Why are pharmacies so slow?

Factual Questions
61

And yet, for years, the local Burger King has been slower than any pharmacy I’ve ever attended. Of course, I usually go to smaller pharmacies. I always wonder why the large and small ones both seem to have the same number of people working–you’d think that would need to scale up for higher numbers of prescriptions.

My long time pharmacy merged with another, and I quit once they actually had to call the doctor and confirm whether that he did not want to put me on the extended release version of a medication, and couldn’t even read the fact that his phone number was on the written prescription, and thus waited until Monday (when we gave it to them on Thursday) to get the number from us and call him.

That, of course, is the one exception to my first paragraph.

62

In Spain the notion of “you just grab the pills off a shelf and pay for them at the till” like OTC works in the US is unknown, so that part is actually slower.

Buying OTC:
Me: sniffle “sorry, hi, I’d like an antihistaminic, please, my allergies are driving me nuts.” sniffle
Tech/Pharmacist: “are you taking anything else?”
Me: “nothing on a regular basis.” sniffle
T/P: searches the shelves “here, take this” rings it up with one of those gun-style barcode readers “it’s €4.15”
The instructions on how to take it, how often, whether with food or not, etc. are in the prospectus contained in the box. Still, it’s common for the T/P to provide the basics (“remember you’re not to take it on an empty stomach”).

Buying my mother’s prescriptions (she’s retired, so no copay):
Me: “hi, I’d like these please”.
T/P who doesn’t know us: “is it for you?”
Me: “no, for my mother, she’s 70 and has a medical history about three books thick including skeletal and digestive problems.”
T/P: “ok, one moment.” searches the shelves rings everything up with the reader * cuts off every barcode and sticks them to their scrips* “here you go.” hands me the bag
me: “thank you.”
If they see something strange they’ll remark on it and make sure everything is ok, whether it’s OTC or with a scrip.

Scrips are printed out, so no handwriting to decipher. Pills aren’t counted and reboxed; boxes aren’t labeled with the data on the patient and doctor; every box comes with the prospectus. You may on occasion get what’s called a fórmula magistral, where the doctor tells the pharmacist to make the drug (I’ve mostly seen it for creams), but that’s the only time the pharmacists will be handling drugs which are outside a bottle or blister pack.

63

It depends on the dose in the UK. OTC you can buy co-codamol with 7.5mg codeine but the stronger variants (15mg and 30mg) are prescription only. As one contains 500mg paracetamol taking more to get a greater codeine hit is less of a problem than the potential for overdosing on paracetamol.

64

Well yes, much as I said in my earlier post (#31). The issue, however, is how long does it take the pharmacy to process things between clicking on the website and driving up to the window to collect. Do you think they would have it ready id you drove there immediately after clicking? That is certainly not true where I am. I order my refills over an automated phone system rather than on the web, and they give me an estimated (i.e., don’t totally rely on it) pickup time that is usually two business days after my call. The people her in UHC single-payer countries are saying that they can go in with a script and get their medicine in 5 minutes or less. (This of course, largely obviates any need to phone or go online to order in advance, though the facilities to do so may still be available, I don’t know.)

Thus, the appropriate comparison seems to be:
Typical processing time in U.S.A.: 20 mins to 2 days
Typical processing time in UHC/SP countries: 1 min to 10mins.

65

I wouldn’t say 5. Maybe 10 or 15 at a push. Hell, it took about 15 mins to get a prescription for my cat filled at a pharmacy the other day (and yes, I used the exact same pharmacy I’d go to for my own prescriptions).

If they don’t have what I need in stock (which is rare - and unfortunately over the past decade my health has not been good so I have been doing it a lot) they have it by the afternoon the next day without fail.

The only downside to this in Sweden is that the right to run a pharmacy has only this year been open to private businesses, so there are not as many pharmacies as in other countries. Still, I have one across the road from work and 2 mins from my GP’s surgery, so I’m not suffering.

66

I have thought a bit about this, and I still see more problems with the US approach to pharmacies than the European one. Leaving aside all the hassle with the insurances (which seems to eat up the bulk of the additional time in the US), and looking only at “count the pills, put in orange plastic jar, put label on” vs. “grab a pre-packaged, individually blistered, carton from the shelf”, I see the following problems with the former:

  1. more potential for erros. Buying in bulk and counting out means that the lab tech counting, or the pharmacist checking, can make mistakes.
    Moreover, if the patient takes more than one different medication, it’s far too easy to make mistakes at home, if all are white pills in orange jars.

In the European system, each medication comes in a differently coloured cardboard carton.

1a) Blind people: some years ago, they finally started printing the names of the medication on the cartons in Braille. Have US pharmacies the equipment to print labels in Braille for blind people - all, some, none? If not all, what do blind people do - are they screwed as with US money?

  1. longetivity: it’s been mentioned that the expiration date is max. 1 year, because the pharmacy can’t control for heat and humidity once the tablets leave there. But having a large supply (for chronic ill people), in one container, which you open every day to take out one single pill, is not good.

Having each pill seperatly blistered keeps them fresh much longer (on each foil, the expiration date is stamped by the factory), even if the patients home is not ideally temp. controlled.

