Pharmacists in the ER Equals Better Patient Care

One of the biggest impacts a pharmacist can make in the hospital setting is in the emergency department (ER). There has been a growing interest and trend in placing pharmacists in the ER to review medications, both reconciliation of home medications and medications administered in the ER to ensure correctness and cut down on medication errors and drug interactions that contribute up to 7,000 yearly deaths in the US. A pharmacist in the ER can review real-time orders that are typically bypassed by staff pharmacists due to the urgency of an ER patient.

Pharmacists can also improve flow of patients through the ER, educate prescribers and staff development about medications and their costs and also utilize the ER as a place to precept and mentor students and residents. Pharmacists can participate in codes, help with admissions in home medications and help with discharge medication reconciliation. Pharmacists in the ER can also be involved with the ER department in providing presentations, publications and other activities to the department. Pharmacists can monitor the use of expensive medications to make sure use is consistent with approved criteria (Factor VII, alteplase, etc.) and conduct MUEs in the emergency room setting. These pharmacists could also be involved with microbial culture follow-up. The emergency department is usually a place of unpredictability in acute illnesses and patient volume. High risk medications are used more often and a greater chance of a medication error reaching the patient.

Currently in most hospital settings, hospitals use a clerk to fill out a home medication sheet which typically can include errors in drug name, drug strength and directions. Many times staff pharmacists are clarifying home medications days later than what is optimal. I have personally witnessed mistakes in high-risk medications like warfarin that are discovered days later. In short, when a patient is admitted, they are prescribing for themselves with no oversight from a pharmacist, and physicians do not want to take ownership of what the patient takes at home since they are presenting with something acute that may have nothing to do with the herbals they take on the side.

The American Society of Health-System Pharmacists (ASHP) believes every hospital pharmacy department should provide its emergency department with the pharmacy services that are necessary for safe and effective patient care. The Joint Commission also has compliance requirements that can be met with a pharmacist in the emergency department (MM.4.10. which requires that all medication orders be evaluated by a pharmacist prior to administration of the first dose and MM 7.10 which identifies high-risk or high-alert medications and all the processes involved from procuring to monitoring and medication reconciliation). One of the National Patient Safety Goals is to accurately and completely reconcile medications across the continuum of care which would include the first stop in the emergency department.

One of the most common reasons most hospitals do not employ emergency room pharmacists is due to cost. Small hospital pharmacies are staffed at a bare minimum. Most hospitals do not realize that pharmacists working in the emergency room can reduce readmissions, medication errors and drug interactions to save money but more importantly increase patient safety while being treated for an acute illness.

1.       Impact of a prescription review program on the accuracy and safety of discharge prescriptions in a pediatric hospital setting. J Pediatr Pharmacol Ther. 2008 Oct;13(4):226-32. doi: 10.5863/1551-6776-13.4.226.

2.       Levy DB. Documentation of clinical and cost saving pharmacy interventions in the emergency room. Hosp Pharm. 1993;28:624-627,630-634,653.

3.       American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health Syst Pharm. 2003; 60:1993-5.

4.       Cohen V, et al. Effect of clinical pharmacists on care in the emergency department: a systematic review. – Am J Health-Syst Pharm. 2009;66;1353-1361

National Patient Safety Goals: The Joint Commission

Converting From One Anticoagulant to Another

One of the most common questions I have answered in the past year has been in regards to converting from one anticoagulant to another (especially with the release of the newer rivaroxaban, apixaban, and dabigatran). Perhaps the physician wants the patient to avoid multiple labs with warfarin monitoring with one of the newer agents while outpatient or maybe the patient cannot keep their Vitamin K rich food intake consistent with warfarin. Whatever the reason, these factor Xa inhibitors (apixaban, fondaparinux, and rivaroxaban) and direct thrombin inhibitor (dabigatran) are chipping into the warfarin market for different indications. 

