I was a staff pharmacist working in my first hospital. This was before I went back to school to get my advanced degree. This was even before I became a pharmacy manager. I liked working as a staff pharmacist in a hospital. From what I had heard, it was better than being a retail pharmacist.
I was working the evening shift on that particular day. I started at 2:30 pm and worked until 11:00 pm. It was just me and the pharmacy tech working that evening. We received medication orders to fill for the patients. Most of them were written by residents in the hospital.
I received an order for NeoCalgucagon Syrup. It is used to treat calcium deficiencies. The generic name is calcium glubionate. It is a liquid where one teaspoonful (5 milliliters or ml) contains 1.8 grams (g) of calcium glubionate, thereby providing 115mg of elemental calcium.
The order was written in a strange way. It read, “5.4g orally three times a day”. I found it odd that the order was written in grams, especially since it was a liquid medication. Most times, a liquid medication reads “one teaspoonful (or 5 ml) several times a day”. Seldom does a physician write a liquid as “250mg several times a day.”
I decided to calculate the dosage quickly. NeoCalglucagon Syrup is generally prescribed “15ml three times a day”. A 5ml dosage contains 1.8g of calcium glubionate which provides 115mg of elemental calcium. Thus, if a doctor wanted his patient to receive 3.45mg of elemental calcium, he would prescribe 5.4g of NeoCalglucon syrup. The prescription was right but very confusing.
I called the doctor on the phone. It was one of the residents. I had nothing against this resident. But this resident felt that he was very important. What’s more, he wasn’t about to let anyone (especially a lowly pharmacist) tell him what to do. I asked him to rewrite the medication order so it would not be so confusing. He refused. I told him that I would not fill the order unless he changed it.
I knew exactly what I was doing. I was not about to deny the patient their necessary medication. I also was not going to get into a battle with the resident, especially at the patient’s expense. But I was going to stand my ground. I knew what the resident’s next move was going to be. He would report me to the nursing supervisor since she was the most senior manager in the building at that hour.
I have been in hospital pharmacy management for over thirty years. I have questioned many doctors, argued with many nurses, and battled with many administrators. I am not intimidated or afraid to talk to doctors, nurses, or administrators, especially when I’m right!
In this particular case, I knew the resident would contact the nursing supervisor. In a few moments the resident and the nursing supervisor came to the pharmacy. I let the resident speak first. He was upset that someone was questioning his order, and he didn’t think that was right. Especially since it was a valid order and furthermore, he was the doctor.
I explained my position. I said:
“Yes, it’s a valid order. But it’s very confusing. Now the three of us know that based on the directions, the patient should receive 3.45mg of elemental calcium or 15ml per dose. But the medication order is written from the calcium glubionate viewpoint, which means that whoever has to administer the medication has to perform the calculations. Which is no big deal, because the calculation is a simple ratio problem.”
I continued, “Now we all go home at 11 pm, but early tomorrow morning, some poor nurse will look at this order and become confused. She’ll try to call you (the resident). Maybe she’ll try to call me (the pharmacist). Or she might get in touch with you (the nursing supervisor). Which is fine because then we can explain to her what is meant by this order.”
“But what if the nurse doesn’t get one of us on the phone? What if she gets someone else? In that case, hopefully whoever she gets on the phone can explain what the intention of this medication order is.”
“But regardless, by the time the nurse tracks somebody down on the phone, there’s going to be a delay in the treatment of the patient. Or maybe there might be a different dosage of what you (the resident) want. Do you really want that? Why don’t you (the resident) write the medication order so that there’s no doubt as to what the patient should be getting?”
The resident rewrote the medication order.
Filling A Dexamethasone Prescription
My girlfriend was taking Dexamethasone oral solution. It was available at a dosage of 0.5mg/5 ml. She was taking the medication four times a day. We have encountered major issues with the prescription and this medication.
As a hospital pharmacy manager, I have been in the medical field for over thirty years. I have a strong medical background. In addition, since I am a pharmacist (with this vast medical knowledge), I have dealt with doctors, nurses, and administrators throughout my career.
