PA/NP/CNM/Janitors with Rx Authority

Why is it that 9 out of 10 Rx’s with a huge glaring mistake are written by NP/PA/CNM/Janitors who somehow got prescriptive authority before the people who actually went to school to learn about drugs?

Maybe its just where I’m at the PA/NP cribs are painted with lead paint, but its to the point now where when I see an Rx from one I just sigh and prepare to be frustrated.

Real life shit I deal with on a daily basis:

  • Amoxicillin 250/5 –  4.5mL q8 x10d
    • Come the fuck on, 4.5mL?  What the fuck is 25mg of amoxicilin going to do?  You can’t make it an even teaspoon?  A palm pilot is not a substitute for common sense.  Get your head out of your ass.
  • Amoxicillin – 158mg q8 x7d
  • (Just from today) Amoxicillin 648mg q8 x10d
    • This makes me want to murder people.  You get 1s, 1/2ths or 1/4ths of either 125, 250, 400.  Those are your only choices.  Choose wisely.

You know, dosing amoxicillin isn’t rocket science.  What the problem of PA/NP’s have is that their common sense is in the little electronic device that spits out a dose when you put in the patients weight.  The entire concept of having a mother who is barely able to wipe her own ass by herself is NOT going to be able to measure out anything that does not have easy to read numbers and big lines.  Thats 1/2, 3/4 and 1 teaspoon.  Case closed.  If this somehow involves fucking and having children you cannot afford, then maybe she’ll be competent enough to be okay, but dosing amoxicillin doesn’t fall into that group.

So I call the PA/NP and ask if they have a syringe they can give the patient that has readings out to the hundredth mL.  When they get the bitchy “Why would they need that?” I respond with “To measure out the amoxicillin dose that you wrote for.”  Once in a while they’ll get the idea, but usually it just goes right over their heads.  Rx authority people, this is who you are giving it to.  A fucking monkey can use a palm pilot and get a dose.  Some days I think I would have a better chance with a money.

  • Nebulizer, Ventolin HFA, Xopenex neb solution (DAW-1 of course), prednisone 60mg x5d with a huge note “DX: ASTHMA”
    • Steroid?  What the fuck good is this person going to get from all this shit with no steroid.  Lets just take care of the symptom without taking care of the cause.  I bet they would just throw vicodin at pneumonia without even thinking about antibiotics.
  • Metformin 750mg bid
    • 1.5 of the 500mg tablets? 100mg isn’t going to kill someone, just do one of the 850’s and save the patient the hassle.

The list just goes on and on and on.  Its gotten to a point now where if I see an Rx, and see that its written by a PA/NP I expect to spend about 20 min trying to sort out their fuckups.

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26 Comments

  1. SCPharm says:

    I see your point! On a side note, while my pediatrician carries a calculator with her script pad, she does ROUND the number from the calculator UP (or down) to an apppropriately measurable dose! (Must be that good old common sense at work!) She’ll even write for the higher “strength per ml” and use a lower “volume per dose” which I LOVE her for…the less volume to have to get the child to take, the better!!
    Think there was a cartoon strip in the Sunday paper touching on the subject of Nurse Practitoners doing the “work” b/c the docs are “just too busy.” While I do fill more and more Rx’s from NPs and PAs, my problem isn’t their dosing, it’s trying to get an insurance company to PAY THE CLAIM using the DEA or NPI number they supply me with! (It’s usually a lot easier to just use the primary physician’s info and call it a day!)

  2. Fellows and Residents are just as bad… 1.94mg Morphine, out of a 2mg/ml vial?

  3. The *Angriest* Pharmacist says:

    Luckily, I’ll have prescriptive authority through collaborative practice fairly soon…
    I don’t know how that’s going to fix the retardation, but it will at least give me the opportunity to show these folks the right way to write a script…

  4. Brad says:

    In our ER, the prescribers order through a computer which doses on mg/kg, and forces them to use these jacked doses for amoxicillin, et al. Nurses draw up in oral syringes to get “sorta” close to the 381.2mg ordered.
    The prescribers tend to forget to turn on their brain when they write the script, and just use the dose they got in the ER computer system.

