FORGERIES, ALTERED RXS, ETC

I took my first look at the prescription and the red alert siren from Star Trek started blaring inside my head. Not the handwriting for that doc, not instructions that were anywhere near normal for that opioid, and the patient—sweating profusely despite the cool air– was standing there watching me intently.

“I need to clarify the prescription with the doctor,” I told him.

“Wh-what’s wrong?”
“Just a problem a quick call will resolve,” I reassured him.

(Never, never tell someone what is wrong with a forged prescription. This just educates the person on how to do better next time.)

As soon as I had the doctor’s office on the line, he turned and ran out of the store.

What do you do when faced with a forged prescription, or a prescription that has been altered, or a prescription that is unlawfully possessed?

(A forged prescription is one that has been called in/created/written on a stolen pad by a non-prescriber. For example, this recent spate of phoned-in prometh with codeine prescriptions. An altered prescription is a legitimate prescription that has been changed in some manner to obtain the presenter with more pills, stronger pills, more refills than were intended by the legitimate prescriber. For example, I once had an Rx for Fiorinal w/ Codeine #12—the patient turned the 1 to a 4 and marked the Rx for 3 refills—the prescriber had made no notation at all on the refill line. An unlawfully possessed prescription is usually a legitimate prescription being presented by someone who should not have had possession. An unlawfully possessed Rx may be a legit Rx for pain that was stolen from the patient.)

Initially, how sure are you that the Rx is forged or altered? Most states have created regulations that provide protection against liability for a wrongful accusation if the pharmacist is reasonably sure that the Rx is not wholly legitimate. “Reasonably sure” is defined as “more likely than not.” So, if you are 50.1% sure that the Rx is forged, you may act without fear of liability.

For some pharmacists, the quick way out is to state that ”we are out of this” and hand the Rx back. This is an acceptable response sometimes, but not always. What this does is simply hand the problem over to a colleague at the next pharmacy down the street. See next paragraph; but if there is no reasonable danger to the pharmacy staff, do not pass along this problem.

The first thing to do, once a reasonable suspicion is aroused, is assess the safety of the pharmacist and other pharmacy personnel before making a decision to seize and retain the prescription. Is the person presenting the prescription also presenting some sort of attitude, demeanor, or even blatantly threatening the staff? Whether or not to act depends on the probability/possibility that confronting the presenter would create peril. If only an iota of such seems likely, then do what is necessary for the safety of the personnel.

One question that arises occasionally: what if refusing to fill the forged Rx creates a danger to pharmacy staff? The answer is, if this danger is reasonable, fill the Rx. Safety first. Follow up by documenting on the Rx why you filled a forgery and then call the police. Boards of pharmacy are unlikely to punish you for doing this. Of course, this should be a one-time occurrence. However, if you have a stack of forgeries you filled because you thought there was a danger in not filling, expect to have a long talk with the Board about staffing and security, as well as punishment.

Reasonable suspicion? Yes. Safe? Yes. Now is the time to decide to seize and retain the prescription or just hand it back to the “patient.” Most states still make this the pharmacist’s decision. So up to this point everything is permissible.
But once the decision to seize is made, everything goes from being “permissible” to “shall” or “must.” Different states look at this is varying ways, but they are very similar.

Now that the seizure of the Rx has been accomplished, the pharmacist needs to determine lack of or legitimacy (not where the forgery or alteration is obvious and blatant—however, again, any iota of doubt needs to be confirmed). Legitimacy should be determined in a reasonable amount of time. If during office hours, this should usually be within a couple of hours. After hours, a few hours to find and confirm with the prescriber. If after hours and the prescriber is unavailable, the next day is not unreasonable. A question that arises: if the prescriber cannot be contacted within a reasonable time, can the patient demand the Rx be given back? If there is some doubt as to legitimacy—the forgery is not obvious and blatant, the answer is “Yes, the patient has the right to get his/her Rx returned.”

(Another question that arises regularly: if you return the Rx to the patient, can you write something on the face of the Rx blank? This is tricky. Facts are OK, opinions are not. For example, you refuse to fill a pain Rx because it is 10 days early. It is fine to write the date and “10 days early” on the Rx. But with suspected forgeries, be more careful. If a note from you arouses a suspicion of forgery from another pharmacist where it would not have arisen otherwise, your protection from liability may be lost.)

Once it is determined that the Rx is forged, altered, or unlawfully possessed, most states now require the authorities be alerted. This was voluntary for years, until the late 1990s-early 2000s when many chains told their pharmacists to just turn away forged or altered Rxs. The reason behind this was that the chains were seeing too many pharmacist-hours spent in court or with the police, an economic and staffing problem. Another issue along the same lines was that some prescribers did not want to deal with the hassle of forged or altered Rxs, so they asked pharmacists not to take action. (Many of the docs did dismiss the patient.) Boards reacted to this, and now it is codified in most states that the police must be called. You must act.

When the police are called, they will confiscate the forgery. Check your employer policies to determine if you should make a copy for store/company records.

As the drug abuse epidemic worsens, pharmacists are faced with a plethora of problems and challenges from unscrupulous people seeking to obtain drugs through illegitimate means. One of our roles—after our safety has been established—as gatekeepers to medications is to act appropriately when faced with these issues.