CONVERTING APIXABAN (ELIQUIS)

warfarin to apixaban	stop warfarin and start apixaban when INR <2
apixaban to warfarin	start warfarin and stop apixaban 3 days later OR stop apixaban, begin a parenteral anticoagulant (UFH or LMWH) and warfarin at the time apixaban would have been due and stop LMWH or UFH when INR therapeutic
LMWH/fonda to apixaban	stop LMWH/fonda and start apixaban 0-2 hours before next dose LMWH/fonda due
heparin to apixaban	stop heparin and start apixaban same time
apixaban to LMWH/UFH	stop apixaban and start LMWH/UFH at the time apixaban would have been due
apixaban to oral anticoagulant other than warfarin	stop apixaban and begin the other at the time the next scheduled dose of apixaban would have been due

CONVERTING DABIGATRAN (PRADAXA)

warfarin to dabigatran	stop warfarin and start dabigatran when INR <2
dabigatran to warfarin	CrCl > 50 mL/min: start warfarin and stop dabigatran 3 days later CrCl 31-50: start warfarin and stop dabigatran 2 days later CrCl 15-30: start warfarin and stop dabigatran 1 day later
LMWH/fonda to dabigatran	Stop parenteral anticoagulant and administer dabigatran 0-2 hrs before next parenteral dose would have been given
IV heparin to dabigatran	Administer first dose of dabigatran at time of discontinuation of IV heparin infusion
dabigatran to LMWH/UFH	CrCl > 30 mL/min: start 12 hours after the last dose of dabigatran CrCl < 30: start 24 hours after the last dose of dabigatran
dabigatran to oral anticoagulant other than warfarin	Stop dabigatran and begin the other anticoagulant at the time the next dose of dabigatran would have been due

*Dabigatran may alter INR results

CONVERTING RIVAROXABAN (XARELTO)

warfarin to rivaroxaban	Stop warfarin and start when INR < 2 (manufacturer says < 3 however, expert consensus recommends wait until INR ≤ 2.0 before starting a new oral anticoagulant.)
rivaroxaban to warfarin	Start warfarin and stop rivaroxaban 3 days later OR stop rivaroxaban, begin LMWH/UFH and warfarin at same time the next dose of rivaroxaban would have been given and stop LMWH/UFH when INR is acceptable
LMWH/fonda to rivaroxaban	Stop LMWH/fonda and start rivaroxaban 0-2 hours before the next dose of LMWH/fonda would have been given
IV heparin to rivaroxaban	Administer first dose of rivaroxaban at the same time as d/c heparin
rivaroxaban to LMWH/fonda	Stop rivaroxaban and administer at the time the next dose of rivaroxaban would have been given
rivaroxaban to oral anticoag other than warfarin	Stop rivaroxaban and begin the other anticoagulant at the time that the next scheduled dose of rivaroxaban would have been given

Sources: Pradaxa package insert, Eliquis package insert, Xarelto package insert

 Read more at: 

http://www.pharmacytimes.com/contributor/beth-lofgren-pharmd-bcps/2015/01/how-to-convert-between-anticoagulants

Leaving the Anti-Vaccine Movement

The anti-vaccine movement had me in its grips after the early birth of my first child In 2008. My son's lungs were not fully developed, and he needed the NICU. My husband and I had signed up for a "natural" childbirth class where epidurals were evil and rupture of membranes did not mean go to the hospital. We were also told to forgo the hepatitis B vaccine for our newborns because "babies don't have sex or do illicit drugs by injection." I am a hospital pharmacist and was falling for it all.

Jenny McCarthy and Dr. Andrew Wakefield were regularly in the news for the connection between vaccines and autism, and I was fearful for my son. After all, Dr Wakefield was a physician with a research paper in support of the connection between vaccines and autism. Also it was a little bit popular to be anti-vax.

Herd immunity is a form of immunity that results when the vaccination of a significant portion of the population provides a measure of protection for those who have not developed immunity. Herd immunity disrupts normal transmission of diseases covered by vaccination. The anti-vax movement directly compromises this immunity resulting in less people becoming vaccinated and increases in diseases that were virtually eradicated.

Measles is on the rise. Dr. Mark Grabowsky, a health official with the United Nations, wrote last year in the Journal of the American Medical Association-Pediatrics. “Many measles outbreaks can be traced to people refusing to be vaccinated; a recent large measles outbreak was attributable to a church advocating the refusal of measles vaccination.” Measles was once considered eradicated. For every 1,000 children who get the measles, one or two will die from it, and one will get brain swelling so severe it can lead to convulsions and leave the child deaf or mentally impaired, the U.S. Centers for Disease Control and Prevention said. In contrast the fears parents have to vaccinate in relation to autism and MMR according to the Wakefield study continues to rise even though the study was proven false. Wakefield was stripped of his license to practice medicine, and numerous conflicts of interest surrounding the study were discovered. Once upon a time before vaccinations, nearly everyone in the U.S. got measles before there was a vaccine, and hundreds died from it each year. Today, most doctors have never seen a case of measles, but cases keep popping up, the latest starting in Disneyland.

