It seems like most patients have a hard time understanding why there is always a wait time at the pharmacy.  After all, what is so complicated about putting a few tablets in a bottle, sticking a label on it, and then handing it to the patient?  Furthermore, how could we ever make a mistake in filling the right medication?  To patients, this should be an error free, speedy process.

Pharmacy Workflow:

At the time of taking the prescription from the patient, we double check the patient’s date of birth and phone number to make sure we are typing the prescription under the right patient, picked from our national database.  We contact the doctor if the prescriptions are not legible, or if the dosage does not seem appropriate.  We double check the typed prescription by the technician to correct any mistakes or typos.  We contact insurance companies to resolve any coverage issues.  We double check the color, the shape, and the NDC number (a unique number designated to each medication) of the medication to make sure the right medication with the right dose has been dispensed.  Finally, we verify the patient’s address at the register to avoid giving the prescription to the wrong patient.  Of course, all these preventative steps are done in the midst of answering the phones which are ringing nonstop, answering patients’ questions on their prescriptions or over the counter medications, or even questions like which isle has the shaving cream, or whether we carry Revlon eye make up remover. 

Surprisingly, to the patients who are standing behind the counter, our job seems super easy.  After all, what is so difficult about putting a bunch of pills in a bottle?  Why is there always a wait?  No body is in the waiting area any way.  Why don’t we pick up the phone on time?  Why don’t we know which vitamins are on sale?  Why can’t we read the doctor’s hand writing? Why are we even questioning the dosage the doctor has picked on the prescription?  After all he is a doctor who has been practicing for 15 years, and there is no way he would make a mistake.  Being under so much pressure and bombarded with so many tasks at the same time, we still have to stay very focused and calm to avoid any mistakes. 

The reality is mistakes do happen.  No matter how careful we are, and how many different ways we implement to double check our work, we all still end up making some mistakes during our practice as a pharmacist.  The key is to stay vigilant, focused and follow procedures.  So, the next time you are picking up your prescription, remember the many checks and balances that goes into ensuring you get the right medication.

So what is the deal with Zocor (Simvastatin), Zetia (Ezetimibe), and Vytorin(Simvastatin + Ezetimibe)?  Over the past couple of months, there has been extensive media coverage about an unpublished study at the New England Journal of Medicine about Comparing Vytorin with Zocor.  Without going into extensive details, there was no difference between the two drugs when looking at the thickness of the carotid artery, called intima-media thickness (IMT, a measure of atherosclerosis).  So what?

 Well, Vytorin, which is a combination of Zetia and Zocor, is a powerful medication when it comes to lowering of the blood cholesterol level, specifically the LDL.  So, it goes without saying that the authors of the study expected that this will result in a reduction in the atherosclerosis in the selected patients with familial hypercholestrolemia (FH).  Today, the final results of the study were finally published and presented at the American College of Cardiology.  Thus, the renewed media interest and the flood of calls from frantic patients to their pharmacies and doctors.  One patient asked me, "Zocor is off the market, what should I take now?". 

 Of course, Zocor is NOT off the market nor are Zetia or Vytorin.  In fact, there is no new data on the effectiveness of Zocor.  The ENHANCE Study, which only included patients with a familial form of hypercholesterolemia, concludes that there is no difference in the intima-media thickness of the carotid artery between the group that took zocor alone versus the group that took the combination of zocor and zetia (vytorin), despite significant lowering of LDL and C-reactive protein in the Vytorin group.  So what does this mean?  Should I stop taking my medication if I am taking one of these medications?

 The best recommendation is: do not panic.  This study did not show any harm.  At its worse, the study tells you there may be no additional benefit when taking Vytorin versus Zocor alone.  Also, don't stop any medication on your own, before talking to your doctor.  Ultimately, the goal of any cholesterol lowering medication is to prevent cardiovascular events, such as strokes, heart attacks, or death.  This study does not address any of those end points.  Finally, keep in mind that any new study that has a conclusion contrary to the current knowledge, needs to be verified and reproduced with other larger studies.  There are many reasons, other than "zetia doesn't work", that could explain these findings.  There may have been too few patients in the study, the patients in the study may not have had a severe enough disease to show a difference, the study may not have gone on for long enough to result in a meaningful difference, or, the combination may actually reduce heart attacks and strokes despite no reductions in the intima-media thickness.  There simply needs to be more data...

That is a question I was asked by one of my patients.  She just had picked up her antibiotic and had to pay $84 for it since that particular antibiotic was not part of her insurance formulary.  She then called me in couple of hours with so much disappointment asking why did we not check for her insurance formulary before we dispensed her medicine. 

The matter of the fact is, your doctor usually does not know whether the medication he is prescribing is covered by your insurance or not.  Your pharmacist does not know that either until he types your prescription and submits it to your insurance.  At that time, he gets prompted if your medicine is not covered.  If you are patient enough to wait for your pharmacist to enter your prescription before you leave the pharmacy, you get informed of your out of pocket cost.  At that point, you could decide whether you want to pay or ask your pharmacist to call your doctor for changing it to something cheaper.  Your doctor however, may refuse to change your medicine, since to his medical judgment nothing else would be as effective, or he may not mind changing it to something cheaper. 

If you leave the pharmacy before obtaining the price of your prescription though, you may end up with lots of disappointment.  By the time you come back to pick up your prescription, the doctor's office may already be closed leaving you no choice but paying a fortune.  You need to consider that due to heavy volume and your pharmacy's time constraints, it is really not practical for the pharmacist to call every single patient whose medication is not covered.  Plus, many patients decide to pay out pf pocket for the uncovered medicine anyway. 