Sexual Harassment

I listened as the young woman described the suggestive comments and the inappropriate touching. While I kept a straight face, inside my head I was aghast: “This still happens in the new millennium?!”
When she was done, I immediately picked up the phone and called the college of pharmacy where she was enrolled. Put through to an assistant dean, I identified myself and the student and then described what the student was having to undergo in her school-endorsed rotation. In short order, much to the college’s credit, the young woman’s story was verified, she was moved to another rotation, and the preceptor had charges filed against him by both local police and the board of pharmacy.
Sexual harassment is alive and getting along. While some studies indicate such harassment is declining, the persons still engaging in this behavior are doing so as outrageously as ever. Demanding sexual favors for promotions or good grades, inappropriate comments, inappropriate touching, etc continue unabated in some areas.
Pharmacy, unfortunately, is one of those areas. While more and more pharmacists are female, technicians are still, by a large majority, also female. One study showed that more than half stated that they had endured sexual harassment in some form during their careers.
Sexual harassment is defined as a form of sex discrimination in the workplace that includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature that tends to create a hostile or offensive work environment.
There are two general types of sexual harassment: quid pro quo and hostile work environment (HWE).
Quid pro quo was the first recognized and seen in the courts. This is where the person doing the harassing makes a demand and withholds something until sexual favors are granted. A promotion, endorsement, policy or procedure change, evaluation, and/or a good grade can be refused until and unless the harassing person gets what is demanded.
While recognized later, hostile work environment covers a much broader area. HWE does not always include sexual favors—it could be a person working in a pharmacy where the pharmacist makes inappropriate comments about customers (“look at the [breasts] on that girl” or “doesn’t he have a nice [rear end]?”), tells jokes of a sexual nature, or just commonly uses derogatory language of a sexual nature. The comments and language do not even have to be aimed at the person who is offended; just having to be in the environment that is offensive is sufficient to meet the criteria for sexual harassment. More cases are based today on HWE than quid pro quo
Some basics on sexual harassment:
–sexual harassment must emanate from someone higher up in the company to a lower ranked employee. The standard is that a lower ranked employee could be fried by someone higher up for such acts.
–though all early cases were male to female harassment (and this is still the majority of cases), sexual harassment can also exist female to male or same sex.
–depending on the egregious nature of the act, a single act of sexual harassment is actionable
–submitting to the demands of a harassing individual makes prevailing in a legal action much more difficult.
An employee being sexually harassed has certain requirements to meet in order for a lawsuit for sexual harassment to be viable. The employee must report the harassment within a reasonable time after the harassment begins. In one case, a technician lost a sexual harassment case for waiting six months before reporting. The court allowed as how fear of losing her job was a deterrent to reporting for a time, six months was too long. If you stay in the environment without complaint for a significant length of time, the court held, you have indicted your acceptance of the environment.
The employee must report the harassment to someone higher up in the company than the harassing individual. The exception to this is when the harassment comes from the highest person in the company. In such a case, go to HR if there is such in the company. Where there is no such department or person, see a lawyer.
One problem is proving the harassment. If others in the work environment do not support the claimant, it becomes a he-said, she-said, and a long time valued employee may be protected against unsubstantiated claims. A person claiming harassment should not hesitate long to complain, but long enough to gather sufficient evidence of sexual harassment.
Employers too have certain duties when they receive a sexual harassment claim. An investigation must be made by the company. The investigation must begin within a reasonable time—delay increases the employer’s liability. Also, the employer needs to remove the employee making the claim from the hostile work environment (this can be accomplished by removing the harassing individual instead of the claimant). However, the employee can be left in the hostile environment for a short and reasonable time while the investigation is ongoing. This is dangerous for employers; if the harassment continues, it is difficult to prove the time period was reasonable. Finally, employees may not be retaliated against for making such a claim, so long as the claim was reasonable. False claims are actionable by both the employer and the person accused.
Employers often pre-emptively address this issue in their employee orientation and/or employee handbook. There may be policies on dating and behavior by employees within the company. Be aware and follow them.
What about sexual harassment from customers/patients? First, this is true harassment. Second, employers are just as required to take action against these people as they are within the company. The general concensus among employers is to warn the customer upon his first harassing act (unless it is outrageous in nature) and then to ban the customer from the location if a second occurrence follows. The affected employee should have input into these decisions. Failure to act against customers engaging in sexual harassment of employees is as actionable as if the harassment came from another employee.
Sexual harassment still exists. Pharmacy employees should stand against it and take whatever steps are necessary when they see it.

Duty to the Employer

“When I started working decades ago for a chain, the amount of tech help you got was based on the number of prescriptions you filled.

Then the chain added patient calls, and doctor calls.  And the amount of tech help you got was still only based on the number of prescriptions you filled.

And then the chain added immunizations.   And the amount of tech help you got was still only based on the number of prescriptions you filled

And then the chain added MTM.  And the amount of tech help you got was still only based on the number of prescriptions you filled

And then the chain added  Point of Care.  And the amount of tech help you got was still only based on the number of prescriptions you filled

And then the chain changed the workflow so that filling a prescription now takes almost twice as long to fill.  And now we have to do initial verification of prescriptions for other stores.  And the amount of tech help you got was still only based on the number of prescriptions you filled

And then the chain cut my tech help.”

–Anonymous pharmacist

The relationship between pharmacist employee and employer—usually corporate—is perhaps at its lowest point since these entities joined years and years ago.  Pharmacists froo a long time had the upper hand in this relationship due to the chronic dearth of professionals.  With the current plethora of colleges of pharmacy and numerous graduates, the pharmacist shortage ended and employers found themselves with more than enough applicants to fill openings.  With this shift in circumstances, employers have exercised their ability to now demand from those who use to do the demanding.  And this has led to a sharp decline in the employer-employee dynamic.

While the paradigm has shifted, pharmacists must keep in mind that they still have duties of loyalty to their employers.  Failing to meet these may result in deiscipline, termination, and, in some cases, liability.

WHILE EMPLOYED

During a time of employment the pharmacist should:

–follow the policies and procedures outlined by the employer.  Exceptions to these are when such are in conflict with applicable law and/or the proper exercise of professional judgment.  For example, if it is the pharmacy policy to fill CS Rxs two days early, the pharmacist should follow this policy except when the Rx states not to be filled until the day due or when the pharmacist’s professional judgment reasonably determines that filling this early is not in the best interests of the patient.

–seek to maintain the business, build the business, and/or minimize business loss where such loss is unavoidable

–do not disparage the business either while on or off duty in any public forum.  If you wish to gripe about your employer on social media, 1) do not mention your employer by name and 2) remove your employer name from your social media profile beforehand.  Keep in mind that while truth is a defense against defamation, even spreading the truth with the sole intent of causing harm may lead to liability.

–avoid actions that could harm the employer, except where these actions are required by law and/or are in the best interests of the patient.  Do not make derogatory remarks about prescribers, keep your political opinions to yourself, do not disparage the products you are selling, etc, etc

Failing to abide by these precepts may lead to discipline and/or termination.  Courts have upheld the right to terminate employees who violate internal policies more times than you would care to count.  And while many employment laws were written to protect the employee, employment law overall favors the employer.

WHEN THE EMPLOYEE IS PLANNING TO LEAVE

Usually when a pharmacist is planning to leave a job, it is to take on other employment.  The mere mention of leaving to go to another job is usually forbidden by corporate policy—such conversation may indicate to a patient that the pharmacist is unhappy with the current employer.

When planning to leave, the pharmacist must keep in mind that he has a fiduciary duty to the current employer; this is a duty of loyalty to guard and care for the current employer and its business.  As above, until after leaving the job, the pharmacist should continue to follow policies and procedures abd seek to maintain the business.  Especially if the new job could directly or indirectly come into competition with the current employer, the move should not be mentioned.  Any action by the pharmacist that could be interpreted as seeking to steal business for the new job location is actionable by the current employer and punishable by the Board of Pharmacy.

AFTER EMPLOYMENT HAS ENDED

A duty to the employer does not automatically terminate upon an employee leaving the company.  Causing harm to the former employer through the use of information gained during the time worked, again, may be actionable.  Pharmacists should maintain an air of professionalism toward a former employer.

If there was an employment contract, it needs to be reviewed carefully.  A non-compete clause must be followed exactly as to time period and geographical area.  Certainly, these criteria can be ignored if the new job will in no manner interfere directly or indirectly with the former employer’s business.  For example, a pharmacist formerly employed in retail could immediately upon departure take a job in a home health infusion pharmacy.