Still the anti-vax movement continues. 

Mumps have also made a comeback. Before widespread vaccination, there were about 200,000 cases of mumps and 20 to 30 deaths reported each year in the USA. Mumps can in some cases lead to encephalitis and deafness. Herd immunity is important because the mumps vaccine is just 88% effective, explaining why someone can easily contract the disease even if they have been vaccinated as I did back in 9th grade from a foreign exchange student. I was vaccinated, but for whatever reason was infected from someone overseas. The CDC reports that the number of mumps cases doubled in the past year - affecting more than 1,000 people nationwide.

Mumps in the United States from 1970-2005

Mumps in the United States from 1980-2005

Pertussis or whooping cough was a universal disease in the pre-vaccination era was almost always seen in children. Between 1940 and 1945, before widespread vaccination, as many as 147,000 cases of pertussis were reported in the USA each year, with approximately 8,000 deaths caused by the disease. It is estimated that at the beginning of the 20th century as many as 5 of every 1000 children born in the USA died from pertussis.

Pertussis in the US from 1940-2000

Pertussis in the US from 1980-2005 (on the rise)

Why don't parents vaccinate today? Parents today did not grow up with these diseases and see the thousands of children die. We are not afraid of these diseases because they have not been a part of our lives and take for granted how these diseases can cause death or severe consequences. Parents hear celebrities like Jenny McCarthy, Alicia Silverstone and Kristin Cavallari cite fear as a reason not to vaccinate. But what many don't realize is that those against vaccines and not vaccinating their children depend on the rest of us to vaccinate to stay safe. The more people that join in the crusade that vaccines are evil, the higher the risk their own children will succumb to diseases that were virtually gone just a few years ago. 

Side effects of vaccines are mild according to the CDC. And while there are very rare cases of vaccine-related issues, the benefit far outweighs the risk if you compare the numbers pre-vaccination era vs. after vaccinations were introduced.

Why should parents vaccinate? Parents should vaccinate because vaccines are preventing complications from preventable childhood illnesses that can cause deafness, blindness, hospitalization, other life altering effects and death. Parents should become informed and become critical thinkers about the decisions made to increase the risk of these diseases to their children and others who are unable to fight infection (elderly, immunodeficiencies, and the very young). Parents should not, as I did, make decisions by fear and paranoia and look at the facts. We should also as a society consider public health and realize that vaccines are safe and very effective and not vaccinating is irresponsible.

Fortunately, I woke up from the "anti-vax movement" before endangering my son further. Although his vaccines were spaced out individually and further apart, he ended up receiving them all. My daugther, on the other hand, received them all on time as outlined by the CDC. I do have much greater peace of mind knowing the numbers don't lie, vaccines save lives and have since they were first introduced years ago. I am glad I did not let the fear of the unknown and debunked guide my choices to put them in harm's way.

Should Pharmacists Become Board Certified?

I enjoy brainstorming with other pharmacists on becoming board certified.

I remember back in 1998-1999, the assistant dean of my alma mater, the University of Tennessee at Memphis, stressed how important it was to consider residency and board certification. At the time, I was 25 years old and making decisions that would impact me for life.

I decided back then to decline that path. I only saw the dollars that were before me in retail pharmacy and the student loan debt approaching 6 figures. So, I quipped, "Why would I want to work for half pay or less for a whole year?" and "Why would I want to spend money and time to become board certified when there are no immediate financial rewards?"

Hindsight is 20/20. Fast forward to a 40-something in the profession for more than 14 years experiencing all sorts of different pharmacy experiences. After trying most, I have regrets regarding my earlier decisions. I regret not doing a rotation overseas. I regret not doing a residency. I regret that I dismissed it all for more money.

