To be fair, pharmacy schools simply cannot duplicate the setting in which most retail pharmacists must conduct this important function. The ‘lab’ is, at best, an anemic attempt to reflect the real pressures and distractions that go on in the real world.
I remember having two APPE students standing side by side with me as we talked through my thought process when verifying a prescription. We did this for about 30 minutes. When finished, they both remarked that they had never had an experience like that before, and thanked me profusely. This was 3 months prior to graduation.
I am writing this article not because I believe I have developed the world’s best approach to flawless prescription verification. I am also not writing to impose my personal approach on seasoned pharmacists who have their own system and method for making sure the prescription is correct.
Rather, I write this in the spirit of sharing a few hints and suggestions to new pharmacists, and students, from a pharmacist who has been doing this for 25 years. The following are the things I do each time I verify a prescription. This isn’t intended to be exhaustive or comprehensive, but sufficient for most new pharmacists to have a good idea how to conduct this critical function. I also appreciate that software varies, and the steps you engage in will sometimes be dictated by your filling software as well.
1. Organize the work.
The first thing I do is make sure the items I am about to verify are organized in a way that I can easily identify the scope of my job. Is it just 1 prescription? Is it 10? I do a quick check while organizing them to make sure they all belong to the same patient. Once organized, I then proceed to work my way through the order 1 prescription bottle/inhaler/vial/cream, at a time.
2. Check if this is a new prescription or the first refill.
The very first thing I look at when picking up the first vial (I’m going to say ‘vial’ even though I know it may be a different type of item) is to see if this is the first fill or a refill. I do this because it prepares my mind for the ‘type’ of mistake I am likely to catch. The first fill (or even the first refill) will often reveal a different type of error than you expect to see on the 10th refill of a medication. I’m not suggesting you are more careful with the first fill, but only that the type of mistake is usually different,m and you must prepare your eyes to catch it. Basically, for the first fill or first refill I tell myself that “all bets are off” and literally anything could be wrong. Check it all. Carefully.
3. Ask if the prescription is reasonable.
The next thing I do is very important. Actually, it is what I do not do that is the key. I do not begin comparing the label on the vial to the written prescription image yet. Rather, I simply look at the label, the patient name, the drug and dosage, and I ask myself this simple question: Is it reasonable? Regardless of what the actual prescription says, is what is written on this label reasonable for the patient? It is my experience that more than half of all mistakes that leave a pharmacy could have been caught by simply looking at the label, and thinking about it clinically. For example, levofloxacin 500mg 4 times daily does not make sense…no matter what I am going to find on the prescription itself. You must stop and think. Pause and ponder.
At this stage, I am also allowing my mind to recall the ‘possible’ mistakes that are most frequent with the given drug I am verifying based on my experience. For example, is it for Metformin? Then I am thinking something like ‘was it written for regular metformin or metformin ER?’ Is it for bupropion? Then I’m thinking about the different dosage forms of bupropion that are frequently confused. Is it for amoxicillin, a sulfonamide or codeine? These are all common allergies, so I am thinking about that possibility. Is it for hydroxyzine? Then did they pick the correct form (pamoate vs. hydrochloride)? Is the drug a common ‘look alike/sound alike’ drug? Like Haldol vs. nadolol. These thoughts are what I am considering before I ever even take a look at the prescription,
Finally, as part of this initial review of the label itself, I am thinking in my mind ‘Is this normal?’ For example, omeprazole 40mg twice daily is technically ‘reasonable’ (under certain circumstances and for some diagnoses), but it is definitely not the norm. Ibuprofen 800mg once daily may be reasonable, but it is not the ‘normal’ way it is dosed. When I see something is not ‘normal,’ I am preparing my mind to check this closely on the original prescription.
These, then, are the first 3 steps I take in the prescription verification process. Please check back for Part II of this article where I share the final 3 steps in my own process for verifying prescriptions!