  5. retail whippin' boy says:

    Hey TAP,
    You’re right on point with the amox dosing. Why don’t they just tell me to instruct mom and dad to give some decimal amount of a mole of amoxicillin TID. It would be the same thing as writing for 648mg!
    Years ago I worked at a big teaching hospital. A PA there killed a patient by administering a pre-op IV dose of pentobarb too quickly. The investigation afterwards revealed that he studied the entire classs of barbiturates for a total of twenty minutes of classroom time during his training. TWENTY MINUTES!!! Too late for the deceased patient, but the policy regarding who was allowed to administer IV drugs got changed pronto!
    I also lectured in pharmacology to nurses who were studying to become NP’s at a local university. A generally bright bunch, but I think the limits of their competence lies within the 10-20 drugs they routinely prescribe…..although the amox dosing stories put the lie to this.
    For all their faults, it’s better to have a PA/NP/CNM writing for that with which they are familiar than to have the doctor’s wife/secretary/receptionist OK’ing refills for lipitor, digoxin, antibiotics, etc! If I were the patient, I’d honestly RATHER have the janitor make the decision about continuing my drug therapy. At least the janitor would feel some justifiable fear at the prospect of making a decision for which he was not qualified! In some practices the office clerical staff feels ENTITLED to speak for the doctor on all matters regarding prescription drugs (including drug-drug interactions!), and seems to view their job as keeping me from getting the doctor on the phone.

  6. Shalom (R.Ph.) says:

    What bugs me on the antibiotic dosing is when they write for non-existent package sizes. Just this second I got “Keflex 250, 3/4 tsp TID x10d”. OK, that adds up to 112.5ml, but it only comes in 100ml and 200ml sizes, so they’re throwing out nearly half the bottle. Worse than that is the Omnicef. There’s a local pediatrician whose office loves to write for Omnicef, either strength, 1-1/4 teaspoons QDx10. This adds up to 62.5ml, and what size does it come? 60ml and 100ml. For that extra 2.5ml, we have to give the next size up. Bad enough that Americhoice (spit) is reimbursing below our cost on cefdinir, but we lose more on the larger ones, and they’re throwing out close to 40ml for a lousy half teaspoon. It’s even worse if they’re paying out of pocket for it and having to waste that much (if so, I’d probably call the prescriber and ask them if 9 days was enough).
    (Although if you have that surplus, you’re less likely to get the phone calls. “You shorted me on the antibiotic, it’s only 9-1/2 days [or sometimes 6 days if they measure particularly badly, or spill some] and I’m already out of it!”)
    While you’re ranting, I’m gonna jump on your coattails and rant a little myself about doctors, and especially dentists, who don’t seem to know about the limits on APAP dosing. How many times do you see “Vicodin ES, 1-2 tabs Q4-6h prn” or similar? I’ve given up trying to educate them, I just write whatever stupid sig they gave me, and follow up with “**MAXIMUM 5 TABS/DAY**”.
    Oh, here’s a great conversation that just happened now with one of the doctors’ offices’ staff (not even an RN, just a secretary). Phone rings.
    Me: “$PHARMACY, Shalom speaking.”
    Her: “I have a prescription for $NAME.”
    Me: “Date of birth?”
    Her: “3/11/08.”
    Me: “That’s today’s date. Was he born today?”
    Her: “No, sorry, it’s –/–/07. Prescription is for Tylenol chewable tabs.”
    Me: “To a six-month-old you’re giving tablets? That doesn’t sound right.”
    Her: “Let me check, hold on.” (goes away) “No, it’s for the drops, 1-1/2 droppers full. Next prescrip–”
    Me: “Hold on a minute, that one’s not finished. How often?”
    Her: “Let me check, hold on.” (goes away) “Every four hours.”
    Me: “As needed?”
    Her: “Yes.” (then gives me prescriptions for $NAME’s sister, one albuterol inhaler and one for triple paste. Did I mention these are Medicaid patients?) “And one more for her, Tylenol chewables. 2 tablets every four hours.”
    Me: “Is it 80 mg?”
    Her: “Yes. Oh, they only want it if it’s the Tylenol brand.”
    Me: “If they want the brand name, they’ll have to pay out of pocket for them, their insurance only covers generics.”
    Her: “OK, cancel it then.”
    Me: “For the brother also?”
    Her: “Yes, cancel them both.”
    Me: “OK, fine by me.”
    Note how I have to drag every datum out of her like pulling teeth. Not to mention that there are about 10 MDs, NPs, and PAs at this practice and I have to ask them, every time they call, which prescriber it is. (And sometimes they announce themselves on the phone as Dr A’s office, and at the end when I ask who the prescriber is, it turns out to be Dr B, or Mrs C, RN. At least I’ve got most of them trained to give me the date of birth unprompted.) I won’t even get into the idiocy of a medicaid-HMO patient expecting brand-name Tylenol.
    Regarding “Metformin 750mg bid”, it’s obviously a mistake, but it could be either of two mistakes: 1, they wanted 850 and messed up the dose, or 2, they wanted Glucophage-XR 750 and forgot the XR. No way to guess which without a phone call.
    Also prednisone was a steroid, last I checked. Could be the prescriber thought that the pulse of oral steroid would be enough without adding an inhaled one, I don’t know. It’s certainly obvious that they don’t know what DAW means, or they wouldn’t be putting it on a single-source product.
    The RNs and CNMs around here aren’t so bad, maybe you’re just unfortunate enough to have a run of morons where you are, or maybe I’m just lucky. One thing I do have to credit them for, at least they have better handwriting than the docs…
    @whippin’ boy: You know what’s worse? how about the wife/secretary/etc. calling in prescriptions for their families and friends? and sometimes even calling *from home*? “Oh, I work for Dr A, can I just call in a prescription for my son for amoxicillin?” “No, you can’t. Have the office do it.”
    Shalom