I know that not everyone feels like me, and that is understandable. Perhaps I am just a different sort who realized fairly quickly that I was falling behind. Whatever the reason, I decided to pursue a Board Certified Pharmacotherapy Specialist (BCPS) certification a couple of years ago. I work in a small community setting in a smaller city, and although it is nothing like Memphis in terms of clinical opportunities, such opportunities can be found with a little luck. Passing the test was probably up there with my other personal accomplishments.

Why should you become board certified?

1. According to the Board of Pharmacy Specialties (BPS) website, "From patient to provider, the value of the BPS-certified practitioner registers throughout the health care continuum. For pharmacy professionals, documentation of specialized experience and skills yields the additional benefits of personal satisfaction, financial rewards and career advancement." I definitely agree, but most BCPS-certified pharmacists I have spoken with did not receive a raise unless they changed jobs. While BCPS certification may have helped with landing a clinical job in the past, it might just be something to separate you from a PharmD without BCPS on any pharmacist job interview today.

2. If you have been out of school for more than 5 years, I bet you have already forgotten some of what you have learned. You can either depend on your local hospital's computer system to remind you of every little thing OR you can take charge of what you know and remain committed to being the best pharmacist you can be. Think of it like this: if you work in a hospital and are commanding larger salaries than new graduates with fresher knowledge, there comes a point at which you are replaceable. Remain competitive in your field, which means using continuing education to really learn something, rather than last-minute cramming to renew your state license.

3. A paper published in 2006 states that "Future Clinical Pharmacy Practitioners Should Be Board-Certified Specialists.” In the past, clinical pharmacists have not made board certification a priority, but this is changing rapidly in both clinical and staff positions. As pharmacists move in the direction of becoming reimbursed professionals for optimizing medications, there will be a trend toward licensing agencies requiring board certification in certain scenarios. Sure, that is not the case today, but if you would have told me in 2000 that the market would be in its current shape with oversaturation and residency demand, then I would have done things very differently in 1999-2002.

4. The PharmD curriculum is not enough to get you in sync with other health care professionals. Experience in dealing with physicians and their assistance along with board certification will take you to the next level in recommending appropriate treatment. Placing new graduates in clinical positions without experience and expecting them to build relationships with clinicians is not the best-case scenario for building pharmacist clinical teams. Requiring board certification ensures a higher level of expertise and is moving toward becoming a requirement in many hospitals. The benefits in just preparing and studying for the test are immense, in my experience.

5. Last, but not least, you should become board certified to give your patients the best care possible. This was my number 1 reason. I remember the day when I sat at my desk years ago and realized I had no idea about new practice guidelines and that order entry had essentially turned me into a robot dependent on the computer. I realized that it was time to make some personal changes that would cost me both dollar and time, yet result in amazing benefits for my patients.  

Most pharmacists are reluctant to pursue BCPS certification because no one wants to fail, much less fail twice. Although it is humbling to fail once, it is euphoric to pass, even the second time.

I hope to inspire more pharmacists to be their best in our profession. If you fail, realize that any amount of learning will significantly change how you practice pharmacy. 

The Top Searched Medications of 2014

The Top Searched Medications of 2014

Interested in the top searches in medications in 2014? This year’s list includes:

1. Antibiotics: No, this is not a drug but a drug category; however I suppose capturing the whole category is OK. We have issues with antibiotic resistance, drives for antimicrobial stewardship, and drug-drug interactions. 

2. Adderall: Increased from #6 search last year though it’s been around for years. Adderall has spent the past 10 years in the top 10 of medication google searches.

3. Alprazolam: Same as Adderall has been searched enough to be in the top 10 for 11 years.

4. Ibuprofen: Who knew but I bet all the parents of kids are constantly looking up doses.

5. Steroid: This could capture creams, tablets, and parenteral.

6. Tramadol

7. Tylenol

8. Paracetamol: Another term for APAP 

9. Naproxen

10. Aspirin

11. Sildenafil: I wonder if online pharmacies are the reason? Privacy in purchasing.

12. Sertraline

13. Amoxicillin

14. Gabapentin

15. Cyclobenzaprine

16. Analgesic: Again a class of drugs that contain many specific ones on this list.

17. Fluoxetine

18. Bupropion

19. Omeprazole

20. Escitalopram

With mostly medications for pain, depression/anxiety, and infection the list captures usage as well. Cite top prescribed drugs in same year?

