I’ve sat through forty years of continuing education and pharmacy update sessions, always hearing from lawyers about how many ways I could get sued and lose everything in my life. This is a regular theme with which all pharmacists are all too familiar. From the abundance of ominous warnings, it is apparent that even in the course of trying my best to do my job in good faith, things could unexpectedly go south at any time, and bring miserable personal ruin.
I have heard story after story of how some unlucky soul was maybe a little over stressed, or tired, or short handed for help, or had bad help, or no help, or for a hundred other reasons something went wrong, and there were real consequences. Needless to say, it is engrained to my core, from way back, to respect the liability aspect of what I do. This is why we do our best to cross every “t” and dot every “i” in the most heavily regulated profession there is.
Along with regular warnings from the establishment, experience has also engrained first hand lessons. Experience teaches that liability can be a wild monster that has to be calmed to keep it from eating you alive. This is especially so when a patient tries to manipulate you and the system by a bogus action meant to extract additional or unauthorized controlled drugs.
I’ve seen every trick in the book. Sometimes, I feel like I wrote the book. Maybe I will write the book. Even so, every single time one of these dramas unfolds, regardless of the players, the details, or what it is they are trying to get this time, or for what underlying reason, there is always that knotted feeling in the pit of my stomach that is there from start to finish. It’s never pleasant, and it always taints your relationship with that patient, damaging your trust for them always.
I’ve compared notes with countless pharmacists and techs about old tricks, new tricks, and novel approaches to standard tricks. I’ve dealt with the people pulling the tricks, over and over. I, along with every other pharmacist alive, have adopted preemptive safety routines such as double and triple counting, special verification marks, two person verification, and on and on. I very well know how it feels when one of those tricks are hurled my way. I am very aware of what a threat they might be. I am certifiably trained and seasoned in how to respond, disarm, and resolve tricks.
When it happens, that miserable nauseous knot in the pit of my stomach usually appears instantly. It’s a reflex. It doesn’t matter that the real truth is obvious, and resolution will come with minimal confrontation, the feeling is still there. Heck, even when it happens where I work, but to another pharmacist, I have a “sympathy” knot. These tricks are just that way.
In my older age, when it happens, I imagine turning burning red laser eyes on the trickster and directly asking if they truly think with all my years of seeing tricks, do they really think I am stupid enough to comply with whatever their scheme is, and just hand over whatever it is that they want? Do they really think I wouldn’t know? Really? Folks, this is what I do.
So, here’s the facts from the one that happened last week: The patient has a diagnosis of cancer. The patient has been regularly using opiates for pain. The patient is under the care of a pain management clinic. The patient had earlier asked the prescriber for a stronger prescription because the one they had was not working, but it was still several days early for a new fill. The prescriber agreed to give a new prescription, but the patient had to bring the balance of the medication that was not working, back to the pharmacy for destruction before the new prescription could be issued. The new prescription was special ordered for the patient as the pharmacy had no one else on that drug. When the patient brought the balance of the old script in, they stated they had covered the pills in the bottle with water to aid in the destruction process. The bottle was about three fourths full of a white milky liquid that was about the consistency of lotion with a few random white solids. Though skeptical, the pharmacist accepted this and dispensed the new prescription. The prescriber required that the patient would bring the bottle in on specific dates for pill counts to insure that they were only taking the prescribed doses. The patient took the bottle to a different pharmacy ten miles away for the count, saying it was too far to drive to have the dispensing pharmacy count it. The pharmacy that did the count found that the actual medication that was supposed to be in the bottle had been replaced with an over the counter pain medication. They confronted the patient and called the prescriber. At the same time, the patient called the dispensing pharmacist at closing time, and accused them of filling the bottle with the OTC drug. The prescriber also called the dispensing pharmacist to get to the bottom of it. The patient threatened to bring charges against the dispensing pharmacist, and stated that their spouse works for the local drug task force. The dispensing pharmacist, pulled the ordering and dispensing inventory information for the drug in question which matched the physical count of what was left in the safe. The security camera record was pulled for the date and time of dispensing, and it clearly showed the tech walk to the safe, pull a bottle from the spot where this drug is kept, and proceed to count it with the capsules clearly showing on the counting tray. The footage showed this script be packaged and taken to the register where the patient received it and signed for it.
This was resolved fairly quickly with the prescriber “firing” the patient.
For the dispensing pharmacist, it was a turbulent night of restless insomnia, knowing that even though this was a false accusation, it could cause some very expensive grief. Thank goodness, it was resolved fairly easily the next morning. It is not always so easy.
When I heard this all after the fact, I have to say surrounding my “sympathy knot” there was at least a little anger. My first reaction was that they were not asserting that a mistake was made, they were making-- albeit false, an accusation of dishonesty on the part of the pharmacist. Anybody with one eye and half sense should know engaging in that kind of behavior would be the fastest ticket out of business you could get. Again, really?
This patient will most likely show up to fill a prescription again. It’s a small town, and they do come back. Go figure.
Henceforth, we will approach this patient without trust. This episode hampers our being able to do our very best for this particular patient always. The guard will be up. It’s kind of like the Bible saying you should pray for your enemies, and even when you try to do what you’re supposed to do, it’s hard to get your heart in the right place for it.
Even worse, that defensive cynical mistrust will creep into interactions with other patients at least to a small degree forcing all that preemptive stuff in avoidance. We will be on our guard. Experience has taught us that you never know when the next trick will come or from whom. Try as we might to be conscientious, and do our professional best, unpleasant confrontations come along. It’s the reason we pay money to sit through those lawyers droning on and on with their warnings of doom. Are we better pharmacists for it? I sure hope so.