The bottom line is, if money is an issue, and you don't want to end up paying a fortune for your medicine, ask your pharmacist to enter your prescription before you leave the pharmacy.  You could also call your pharmacy in half an hour to inquire about the price.  That way, you leave yourself with enough time to have your doctor contacted in case your medicine is not part of your formulary. 

Good luck, and be well.

As a pharmacist, my biggest nightmare is to find out I failed to give the right medication to the right patient.  Even though there are many steps we take in the process of filling a prescription to avoid mistakes, and regardless of how competent, careful, and caring we are, it is utterly impossible to not make any mistakes throughout our practice as pharmacists.  So you, as a patient, need to also be more proactive in managing your prescriptions to avoid ending up with the wrong medication.  As a matter of fact, you can take 10 simple but smart steps to minimize prescription errors, and potentially save your life.  

1.  At the time of getting a new prescription form your doctor, always ask your doctor if you should discontinue any of your old prescriptions.  Quite often, I encounter a patient who was given a new dosage of a medication or a substituted medication, without being clear on what medication is being changed, and ending up taking the old and the new medications simultaneously.  This could cause overlapping side effects and potentially threaten patient’s life.  For example, it is very common for doctors to substitute a new blood pressure medication for an old one.  Taking the two medications together can drop the blood pressure too much or even affect the heart rate. 
2.  Make sure all your doctors and your pharmacies have a complete list of your current medications.  For example, a patient who is on a blood thinning medication such as Coumadin by the cardiologist may be prescribed an antibiotic for a simple strep throat by his internist.    However, there are some antibiotics that can significantly interact with blood thinning medications and cause bleeding.  So it is crucial that your internist be informed of your active medication list.  There are many tools available on the internet that allow you to create and manage your medication list.  One such tool, MedSort, lets you do just that. 
3. Also try to stick to one pharmacy.  This could assure you that the pharmacy has a complete list of your medications in their database, which allow them to check for any significant drug interactions.    
4. Make sure all your doctors and your pharmacies are aware of all your drug allergies.  There are some significant cross allergies among different classes of medications which patients are not aware of.  For example, a patient who is allergic to sulfa antibiotics could also be allergic to Celebrex which is an anti-inflammatory/anti pain medication.    
5. At the time of ordering your refills wheather through the automated phone service or manually by talking to someone in the pharmacy, be sure to mention both the name and the dosage of your medication.  Quite often, you may have been taking the same medication with a different dosage in the past, and if you don’t mention that on the phone, the pharmacist may end up filling the old strength of your medication.  It is not always that obvious to the pharmacist what the current dosage is unless we go into the details of your profile.   
6. If your pharmacist tells you that he needs to call your doctor to clarify your prescription, do not resist.  Let him do his job.  We know you are tired and can’t wait any longer, but waiting longer is better that having the pharmacist guessing the name or the dosage of your medication and you ending up with the wrong medication.
7. At the time of picking up your medication at the pharmacy, double check for your name on the medication bag.  This may seem obvious, but you will be surprised how often the wrong medication bag is handed to some one with similar first or last name.  Also cooperate with the cashier to verify your address at the pick up window, even if you are a regular customer.  Verifying the address is one of the best ways to ensure you are handed the right medication and is not because your business as a regular customer is not being acknowledged.
8. Always get consultation for any new prescriptions.  The most important information you need to obtain at the time of consultation is:            
   • Find out what the medication is for.  A very common mistake in filling a prescription occurs when two medication names look alike or sound alike. These kinds of mistakes can easily be caught at the time of consultation.  For example Lamisil is a medicine for fungal infection, and Lamictal is a psychiatry/neurology medication.  Thanks to the beautiful doctor’s hand writing, it is very easy to mistake one for the other on paper.  By getting a consultation, you will find out which medication you are getting and you can catch the pharmacist’s mistake in case you are being dispensed the wrong medicine.        
   •  Find out when is the best time to take your medication.   For example, oral corticosteroids, such as Prednisone, are best taken in the morning since they could cause insomnia. Water pills given for blood pressure such as Hydrochlorothiazide or Lasix should be taken in the morning since they make you urinate more frequently.
   •  Find out whether you should take your medicine with or without food.  For example, anti-inflammatory medications such as Motrin should be taken with food to avoid stomach pain and stomach ulcers.  Narcotic Pain medications such as Vicodin are better to tolerated with food to avoid stomach upset and nausea.          
   • Find out about your medication’s common or serous side effects.  For example, a common side effect of water pills such as Hydrochlorothiazide is dizziness, especially when you change positions, which over time your body gets used to.  A rare but serous side effect of Trazodone which is a psychiatry/sleeping pill is periapisam.  Periapism is prolonged penile erection, which is very rare but also very serious and requires immediate medical attention.
9. Before leaving the pharmacy, check all your medication bottles and be sure you got everything you ordered.  Quite often, we deal with frustrated patients who did not get everything they ordered.  This could be due to not using the automated phone service correctly, or being out of refills and having to wait for the doctor to approve additional refills. Patients may also be on two sound alike medications which could lead to mishearing the name at the time of ordering and dispensing the wrong medication.   By double checking your medications before leaving the pharmacy, you may save yourself from an extra trip to the pharmacy and lots of frustration.
10. Always call your pharmacist if you notice your medication looks different from before.  Most of the time, this is due to a change of manufacturer.  In this case, your medicine is exactly the same, but looks different.  Occasionally, though, the medication looks different because the wrong dosage or wrong medicine has been dispensed.   

I hope these 10 simple steps to avoid medication errors at the pharmacy will help you on your next trip.  Remember, we are all human and we need multiple checks and balances to avoid potentially serious mistakes.  You can be an integral part of this process.  Help your physicians and your pharmacists to help you. Good luck and be well.  .