Even if the employer engaged in questionable or outright illegal tactics to get rid of you, tread carefully in your response to such termination.  My telephone and email are full of communications from pharmacists employers are trying to rid themselves of—usually the older higher paid pharmacists.  But get a lawyer and seek legal redress in an appropriate manner.   Violating the fiduciary duty that exists even after termination or publicly dissing your former employer will hurt your case and even open you up to action by the employer.

Despite how an employer may treat a pharmacist, and the manner in which this occurs is certainly changing in the current environment, the pharmacist must be careful in responding.  There is a level of loyalty that is demanded and deserved.  Employers must be respected, at least to the degree that professionalism is respected in return.

HIPAA–What Can Pharmacists Say?

I have been inundated with HIPAA cases recently.  Of these, only a few had merit.  It seems like someone gave the public a bad lesson in this law and it is being mis-interpreted so badly that every word spoken by a pharmacist is considered a HIPAA violation.

This is not helped by employers whose HIPAA  training takes the same tone.  Most of these programs take the attitude that words spoken in the pharmacy should be few and so innocuous that those hearing them might not even understand what is being addressed.

The Health Insurance Portability and Accountability Act was enacted to, among other things, protect patient privacy.  Many states had highly differing laws regarding the privacy of medical information in different settings, and there was no federal example or precedent to follow.  Several provisions address what and how much Protected Health Information (PHI) can be obtained, passed along to other parties, and used in counseling.  It even goes so far as to specify the destruction of PHI—specific garbage cans, who can have access to it, etc. However, while well meaning, the law has created a number of issues, among the top being verbal HIPAA violations in the pharmacy.

These usually arise because most pharmacies, while not physically accessible, are so open that words spoken in the prescription area can be easily overheard by the visiting public.

This discussion does not include counseling.  HIPAA acknowledges that counseling may well be overheard as many states do not mandate private counseling areas but rather understand that pharmacies are public forums.  Counseling is vitally important to proper and timely health care.  Therefore, counseling is generally acknowledged to have NO privacy or privilege or confidential nature.

What the public does not realize is that there are three primary HIPAA exemptions.  For these, health care providers are under only one constraint in the use of PHI.  These exceptions are 1) communications  with  the patient, 2)  billing and3)  communications between healthcare providers providing direct care to the patient.

The latter is often misconstrued as being communications between two or more entities at different locations: pharmacy and doctor’s office, doctor’s office and hospital, etc.  BUT this also includes persons in the same space, such as a prescription area of a pharmacy, such as discussions between two pharmacists, a pharmacist and a technician, and a pharmacist and a pharmacy intern.

These conversations may be overheard and someone may become aware of some PHI regarding a patient of the pharmacy.  However, these conversations are important and essential to proper and timely medical care—weighing the public hearing a piece of PHI against the patient’ s health and well-being—there is no doubt which way this needs to come down.  That is why these discussions are exempted from HIPAA.

I mentioned above that there is one constraint.  This is the Minimum Necessary Information (MNI) standard.  Basically, HIPAA does provide that when PHI is discussed, this standard be the basis of the conversation.  Some legal commentators say the MNI standard even follows the three exemptions and most employers train their pharmacy staff in this manner.  Other commentators, myself included, believe the MNI standard does NOT follow the three exemptions, that these exemptions should be conversations as full and frank—as detail oriented—as the health care providers sees fit in her exercise of professional judgment.  A legitimate fear is that a health care provider following the MNI standard might, in the interests of protecting privacy, inadvertently or deliberately omit something the patient or other provider would have seen as important.

Further, there is a fourth exception recognized by the feds and the states: the educational exception.  When there is a pharmacy student or intern in the pharmacy, conversations seeking to expand and fulfill the education experience should also be unfettered.  Patient privacy is protected by the college of pharmacy which teaches and trains its students in respecting patient privacy and following applicable law.  Most employers additionally have interns and rotation students take that company’s HIPAA training before letting them into the pharmacy environment. Thus, students come prepared to learn but not to share.

There are two rules to follow in pharmacy conversations about patients

  1. Is the conversation necessary? Does the comment or question really need to be made?
  2. Does the conversation follow the MNI standard? While I do not like nor agree with this standard, some Boards and employers do.  Pass along everything you consider necessary, but stop there.

Some employers also want their employers to ask before speaking: Is it appropriate?  While this may seem like a restatement of the “necessary” rule above, some HIPAA cases arise because pharmacy employees do give inappropriate information as part of a discussion.  Some comments are easily determinable as inappropriate—the patient is divorced, the patient’s father is an alcoholic, his son take amphetamine sfor school—but may become necessary with the patent history (was alcohol the only drug misused/abused) or drug regimen.  Here, the pharmacist’s professional judgment should dictate what words to say and what facts to relate.

Some employers also like the adage, “When in doubt, leave it out.”  This is not good patient care.  The opposite should be followed; “when in doubt, include.”

One thing in which there is no doubt, wading through the waters of HIPAA is quite tricky and is full of traps.  A violation or breach of HIPAA opens the person who does so to huge fines from the federal government, exclusion from federally funded programs, as well as Board action and a permanent black mark on their record.  However, pharmacists’ primary goal must continue to be providing the highest quality of health care, and having whatever discussions needed to provide it.

What Do I Do If…?

What do I do when

I get a forged or altered prescription ?

The first thing is to think of your safety.  Giving back the Rx is not a desirable solution, as it merely pushes this issue off on another pharmacist at another store.  But you should make a decision to give it back or retain based initially on any possible danger to yourself and the staff.  Do so if it seems the safest thing.
If you keep the Rx, you must ascertain that it truly is forged or altered within a reasonable time.  Once this is done, you must call the police.
A couple of notes:  what is a reasonable time?  If during office hours, usually no more than a couple of hours.  If after, waiting until the next day is usually reasonable.

 

If you feel the danger is substantial and you think the safest choice would be to fill the Rx, will the Board punish you?  No, as long as doing this is not a habit.  And if you do this for a safety reason, call the police after the “patient” leaves.

What do I do if

I catch someone in the pharmacy stealing/diverting CS?

Immediately remove the person from the pharmacy.  Terminate the person.   Check your state law–it may require you call the police and have the person prosecuted
Inform the Board of Pharmacy.  Most states have a requirement that such acts be reported.  The Board can act against the license or registration to prevent the person from being employed at another pharmacy.
Do a CS inventory to determine just how many CS doses have been stolen/diverted.  Fill out a Form 106 and provide to the DEA, Board and any other entity required by your state law.

What do I do if

There is a doctor who continually OKs early fills on CS Rxs?  Listen to your professional judgment and then listen to me.  Refuse to fill.

