Advanced Pharmacy Practice: Prescription Entry, Verification, and Clinical Database Navigation, and Professional Judgment

Prescription Intake and Initial Data Verification

• The primary goal of initial data verification is to ensure correctness and appropriateness of the prescription before it proceeds further in the filling process.
• Verification includes checking sick codes and adhering to best practices established in the pharmacy workflow.
• Generation of patient labels must prioritize clarity and user-friendliness. Directions on the label must be written at an appropriate level of health literacy. It is essential to remember that patients may not be familiar with specialized healthcare terminology.
• Pharmacy staff must use patient-friendly language and avoid assuming a patient's level of health literacy.
• The verification process includes confirming that the day supply is accurately reflected in the system, as this affects billing and patient safety.
• Upon entry to the pharmacy—whether brought in by the patient or received through electronic prescribing—the prescription must be input into the computer system.
• Initial input requires checking patient information, gathering allergies, and ensuring the correct patient profile is selected.
• Necessary information on a prescription includes the patient's name, drug, dose, and directions. While a National Provider Identifier ($NPI$) is not strictly required to be written on the prescription, it is helpful and found on most documents.
• A Drug Enforcement Administration ($DEA$) number is explicitly required for any prescription involving a controlled substance.
• Pharmacy software systems are often designed with built-in logic that flags missing information, making the checking process an ingrained part of the technician or pharmacist's routine.
• Laws regarding prescription requirements vary from state to state, with some states having more stringent requirements than others.

Drug Utilization Review (DUR) and Clinical Judgment

• The Drug Utilization Review ($DUR$) is both a system prompt and a clinical process used to review a prescription for safety and appropriateness.
• DUR covers various factors, including drug-drug interactions and drug-disease state interactions.
• If errors or issues are identified during a DUR, steps must be taken to reach out to the patient and the healthcare provider if necessary.
• Professional judgment and clinical decision-making are used to determine if a prescription is for a legitimate medical purpose. While a pharmacy technician might perform initial input, a pharmacist must verify this information at some point in the process.
• In the state of Kentucky, a Social Security Number ($SSN$) is required specifically for filling controlled substances. This information is entered into the system to run a CASPER report, which is part of the state's Prescription Drug Monitoring Program ($PDMP$).
• For pediatric patients, the $SSN$ must be that of the patient, not the parent.
• If the $SSN$ is missing for a controlled substance, a "hard stop" or flag should be placed on the profile so the information can be collected before the medication is dispensed to the patient.
• Over-the-counter ($OTC$) products may appear in the system for billing. Many $OTC$ products are not covered by insurance. In some cases, it may be more cost-effective for a patient to buy the item directly off the shelf rather than through the pharmacy system.
• A critical part of the pharmacist's role is ensuring the dose is safe and appropriate. If a dose is higher than the standard norm, the pharmacist must stop the process to investigate and contact the provider.

Data Entry and Error Identification

• The data entry phase involves scanning the original prescription into the system and manually typing the data (performed by either a technician or a pharmacist).
• Modern pharmacy software typically sections out the review screen as follows:
  • Patient information at the top.
  • Drug information (separated by drug name, directions, quantity, and day supply).
  • Provider information (including phone number and address).
• It is vital to select the correct provider profile. Selecting a provider with an incorrect phone number or address—even if the name matches—can lead to errors. For example, if a refill request is faxed to an old practice site ($555$ numbers in examples), the pharmacist will be contacting the wrong office.
• Providers, much like pharmacists and technicians, frequently change job locations and practice sites. Verifying current contact information is a standard part of due diligence.
• When encountering a brand-new provider for a controlled substance, pharmacists must verify they are a legitimate practitioner. Some software systems may restrict the entry of new provider credentials without verification.
• Historical examples include offices where prescription pads were not necessarily stolen, but unauthorized individuals handwrote prescriptions for non-existent providers or providers who did not practice at that specific location.
• When receiving a voicemail from an unfamiliar or out-of-state provider, research should be conducted to find the provider under a different verified phone number. Fraudulent calls often use providers from outside the local area to exploit a pharmacist's lack of familiarity.

