STATE BOARD NEWS - FEBRUARY 2000 ISSUE
(State Section Only)
The February 2000 issue of the Ohio State Board Newsletter that was mailed to all pharmacists and pharmacy interns holding a current license in Ohio contained an error. The reference to Percocet containing hydrocodone should have read oxycodone. The correct wording appears here. I apologize for any inconvenience.
--- William T. Winsley, Executive Director
GOOD NEWS FROM DEA
As you are probably aware, Endo now has four different formulations for Percocet: Percocet-2.5 (2.5mg of oxycodone and 325mg of acetaminophen), Percocet-5 (5mg of oxycodone and 325mg of acetaminophen), Percocet-7.5 (7.5mg of oxycodone and 500mg of acetaminophen), and Percocet-10 (10mg of oxycodone and 650mg of acetaminophen). Based on the number of telephone calls received by the Board office from pharmacists and physicians, the information regarding the new strengths and labeling for the Percocet products was not widely disseminated. In fact, the Board staff was unaware these products had been released until the requests for information began. Since we had received no information from the manufacturer, we had to request the necessary information from Endo. Telephone calls were coming into the Board office from pharmacists frustrated over the lack of information provided to physicians about the Percocet strength changes. This deficiency was causing pharmacists problems when the prescriptions being written for Percocet did not have any strength designation. The improperly written prescriptions made it difficult to obtain new prescriptions for the Schedule II medication. Because of the continuous stream of calls from pharmacists, the Board office contacted the federal Drug Enforcement Administration (DEA) to see if there could be agreement on a suitable solution.
To our surprise, DEA has a policy in place that enables pharmacists to deal with problems related to Schedule II prescriptions without the need for the prescriber to issue a new prescription. This policy is in keeping with the Board’s philosophy that pharmacists need to act in the best interest of the patient and, therefore, it is a policy the Board strongly supports. The policy is reproduced here. Please review and follow it carefully; it will save prescribers, pharmacists, and patients a great deal of time and frustration.
Policy Received From DEA (Reproduced verbatim)
SUBJECT: Information That Can Be Changed on a Schedule II Prescription
POLICY: The majority of changes can be made only after the pharmacist contacts the prescribing practitioner. After consultation with the prescribing practitioner, the pharmacist is permitted to change the patient’s address, drug strength, drug quantity and directions for use. The pharmacist is permitted to make information additions that may be provided by the patient or bearer such as the patient’s address, and such additions should be verified. The pharmacist may also add the dosage form to the prescription order after verification with the prescribing practitioner.
The pharmacist is never permitted to make changes to the patient’s name, controlled substance prescribed (except for generic substitution permitted by state law) or the prescriber’s signature. These types of changes challenge the necessity of the original prescription and would require a new prescription from the prescribing practitioner.
In those cases where a prescriber either omits the strength, quantity, or directions or where the pharmacist doing prospective drug utilization review discovers an error in any of these required elements, this policy allows the problem to be dealt with by a telephone call rather than a trip back to the prescriber’s office. The pharmacist should always document the time and date that the prescriber was contacted about the correction, and should always ask the prescriber to document the change in the patient’s chart so that both the prescriber and the pharmacist have a record of the conversation. Please contact the DEA or the Board office if you have any questions about this policy.
The Board has conducted several hearings recently regarding dispensing errors that have led to serious patient harm. The common factor in all of these cases was that the patient harm could have been avoided if the pharmacist had taken the time to follow up on a telephone call received from the patient.
In one case, a patient received a refill of a Coumadin prescription that was double the prescribed strength. When the caregiver called to inquire about the different color of the tablet, the pharmacist dismissed the difference as “probably a generic” without verifying the markings and color of the dispensed tablet against the original prescription. The patient took the double-strength warfarin for some time and required two surgeries to deal with the side effects that resulted from a pharmacist’s failure to follow up on a call that should have been recognized as a potential problem.
In another case, three pharmacists were involved in the dispensing of the wrong drug to a child, which caused the child to suffer severe psychological trauma and be set back a year in school. In this case, one pharmacist took a telephone prescription and wrote it out with the wrong strength. The second pharmacist, on checking the filled prescription, noted that the technician who entered the data into the computer system had typed incorrect directions for use, but missed the entry of the wrong drug name into the computer. Since this was a continuance of the patient's treatment, the patient’s mother called to question the appearance of the tablets before she gave any to the child. The third pharmacist dismissed her inquiry with a statement to the effect that the drug was “probably a generic,” without looking at the original prescription or the patient profile. It took the patient quite some time to recover from the effects of receiving the wrong drug.
It is not our intent to embarrass or ridicule the pharmacists who inadvertently dispensed the wrong drugs. The Board recognizes the fact that pharmacists are human and will, occasionally, make a mistake. The majority of times a mistake occurs, the pharmacist handles it appropriately, and the Board never hears about it. The Board, however, also recognizes the great amount of trust the public places in the pharmacist. The public does not expect to receive the wrong drug and, when told by their pharmacist “it is a generic”, they trust the pharmacist and take the medication. Neither the public nor the Board is willing to accept a pharmacist who fails to follow up when a patient calls and questions the appearance of the drugs they have received. Every time this happens, the pharmacist should review the patient’s profile, the original prescription, the dispensing log, and should also verify the dosage form’s color, shape, and markings with the patient or caregiver. In both of the cases described here, as well as in others that have come to the Board’s attention, had the pharmacist who received the telephone call taken the time to do these few things, the patient would have been spared a great amount of suffering.
Unfortunately errors occur, and it is sometimes difficult, and always embarrassing, to have to deal with them. The Board has never accused a pharmacist of committing an error on purpose. However, covering up an error or failing to deal with one when approached by a patient can only be viewed by the Board as an intentional act. At that point, it ceases to be just an error and approaches unprofessional conduct. There is no excuse for failing to care for a patient.
Anyone having a question regarding the license status of a particular practitioner, nurse, pharmacist, pharmacy intern, or dangerous drug distributor in Ohio should contact the licensing board that regulates the profession or activity, as follows:
State Dental Board (614/466-2580) (www.state.oh.us/den/)
State Medical Board (614/466-3934) (www.state.oh.us/med/)
State Nursing Board (614/466-3947) (www.state.oh.us/nur/)
State Optometry Board (614/466-5115) (www.state.oh.us/opt/)
State Pharmacy Board (614/466-4143) (www.state.oh.us/pharmacy/)
State Veterinary Medical Board (614/644-5281)
Drug Enforcement Administration (800/230-6844)
STATE PHARMACY BOARD:
Only disciplinary actions that suspend, revoke, or restrict an individual’s license to practice are normally listed here. Due to space constraints, none are listed in this issue. However, all actions taken by the Board may be viewed on the Internet (go to the Board's home page address listed above, then click on the Board Minutes box).
STATE MEDICAL BOARD:
A document of legal actions taken by the Medical Board may be accessed on the Internet at the Medical Board's home page (see address above) then click on Monthly Formal Actions. If you would like a more detailed history of a legal action for an individual practitioner, return to the Medical Board's home page, click on the Licensee Profile & Status tag, then follow the instructions. Please contact the Medical Board if you have questions.