When a doctor OKs early fills more than one time, get a reason and document on the hard copy.  If the prescriber continues and you see no legitimate reason, refuse to fill early.   When the doc sends the patient elsewhere, notify whatever state entity you need to.

Remember, there are lots of legal cases out there that state pharmacists have liability for continual early fills

What do I do if

I forget to get all my required continuing education?

Self-report to the Board as soon as you realize your mistake.  Pay the fine and do the additional CE.  Most states will, after a period of time, permit you to get this pharmacy law violation expunged from your Board record.

Don’t try to hide it.  Your CE goes to a national database today and discovering your lack of required hours is not hard.  And the punishment for hiding it is much worse in most states and THAT does not get expunged.

What do I do if

I want to be a PIC at two locations?

Most states permit this, but usually only for a limited period of time.

Make a written request to your Board.  Nmae both locations and addresses, acknowledge you will be spending the required number of hours at each location, state why you need to be PIC at both locations, and provide a time period, at the end of which you expect the second location to have its own PIC.

Some state Boards require an appearance before the Board to discuss this.  But Boards are reasonable and they almost always allow this under reasonable circumstances

What do I do if

I am licensed in three states and one of the states punishes me for a pharmacy law violation.  Do I inform the other two state Boards?

It would not hurt to do so, and they might see your coming forward in a better light.  But punishments by Boards these days go into a national database.  The other two states will become aware no matter what.

And be prepared.  Almost all the time, the other two states will match the punishment of the original violation state.

What do I do if

My PIC quits and the other pharmacist does not want the position?

PICs in most states must be onsite 10 hours a week.  Boards overlook those weeks when a pharmacist is on vacation, ill, on a business trip, etc, so long as this does not go over 30 days.

Most Boards will allow a pharmacy to go without a PIC for up to 30 days, but check with your state Board.  Make sure you inform the Board within the required time that your PIC has left.

30 days is considered enough leeway for you to find a new pharmacist who will be your PIC.  Within the required time, inform the Board that your new PIC is in place.

What do I do if

The sole pharmacist on duty becomes ill?

Of course, the primary goal must be to go to the aid of the sick pharmacist.

I am guessing here that you mean sick enough to be unable to function professionally.  In this case, all states pretty much have law that says all pharmacy business must cease.  Even the verified prescriptions in the waiting bins cannot be sold.  If the pharmacist leaves, all pharmacy personnel must leave the pharmacy area and the pharmacy must be closed off.  If this cannot happen, the entire store must close.

What do I do if

The local doctor’s nurse leaves one voicemail but with multiple Rxs for each patient, and she talks 100 miles an hour.

Erase them.

You want to take a chance on getting something rwrong from somebody who is through spouting prescriptions before you can get your inkpen out of your pocket?  This is like bad handwriting—only one case has held a doctor responsible.  Otherwise, it is the pharmacist’s fault for not clarifying the handwriting, or the voicemail.

I listen to voicemails 3 times.  If I have any questions, I then call and have the nurse give me the prescription again, all of it.

If I have an issue like you mention (and I have), I fax a protocol to the doctor’s office and give them a couple of days to conform: no more than two patients per call, no more than a total of five prescriptions per call, birthdays must be included, no voicemails for CS after office hours, etc.  When they do not follow these protocols (and after having been warned in the fax) I

Erase them.

 

Got a “What do I do if…?” question.  Submit it to pharmacylawsource@gmail.com  When enough come to me, I will do a Part II to this blog

Interns and Legal Issues

Interns.  At one time—for some of us a long, long time ago—we were all pharmacy interns.  Working for pitiful wages back in my day, but hourly rates that jumped considerably when the shortage got significantly worse, gathering hours necessary for licensure, developing relationships that led to opportunities,  jobs and lifelong friendships.

Today, internship requirements have evolved form they were back in my school days.  Some duties and restrictions created by the Boards of Pharmacy have come and gone while others remain in effect.  The end result is that interns, like their pharmacist preceptors, in the face of expanding duties and responsibilities, also face increasing liabilities.

The legal doctrine towards professional students in the experiential part of their education is that these persons are expected to make mistakes.  Errors are part of the learning process, and thus the patient who consents to be treated, diagnosed, or counseled by a student is usually assuming  a risk not taken with the licensed professional. However, there  are a growing number of exceptions to this philosophy, the main one being the corresponding responsibility rule.

But first let’s remind the person seeking to become a pharmacy intern of his/her responsibility.  In most states, you must be actively enrolled or have been accepted to a college of pharmacy (CoP) before you can become an intern.  Contact the state Board of Pharmacy or look on their website to see what the requirements are for becoming an intern.  Depending on the state where you seek to be an intern, the CoP must be either approved, accredited or—in at least one state—“recognized” by the state Board of Pharmacy; check with the Board to make sure your CoP is acknowledged by the Board.  An application must be filled out and filed with the Board.  Some of these will require a background check and drug test.

When you get your intern registration, keep in mind how often it must be renewed.  File your collected intern hours in a timely manner—some states require monthly, others longer periods of time.  Also review the intern rules to see when your registration is good: for most states it is good while you are enrolled in a CoP, on a scheduled break from school, awaiting licensure exam and awaiting licensure results (the latter two are called “graduate intern” in most states but there is usually no difference in status or duties you can perform).  There may be circumstances where you will need to contact the Board to continue active registration.  For example, a CoP student leaves early in the semester due to the death of a parent.  Usually, contacting the Board and assuring them you will return to school the following semester or academic year suffices to continue active status.

Finally, make sure your pharmacist is a registered preceptor.  Having a non-preceptor sign papers that you worked 200 hours of internship and seeing those hours lost is something I see a little too often and nothing I can do about.  Those hours are lost.  At the beginning of your internship, preceptor and intern need to discuss fully those duties the intern may perform, both as seen by the Board and the pharmacist-preceptor.  Employers and preceptors may further limit what the law allows but the intern should question this when the limitations get to the point of negating the educational experience.  I have heard stories of pharmacists who hire interns but then do not let them do anything delegable, instead turning them into cashiers.  That is not learning how to be a pharmacist.

Pharmacists, if you are not a preceptor, become one the minute your state permits you to do so.  We need you to help provide the experiential part of the pharmacy student’s education, as important as any class that student has sat or slept through.  Most states will require an association as a community based faculty member and this means some extra training.  Usually this is accredited and can fulfill continuing education requirements. Make sure you are acquainted with the CoP’s experiential goals.

  1. Time to move on to legal issues. Interns can and do have legal issues.  Quite often, this is when they step over a line.

Performing a duty that is not recognized as a pharmacist delegable duty, even if the preceptor tells the student to perform the duty, is acting outside the scope of the pharmacy intern.   This is why most CoPs have students take their pharmacy law class before they embark on rotations—they have a knowledge of what the law permits.  Acting without authority opens up the student to liability and sanction by the Board.  Do not perform the final verification of a prescription.  Depending on whether your state allows it, do not counsel a patient or do not counsel a patient outside the range of the preceptor.