Thus as I previously stated, I am not intimidated by medical personnel. If something seems strange or confusing, or downright wrong, I am not rude. But I will question the medical person’s actions. I will call for corrections or even suggest alternatives.
I feel bad for other individuals. I’m a very good advocate for myself and those I love. Most people I know blindly accept the word of medical professionals. However, I speak up when something doesn’t seem quite right. I question their actions and occasionally have found the medical professionals to be wrong.
These were the problems my girlfriend and I experienced with Dexamethasone oral solution:
The pharmacy does not carry Dexamethasone oral solution. Really? This one baffled me. Dexamethasone oral solution is not a narcotic or controlled substance. It is not a product that a pharmacy would be scared to have on its shelf (due to theft). It is an oral liquid that is available from many different companies. It comes in an eight-ounce or sixteen-ounce bottle. Most wholesalers can supply Dexamethasone oral solution to their individual pharmacies.
Now I’ll admit that a pharmacy may not stock it on the shelf if the pharmacy doesn’t have a patient on it. But most pharmacies should be able to obtain it in a day or two if they need to fill a patient’s prescription especially since my girlfriend was a regular customer of this pharmacy. She has all her prescriptions filled at one particular pharmacy. Yet she was told, by the pharmacy, that they do not carry it (and couldn’t get it for her). She had it filled at another pharmacy.
Writing the dosage as a percentage. When it comes to Vitamin C, a 500mg tablet provides 556% of the daily value of Vitamin C needed. However, a physician would never write a prescription as “take 556% of Vitamin C daily”. In other words, the prescription would be written according to the milligram (mg) dosage (500mg of Vitamin C), as opposed to the daily percentage value.
Dexamethasone oral solution is available as a 0.5mg/5 ml liquid. The prescription should read “Dexamethasone oral solution 0.5mg/5ml.” Why did the physician write the prescription for “Dexamethasone 10% oral solution?” The percentage is correct— but confusing.
No wonder my girlfriend’s pharmacy claimed they didn’t carry it. I took the prescription to two chain pharmacies before the pharmacist called the physician to clarify the prescription. I also made sure that subsequent prescriptions were written as a dosage and not as a percentage.
An inadequate quantity was prescribed. My girlfriend was taking 5ml (1 teaspoon) four times a day. That’s 20ml per day. The physician told my girlfriend to make an appointment to come back in two weeks. The prescription was for 100ml. It would run out in five days.
I called the doctor’s office and got an office staff member on the phone. I have dealt with different office staffs many times when I called doctors’ office.
There are certain rules that should be followed when calling a doctor’s office. They are:
1) Don’t yell and scream at the office staff. They aren’t the ones who wrote the prescription incorrectly.
2) The office staff workers are only the messengers. Don’t shoot the messengers.
3) The doctor is always busy when I call. I’m usually told he’ll/she’ll call me back when they’re finished seeing patients. They rarely call me back. I have to call them back— usually after hours.
4) The office staff will never pass along the message to have the physician call back if you’re nasty to them. Thus, be nice to the office staff workers. After all, you can catch more flies with honey…
I eventually received a call from the doctor. I said that my girlfriend was taking 5ml (1 teaspoonful) four times a day or 20ml daily. I stated he wrote the prescription for 100ml, and thus the medication would run out in five days. I reminded him that he had told her to make a follow-up appointment in two weeks.
I told him that this would create a problem for my girlfriend. She would be without the medication after the fifth day. He apologized and said he would contact the pharmacy. He would change the amount from 100ml to 250ml.
The doctor did not prescribe any refills. This piggybacks on the previous issue. The physician told my girlfriend to come back in two weeks. He prescribes a liquid medication and gives a 5-day supply. But he doesn’t write for any refills! What was he thinking?
I know some physicians are reluctant to give six months or one year’s worth of refills for fear that the patient will avoid future appointments. But to give an insufficient amount of medication with no refills? It’s just wrong.
The directions were incorrect. My girlfriend had been taking Dexamethasone oral solution for several months. In February 2023 she had her next to last refill of the prescription filled. She also dropped off a new prescription which the pharmacy kept on file. At the beginning of March 2023, I stopped by the pharmacy and asked for the last refill of the Dexamethasone oral solution.
