Monthly Archives: July 2017

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.