Ignoring a duty is also actionable.  Refusing an order from a preceptor or refusing to perform a delegated duty provides a basis for ending the internship at the pharmacy level and possibly open the student to Board and CoP sanctions.

One duty that some pharmacy students ignore raises the ire of state Boards.  And that is reporting the preceptor for acts that are illegal.  Even in the 21st century, some pharmacists will tell the intern to fill prescriptions, even doing the final verification.  After this, some pharmacists actually leave the pharmacy—go to lunch, get a haircut, go check on the husband, etc.  Hard to believe this still occurs today, and the number of incidents is decreasing, but it does.  The preceptor who does this usually intimates the student with fear of failing the rotation (if a rotation student) or ruining their school career.

Another example here is when the pharmacy intern, again out of fear, does not report an impaired preceptor.  The pharmacist who takes advantage of having an intern or rotation student to drink or take drugs is also a dying, but not quite dead yet, breed.  Patient lives are at stake; act accordingly for them.

In both of the above, the intern should report the preceptor to the director of intern rotations at the CoP and to the Board of Pharmacy.  Do not be in fear.  Report it.  Having dealt with these issues, I can pretty much categorically state both entities will rally round the intern.   And keep in mind that permitting these acts to occur and not reporting them places the intern  in peril.  Should a Board discover that a pharmacist left an intern alone at a pharmacy or that the preceptor was impaired AND the intern did not report—that is likely to be the end of the intern’s career.

Other issues that some interns still face, despite our being such an advanced society:

–discrimination.  Whether gender, sexual orientation, race, religion, or national origin, you do not have to put up with acts or words that insult your status.  In the pharmacy, we are expected to work and act together as a team for the betterment of the patients.  Intolerance of any sort should be quickly reported.

–sexual harassment.  This is hard to believe but it still exists in the workplace where the personnel are mainly licensed professionals.  Inappropriate language and/or touching, demands for sexual favors—whether for a good grade, a passing grade, or not—should be immediately reported to the CoP, the Board, and, if appropriate, to the next highest official at the place of employment or rotation.

Finally, the question: “Should I, as an intern, get malpractice insurance?”  Especially before fourth year rotations, my answer is “yes.”  Under the corresponding responsibility rule, interns can be included as a party to liability where the intern’s action contributed to the harm to a patient or a violation of pharmacy law.  Besides, it is pretty cheap.

Becoming a pharmacist is a daunting task, a challenging curriculum in a CoP, and internship that can be as tasking as it is rewarding.  Interns should make themselves aware of the requirements, find a good preceptor, and acquaint themselves with the possible pitfalls.

Drugs to Watch

Drugs have prescription status because they have effects that are beneficial but sometimes dangerous, side-effects that are dangerous or have a strong tendency to be so, invite misuse and/or abuse, and a host of other reasons.  Due to these effects, the educated pharmacist has a duty, along with potential liability, to ensure the “right dose, right patient, right medicine, right time.”

Some drugs demand a heightened attention, sometimes for a reason known at the time the drug comes on the market, sometimes only after the drug has been available for a period of time.  This blog entry is going to list some drugs that require this heightened attention.  Further, it is going to explain that there is legal liability from the unfettered dispensing of these medications.  Failing to ask a question, failing to speak to the prescriber, failure to document when you do dispense, and, in growing numbers, a failure to refuse to fill when appropriate is leading to lawsuits and/or action by the Board of Pharmacy.

Do not for a second think this is the whole list,  Feel free to respond to this blog with your additions.

Obviously, the first on any list is controlled substances.  Heck, I just did a two-part blog on these in 2016.  But let us look at a couple of examples.

First, in 2016, (20 years too late for a lot of pharmacists) the federal government issued a statement that combining opioid analgesics with benzodiazepines was not a good idea.  Mental depression, CNS depression, respiratory depression.  This combination, especially among chronic pain patients, has been a staple for years.  Now, pharmacists are on notice that these patients should not just automatically receive their monthly fills.  When needed and appropriate, the pharmacist should consult with the prescriber where a patient seems depressed, has trouble communicating or being mobile, etc.  Ignoring symptoms in favor of the prescriber’s regimen is fast becoming a dangerous gambit.

Second, this is new to me in the last six months but I am seeing chronic pain patients on the opioid-benzo combination getting an ADD/ADHD C-II Rx added to the mix.  Multiple drugs that depress the body now mixed with drugs that stimulate.  I am no doctor and not even a pharmacologist, but  I wonder at the long term effects of such a strong push-pull effect on the body.  And if that effect is substantially detrimental…well, this one worries me, folks.

On the same tact as the previous paragraph, watch out for opioid-benzo patients getting prescriptions for phentermine.  Unscrupulous docs are prescribing this to avoid adding a C-II ADD drug to the regimen (it makes the KASPER or other PDMP not look quite so bad, the thinking goes).  Many states, KY included, do not require pharmacists to get a BMI for a phentermine Rx.  Here, I would highly advocate taking a moment of your time to look further into the propriety of the prescription before dispensing.

Sleeping pills I: with only a couple of exceptions, sleepers are indicated “for occasional use only.”  Yet, I would guess that most pharmacists reading this fill benzo sleepers and zolpidem monthly for a lot of patients.  Research states that sleepers will put one to sleep but they actually rob the patient of the restful REM sleep, thus creating a vicious cycle of the patient feeling like she slept badly and wanting the drug even more.  As this trend of regular use of a class of drugs meant only for occasional use nears 20 years, we should start seeing studies indicating what, if any, the long term adverse effects of such therapy are.  From my early days as a lawyer, when I actually did a few automobile accidents and other “Have you been injured in some kind of accident?” cases (Yes, I even had a few Fen-Phen cases), I got to know some of the tort kings.  These lawyers, I can tell you, are anxiously awaiting these studies.

Sleeping pills II: a little over a year ago, the federal government handed down  dosing guidelines on zolpidem, mainly that women should not go over zolpidem 5 mg or zolpidem ER 6.25.  As time has gone by, many prescribers ignored this or have relaxed their prescriptions on this.  But the lawsuits from females over getting the higher dose are no longer few in number.  Question the prescriber and document the response if you decide to dispense the higher dose.

Long term use of cough syrups containing codeine or hydrocodone:  not only has this instigated lawsuits against pharmacists for failing to consult or interfere in some way, but both federal and state entities are looking into this.  If this occurring in your pharmacy, check with the prescriber.  A pulmonologist or oncologist, maybe 1 time a year.  Family practitioner, no less than 2 times a year.  And document.

And now a few non-CS drugs.