Pharmacy Distractions

Yesterday, I decided to record the number of distractions I faced on a regular work day. This proved to be a distraction in itself considering the pharmacy where I worked is in an open plan where technicians, phones, cubicles and door to the hospital hallway are all within ten feet of where I sit. There are four or five telephone lines which ring regularly. There are usually one to two other pharmacists sitting within five feet and two to three technicians in the same vicinity.

Yesterday I recorded over 150 interruptions. I even faulted myself for starting personal conversations which distracted others. 

What are some things we can do to make the pharmacy workplace have less distractions? Interruptions contribute to medication errors and having a dedicated space where interruptions are not allowed should be implemented. Chemotherapy entry, preparation and checking definitely falls into this category. The Institute for Safe Medication Practices found that each interruption is associated with a 12.7% increase in errors. I have personally attempted to enter new chemotherapy on a patient in the noisiest place where phones are ringing consistently, technicians are interrupting the workflow with issues on the phone that they cannot handle and other staff are just walking by to chat, all while the TV is reporting the news and a radio in the back is piping out 80s music. It is enough to cause me to go into panic mode. Ask for a dedicated space with less distractions or a no-interruption zone. You may not get it but it is on the record that you asked. In the meantime, one tip I have tried is headphones with something soothing to completely block out all noise when concentration is key. Bose makes great noise-canceling headphones that work! Though I would love to work in silence, blocking out everything but one sound is better than ten sounds all interrupting and distracting what you are trying to do safely. 

Another source of interruptions is when a medication is out-of-stock. This issue can completely lead a pharmacist into a rabbit hole of issues. First I have to ask if we have the medication which leads to comments of inventory failure and what process is to blame. Second we have to call other hospitals and ask to borrow a medication which interrupts them as well. We also have to call a courier service to deliver the medication which leads to delay in delivery of treatment to the patient. If we could reduce missing medications, we could reduce distractions and phone calls. This type of interruption falls under system distractions along with medication timing and other issues that causes distractions on how we handle system failures or deficits.

Alert fatigue is another source of distraction. It is common for me to receive five or more alerts per order when entering a medication with the majority being unnecessary. For example, when entering a sodium chloride IV fluid, I will routinely be alerted that the chloride in the IV fluid will be a duplication with the potassium chloride (chloride duplication). I will also receive an alert that sodium chloride is on national backorder. Most of the times medication alerts include what is formulary, nonformulary, to notify IT staff when medication is depleted, duplication of class that isn't clinically significant, insignificant labs that can include a time period longer than current hospitalization and even how to enter medications differently for a new process that can change quite often. It is used more times than not as an email to communicate inventory issues that should be saved for another time and not when entering a medication where the most important issues are drug, strength, indication, directions and allergies. All of the important stuff can be diluted quickly by things that are nowhere near as important than the task at hand.

Educating the staff is very important in handling distractions and improving patient safety. Educating the staff to know when to interrupt with something important that cannot wait a second and when to write a note for the pharmacist to handle a few minutes later is important. Placing phones with multiple lines in a separate area to lower distractions while the pharmacist is entering orders or checking orders and/or having a designated technician to answer phones and not filling is an idea to consider. Also educating a technician on how to answer the phone and troubleshoot is invaluable!

The Institute for Safe Medication Practices has looked at this issue and has an invaluable write-up about things that can be done to help pharmacists and technicians focus on what matters most... patient safety.

Creative Ways Drug Companies are Changing Drugs of Abuse

The FDA has taken a stance on decreasing drug abuse and pushing for drug companies to find ways to deter people from abusing prescribed medications (crushing, snorting or injecting tablets) or using medications the way they were not intended to be used.

Some of the novel drugs that have been created include:

• Hysingla is a harder to abuse hydrocodone that deters crushing, dissolving and injection because the contents turn into a thick gel when attempting to dissolve.
• Targiniq, when crushed and snorted or crushed, dissolved, and injected, the naloxone blocks the euporic effects of oxycodone making it less liked by abusers than oxycodone alone.
• Embeda is an agonist/antagonist combination of an extended release morphine with naltrexone. Naltrexone is not an active component unless the tablet is chewed, crushed, or dissolved.

