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Tuesday, March 27, 2018

Causin A Feck

Okay. I guess we shouldn't be surprised. E-Script software is bad. It sucks so bad that my phollowers have started quoting me back to myself: "E-Scripts have not resulted in fewer errors; only more, legible errors." and I love it. 
But what can we possibly do? We can raise awareness by bringing these errors to the people in charge - the programmers, the State Boards of Pharmacy who approved these systems, our feeble State Pharmacy Associations, APhA, or national media outlets. It should be simple.

Q. What is the problem? 
A. Many prescribing errors via e-script software from the lamest typos (PORN instead of PRN) to the life-threatening (wrong drug/dose/strength/frequency).
Q. What is the cause? 
A. The software and user error. 
Q. How do we fix it? 
A. Someone in power and a sense of urgency meets with the software providers to force them to change. 

Think of it this way. 
Q. What happens? 
A. I get a yeast infection. 
Q. What causes it? 
A.  Every prescription I have ever had for an antibiotic. 
Q. How do we fix it? 
A. Prescribe prophylactic dose(s) of fluconazole with each antibiotic. 
Q. Problem solved? 
A. Problem solved.

Me: Did you just compare e-script errors to yeast infections?
CP: Yes. They're constantly irritating and they never seem to go away.
Me: If they never go away, I think something else is wrong with you.
CP: Shh. Don't add logic to my metaphors. It's close enough. They'll get the point.

Monday, March 26, 2018


Change the pronunciation, hear it the same phrom now on, you will.

With you now my phuture is more bright
Not hypothyroid
You can make all my thyroid levels just right

Now I'm not tired and my head's right
No more hypothyroid
You fixed my symptoms and now I'm all right

With you now my phuture is more bright
With you now my phuture is more bright

levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)

I knew I really felt bad
I felt so cold and so sad
Gained some weight and then fatigue set in
You make me weak when I don't have you

My hair and skin and nails
Their care it always fails
Need your T, I won't ask you again
It's a bad day

With you now my phuture is more bright
With you now my phuture is more bright

levo-thy-ROXANNE (with you now my phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)

Friday, March 16, 2018


This is where we are.
This is what we have become.
We are a slave to the system.
We are its whores.
We ask "What is thy bidding my master?"
Worse, we are afraid.

When I was an intern, I typed "Inhale 2 sprays in each nostril once a day" as the directions phor Phlonase Nasal Spray.
My Pharmacist Of The Day: You need to fix that.
Padawan CP: Why?
MPOTD: You can't inhale through your nose.
PCP: Come again?
MPOTD: You can only inhale through your mouth.
PCP: Wanna bet?
MPOTD: You only inhale through your mouth.
PCP: You repeating that will not make it true. I bet if I came over there and covered your mouth you'd inhale pretty sharply through your nose. Shall I?
(I was definitely on the path to the Dark Side early in my career.)

Which brings me to this.
Inhale: (verb) Breathe in (air, gas, smoke, etc)
Breathe: (verb) Take air into the lungs and then expel it, especially as a regular physiological process. (The second example sentence is 'breathe in through your nose'.)

But that's not why we are here.
When I started, and until quite recently, oral inhalers would be dispensed with directions as phollows:
"Inhale 2 puffs by mouth every 4 to 6 hours as needed" or
"Inhale 2 puffs by mouth once a day" or whatever the medicine required.

Today, with e-scripts, corporate pharmacy protocols, phear of lawsuits, and new pharmacists being trained to NOT think for themselves, we have to deal with this instead:

"Inhale 2 puffs into the lungs every 4 to 6 hours as needed."

I don't like it. Is there anything wrong with it? Sure. It doesn't say "by mouth" which means they CAN inhale it through their nose.
Phine, what about: "Inhale 2 puffs by mouth into the lungs every 4 to 6 hours"?
Really? Stupid and redundant.
Yet this is what is happening.
If the e-script says it, people are being trained to type it verbatim.
Our job is and has always been to make the directions clear to the general public (read: lowest common denominator). The more you add to something, especially directions, the more complicated it can become.

