Interview with a VA Pharmacist: Prescription Process Insights

Introduction

Health care practitioners are frequently required to engage in interprofessional collaboration in order to provide optimal patient care (Poling, Wilson & Finke, 2016). Because the vast majority of inpatients will receive some type of pharmaceutical as part of their health care regimen, collaboration between tertiary care pharmacists, nurses, and other health care providers is an ongoing need (Angel & Friedman, 2016; NLN releases a vision for interprofessional collaboration, 2016).

This paper presents the results of a face-to-face interview with a pharmacist employed at a major medical center operated by the U.S. Department of Veterans Affairs (VA). Topics addressed include a description of the process of filling a prescription, some of the more common reasons pharmacists call providers to clarify orders, the information contained on a proper prescription, and some of the more common omissions that pharmacists encounter when they receive prescriptions. Finally, a description of common medication errors pharmacists encounter and a discussion of the prior authorization (PAR) process and common PAR medications are followed by a summary of the research and a reflection on how this information will inform future prescription writing practice.

The Process of Filling a Prescription

A prescription is transmitted to the pharmacy either as a handwritten hard-copy order or electronically. Upon receipt, the information on the prescription is entered into the pharmacy's database and checked for contraindications with other prescribed medications and known patient allergies. The drug is then dispensed or formulated from the pharmacy's stores, transferred to an appropriate container, and labeled. Finally, the patient's identification is verified and the drug is dispensed.

Common Reasons Pharmacists Call Providers to Clarify Orders

Despite the increased use of electronic medical record systems that allow prescriptions to be filed digitally, pharmacists still receive a large number of handwritten prescriptions. In the case of electronic prescriptions, pharmacists typically call providers to clarify orders only when the prescribed pharmaceutical is contraindicated for the patient — due to other prescribed medications or known allergies. In the case of handwritten prescriptions, busy physicians and advanced practice nurses may omit important information (see the section on common omissions below), or their handwriting may be illegible to the point where the pharmacist must contact the prescriber for clarification.

What Is on a Proper Prescription

In general, prescriptions should include the name, address, and telephone number of the issuing provider; the provider's Drug Enforcement Administration (DEA) number and signature; the patient's name and date of birth; the date; and a description of the prescribed drug and its dosage, as well as the frequency and route of administration.

Common Omissions and Medication Errors

Many of the omissions on prescriptions involve the so-called "Five Rights" — the right patient, the right drug, the right dose, the right route, and the right time. Other common omissions include the provider's signature and the date of issuance.

With thousands of drugs in a typical pharmacy's formulary, there is always significant potential for adverse interactions between contraindicated drugs. In addition, dosage abbreviations are frequently expressed incorrectly or illegibly, and decimal points may be misplaced. Likewise, pharmacists routinely encounter instances where an incorrect but similarly sounding drug name is used on a prescription, necessitating clarification with the health care provider.

The Prior Authorization Process and Common PAR Medications

The VA recently implemented a prior authorization process for several drugs on the VA National Formulary (VANF), including benzocaine, lidocaine, and various preparations of insulin, among dozens of others (VHA Directive 1108.08, 2016). The use of a prior authorization process confers a number of benefits for VA pharmacists, providers, and patients alike. For instance, according to the Academy of Managed Care Pharmacy, prior authorization "gives the prescriber the opportunity to justify the therapeutic basis for the prescribed medication. Guidelines and administrative policies for prior authorization are developed by pharmacists and other qualified health professionals" (Prior authorization, 2012, p. 1).

Conclusion

The results of the face-to-face interview with a VA pharmacist and supplementary research confirmed that the prescription writing and filling process is fraught with opportunities for errors of all sorts, including the omission of vital information and the inaccurate expression of dosages or frequencies of administration. Although the responsibility for ensuring that a prescription contains all the information needed by a pharmacy to process an order appropriately begins with the health care provider, pharmacists play an important role in ensuring that dispensed drugs are not contraindicated for patients due to allergies or other medications. It is equally important that providers understand the requirements of the VA's prior authorization system in order to take advantage of the cost savings and other benefits this process provides.

Angel, V. M. & Friedman, M. H. (2016, July 1). Integrating bar-code medication administration competencies in the curriculum: Implications for nursing education and interprofessional collaboration. Nursing Education Perspectives, 37(4), 239–243.

NLN releases a vision for interprofessional collaboration in education and practice. (2016, January–February). Nursing Education Perspectives, 37(1), 58.

Poling, D. B., Wilson, M., & Finke, L. K. (2016, November 1). Interprofessional research guidelines for health care students. Nursing Education Perspectives, 37(6), 345–349.

Prior authorization. (2012, April). Academy of Managed Care Pharmacy. Retrieved from

VHA Directive 1108.08. (2016). U.S. Department of Veterans Affairs. Retrieved from [redacted address].