“I’m sorry,” said the pharmacy technician behind the counter, “It’s too soon for the refill.”
“Excuse me?” I said.
She replied, “It’s too soon for the refill. The insurance won’t pay for it.”
Now I know that even if a person has several refills on their prescription, they must wait until the medication is almost gone before requesting another refill. If not, the insurance company will not pay for the medication (unless it’s an emergency or unusual situation). However, this was not the case.
I continued, “When would she be eligible for her next refill?”
“On the 27th,” replied the pharmacy technician.
“Of February?” (It was already March 2nd).
“No, March 27th,” she stated.
I looked at her and said, “How could that be? My girlfriend got 250ml of Dexamethasone oral solution on February 22nd. She’s taking 5ml (one teaspoonful) four times a day. That’s 20ml per day. Today is March 2nd— which means she used about 180ml. Why wouldn’t she be ready for a refill?”
“Because the prescription is for 5ml once a day, not 5ml four times a day,” she answered.
I froze. When I worked in my four different hospitals, there was a regulatory group called the Joint Commission (JCAHO) which performed inspections or accreditation surveys on a regular accreditation basis. One practice that JCAHO did was publishing a list of unacceptable abbreviations. These were abbreviations that were not allowed to be used in the facility. These abbreviations could be misinterpreted and could result in potential harm to the patient. Thus, should a physician (or healthcare worker) write these abbreviations, the order would be refused. Plus, the physician (or healthcare worker) would have to rewrite the order.
Two of the unacceptable abbreviations are “OD” and “QID.” If you use periods with the abbreviation ”OD,” it looks like “O.D..” If a physician has terrible handwriting, the “O.D.” can look like “QID.” Thus, a medication that is supposed to be taken OD or QD or once a day can be misinterpreted, and taken QID or four times a day. This is why OD and QD are unacceptable abbreviations in hospitals and healthcare facilities.
JCAHO’s list of unacceptable abbreviations applied to hospitals and healthcare facilities. Not to doctor’s offices and retail pharmacies.
I spoke, “No, she’s been instructed to take it [the medication] 5ml four times a day.” I said nothing more. The pharmacy tech went back to speak with the pharmacist.
I couldn’t exactly hear what they were saying. But from what I saw, it didn’t look too good. There was a lot of what appeared to be yelling and arm waving. The pharmacy tech went to retrieve the original prescription. Meanwhile, the pharmacist searched another area for the new prescription that was being kept on file. The pharmacist and the pharmacy tech compared the two prescriptions with what was entered on the computer. Eventually, the pharmacist came over to speak with me.
I never saw the original prescriptions. But I knew what had happened. The doctor wrote QID or four times a day. The pharmacist misinterpreted it as QD or once a day. Fortunately, my girlfriend and I knew what the correct directions were supposed to be. I can only imagine someone getting the medication who didn’t know how they were supposed to take it. They would be underdosing themselves and taking the wrong dosage.
I wasn’t interested in why a mistake had been made. I wasn’t interested in whose fault it was. I wasn’t interested in pointing out that this was a medication error. I just wanted to get my girlfriend’s medication and leave.
The pharmacist blamed the doctor. The pharmacist stated that she compared the two prescriptions. In the first prescription, when the physician wrote QID, the mark between the Q and the D looked like a period. In the second prescription, the mark between the Q and the D looked like an I. The pharmacist who filled the original prescription interpreted it as 5ml once a day. Had the physician written the prescription more clearly, the original prescription would not have been misinterpreted.
The pharmacist blamed the doctor, not the other pharmacist, for the error.
Being a pharmacist, I’ve always checked that the correct medication was placed in the container. Sometimes, I check the directions on the label as well. After this incident, I’ll always check the directions on the label.
But what about those people that don’t have a medical advocate (like me) to check, double check, and question the physician or health care professional’s work? Who will be there for these people?
Daniel Shifrin, R.P., M.S. is a recently retired pharmacist who enjoys sharing his insights about hospital pharmacy. He is proud to own one of the largest collections of Pharmacy Stamp First Day Covers.