Clinical Review and Pharmaceutical Databases

• Pharmacists must use professional judgment to check not only if the directions match the prescription but if the therapy is appropriate for the patient's condition.
• For unfamiliar drugs or off-label dosing—where a drug is used for a condition it is not technically FDA-approved for but has supporting data—pharmacists utilize drug information databases.
• Prescriptive authority must be considered; the pharmacist checks if a drug falls within the provider's scope of practice. For instance, a podiatrist would not typically prescribe birth control.
• DUR alerts often pop up after initial verification and may include:
  • Drug-drug interactions.
  • Drug-allergy alerts.
  • Abnormal dose alerts (high or low).
  • Duplicate therapy (e.g., two different antibiotics or blood pressure meds in the same class).
• "Soft alerts" may include notifications such as "late to refill" or "early to refill." While these are not hard stops, they can indicate adherence issues.
• Pharmacists must avoid becoming desensitized to alerts. Overriding alerts without proper investigation is a common source of mistakes in a busy environment.
• Resolving an allergy alert for a common antibiotic like Azithromycin ($Z-Pak$) involves checking the patient's history to see if they have taken it before and contacting the patient to determine the nature and timing of the reaction.

Database Navigation: Clinical Pharmacology and Lexicomp

• Clinical Pharmacology:
  • Contains Therapeutic Equivalence ($TE$) codes (found in the "How Supplied" section).
  • Lists inactive ingredients (useful for patients with specific dye or gelatin allergies).
  • Provides frequency rates for adverse reactions (e.g., infrequent, rare, common).
  • Features a drop-down menu for indications and dosing, categorized into labeled and off-label uses.
  • Includes specific sections for hepatic and renal impairment dosing.
  • Storage and administration information is found in the "Administration" section.
• Lexicomp (Lexi):
  • Features a pronunciation guide for drug names to assist in patient counseling and professional communication.
  • Includes a dedicated "Storage" tab for quick reference.
  • Categorizes warnings and precautions, including Boxed Warnings (the most serious safety alerts).
  • Features a robust pregnancy section for contraindications (e.g., Isotretinoin/Accutane is strictly contraindicated in pregnancy).
  • Provides patient counseling points in a specific section.
• Pharmacists often use both databases because information can differ or be updated at different times. No database is perfectly up-to-date at all moments.

Case Studies and Practice Scenarios

• Tablet Identification:
  • A white tablet imprinted with "Kleva $334$" was identified as a test drug.
  • A tablet imprinted with "Dan $365$" was identified as Generic Tylenol #2 (Acetaminophen with Codeine).
  • In drug identification, specifics such as color, shape, and imprints are critical. If a search is too vague, multiple results may appear.
• Drug Interactions:
  • Warfarin and Ibuprofen: A moderate interaction exists. Ibuprofen increases the risk of bleeding for patients on Warfarin.
  • Interactions can also be checked against food (like grapefruit juice), alcohol, tobacco, and specific patient allergies.
• Clinical Dosing Practice:
  • Drug: Bactrim DS (Sulfamethoxazole/Trimethoprim).
  • Patient: $29$-year-old female.
  • Condition: Uncomplicated acute urinary tract infection ($UTI$).
  • Standard Dose: One double-strength tablet twice a day for $3$ days.
  • Doses for $UTI$ can vary based on the patient's gender (e.g., different for males).
• Administration and Storage Examples:
  • Cephalexin ($Keflex$) oral suspension: Requires shaking well before use. The pharmacist must look up the stability of the product after reconstitution and provide the patient with a "beyond-use date."
  • Not all antibiotics require refrigeration; some must be kept cold while others are stable at room temperature ($25^\circ\text{C}$).

Questions & Discussion

• DEA Requirements: Participants confirmed that the DEA number is required specifically for controlled substances.
• Provider Information: Discussion occurred regarding what happens if a provider's phone number in the system does not match the prescription. It was noted that this could lead to refills being sent to the wrong office or location.
• Fraud Examples: Someone mentioned the concept of "fraudulent" prescriptions. It was shared that in one instance, a provider's office had prescriptions being filled for doctors who were legitimate providers but did not actually practice at that office.
• Database Access: A participant asked about accessing Lexicomp on their phone. It was advised that as long as they have access to the university's health links, they can access the database through a mobile browser.
• UTI Dosing: A participant identified the Bactrim DS dose for an uncomplicated $UTI$ in a female as one tablet twice daily for three days using Lexicomp.