  7. RJS says:

    Can’t say we have the same problem with PAs and NPs that you seem to.
    I see more stupid stuff from doctors and dentists than I do from NPs or PAs. (%-wise, anyway.) I think it’s an ego thing.

  8. David S. says:

    Yep know what ye talkin about. Here in Indianapolis, IN we have to watch out for the docs in the Wishard ER all the time. These dumbfucks want to give 3 year olds 1750mg of Amoxicillin tid. You call the ER to ask what they are thinking and you get a recording…it’s not our policy to return phone calls…no fuck!!!…and this is after you hear the first recording touting Wishard as a world-class institution.

  9. CPhT says:

    TAP,
    The local pediatric hospital sends in amox doses just as a mg/kg we have to decipher with the kg they provide and the strengths of amox we have in stock. Typically, their doses can get crazy stupid, like 6.825 ml q8, or something just as ridiculous.

  10. rph3664 says:

    How about the elephant-sized doses for an adolescent, according to weight? I once had a customer who probably weighed 400 pounds and his doctor didn’t give him that much amoxicillin.
    “But the book says 50mg/kg!”
    “The book isn’t sick.”
    oooookay

  11. chsrx says:

    I work in rural area and PA’s and NP here have a few screws loose. This one NP… My favorite is that every last patient gets Vicoden ES for cough, “dexamethasone taper”…with no instructions…and my favorite bullshit drug of the century…Lodrane D-24hr…(BPM and Pse)…how the hell is this any damn different than claritin D? or Drixoral for that matter? You can tell which drug rep made a pit stop that week. Oh and how can I forget Spectracef…how is it that only PAs and NP write for this shit?
    Unrelated, but has anyone ever heard of a psychiatrist writing for Oxycontin 40mg 3 tabs qd #90, for “chronic pain syndrome”. Me thinks this falls outside the realm of psychiatry, unless of course the chronic pain syndrome is all in pt’s head! and me thinks that pt will be 12 hours with pain…I gave it back to pt. and told them to find someone else who’s fill it like that.
    Oh regarding APAP thing… totally agree with you on that one…hydrocod 7.5/750, 1-2 q4-6 prn pain….I too tack on ” no more than 5 tabs in 24 hours”, but patient loses their damn mind when I do that, because I am not filling how DR. wrote it and they cant get their refill early…what’s even worse is that Dr. and nurse are clueless when I bring it to their attn. Pts with chronic pain end up dying from liver failure half the time, not hydrocodone OD. I heard of a pharm in WA whose lic has been suspended for not telling pt the max per day even though DR. wrote 1-2 q4-6. Scary shit…

  12. TheDruggist says:

    I had a NP/PA call me the other day to find out a patient’s weight for calculating a dose……um..how the hell do I know!!! Don’t they write all that crap in the chart for a reason?

  13. indietech says:

    i can’t stress enough, PERFECT TIMING!! last night i was visiting a good friend of mine who is currently planning on applying to med school in the next year or so. however, some idiot who had his head up his rear end thought it would be a good idea to convince her that “NP/PA is the way to go! all the money, none of the liability!” i have since tried to tell her what a horribly AWFUL idea that would be, and how many stupid PA/NPs i know. if she were to become one, i’d be forced to kill her. she’d even shoot right past the 3 FNPs on the top of my list who apparently get high from writing as many different HRT combinations as possible. (usually we get 2 different scripts, exactly the same, but the estradiol strength is 0.05 mg off, or some such nonsense.) one thing i’ll never understand is how these idiots are allowed to prescribe or even call in prescriptions, when techs can’t even do a transfer. sure, put the lives of your children in the hands of the PA who can barely spell their own name, but goodness forbid a tech read some words off a computer screen.