It's like "swallow your food into your stomach". Where else can it go?

In order to get ahead of the curve, I am going to change all directions phor solid and liquid oral dosage forms to this:
"Take 1 capsule / tablet / teaspoonful by mouth and swallow into the stomach 2 times a day".


Alexa? Siri? Anyone?

In the (not-too)-distant phuture, I see the next evolution of healthcare.
Just this week I received the prescription posted that included these lines in the directions: "Instructions to pharmacist. Please clarify directions. They are not clear."
No shit they're not clear. For centuries our job has been to make it clear. Whether to keep patients from harming themselves or their prescribers from killing them, that has been our job.

Later in the week I received a note phrom a pharmacist where an office called asking how to prescribe a medication. They wanted to know how to use (why to prescribe it), how to administer it, and for what duration therapy should continue. When the office staff said she'd "just google how to use it", the pharmacist provided adequate support, but was surprised by the dearth of knowledge. If you do not know HOW to prescribe a medication, why are you prescribing it?

It the (not-too)-distant past, prescribers researched. They went to libraries and called Drug Information Services at hospitals. Now they are calling retail pharmacists about new drugs.
(Carefully, CP walks the line of "we are drug experts so people SHOULD call us" and "this is a new expectation an office staff member has because her prescriber said research it".) Should we know? Many things we do. But even the greatest among us do not know all there is to know about everything, especially when it comes to new, specialty medications. Can I research it for you? Sure. But it is going to take some time.

As phor that not-too-distant phuture prediction?

I see an Amazon Echo in every office and Echo Dots in every room.
Nurse: "Alexa, what's a good blood pressure?"
Dr. Zoffis: "Nurse, I want a Z-Pak. You finish inputting the prescription."
Nurse: "Alexa, What dose should I give? How long do I give a Z-Pak?"
Dr. Zoffis: "Alexa, when I don't know what's wrong, is it ok to just give a Z-Pak and Tamiflu?"
Nurse: "Alexa. . . If I'm out of Vitamin B-12, can I just give a double dose of B-6?"
Nurse: "Alexa, what does asystole sound like?"

Of course this is likely what would happen:
ALEXA: "I don't know. Google it."

Friday, March 2, 2018

Pharmacists vs. Doctors, IV

As more and more professionals are responsible for prescribing, more and more professionals are responsible for irritating me.
As more and more professionals delegate more authority in their offices, more and more items fall further and further down the priority line.
As rapidly as technology advances, it seems our ability to develop social mores regresses or fails to advance as quickly.
If you are going to use the technology, please understand how it works.
If you are going to employ different types of technology, be sure you are using them correctly and in the correct circumstances.

If I call you, I expect you to call me.
If you need to reach me right now, speak to me.
(Translation: Do not leave me a voicemail.)

If you send an email in error, what is the worst that could happen?
I suppose the recipient(s) could read the email.
But, what if your email alarmed the recipient(s) and they took actions that resulted in harm to themselves or others?
If you just "delete it" from your screen, does that make all trace of its existence disappear?
Does it "unsend" itself and automatically erase itself from the minds of those who have seen it?
What if you realised your error and wished to recall it?
How do you recall it?
Do you send another email?
What does it say?
"Sorry. JK. lol."?
Do you leave a voicemail?
Send a fax?
Smoke signals?

Sounds silly, right?
No way that could happen. (Who uses smoke signals anymore? And the final telegram was transmitted July 14th, 2013.)
Except that it does. All day, every day.
Where, you ask?
In your local pharmacy.
Prescribers love to send electronic prescriptions but they have a difficult time knowing what to do when they are sent mistakenly, incorrectly, in error. This is where the delegation issue comes into play. If it's wrong and you know it, call me. Now. (Translation: Ixnay on the OicemailVay, comprende?)