Gabapentin: abuse and misuse of this medication is expanding exponentially.  KY has labeled this a “drug of concern” and is one of several states looking to reclassify the drug as a controlled substance.  Until such time, I have advocated and still do that pharmacists treat gabapentin like it is already a controlled substance: no early refills, consult with prescriber when needed, etc.

Clonidine: this is a new one for me.  As heroin abuse grows, clonidine abuse matches it, due to claims (true or not I do not know) that this medication enhances the heroin “high.”  Many times, as I am hearing it, heroin users either seek to get themselves or their children diagnosed with ADD/ADHD so as to get an amphetamine to treat the condition and also clonidine to take at the end of the day   Watch compliance on your patients taking this drug.

Anti-psychotics: as some states tighten their Medicaid formularies, sleeping pills are being deleted.  A number of third party insurances are also eliminating these or cutting patients down to 10-15 tablets every thirty days.  Some prescribers are replacing these with anti-psychotics, such as quetiapine.  Adverse effects from these meds have spawned a small number of lawsuits.  Counsel the patient getting these drugs for sleep as to the side effects and document.

Cyclobenzaprine:  there are scattered reports of abuse and misuse.  Also, in one of the popular pharmacy journals this last year, there was an article reiterating that cyclcobenzaprine is indicated for 21 days or less.  Us eof this drug for long term therapy is not recommended.  However, most of us see continual use well beyond this time period, many of us on a regular basis.  Are to the point yet where we need to do prescriber consults due to the possibility of abuse or due to the long term use?  Not yet is my gut feeling here, but the day may not be far off.

Drugs on the Beers List: I have regular contact with both federal and state entities that deal with drugs in my practice.  On the federal level, there is continuing , if not growing, apprehension over the casual manner in which the Beers List is ignored by prescribers.  These drugs should be watched, doses adjusted, and ultimately discontinued in the elderly.  At the same time, this is another class of drugs where the tort kings are watching with baited breath.  Once the government lays the law down on prescribing these drugs, start watching for the TV commercials advertising whether your aged loved one has been harmed by a Beers List drug.

Pharmacists have long been aware of the need to exercise a heightened sense of awareness regarding the dispensing of certain drugs.  This list, sadly and for varying reasons, is expanding all the time.  With the above, and probably more, pharmacists must take the time to investigate, make calls, do consults, and document, document, document to protect themselves, though still not being able to be secure that this will provide a full shield against liability or sanctions.

“On The Premises”/”On Call”

“On The Premises”

Phyllis Pharmacist and Mary Pharmacist are working at their respective chain pharmacies when the Board of Pharmacy inspector comes in.  When the inspector asks to see their current licenses, Phyllis goes to the back room and gets her purse from her locker.  Mary runs out to her car where she leaves her purse while on duty.  Board Inspector writes up one of the pharmacists for not being “on the premises.”

Who did BI write up?  Pharmacy law requires pharmacists while practicing to have their license “on their person” in most states; neither one here did.  The answer is: BI wrote up Mary for leaving the premises.  Boards have acknowledged that purses may be used to divert prescription medications and they are OK that purses may be stored outside the pharmacy per company policy.  The important note here is that in order to get to her license, the pharmacist may NOT go outside the premises.

For a pharmacy to conduct the usual and customary business that a pharmacy performs, a pharmacist must be “on the premises.”  When a pharmacist is not present, ALL pharmacy business must cease.  No sale of previously verified prescriptions, no new prescriptions or refills being prepared, no information being fed into a computer.  Indeed, if the pharmacist is truly off the premises, all pharmacy personnel must leave and secure the pharmacy area.

On the premises was once defined as “under one roof.”  As long as the pharmacist was in the building, business could continue even if the pharmacist was outside the pharmacy area.  To a degree, this continues today.  If Phyllis or Mary makes a quick trip to the bathroom or goes out front into the OTC area to counsel a patient on an OTC drug, or merely runs up front to buy a snack, she is still on the premises.

But this rule is no longer 100%.  When the pharmacist leaves the pharmacy for an extended period, especially if this is for a planned event—such as a meeting with the supervisor or a lunch break—even though the pharmacist is still under the same roof, the pharmacy should be closed.

Be careful here.  The rule does not go 100% in the opposite direction.  A quick outside-the-pharmacy private talk with a pharmacy supervisor need not require a closure; a pharmacist eating in the pharmacy need not close the pharmacy if she can be interrupted to conduct business.

Whether or not to close during a pharmacist absence from the pharmacy area?  Let us look to three criteria: time outside the pharmacy, intent to leave, and availability.  While there is no hard and fast number of minutes that determines whether a pharmacist is “off the premises,” pharmacists should always seek to minimize time out of the pharmacy area.  I would guess that up to ten minutes would not necessarily call for closure, but I would start leaning strongly toward doing so for any absence longer than 15 minutes.  Intent is the same; if the pharmacist intends to be outside the pharmacy for any purpose longer than 15 minutes, closure should be strongly considered.  Finally, a pharmacist outside the pharmacy area who desires that business be ongoing should be immediately available to return to the pharmacy for such acts as she is required to complete.

And a pharmacist can actually step outside the building and still be “on the premises.”  She must be outside for a minimal length of time and she must be conducting pharmacy business.  I have stepped outside for a minute or two to give a vaccination to a patient who had trouble with mobility.  I have taken prescription medications out front to patients with mobility problems that would not fit through the drive-thru window drawer.  Boards find such acts acceptable.

An area where issues have arisen with being “on the premises” is in the hospital setting, especially in the new mega-hospitals with the Women’s Hospital connected to the Children’s Hospital connected to the Heart Hospital.  Boards of Pharmacy have had issues with a pharmacist going from one type of hospital to another (while never going outside, mind you) and still being considered “on the premises.”  Even in some of the single larger hospitals, Boards have shown reluctance to acknowledging being on the premises when the pharmacist is some distance away from the pharmacy.  Usually this is of little concern as larger hospitals have more than one pharmacist on duty at a time.  Hospital pharmacists need to be 1) immediately and easily communicated with (eg, via cell phone) and 2) able to return to the pharmacy when required within a few minutes at most, immediately if needed.

Another “on the premises” question Boards face somewhat regularly: is a pharmacist still on the premises if part of the pharmacy is separate from the main prescription area?  I have seen pharmacies where a compounding room is separate from the prescription area but under the same roof.  The Board was fine with that.  In another matter, a pharmacy had two sections, separated by a public corridor.  The pharmacist had to cross the corridor, locking one door behind her and unlocking the other.  The Board agreed that she was still on the premises so long as there was instant and easy communication—intercom, cell phone—and an ability to immediately return across the hallway.

“On Call”

Kentucky (and every other state that I am aware) requires its hospitals to provide 24 hour service, having a pharmacist on call when the pharmacy is closed.  While on call situations almost always refer to hospital pharmacies, these can be easily relatable to the home health or other pharmacy that seeks to provide 24 hour service through an on call pharmacist when the pharmacy is closed.

