The other day one of my clients wondered why, on a particular prescription bottle, the number of pills was circled. And I used to work in a pharmacy, so I could supply the not-very-interesting answer! I shouldn’t say it’s not interesting, because it IS interesting to ME. I like knowing this kind of behind-the-scenes stuff.
The first thing to know is that in the pharmacy where I worked, pharmacy technicians (that’s an entry-level job) did almost all of what you might picture being the pharmacist’s job: counting pills and putting them into bottles, putting the labels on the bottles. The pharmacist would then verify that it had been done correctly.
At my pharmacy, a circled number of pills was the technician saying to the pharmacist, “I noticed that this number was not 30.” So many prescriptions are for 30 pills at a time, that one of the more common pharmacy errors is putting 30 pills in a bottle when it’s supposed to be 10 or 45 or 90 or 120. So a technician might circle the number to let the pharmacist know that the non-30 number was taken into account.
If the number is 30 and it is circled, I’m not sure what it means. That pharmacy might have a policy of circling all numbers, as a way to remind the technicians to check it every time.
If there is a “DC” handwritten next to the number, it meant the technician double-counted the pills. One reason for counting twice is if the medication is a controlled substance, such as a narcotic. Pharmacies have to rigorously document any controlled substance, and there are regular inspections. If the number of pills in the store differs from the number there OUGHT to be, there is trouble: even a single missing pill will have everyone on hands and knees looking under the furniture. So it’s common for a pharmacy to have a policy of double-counting any controlled medication.
Another reason for counting twice is if there’s a note in the customer’s file mentioning a past problem. If a customer recently received the wrong number of pills, for example, we wanted to be careful not to let that happen again soon afterward. Or if a customer repeatedly complained about getting the wrong number, we wanted to be able to say we had counted them twice. Sometimes the technician would count them twice and then the pharmacist would do a final count, just to be really, really sure. If the prescription is a narcotic AND it’s for a customer who routinely says they were shorted on the number of pills, the technician might count THREE times, and write “TC” next to the number.
If you see initials written next to the number, those are usually the initials of the technician who counted the pills and put them in the bottle. Some technicians like to do this because there’s no other way to know who filled what: if a number of errors are being made, a technician might want to be able to say, “My initials aren’t on this, so it wasn’t me.” Sometimes pharmacies will have everyone write their initials every time; other times it’s optional. Or sometimes only new employees do it, so that the pharmacist knows to be extra careful checking those.
In the pharmacy where I worked, the pharmacist didn’t add their initials because we had only one pharmacist working per day, and the computer added their initials automatically to the labels of all prescriptions processed that day. On the very rare occasions when we had two pharmacists, the pharmacist would write his or her initials after the tech’s: ST/CA would be Swistle Thistle (tech) and then Carla Alamo (pharmacist).
In fact, one reason many of the technicians wrote our initials on the labels of bottles we filled is that the computer ALSO automatically added the initials of the technician who had printed the label. But it was very very common for the prescription to be filled by a different technician than the one who had printed the label. It was annoying to see another technician’s initials on the label of a bottle I’d filled, so I liked to add my initials. “No, it was ME!!” Plus, if I made a mistake, I wanted to know about it; and if I DIDN’T make a mistake, I didn’t want to get blamed for it. Plus, I like writing my initials.
Hi Swistle, just popping in to comment (for the benefit of your readers, since if you worked in a pharmacy you know this) that yes, the data entry and counting tablets and labelling and so on is the assistant/technician’s job, not the pharmacist. The pharmacist does check to make sure a prescription has been filled correctly, but is also responsible for advising people about their medication (both prescription & over-the-counter), conducting medication reviews, identifying prescriber errors like inappropriate dosing, making recommendations to prescribers about drug interactions, etc.
That’s very interesting… I rarely take medications and when I do, usually they are of a liquid sort, so I would never have noticed this personally.
That is interesting. I always assumed it was the pharmacists initials. Our family gets several “controlled substances” each month (ADD meds, anxiety meds, etc.) and I have to say that while I UNDERSTAND the reason, it’s VERY annoying to have to go to the doctor each month to pick up the script and drop it off versus it being called in. Also, I have a feeling that someone recently got in to some trouble at my pharmacy. My doctor wrote a script for cough syrup and when I dropped it off the tech asked “hmmm…it doesn’t specify if this is the kind without Codeine or with it…do you want the Codeine in it?” OF COURSE I SAID YES!! But later it occurred to me that if it doesn’t specify…perhaps he should have called the doctor. So the next time I was at the doctor I mentioned how great the Codeine was in the cough syrup because it helped me sleep through the night without coughing and he was all “I didn’t prescribe Codeine cough syrup” and when I told him that they gave me a choice he almost fell off his stool.
Yes, that seems quite questionable, doesn’t it? “Would you like a narcotic you probably weren’t prescribed?”
At the time I was so out of it due to being ill that I thought “Oh, how nice to have a choice”. But later it all clicked and I realized how incredibly irresponsible that was of them.
