Susan J. Bliss, RPh, MBA, has practiced long-term care and community pharmacy in Oregon for more than a decade and has served on numerous professional and community boards.

Susan J. Bliss, RPh, MBA

A worried man in his forties comes to your pharmacy and shows you the pill in his hand. He wants to know how it is used. You are quite sure that it's a birth control pill. A week later, a woman picks up a prescription for her boyfriend and asks you what the drug is for. The prescription is for genital herpes. How should you approach these questions? 

In addition to observing HIPAA, pharmacists also have a clear duty to warn. The pharmacist (the expert) is required to warn the patient (the non-expert) about the hazards and appropriate use of medication. For example, pharmacists would agree that if the patient is not warned about potential drowsiness from pain medications, the pharmacist has failed in that duty. This responsibility also extends to information. When a pharmacist advises a patient about OTC or prescription drugs, a relationship is established. The patient trusts that the advice is both competent and confidential.   

 If you have records of care (prescriptions) for a patient and someone else asks about that care, you must be certain that the patient has consented to share that information, if he or she is of legal age (standards vary by state). 			

If someone asks, "What is this drug for?" you may answer directly, but be careful if a relative or friend is asking the question. If the man at the counter tells you he's found a drug in his daughter's room, ask him to take the drug to his daughter and discuss it with her if she chooses. If you dispensed the prescription, you have a duty to the patient that must be honored; you may even need to consult a lawyer. Keep notes on any such exchange. 

In an emergency, HIPAA allows healthcare providers to act expediently, to protect the patient. If a patient is in the midst of what you believe is a critical situation, you take a risk by revealing protected health information, but the patient's need for help overrides your risk. You may decide to recommend that the caller contact 911 or poison control, or take the patient to an ER. If you are contacted by emergency personnel, always phone back to verify the identity of the caller before discussing the patient's care. 

Each state varies on the age of majority (full adult rights and responsibilities) and on parental notification regarding medical treatment, birth control, and so on. It would be sensible to formulate an ethical approach to these questions before the situation arises. 

This column highlights ethical situations that often occur in pharmacy practice. It is designed to stimulate discussion on how to deal with these situations and is not intended as legal advice. Pharmacists who need immediate assistance should consult their attorneys, employers, state boards of pharmacy, and state and federal laws. 

We Will Be Healed: Spiritual Renewal for Health Care Providers,

 recently published by ACTA Publications. She has practiced long-term care and community pharmacy in Oregon for more than a decade and has served on numerous professional and community boards.

Articles

Pharmacists must observe HIPAA regulations and also have a clear duty to warn patients.

Eye on ethics: Whose prescription is it anyway?

 There is an old saying: "Be careful what you wish for; you may get it." As pharmacies open on every corner, the demand for pharmacists has become critical. Even the best managers mutter, "We need to get enough bodies in here." Sometimes it seems that they will hire anyone, whether they are ready to work, or not.  

While training the new pharmacist, you should schedule your best technician to work the same hours. Extend the training period if needed, or repeat the training as a refresher for the whole staff, to avoid singling anyone out. If possible, adjust shifts and honor reasonable requests; often, the lead tech is offered a 9:00-to-5:00 schedule while all pharmacists are expected to work 12-hour shifts. Insist on quality counseling on all prescriptions, which also helps prevent errors. Resolve errors immediately, and look for simple changes that could alleviate them.   

Treating a co-worker with respect and compassion will make it easier to work through problems that may arise. You may try to talk privately to the pharmacist about his or her performance. Be prepared for any reaction, from anger to fear; the pharmacist may even express relief. Most people know when their performance is not good and are aware of the potential consequences. A pharmacist who is faced with his or her own errors may need some time to reevaluate. 

Should you call the manager? If you suspect physical or emotional illness or substance abuse, or if there is any risk of harm to patients, you must talk directly and immediately to your district manager. Never e-mail sensitive information. E-mail is also often skimmed or ignored. The manager may use the software audit trail or other data to help analyze performance. 

Technically, it is correct to first call your manager when you have concerns about another employee's performance. However, some large chains use an assembly-line approach to management and training; employees who don't "meet the company standards" may be treated brusquely. Almost every issue of this magazine publishes letters from pharmacists who give patients their best but are deeply disappointed in the unrealistic expectations of the corporations that employ them.   

The district manager of your chain pharmacy searched for a new pharmacist for months, and finally hired someone you know casually. You are assigned to train the new pharmacist before he joins the float pool. During his first few weeks, your lead technician has caught several errors made by this professional, and you have intercepted errors yourself. The manager doesn't respond to your e-mails of concern. What do you do?

Eye on ethics: Dealing with a problem R.Ph.

When seniors were brought into the Medicare Part D prescription plan, many of them were new to the complexity of prescription insurance, but they expected to pay a share of costs to receive the benefit. Dual-eligible patients were previously asked for co-pays under Medicaid, but they were never sent home without a drug if they could not pay. After switching to Medicare Part D, however, if patients refused to or were unable to pay their co-pays, pharmacists have the option of not dispensing the drugs to them. This is a rude awakening to many patients. 

Independent and chain pharmacists report that some dual-eligibles left prescriptions at the counter, scrounged up the co-pay, and returned to pick up their drugs hours or days later. Pharmacists often provided an emergency three-day supply or ran a tab for cash-strapped patients. Some kindhearted pharmacists and technicians also dug into their own pockets to help indigent patients, while others phoned health department caseworkers to secure assistance for those who couldn't pay.   

Impossible for pharmacists or patients to forget, the demise of the Oregon Health Plan is an invisible but steady undercurrent in Oregon, motivating patients to continue their medication and impelling pharmacists to prepare patients for the financial realities of the times. Though patients often express their anger over co-pays, very few have failed to find a few dollars for needed medication. 

Pharmacy staffs in chain stores are required by ownership to balance the register at the end of each day. Independents need to maintain their cash flow to keep their doors open. As dispensing volumes increase from Part D while the overall revenue drops, managers have cut staff to help bridge the gap. Drug prices charged by wholesalers have not decreased. One Oregon independent said, "There is no free lunch" and kindly but firmly coached his patients to plan for the inevitable. 

Without group discussion, pharmacy management in aggregate seems to be siding with patients, investing staff time in teaching patients about the plans, and accepting some losses as part of the cost of Part D. Is it ethical, or even rational, for managers to assist each patient with his or her needs and write off co-pays and prescriptions if it ultimately leads to closing their business? 

Without realistic reimbursement for drugs and services, pharmacies that have served patients for years may begin to disappear one by one, along with their patients' source of medication. Despite new giveaway plans by several chains, created for their public relations effect, pharmacy cannot be sustained by giving away drugs and valuable services.   

Looking into the eyes of patients every day as executives seldom do, pharmacists should not and cannot be expected to bridge the overlooked gaps in Part D legislation. As drug manufacturers post record profits, pharmacists should not and cannot give away prescriptions and their livelihood. After giving patients a few doses of medication and several warnings, we cannot continue to send dual-eligible patients home without demanding the very modest co-pays required. 

We Will Be Healed: Spiritual Renewal for Health Care Providers

, to be published by ACTA Publications in January 2007. She has practiced long-term care and community pharmacy in Oregon for more than a decade and has served on numerous professional and community boards. 

Q: Medicare Part D patients are often unprepared for the realities of the new drug plan. If a dual-eligible patient can't cover his co-pay, should the pharmacist send the patient home without the drug?