Oxycodone Prescription Shorted, Pharmacist Blamed


As a pharmacist, how do you handle phone calls from patients stating they have been shorted on their controlled substance prescription?

Christmas Eve, 30 minutes prior to closing, a phone call comes from a patient stating that he has been shorted on his oxycodone prescription. The prescription had been filled 14 days prior; however, the patient had done the math and realized, based on his stated number of daily doses, he was going to be short on his 30-day supply.

Initially, the patient is quite inflammatory and is positive that we had shorted him. This is a critical point for the pharmacist. As a pharmacist, do we now become inflammatory toward the patient? Do we tell the patient he is wrong by explaining that we have such stringent inventory control and verification on every CII prescription filled that it would be nearly impossible for him to have received the wrong quantity?

Alternatively, we can first acknowledge to the patient that we understand he is under the impression that he has been shorted on his prescription. In this particular situation, I was able to remind the patient that he had asked me to double count the prescription when he picked it up. The technician specifically recalls handing the medication bottle back to me, and then I counted and verified the contents immediately prior to the patient walking out the door with the prescription bottle in hand.

As a pharmacist, I will have the patient explain to me where he stores his medication, how he manages his doses throughout the day, and who else may have access to his prescription bottle. I ask him to recall whether anyone came into his home in the past 2 weeks. In this particular situation, the patient was not budging. He understood that we had double counted the prescription when he came in and that the quantity was correct; however, it was still a mystery to him as to where the extra 50% of the tablets had gone.

The patient still had enough medication for a few days, so I offered to call his physician and explain that there was a full 30-day supply of oxycodone when the prescription was picked up and signed for and that somehow, between the pharmacy and today, nearly half of the tablets have gone missing.

As a pharmacist, I am fortunate to work in a community pharmacy with other professionals who support our due diligence. We all work together and apply rigorous standards with regard to our CII prescription processing.

  • All CII prescriptions filled in our store are verified by either 2 pharmacists or 1 pharmacist and 1 tech.
  • CII prescription medications are maintained on a perpetual inventory with a count-back process on each and every prescription filled.
  • If the count-back is not exactly accurate, the prescription does not leave the store until the inventory is rectified.

This is not a new scenario. After 28 years of pharmacy practice, I have seen this process play itself out many times. Unfortunately, when friends and family know of the existence of controlled substances in the house, the opportunity for loss is increased. If you or a loved one needs to take controlled substances on a long-term basis, please store them in a secure location under lock and key.

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