What’s fascinating is this was all different at the pharmacy where I worked! We generally had two pharmacists working at a time. They could both print labels if it was busy, but often one would be computer entering/printing and one would be checking. The checker pharmacist would circle the number of pills to indicate they’d compared it to the written prescription and the numbers matched. Sometimes the circle would be on the written prescription, sometimes on the bottle. They did this even if they’d printed the label – the policy was to always check the label against the prescription. If if was a refill, the number generally wasn’t circled. They (the pharmacist) would always initial the bottle of all prescriptions they checked as well.
All of this is to say any marking on a bottle in our pharmacy was made by a pharmacist. As techs, we would initial the extra paper/stickers that would come out of the machine so the pharmacist would know who filled the bottle, but nothing that went with the customer would have tech markings on it.
Different from my experience too! I worked at a high volume 24-hour retail pharmacy many years ago that had multiple pharmacists, pharmacy students, and techs working from 8 AM to 8 PM. A pharmacist checked each filled Rx before it went out to a patient but there was no standard procedure for documenting that other than the pharmacist initialing the label on the bag (not the bottle) to indicate who checked it. Narcotics were indeed double counted by both the filler and the pharmacist, and that was indicated on paperwork kept with the supply in the safe. I don’t think there was anything special done for filling controlled subs (other than the pharmacist quizzing the doctors who called them in to ensure they weren’t junkies).
It had never occurred to me that pills need to be counted by hand! I guess I’d thought that…I don’t know, a machine did it? Or they came in the bottles pre-counted? Of course it makes perfect sense that for something like medication it would be important to have an actual person making sure the numbers were right, but I’d never realized that that was someone’s JOB. So interesting!
Years ago a friend went to a doctor in the city who asked patients to come back after getting prescriptions filled at the pharmacy across the street so he could go over the dosage. He would examine the bottle while the patient went down the hall to get water to take the first dose.
Oddly enough, many patients were given too many pills and he kept a few. I’m sure he was using them as free samples for the uninsured….
I have to say, maybe I’ve been watching too much TV, but this immediately sounded to me like an “arrangement” between this doctor and the pharmacy. I’ve NEVER heard of a doctor wanting someone to get a scrip filled, then come back after “so he could go over the dosage”.
Just me?
Definitely not just you!
I find this r-r-r-riveting. I take a lot of meds and never knew what the circles and initials and so forth were for. I love knowing about that kind of stuff!
I love this!
So fascinating! I have a pharmacy question! Why does it seem to vary whether prescriptions “go through” or not? I was waiting to get a prescription filled, and the tech told me it was rejected because my insurance didn’t cover it. Then apparently she tried again and it went through. Are there different ways to submit the request or something? Are there tricks to getting something approved?
(As a secondary question, why can some pharmacies fill something when another pharmacy says that my insurance won’t cover it? I had another prescription that was rejected by insurance at the aforementioned pharmacy, and the doctor had me submit it to a mail order pharmacy, which filled it with no problems. It’s baffling!)
Ooo, good questions, and fun to answer!
I’d say the MOST common reason insurances send back a rejection code is that it’s too soon for a refill. So let’s say an insurance company says you can’t get a refill until you have only 6 days’ worth of medicine remaining, and you call it in when you have 7 days’ worth. The insurance rejects it, but by the time you go in to pick it up the next day, you’re at the 6-day mark so it goes through when it’s resubmitted. (This can happen even if it’s technically a new prescription for the same medication.)
There are a ton of other reasons, and I noticed at our pharmacy that some of us seemed to be able to troubleshoot and fix things, and others of us seemed not to be able to. I am too modest to say which group I belonged to. I will, however, say that SOME of the error codes aren’t fixable at the pharmacy (things such as prior authorizations needed), but there are quite a few where a tech who knows what she’s doing can go typity-typity-type and fix it. Oh, here’s another common reason: the “days supply” section. A doctor might prescribe a tube of medication to use “as directed.” The person who originally puts that prescription into the computer doesn’t know how many days’ supply that would be, so goes for the default option, which is 30. But then the doctor prescribes another tube 10 days later. It’ll go through, but only if someone first goes back to that earlier prescription and changes the days-supply section to 7 or 10 or whatever. Or sometimes someone goes up in dosage—like, maybe they were taking 5mg/day, but now they need 10mg/day, so they took twice as many pills and now the insurance is saying no, too soon for a refill. The pharmacy can put in an override code that says the dose has changed.
There can also be glitches when the insurance company’s computer is briefly down for some reason. My first attempt to solve a rejection problem was almost always to just try it again, because sometimes it would work! Or sometimes there’s a situation such as a prior authorization, where the physician has done his or her part, but the insurance hasn’t processed it yet. So when the pharmacy runs it through on Thursday night, it still says sorry, prior authorization needed; but if they run it through on Friday when the customer comes to pick it up, it goes through because the insurance has received the P.A. by then.
The mail-order thing confuses me too, but I HAVE heard of it from other people. The only thing I can think of is that some prescriptions must be so much cheaper in 90-day mail-order batches, that the insurance interferes to pressure people to use it.