editor, Kirk McKay, has reminded me of how important the work of an editor is. He will be missed.

A Word of Thanks to All Editors

“What do you MEAN it’s not covered?!” he shouted at the pharmacy technician, who was trying to explain the situation. “The doctor ordered this medicine, I need it, and YOU need to give it to me!”

You’ve met this patient. He or she has been at your pharmacy counter many times in your career. You can almost see their blood pressure rising as they stare in disbelief at the enemy holding their medicine in a bag. While the pharmacist or technician tries to explain the situation in a logical and efficient manner, the patient just grows more angry.

There are so many things that can go wrong, and create problems in the prescription filling process that it is no surprise patients get angry. The prescription may have been out of refills. The medication may not be in stock. Sometimes prescriptions require additional prior authorizations, which cause a delay or change in the treatment plan. Sometimes the anger is due to the sheer volume of work and limited staffing in a pharmacy, which results in longer wait times for patients.

Another contributing factor seems to be that people today are just getting angrier and angrier in general. Maybe this depends somewhat on the area of the country you live. I have been practicing community pharmacy for 25 years, and it is my personal perception that people are becoming less patient and less tolerant of any inconvenience. And they appear, overall, less ashamed to make a scene about it. When I was younger it was pretty rare to see a grown-up throwing a tantrum in a store (that was something kids did…and typically were disciplined for). But today, it seems like adults are less capable of managing the unexpected, and the result is often anger, venting, and even violence.

In fact, these days most large companies have training modules to help employees learn to manage situations where violence might erupt. Pharmacies are hotspots for frustration, and therefore staff needs to know how to respond to situations where a patient is getting out of control. Given that our pharmacies are so busy, it is not only important to manage such individuals effectively, but also efficiently, so that the work does not back up any more, and result in more angry patients.

Here are the things that I have learned from dealing with angry patients over the years:

 Give the patient a reasonable amount of time to express their concern. This can be hard because they are typically angry about something that we commonly experience every day. We know the drill. We have heard it all before. So the temptation is to jump in, cut them off, and get to a solution. But all things being equal, it is usually best to let them say their piece.

This is a technique I picked up in a book many years ago, and it works very well. After the angry patient is done talking (or pauses long enough for you to speak), express their frustration back to them using the same words they used. The 'same words' is the critical part. If you change their words, they will often psychologically infer you are trying to change their perspective or re-interpret their experience in your own way. Don’t do this. Use their words back to them. This helps them understand that you listened, and can relate to their experience.

 Don’t cross your arms, which is a signal of defensiveness. Beware facial expressions of disgust or disbelief. It may be appropriate to smile, but you must be careful that your smile does not communicate a patronizing attitude. You want to appear concerned, because you are concerned.

 This is where experience is important. In almost every frustrating situation, there are options available to the patient. For example, if you are out of a particular medication, you can offer to either order the medication or transfer the prescription to a pharmacy that has it. Give the angry patient some choices. This helps them to own the solution and typically calms them down.

 It has been my experience that using these steps will often turn an angry patient back into a calm customer. They often are prepared to apologize for their behavior and recognize they were out of line. Cut them some slack, and tell them it is okay. Smile and shake their hand. This helps them recover some respect, and displays your professional maturity as well.

Of course, we all know that even the best attempts to calm down an angry patient don’t always work. In these cases, my experience suggests it is best to offer to escalate their concern. I ask my technicians and staff to not wait too long before offering to bring in the manager. Just escalating the concern to a higher level of management often is enough to calm down an otherwise irate individual.

I’m not suggesting these steps will always work. But I do know it is part of our nature to get defensive when an angry patient starts to yell, particularly if we aren’t at fault at all. But taking the high road, staying humble, putting yourself in their shoes, and trying to follow this advice will often lead to a happier ending for everyone. 

Angry patients seem to be more common at the pharmacy counter. Here are 5 tips to calm them down.