Large numbers of prescriptions are being lost!

[Lemon Bars]

I'm a recent BSN graduate and I've been a RN at a primary care clinic for five months. We have a disappearing prescription problem and it seems to be getting worse. Through RN protocols, I am allowed to review charts send electronic prescription refills to pharmacies through our EHR system, which is Centricity. Every day patients are calling saying that pharmacies don't have the prescriptions - and when I call the local pharmacies the pharmacy staff say that no refill authorization was received. Schedule III-V controlled substances are not sent electronically, but are printed out, physically signed by a provider (MD, PA, NP) and then faxed to the pharmacy. Patients call because they can't get their prescription filled and the pharmacies deny they ever received the fax, even though our fax machine says it was transmitted successfully.

Sometimes I call the pharmacy, speaking either with a pharmacy tech or a pharmacist, and I give a verbal authorization for a refill, carefully describing the medication, dose, instructions, quantity, refills, authorizing provider, NPI number, etc. And still some of these prescriptions go missing. By listening to snippets of conversation while on the phone with pharmacies, I have figured out that pharmacy staff are not typing the prescriptions into their computer system in real time during our conversation. Instead they are writing the information down on a form or perhaps a scrap of paper with the intent of entering it into their computer system later. Sometimes pharmacy staff fail to enter the number of refills into their system or they misplace the paper - which is sometimes found a day or two later when I call again to ask why the patient still cannot get the medication.

Schedule II prescriptions are handwritten because, I was told, the controlled substance e-prescribing feature for Centricity is "clunky." Handwritten controlled substance prescriptions are a nightmare for many reasons, but what I'm most concerned about right now are missing electronic prescriptions, missing faxed prescriptions and missing verbally ordered prescriptions. This is a serious and apparently widespread problem reported by other nurses at our clinic. I have even experienced the phenomenon of lost prescriptions with my own personal medication about a year ago.

Patients are angry and stressed out because they can't get their medications on time, can't get their diabetic supplies on time. Patients with infections are getting started two days late on their course of antibiotics. And our clinic nursing staff is wasting huge amounts of time reordering medications, re-faxing prescriptions, repeatedly calling pharmacies and waiting on hold for the pharmacist, and getting yelled at over the phone by patients who legitimately should have had their medication days or weeks ago. I cannot trust what I see in the medications module in a patient's chart because often it does not agree with what the pharmacy is saying or with what the patient is saying.

I would like to find the sources of these problems and attempt to find solutions. It is our computer system? Is it our EHR software? Is it the computer system or software at the pharmacies? Does the fax machine not work properly? Or is it mostly human error at the pharmacies, physically losing track of faxes and papers and not copying the information correctly into their computer?

What can we do about this? Should we print physical copies of prescriptions and give them, mail them or perhaps text them to patients so that the patients can show physical copies of the prescriptions to their pharmacies? What would it take to set up a HIPAA secure system for texting copies of prescriptions to patients? I am in California. Apologies for the long post. I'd be grateful for any advice on this. I spend one to three hours out of every workday on this nonsense.

[Forest2]

I would keep tabs on what pharmacies you are having problems with. Are these all local pharmacies? Or mail order , or ? Do clinics have performance improvement initiatives? I assume they do. Who does them? Managers are the people who this needs reported to. It is a big issue for you and I don't see this where I work. They need to do data collection, then do a root cause analysis before putting together a plan. Hopefully the plan won't be, "you nurses need to work harder" because that dog won't hunt.

[bugya90, ASN, BSN, LVN, RN]

This happened frequently with our old EHR system. Is still happens occasionally now with the new one (Epic) but no where near as often. Majority of the time it is a computer or internet problem, sometimes on clinic end and sometimes on pharmacy end.

Keep a log of which pharmacies are not receiving the Rx. If there seems to be one pharmacy (or one chain) that is standing out, your manager or medical director may be able to set up a meeting with the PIC to see if they can find the issue.

[amoLucia]

Disclosure - I have no experience with any type of electronic systems. But in reading you post, it is clear there is a problem SOMEWHERE.

I hope your upper Admin knows about it. Also do you have an outside Pharmacy Consultant?

I'd say almost to make out an Incident Report each time whenever this prob rears its ugly head. An investigation is definitely warranted. And keep a detailed log of who, what, when, etc.

Whether it's a computer problem or something/someone intercepting 'scripts, it needs to be checked out. You don't want the DEA breathing down your neck.

[NotFlo]

We have Epic. Everything including (and especially) narcotics goes electronically. We don't have this problem. I think this should be tracked and documented and elevated to management and your software/informatics people.

[Lemon Bars]

Thanks folks. I am trying to document some of it but I'm so busy at work. I can't get any of the other nurses to track it. We are a small rural clinic and there are only two IT guys. Our office manager is our EHR software expert and she is totally overwhelmed with tasks every day. I'm told that we have no influence or local control over our EHR - we live with whatever decisions are made by big companies on the other side of the country.

[amoLucia]

Sorry to be late - was just hospitalized.

C O V E R Y O U R O W N T U S H !!!

Regardless of the others, do what you must to prove you kept on notifying the upper levels with ALL the critical info. Even if nothing comes about in an investigation, if you get dragged in, it will be YOUR time & effort if you do get sucked into quicksand whirlpool. You're seeing that NOW with all the wasted time you're spending on the prob.

Your office manager doesn't have a license to protect. Nor prob do your EHR folk.

Please, find yourself the time. And good luck!

[ruby_jane, BSN, RN]

On 9/8/2019 at 1:31 PM, Lemon Bars said:

By listening to snippets of conversation while on the phone with pharmacies, I have figured out that pharmacy staff are not typing the prescriptions into their computer system in real time during our conversation. Instead they are writing the information down on a form or perhaps a scrap of paper with the intent of entering it into their computer system later. Sometimes pharmacy staff fail to enter the number of refills into their system or they misplace the paper - which is sometimes found a day or two later when I call again to ask why the patient still cannot get the medication.

Holy H-E-doublehockeysticks.

I don't have an answer and I am sorry this is happening to you....