I cannot tell you the number of times I have had this conversation:
CP: I have a question phor you.
Dr. Zoffis: What now?
CP: Which strength/medication/directions did you want our patient to receive?
Dr. Zoffis: Why?
CP: Well, you sent me a prescription this morning, which the patient purchased, and now I have a new prescription that seems to contradict the first.
Dr. Zoffis:
     Answer A: We left a voicemail to cancel the first one an hour ago.
     Answer B: Well since we sent this one it must be the right one.
     Answer C: Yeah, the doctor canceled the first one in our system.
CP: Let me be clear: That's not how it works. Simple, yet somehow confusing to offices everywhere. If you were to have handwritten the prescription and chose to cancel it, how would you have handled it? Would you have mailed a new hard copy to the patient? That's effectively what you're doing here. The patient could already have filled and started taking the medication by the time the new order arrives. This is what happens when you choose to cancel electronic orders via any means other than a live chat with the pharmacist. No. Counseling does not always catch your mistake because, like today, the patient's niece's boyfriend's Uber driver came in to pick up the prescription and knew nothing about a change in therapy. Your note on the new prescription to "cancel previous" is rather vague and will now be attached to every single prescription you send for the next two years.
Dr. Zoffis: Well, it's canceled in our system.
CP: Ok. I know it's tough to understand how technology works when you simply stare at your phone to get cat videos and your friends' photos of the birthday parties they held for their pets but your patients' lives are at stake. You know what's funny? I take the time to thank prescribers and their staff who call me directly to cancel prescriptions in error. They are surprised to learn they are in the minority.
Dr. Zoffis: So, what do you want from us?
CP: In the immortal words of Blondie, "Call Me". And since your patient left with your initial, incorrect prescription, you get to call him and tell him.
Dr. Zoffis: Um, We don't do confrontation here.
CP: Phine. I will call him, give the copies of both prescriptions, the documentation phrom our conversation, and send him to your office. What time y'all close?

Thursday, March 1, 2018

Why Are You Still Arguing With Me?

. . . Better yet, why am I still involved in this conversation?

CP: Thanks phor visiting CP's Pill Palace, How may I phrustrate you today?
Not Understanding This: I was here yesterday for my wife's medication.
CP: I remember. I mentioned that her eye drops were ready.
NUT: Yes. I am also looking phor a pill.
CP: Ok. They called it in yesterday.
NUT: Right. Where is it?
CP: It was too soon. I put it on file. We mentioned this yesterday.
NUT: Oh. What is it?
CP: Valtrex.
NUT: No. That's not it.
CP: Yes. Yes, it is. I typed it myself.
NUT: No. It's something else.
CP: Is it phrom the same prescriber who wrote the eye drops?
NUT: Yes.
CP: What are we treating?
NUT: Shingles on her face and eye.
CP: That explains the Valtrex. We just filled a month supply last week.
NUT: Well, I don't know what it is, but that's not it.
CP: Well, if you said it is phrom the same prescriber who wrote the eye drops and it is to treat her shingles, and you were expecting 2 medications, one of which is a drop and one is a pill, and you don't know what it is, then I don't know what other answer I can give you. Call the prescriber?
NUT: I did. They said they called it in.
CP: Did they mention the name? Or what is was phor?
NUT: I don't remember.
CP: <waves hand> These ARE the drugs you are looking phor.
NUT: These ARE the drugs I am looking phor.
CP: <waves hand> Have a nice day.
NUT: Have a nice day.
Uber-Intern: Why didn't you just use your Jedi mind trick earlier?
CP: I just wanted to see how long I could play this out until I got bored.
UI: We're not that slow today.
CP: But he's really nice so I was hoping he'd come around sooner.
UI: You must teach me the ways, Master CP.
CP: Much to learn, you have. Much to learn. . .