Unfortunately, the most common route of abuse of these types of medications is the oral route. This cannot be addressed through the physical component of the tablets on the market but has been combated with changes such as state databases showing trends of prescription opioid fills and refills and also changing hydrocodone from a CIII to a CII causing more regulation and different rules for the pharmacist and prescriber to follow.

So You Want to be a Pharmacist?

Inevitably while speaking with those interested in pharmacy as a career or those who have already made the leap of faith and into pharmacy school, the question arises, "If you could do it all over again, would you?"  Or, "Do you regret your choice to be a pharmacist?"  "Is this a fulfilling job?"  The question is the same, really, "Do you like your job?"

I always pause because the answer cannot be summed up in one word though sometimes I do just throw a one-word answer out there.  If I had known what I know today, I can say that I may not have done it again.  You see, pharmacists have this strange backup to the supporting actor role to the main character (the physician).  In the past, a pharmacist filled prescriptions and didn't think much about the interaction as part of a greater team, and if they happened to stumble upon a pseudo-team moment, it was gone just as quickly as it was realized.  Yes, I caught mistakes in retail pharmacy to prompt a phone call to the physician and save the day in my early days.  But, even then, that was not enough.  I am a hands-on person and unfortunately, there are not an abundant of opportunities staring me in the face locally for that type of interaction with the patient.  Sometimes, there are moments where I see the potential for pharmacists in the future, especially when federal laws are modified to include us as providers, but I'm reminded that the process of changing Medicare and other federal laws is long.

If I knew the future and that it would include provider status, I would probably choose pharmacy again. 

As of today, what can you expect?

1.  Expect a non-traditional working shift:  When choosing a career in pharmacy, make sure you understand that generally speaking the medical field equals a non-traditional shift.  You cannot work 9-5 unless you somehow climb a ladder that has been reluctantly vacated by a retiring pharmacist and land in management or you somehow find a niche where possible.  Long-term care offered that for a couple of years or so until the company I worked for went out of business, but there were still rotating weekends.  How can  you make this better?  First, if you happen to work for a company with non-traditional shifts, know that not all companies have rotating shifts where work-life balance is important.  I have worked for companies with a rotating schedule where I knew 2-3 months in advance what to plan and have worked for those who release a schedule days to one week with no preparation on what is next.  The former definitely makes work-life balance better.  If I have learned anything in the past several years of working, a strong rotating schedule can make a work team a lot happier.  So, yes, the work shift may not be traditional and you may have to work holidays, but knowing far in advance really makes a big difference.  Anything short of that may filter the perfect job with a lot of stress and tension with work and outside work activities.

2.  Expect to keep learning.  One thing that I have learned (the hard way) is that learning did not stop at graduation.  FDA discovers that drugs don't work as once thought (and tested), anyone remember Vioxx and Fen-Phen?, and guidelines change (remember every woman in menopause was on Premarin?  I had put my brain in neutral back several years ago and really noticed that feeling of impending ignorance arise when a healthcare professional calls on the phone to ask a question that I could not answer.  This applies really to all jobs.  Continuing education and keeping abreast of the latest and greatest will empower any pharmacist to do a better job.

3.  Expect to move if you need to find a new job immediately.  The job market is saturated.  The Bureau of Labor Statistics reports that employment of pharmacists is projected to grow 14 percent from 2012 to 2022, about as fast as the average for all occupations. Increased demand for prescription medications will lead to more demand for pharmaceutical services. With the increase in pharmacy schools, many new graduates are finding less options for work. As one article is appropriately named, the Pharmacy School Bubble is About to Burst. Also it is expensive.

4.  Expect to consider diversifying and/or find a niche. Many pharmacists today are obtaining board certification status and/or obtaining further education (MBA, MPH). Some go into the informatics side of pharmacy. Finding a niche or obtaining more credentials can help differentiate one pharmacist from another when applying for a job.

As far as the job itself, there is potential of pharmacists in the future. I am optimistic about pharmacists having a stronger role in the healthcare team.  If that happens, I will give a solid, "I would do it again!"

Pharmacist Definition per the Public

I was not at all surprised to read the letter posted about a patient's perceived assumption about what a pharmacist does and what our role is in healthcare.

