What is pharmacy is explained using an example
The other day, I was working and a young mother brings in a prescription for her newborn. The baby had been born a few weeks early and had spent more than two weeks in a regional neonatal intensive care unit. After some time, the baby had been stabilized on a particular cardiac/diuretic medication and was seen fit to be sent home. The hospital pharmacy had compounded the medication and sent it home with the mother.
After a couple days, the mother took her baby into the local pediatric specialist who is also affiliated with the regional neonatal unit. This pediatrician wrote a follow-up prescription for the medication based on the label on the current container. The mother brought the prescription to us late that afternoon and dropped it off. She still had some of the other medication and did not need this one for a couple days. We processed the prescription and set it in our compounding file to put together the next morning.
The next morning, before I began to compound the medication, I wanted to verify the dose. I did not have the patient’s weight, so I did some average calculations. I checked two other resources and based upon my calculations, the dose was approximately 3 times the maximum recommended dose for this size child. I discussed this with my colleague and I also checked in with an inpatient pharmacist. We all agreed, the dose, as ordered, was not the correct dose.
I gather my notes and call the prescribing pediatrician. This physician is very thoughtful and grateful that I have called him. We get the actual weight, did the calculation and yes; we agreed that the dose, as prescribed, is 3 times the maximum dose. The physician states that he wrote the order exactly as it was on the prescription bottle the mother had received when the child was discharged from the regional hospital. He also states that those neonatal doctors know what they are doing and that the baby had been stabilized on that dose. He says he will take responsibility for the dosing and that early next week he will be discussing the case with the physicians from the regional facility and he will discuss the dosing with them at that time.
Ok, so I clearly understand this pediatrician, I take copious notes; I discuss the follow-up process with my manager, and continue on to compound the medication. After a couple hours, the non-English speaking grandmother comes in to pick up the medication. We have a Spanish translator technician that helps me explain all of the follow-up to the grandmother, and off she goes.
I then take my lunch and I can’t get it off my mind. It should be just fine, after all, the physician said he is taking full responsibility for the dosing. All through lunch I am looking for a reference anywhere that describes this particular dosing regimen for this particular patient situation. I cannot find any reference. After lunch, I call the mother of the patient. She is particularly interested in my discussion and more than willing to work with me over the phone to figure this out. She picks up the bottle that had the medication from the hospital and reads all of the information to me. Patients, when reading a prescription bottle, have a tendency to mix up ml and mg; however, she sounded convincing that it was the same as the prescription that we had dispensed.
After another 30 minutes of running this through my head, I called the mother back once again. I asked her for the phone number on the label of the prescription from the other facility. I called the other pharmacy to ask them what they had dispensed and what the directions on the label read. Sure enough, the dose that the local pediatrician had prescribed, we compounded and dispensed was 5 times what the patient had been receiving at the hospital prior to discharge.
I immediately called the mother back. She had not given her baby any of the medication yet because she still had a couple doses left of the bottle from the hospital discharge. We discussed what the actual dose should be and she completely understood. I then called the physician, who was not available. I was able to get ahold of the clinic and discussed the situation with the physician’s assistant. She understood, agreed, and said she would contact the physician to let him know.
This had all taken place on a Friday, and the following Tuesday the physician called back, incredibly grateful for our follow-up. His comment was, “This is why I recommend that all of my patients bring their prescriptions to this particular pharmacy.”
My response to what is pharmacy
When I hear the question, “What is pharmacy?” this is the type of situation I think of. Pharmacy is integrity, follow-up, clinical responsibility, and communication. Of course, whether we work in a hospital, out-patient, industry or educational setting, we all have daily chores that need to be completed. Pharmacy has many technical duties that we are responsible for completing with speed and accuracy; however, these technical duties do not make up the answer to what pharmacy is.
Integrity means that if I say I will be there, yes, I will be there. If I am responsible for a particular task, then yes, I will assure that this is completed to the best of my ability. If I am unable to perform for some particular reason, I will let someone know and get some help. Integrity means that you can trust me in the pharmacy to abide by all of the legal requirements, and to enforce the legal requirements with my co-workers as necessary.
When I first started at a particular hospital pharmacy, I had a seasoned co-worker tell me a line that has stuck with me. I had picked up the phone and the nursery was calling with a discrepancy on a medication that was a carryover from the previous shift. I asked the other pharmacist about it and he said, “You stepped in it, you get to fix it.” Follow-up is always taking care of the issue. Do not put it to the bottom of the stack, thinking that you will be off your shift before it comes to the top again and someone else has to deal with it. If you don’t know how to resolve something, ask and figure it out.
As pharmacists, we need to take clinical responsibility for each and every order that passes through our hands. If we authorize or dispense an order, it is our responsibility to assure that this order meets all of the requirements as to the dose, indication, allergies and interactions for the particular patient. When an order falls outside of the normal recommended dosing parameters, we need to document all of our activities showing that in this situation, the dosing outside of normal parameters is appropriate for whatever reason. If a patient is out of their medication, it is Friday afternoon, and the doctor is not available for refill authorization, we have a clinical responsibility to give the patient enough medication to hold over through the weekend until we can contact the physician. We are clinicians, not technicians.
In my opinion, communication is the key to a successful pharmacy profession. Hospital pharmacists need excellent communication skills in order to work effectively with the nursing and medical staff on a regular basis. Out-patient pharmacists are required, if not encouraged, to discuss medications with patients. Communication skills are a necessity if this discussion with the patient will effectively educate and motivate the patient to participate in their pharmaceutical care.
In my practice, I work to combine integrity, follow-up, clinical responsibility and communication to help provide the best care possible to my patients.
About the Author
Dr. Steve Leuck is currently a community pharmacist in a hospital out-patient pharmacy, where he educates and motivates patients to participate in their own pharmaceutical care. He is also owner of AudibleRxTM where OBRA 90 based Medication Specific Counseling SessionsTM are available in audio format.
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