Two cases pretty well sum up the on call issue: Tom Pharmacist and Joe Pharmacist are on call pharmacists at two different hospitals.  One night they both receive calls to come in and prepare medications for extremely ill patients.

Tom gets in his car and makes the 45 minute drive to the hospital.  He is too late ; the patient has died.

Joe gets in his car and drives his usual route.  At a train track, where Joe has never encountered a train before at night, there is now a train, and it is stopped.  Knowing the alternate route to the hospital would add 20 minutes to his drive, Joe waits a few minutes, then a few minutes more after he hears noise that sounds like the train was starting.  Then he gives up and drives the alternate route.  He arrives at the hospital too late; the patient has died.

Both families of the patients learn that if the pharmacist had arrived earlier, the patient might well still be alive.  Both sue the hospital and the pharmacist for undue delay in providing the medication needed to save their loved ones.

Joe is able to show that his usual 10 minute drive was lengthened by the train and that trains at night along that roadway were rare.  As it turns out, the train 1) was unscheduled for that time and 2) the engine had broken down, causing the stop across the roadway.  The court granted summary judgment for Joe and his hospital.  Joe had made every reasonable effort and the train being there, and broken down, was unforeseeable.

Tom and his hospital were found liable.  The court held that on call services were generally of an emergency nature; therefore, the hospital pharmacist should be able to respond in an undue amount of time.  Living 45 minutes away was too far, the court held.  While the court refused to say how close to the hospital an on call pharmacist should be, it brooked no argument that 45 minutes was simply and clearly too far.

To determine the questions relating to being “on the premises” and “on call,” pharmacists should refer to their state law.  Most pharmacies, retail and institutional, usually have adequate policies in place that match the law.  Where there is any doubt, be cautious and conservative in considering whether an absence from the pharmacy is acceptable.  If a situation looks to be ongoing, such asrequiring so many minutes to reach the hospital or crossing a corridor, write the Board and get a written opinion as to whether this is acceptable in their opinion.

–sponsored by Pharmacy Law Source, PLLC

THE RIGHT TO REFUSE TO FILL A PRESCRIPTION

In 1978 the New York state court of appeals rendered a decision: pharmacists have no right to refuse to fill a prescription.  Of course, in this same time period, other courts held forth in cases like MCLAUGHLIN V SUPERX, LESLEY V SHRAKES, MCKEE V AMERICAN HOME PRODUCTS, and so on.  These cases did not directly address the right to refuse, but they laid duties and responsibilities upon pharmacists not previously attached to the profession.  The NY CA had belittled the profession in its decision, trying to hold the profession to the same standard as a SCOTUS justice once did: “no more important than a sales clerk.”

Of course, pharmacists are more important than sales clerks, and the NY holding faded into obscurity.  No other substantial interference with the right to refuse arose until 2004 when Illinois governor Rod Blagojevich issued an executive order directing the state’s pharmacists to fill all legitimate prescriptions.  This arose out of the conscience/moral/religious objections some pharmacists had to dispensing certain medications in the early 2000s.  The state’s pharmacists chose to file a lawsuit challenging the order; little came of the lawsuit but the definition of just what is a “legitimate prescription” again saw the order fade into almost oblivion.

However, the question of a right to refuse to fill a prescription has not, in and of itself, faded totally away.  Pharmacists are still having issues that arise.

Can a pharmacist refuse to fill an opioid prescription for a chronic pain patient if the fill is several days early?  Absolutely.  The casebooks are replete with examples of pharmacists being held liable for not doing so.  May the same pharmacist refuse to fill a prescription for a child because the child’s race or religion?  Absolutely not.

What criteria are essential for a legitimate refusal?  1)  The refusal must have a sound basis.  Don’t say that you refused to fill your ex-girlfriend’s new boyfriend’s prescription just because you think he is a son of a —–.    He may be, but that is no basis for refusing.

2)  The refusal must be based on professional judgment (PJ) and/or a scientific reason.   However, the basis for the PJ or science need not be 100%.  A reasonable suspicion of harm, abuse, etc is all you need.  And let’s define “reasonable” once again as “more likely than not,” or 51%.  Be 51% sure and act.

Example: Joe Pharmacist gets a phone call from Peter Patient.  Peter has determined that his insurance will pay for his oxycodone five days before it is due and he wants it filled then.  Joe says no, as he is aware of the cases mentioned above.  A legitimate  refusal?  Sure.

Example: Joe Pharmacist checks Patty Patient’s profile.  Patty is taking her estrogen hormone replacement therapy irregularly.  Joe talks to Patty, who says she takes the estrogen only when the hot flashes are “intolerable.”  Joe checks the literature which states the chance for cancer from HRT goes up exponentially with intermittent use.  Joe refuses to refill Patty’s prescription.  A legitimate refusal?  Obviously, this is a harder one.  Let’s make it more difficult: what if the prescriber tells Joe to fill it anyway?  I still hold that this is a legitimate refusal, though not of the same level as the first example.

In the second example, cases vary.  Some have held pharmacists liable, due to our superior knowledge of medications, while others have held that patients have “assumed the risk” after being counseled by the  pharmacist.  The second example is occurring more and more often.  I recently had a pharmacist contact me with a patient who had a heart attack and yet wanted to stay on his Adderall XR 30mg, 2 caps QD dose.  The patient’s prescribers all wanted to have the patient stop the drug but the patient claimed that the Adderall was the only way he could get out of bed and face the day (it was adjunctive therapy for depression).  I had the pharmacist refuse to fill until the patient signed a “Memo of Understanding and Waiver of Liability.”

As I wrote above, this scenario is occurring more and more often with medicines and their interactions, as well as interactions with medical conditions, state rules, CDC guidelines, etc.  Pharmacists dispense dangerous medications (“that’s why they are prescription only!”) but the fact that they are prescription only or are being legitimately prescribed is not enough today to protect the pharmacist from liability.  As a profession, we have a duty and responsibility to act or refuse to act when the necessity exists.

An issue with refusals that creates problems for pharmacists that occurs frequently is when another pharmacist—partner, PIC, pharmacy supervisor—steps in and fills a prescription after it has been refused.  For a while (it has fallen off recently), I had regular complaints of prescriptions being refused and a pharmacy supervisor coming to the store and filling the disputed Rx.  This is, way more often than not, purely and completely wrong.

Yet, many employers hesitate to turn down any prescription, especially in these days of shrinking reimbursement.  Numbers do help make up where fee per prescription are half of what they used to be.  But this is understandable only to a degree.  Patient health, preventing abuse and misuse, and professionalism must supercede.