  14. annoyed says:

    Have you ever seen Zithromax 100/5 (note: not 200/5) written as 1 1/2 teaspoons day 1, 3/4 teaspoons QD x 4 days? yeah, it’s pretty annoying to use TWO bottles, since the 100/5 doesn’t come in a 22.5mL bottle AND it’s pretty difficult to just convert those dosings to the 200/5. Stupid. Just do the 200/5 and be done with it.

  15. Steph says:

    I never say “Max 8 tabs per day” or “Not to exceed 5 tabs per day” because, YES, I have had the pleasure of facing the patient who tries to finesse the warning with the following: “Well, that’s 5 tablets per day…” (You KNOW what’s coming, don’t you??)…”But what about at night?” So, from now on, it’s “No more than 5 tablets in 24 hours.”

  16. Dan says:

    TAP,
    I have the answer to this amoxicillin nonsense. Let’s write an amoxicillin dosing calculator that automatically rounds the dosage based upon the concentrations and package sizes that are actually available. To put the prescriber’s mind at ease, it could also indicate the mathematically exact dosage for comparison.

  17. http://openid.aol.com/rgregg78 says:

    Listen to what happened to me the other night,then followed by the next day. A nurse brings in an rx for D-n-100, wants to pay cash and then talks to me about how she works for this doc. OK, 2 red flags just went up in my book, #1 she’s paying cash for a control and #2 she works for his office. For those of you that aren’t pharmacist, there must exist a DR-pt relationship(ie a chart) for the Dr to write a script for the above nurse. SO, I just had a shady feeling about it. Well, I call the office, ask to verify the script(did I mention that this is an urgent care facility) and her profile lights up with controls from this Dr. ANYWAY, so I call, give my spill to the lady on the phone(she wants to get my number then call me back b/c she can’t locate the chart) I tell her I’ll be happy to hold,then she transfers me to the nurse. I explain to the nurse(give her my spill0 and ask when the MD will be back so I can verify the script(she won’t give me that information) and says she’ll have to take my name and number and call back b/c they’ll have to find the chart. Next thing I know the Dr is calling me back and I verify the script(90% of me thinks there is NO chart…but that’s another story). Script is legit. THE NEXT DAY, pt shows up DEMANDS to see the script, she said her office thinks she’s altered the rx and that YOU the pharmacist have violated HIPPA!!! She name drops our DHEC agents name(DHEC in SC is like a local DEA that monitors our pharmacys and Dr shoppiing and the likes) and says she can call him she knows him and I said it’s not a problem, but by law I can call and verify any script I want to!! For those of you that don’t know, there was no HIPPO violation on my part, there was a violation in her office if her staff is talking about her!!!! Also, explain to me why a nurse of 30+ years is getting controls from the urgent care where she works(not even a gp) and is paying cash, last I checked nurses made around 40-60k a year…???? Oh well! Cheers to all!!!

  18. Pharmacy Hell says:

    Yeah, I swear to God that there are days when the cleaning lady is phoning in scripts.
    “What’s the sig?”
    “Huh?”
    “The DIRECTIONS.”
    “Oh, I will have to call you back.”
    But yet my tech with 35 years of experience cannot transfer an Rx. Go figure.

  19. rph3664 says:

    Pharmacy Hell, I once called a university hospital eye clinic to refill some drops for a person who clearly had a very serious eye disease. (Don’t recall what the drops were). Anyway, the woman on the other end introduced herself as a nurse but it quickly became apparent that she did not know what she was talking about, so I said (exact words), “Could you get me someone who knows what they’re talking about?”
    She put me on hold and did so.
    Impersonating a nurse has serious consequences. I don’t know what her actual title was, but I sure hope she was NOT a nurse!
    I, too sometimes wonder who they let into nurse practitioner school. I have not had these experiences with physician’s assistants. The only advanced-degree nurses I have encountered who are competent across the board (well, mostly so) are nurse-midwives and nurse-anesthetists.

  20. I love your shit but your starting to piss me the fuck off.
    Stop going for the easy targets bitch, like the NP’s or PA’S AND FOCUS ON THE REAL ASSHOLE SHIT SCRIP WRITERS: THE MD’S.
    Fuck you you arrogant little pharm tech. Everyone but you and MD’s are stupid. Go suck a fentanyl lollipop you arrogant shitbag.
    IF YOU ACTUALLY WORKED IN A CLINICAL AREA YOU WOULD BE APPALLED TO SEE HOW LITTLE A SHIT JACKASS DINGLEBERRY, M.D. GIVES . ITS NP’S AND PA’S WHO USUALLY HAVE TO CLEAN UP THE MESSESS AND GIVE A SHIT. MOST MD’S WON’T EVEN TAKE YOUR FUCKING CALL AND YOU KNOW IT. BITCH
    (But I do love your blog, always puts a smile on me face)