Link to article here

From the patient's point-of-view, the pharmacist receives a prescription like an order for dinner.  He/She selects the correct med (double and triple checked with scanning) and sells it to the customer. This is the same customer that spent the entire day rushing around, probably saw a physician or nurse practitioner waiting longer than he/she should. In the patient's mind, the prescriber would never mess up and the pharmacist is the last step in that long drawn out process.

The retail chains have not helped with this perception. Drive-thrus were installed to help facilitate this fast-food mindset. People starting aligning thoughts of McDonalds and Walgreens in one idea: get it now; get it fast.

When I worked retail I felt the pressure of hundreds of prescriptions, the least technology in the business and wanting to please the customer. As the years have passed the number of new medications have increased along with demands and cutting the bottom line which usually translates into deep staffing cuts. I have no regrets leaving.

I had major surgery recently and felt guilty when I thought negative thoughts at the three hour wait the technician claimed on a Tuesday at 2pm at my chain retail pharmacy. You see, in the midst of all the chaos inside, there should still be someone discerning how fast a prescription can be completed based on more than just a prescription. What is it for? Is the patient post-op? But in their defense with how the pharmacy is set up and the minimal staff, it is survival mode. Three hours it is.

I am not sure how to even begin educating the public on what we do. I still have a father that fails to ask me questions about medications/disease states. We are a silent back-seat member of a team with a big piece of information. We go through sometimes eight years of school (6 minimum) to sit in the back seat. Many pharmacists are introverts and are not comfortable calling physicians at times unless absolutely necessary.  

I understand that there may be some interns working in pharmacies learning the ropes, but that does not give you the right to say what's too strong for someone else, and this practice has become more widespread.

GLEN SERLEN

Audubon

I am not sure Mr. Serlen understands the very thing he is questioning is our responsibility. We are held accountable, sir, for the very thing you complain. The sad thing is that I have no idea how to change the paradigm the rest of the country has regarding the pharmacists' role in healthcare. 

The Patient that Made the Difference

Her initials were the same as mine, and we greeted one another after a few phone conversations with "Hi, BB, it's BB." 

We had this connection. Two grown women. Both single and young. The big difference was that I was her home health pharmacist in charge of her pain pump and she had terminal cancer.

When you are halfway through your life (and maybe your career) there comes a time when you look back and remember the patients that change your life and maybe even validate the half-ass "I want to be a pharmacist" decision made by a young twenty-something with no idea how profound the decision would have on every aspect of your life. 

B wanted to go to Florida and be in the ocean one more time.  Her boyfriend was in Florida and since she knew her time was short, the ocean was on her bucket list... with the dilemma of a pain pump. That's where I fit into the story, finding a creative way to make it happen along with a couple home health nurses and some supplies. She was a nurse, too, and was a big part of her own end-of-life care.

It has been eleven years ago. B was 33 years old. I had been a pharmacist for only four years; a baby in the working world with little idea of how that year would change my life.

I had these biweekly chats with her concerning supplies she might need, including the intravenous pain medication itself but we often left the rigid discussion of how we were connected through pharmacist and patient to human conversation of "please do monthly self breast exams," to "live a full life and travel Beth!" to "who cares what people think about you, you certainly won't care when you are at the end of your life" and "I wish I could have been a mother." It was almost as if I had been granted insight into the world of a life ending way too soon and maybe learning my own lesson along the way. I sure did.

I finally went to meet her the last few days of her life. I waited much too long to meet my friend and that is my only regret. There is a professional line you have to keep in place with your patients, but sometimes that looks a little different patient to patient.  She squeezed my hand and had a picture of her vibrant former self before cancer ravaged her body sitting on her nightstand. "You are beautiful," I had said although wishing I had arrived months before.

Pharmacists and nurses along with other healthcare providers can make a difference. 

I witnessed the same thing with my father-in-law's nurse at the VA in Nashville caring for a man that had no family at bedside because of a lack of a relationship with his family. His nurse was amazing and was not only his nurse but his friend.  

I saw it again in Memphis on a hospice rotation where I saw different patients in different stages of terminal illness along with their families in different stages of grief. 

My life changed with each of these moments and patients who touched my life and maybe that young twenty-something college student knew more than I thought about selecting a career?