To step in and do what another pharmacist has refused to do is an interference with PJ.  It undermines the pharmacist-patient relationship, it undermines the PJ of the first pharmacist, it provides those who complain with an outlet for dis-satisfaction with a pharmacist (OK if the act was wrong but wrong if the refusal was correct, as it often seems to be as described to me).

What do you do if another pharmacist steps in and fills a prescription you denied?  Talk to this person first and see if the matter can be resolved between you.  Stress that a basic precept of professionalism is respect for the acts of other pharmacists.

Consider contacting your Board of Pharmacy.  State Boards generally protect PJ like a grizzly bear protects her cubs: strongly, ferociously, and quickly.  Look for a pattern of abuse of PJ before doing so—don’t bother a Board over one incident—the Board will rightfully tell the two of you to work it out between you.  But if there are repeated incidents do what you need to act.

The right to refuse to fill a prescription is not under massive attack by corporate masters, employers, patients and prescribers these days but the right is still being challenged, and often.  Pharmacists should take appropriate steps to protect not only their professional status but also their license to practice.

 

NOTE: this article only touched on the right to refuse for reasons of conscience or morals.  Readers interested in this aspect of refusing to fill a prescription are referred to my earlier blog on this topic.

NOTE: got an idea or question you would like to see the subject of my blog?  You can email me at pharmacylawsource@gmail.com  Your name will not be mentioned and dates, names, places will be changed.  Facts of the case will be altered but only enough that the basic issue of the case/question remains intact.

ILLEGAL/INAPPROPRIATE PRESCRIPTIONS

In the early 1980s I was working relief a day every week in a small town in western Kentucky.  I would occasionally get HCTZ and Lopressor prescriptions from a prescriber.  The name on the top of the Rx blank stated “Dr.John Smith.”  There was no designation after the name, so I filled these several times before I was made aware that the prescriber was a dentist.  The techs where I was working said the dentist “helped out” the local docs by treating hypertension when he saw it in his office.

These prescriptions were illegal in that they were outside the scope of practice of the prescriber.  Dentists are not trained to diagnose or treat hypertension.  And pharmacists who fill the prescriptions can get into a LOT of trouble. (see below)

There are two basic types of illegal prescriptions.

The first is the forged, altered or unlawfully possessed prescription.  KRS 217.214 addresses this in Kentucky.  When a pharmacist has a reasonable suspicion that a presented prescription is forged, altered or unlawfully possessed, the pharmacist MAY retain the prescription.  I capitalized “MAY” because the pharmacist makes the decision whether or not to seize and retain.  The main consideration here is the pharmacist’s safety—if retaining may compromise safety, the pharmacist can return the prescription to the customer.  First and foremost, keep yourself safe in these situations.  (in an extreme case, if you feel that not filling an obviously forged Rx would endanger you, fill it.  As long as you don’t have a handful of these Rxs in your files, the Board is unlikely to sanction your action)

Let us take a moment and define “reasonable.”  If another pharmacist with similar education, skills, and experience would consider the likelihood of forgery or alteration to the same degree you do, you are acting reasonably.  Another way to look at it is to view it under the legal phrase “more likely than not.”  If you believe—not 100% but at least 51%–that more likely than not that an Rx is forged, you may seize and retain.  Seizing and retaining under reasonable circumstances and belief cannot result in liability, even if it turns out the Rx was legitimate.

The second type of illegal prescription is the inappropriately prescribed medication.  The scenario at the beginning of this blog is a perfect example.  Here are some more provided to me by Kentucky Drug Control:

-A dentist prescribing large prescriptions of narcotics for his mother (he was taking them)

–An APRN prescribing alprazolam with multiple refills (pharmacists fill these scripts all the time, uggh)

– An APRN without a CAPA-CS (left practice,they terminated her CAPA-CS, she kept writing controls)

-A doctor prescribing himself Ambien

-A PA calling himself in Ambien under doctor’s name

-A dentist requiring patients bring in their controlled substance prescriptions for him to keep and dispense as needed from office (he is in prison)

-Several cases of providers calling in medication for “patients” and picking it up themselves for “some reason”   HUGE RED FLAG

-Lots of cookie cutter prescribing or “no-exam” Don’t be afraid to ask the patient if anyone took medical history/performed medical exam and what their diagnosis is!

-OB/GYN prescribing to men

-A pediatrician prescribing to ADD meds to adults

-A psychiatrist prescribing Lortab/alprazolam/carisoprodol combinations

-Stolen blanks from an orthopedists in L-ville and pharmacists keep filling the month of Xanax 2 mg rx they wrote, no questions asked- RED FLAG!!!

-Lots of cases where the provider fails to KASPER patient prior to prescribing controlled substance

100s of promethazine w/cod scripts (>300ml) from docs states away for made up patients and person picking up lives in another state – all forgeries and Rph fill them all the time

 

Let me add anorexiant prescriptions where the patient does not meet the manufacturer or legal BMI requirement.  (In my previous blog on Controlled Substance issues, I already touched on postdated CS Rxs)

When a prescriber writes an inappropriate prescription, too many of us ignore this and fill it.  What I thought was a problem of the past is quite prevalent today, and these Rxs lead to a number of lawsuits every year.

What the pharmacist should do is two things: 1) retain the prescription or return it to the patient after writing on the face of the blank the reason that the prescription is inappropriate, then contact the prescriber and explain; and 2)if the prescriber persists in writing these Rxs,  report the prescriber to the appropriate administrative board and/or Drug Control.

If problems arise from these prescriptions being filled, the pharmacist should expect the punishment from the Board to be of greater degree than for a misfill or other error emanating from a legitimate prescription.  Is a jury or the Board going to just look askance because the prescription was inappropriate and illegal?  Hardly.  Under the doctrine of corresponding responsibility, if not already established as a principal duty, a pharmacist should know the prescriber at the very least well enough to determine the legitimacy of the prescription written.  What kind of prescriber?  What is the scope of practice?  Does this Rx fit within that scope? are the questions you must ask.

One of the many dangers here is that malpractice insurance does not cover “criminal acts” and insurers consider filling illegal prescriptions a criminal act.  So, if you fill digoxin for a patient with CHF and the prescription comes from a dentist, and then the patient suffers harm from the drug, the award or settlement to the patient (or family) from the ensuing lawsuit will come from the wallet in your back pocket.

But a lawsuit may not be your biggest worry.  The Board of Pharmacy can sanction you for the harm to the patient under KRS 315.121.  The Board has the right to revoke your license for life and they have shown that they are not afraid to use this right.  And it does not stop there.  The Board can provide evidence of filling an illegal prescription to the state attorney general’s office.  Since filling an illegal prescription is considered to be a criminal act in itself, you can then be prosecuted by the AG.

Prescribers writing inappropriate/illegal prescriptions is more prevalent today than most of us think.  As pharmacists, we need to be aware of the ability of a prescriber and what he/she can actually legally prescribe.  The consequences of failing to do this can be devastating to a career.