  21. Linda Bartmess says:

    Why don’t people seem to understand that dentists are doctors too? The correct verbage is physicians and dentists, not doctors and dentists. Piss off the entire dental community with the slap. Might as well mention vets too, they are also doctors of the animal kind. Thanks

  22. rph3664 says:

    Linda Bartmess, podiatrists are doctors too. They even perform surgery at my hospital!
    When I was in retail, at least once a week someone would walk up with a very sheepish look on their face and ask if we filled prescriptions from veterinarians. They would also apologize for not knowing, and we would reply that yes, they are animal doctors and we do this all the time.
    The most exotic species I ever filled for? A duck.

  23. Shalom (R.Ph.) says:

    @Linda: I didn’t say “Doctors and dentists”, I said “Doctors, and especially dentists”. The word “Especially” implies that the second is a subset of the first.

  24. one_angry_tech says:

    Actually, angry male nurse, the NP (Not Physician) is the worst where we work…

  25. LotusMD says:

    Why do you pick on mid-levels? I have 3 CRNPs and 2 PAs that work for me, and they are the most amazing group of people. I do notice that mid-levels are much more willing to look information up and double check themselves than us Doctors. I’m in an extremely large group, a total of 8 doctors and our 5 mid-levels, and I’ve witnessed first hand the CRNPs helping our newbie doc learn the ropes. You might not see it but they really are all about patient care, and are patient advocates. I think they bring that with them from nursing. I’ve worked with a good number of CRNPs and I would say as a group seem to be much more passionate about patient care. They get the priors done extremely quickly, they fight to get Mr. Aetna to pay for things for the patient. I think there are some crack pot NPs too. When interviewing, it seems the ones who want to write for really strange things tend to be the ones who are older and who did hospital or whatever for 20 years and then went back to school. Experience makes up for alot. Newbie doctors do some pretty stupid things. And admit it so do newbie pharmacists, I can always tell who’s a new grad when their asking me if I’ll ok a change from 30g to 60g and to delete the 1 refill i had on the rx because they only have the 60g tube of cream in stock. I dont get mad, i just say SURE!. Everyone was green once. This includes Np/PA
    And I’d like to do a little rant of my own. I don’t mind having a Pharmacist question a prescription I wrote. However, Pharm Techs really do seem to stand out, as a group that drives me crazy. They call and question a script and then try and convince me to switch the paitent to generic retin-a gel from Differin 0.1% cream. I wrote for that for a reason, and I proceed to explain my reason ( in more PC terms…I dont want to turn them into a lobster) to them and either get the wonderful….”uhhhh….now what? …ok thanks bye” or i get lip that its out of stock or something else. If it needs a prior auth, I’ll take care of it. If its out of stock, most stores are able to next day a product mon-thursday. i admit i get a little insulted that i’m being questioned by someone who has a minimal education. You want to rag on CRNP/PA, they all have masters degrees, I don’t think you can say the same for a PharmTech. ( And i dont mean to bash techs as a whole, I’m sure there are some exceptional ones out there. I just seem to run into the less than amazing group)
    Bottom line, there are good and bad people in every profession. There are horrible doctors and horrible pharmacists. And I know this is the Angry Pharmacist, but all i ask is that instead of basing a whole profession in much the same way that people bash pharmacists. ( I know lots of doctors that have no clue how important you guys really are and wish you would be replaced by robots.) I understand you’re just venting your frustration with funky dosages and the target of the rant was most likely whoever pissed ya off last. But, I like to turn that frustration that incur into something productive. If you have a major issue with a certain Prescriber’s habits why not send them a friendly fax asking them to round up, and explain the importance of it and the benefit to the patient.
    i really do value the pharmacists in my area. I like to view our relationship ( Prescriber – Pharmacists that is) as one of checks and balances, and that we work as a team.

  26. MD who never worked in a pharmacy says:

    I’ve read your blog from time to time and notice you or those leaving comments often complain about scripts written that require using 1/4 of a supply bottle or something similar and saying that the prescribers should know better. But neither Tarrascon nor Epocrates(as of 4-5 years ago when I last used it) list the size of the supply bottle. And I don’t have time to go to PDR or Facts and Comparisons or some other massive resource to look it up either(assuming it is in there. I don’t know). With time I could memorize the supply bottle sizes of my most commonly written scripts where it matters I guess, but as I am sure you can understand, that is not on the top of my list of things to be concerned with during the visit.

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