  1. instruction leaflet: because the foils or the plastic bottle with the syrup or the tube of cream are put into a cardboard carton, the factory can always enclose an package insert with the relevant information. So the patient can read this slowly at home.

If you are given an orange plastic jar with a label, where’s the insert? Does the pharmacist tell orally the patient about all the possible important things? How does the patient remember this one week later?

  1. Privacy: I’m always a bit shocked when on any TV show, the detectives just waltz into a bathroom, open the small cupboard and look at the labels at what medication that person is taking, because name of patient, name of drug and condition are right there for everybody to read! (I know that the bathroom, along with the kitchen, is the worst place to store drugs - but most people do, because it’s convient).
    Outside TV shows, every guest who uses your toilet can peek and see that you are taking drugs against depression or incontenincy or whatever.

With the European system, you hand the recipe to the pharmacist, who gives you the plain carton. He might write “1x3, one week” onto it, to remind you to take 1 tablet thrice daily, but he isn’t obliged to. So in any household with more than one person, nobody knows if you or your child are taking that ritalin.

Aside from that, I wonder why pharmacists have to check for interactions with other drugs. Really no offense against pharmacists - I know and expect them to have several years training and a good basic knowledge of their job - but I expect my doctor to tell me about this and check for it! My General doctor has all the info about regular drugs I might take in my file, and knows what has been prescribed recently. If necessary (that is, I see he didn’t check my file), I will remind him “I already take X which has possible side effects of lightheadness, now you prescribe Y, is there a possibility of interaction?”

67

In my (Canadian, similar to U.S.) experience, they show you the leaflet and put it in the bag with the medication.

68

Its amazing to me reading all the “double checking” processes that pharmacists and techs are supposed to do. More than once Ive had my prescription (including regular refills) screwed up- not getting the correct amount or whatever.

On a separate occasion when I was younger, my brother and I were both very sick at the same time and the pharmacy screwed up the labels. I wound up taking the medicine that was meant for my brother and I wound up back in the ER with a severe allergic reaction to sulfa.

Im sure there are occasional mistakes in other countries when there arent so many steps to be taken, but just in my experience alone, Ive had enough pharmacy errors to last me the rest of my life.

69

That’s an old trope here in the US…party guests peeking in the medicine cabinet to see what the host(ess) is on (and sometimes, if it’s something particularly good, steal a couple). I don’t know how much it happens in real life, but it comes up from time to time in novels or other pop culture media.

70

Computers print out all the contraindications in seconds. people in pharm school are taught to count very slowly to give the impression they have a lot of duties to perform when they get your script. They use pharm techs a lot now. They can not count at all.
The longer you are trapped in the store, the more likely you are to buy something else. You will naturally wander around and buy stuff.

71

The reason we have to check for interactions is because most MD’s don’t know enough about the drugs to know if there is an interaction or not. We spend a minimum of four years in school learning about drugs, their side effects, the way they work, and how they interact with each other. Most medical school put all that into one semester. There have been a few times that we’ve caught major interactions that when we called the doctor about they have thanked us because they didn’t know about it. Plus, most people who take multiple drugs might see different doctors for their various health conditions. Most of the time they don’t tell one doctor what another one might have prescribed for them. This is also the reason that people really should get all their scripts filled at one pharmacy.

This statement is insulting to me, and our entire profession. We are not taught to count slow, or anything of the sort. Pharmacists do not receive any incentive to keep you in the store one second longer then necessary. We do not recieve a kickback for anything you purchace in the store, and if that was the motivation, why would pharmacies open drive-thrus which make it so you never have to set foot inside?

As for the interactions printed out by the computer, most do list all the possible or theoretical interactions between medications, however it takes someone with the clinical knowledge that a pharmacist has in order to know which actually matter, and which can be safely ignored. As we’ve been taught in school, treat the patient, not the numbers.

Oh, and I will say that one thing pharmacists don’t normally doublecheck is the quantity counted. The only time we really doublecheck the count is with controlled drugs. There have been times that I have counted out the tablets, put it in the bottle, had it double checked, and when the patient gets home notice that we only gave them 30 tablets instead of the 60, or 90 that is was written for. This happens, probably at least once or twice a month at the slower store I work at. This happens mainly since most prescriptions are for 30 tablets, that sometimes we might just stop counting there out of habit, and not notice. If this happens, just call your pharmacy and let them know, and we will be happy to get the other 30 or whatever ready for you to pick up at your convenience.

72

Just a few unconnected observations from a pharmacy customer (in the US):

  1. You’d think it would take less time now than back when labels had to be typed (on a typewriter) and insurance phoned in. But it doesn’t.

  2. A friend of mine was doing graduate work at a large univerity (> 40,000 students). Everybody had in-house health insurance. She’d visit the doctor’s office, be seen, and the doctor would enter the prescription directly into a computer. That would be sent immediately to an automated dispensing machine in the basement, and by the time she’d get to the basement, all she had to do was swipe her ID card at the window and wait for someone to bring the prescriptions to the window. Now, this university had some advantages - since it was their own health plan, the machine could stock the entire formulary and not need anyone to call for insurance. Since all prescriptions were from that pharmacy, interactions were checked automatically (and reviewed by the pharmacist). The dispensing machines (they had 2) were huge - I’ve seen some on other pharmacies, but these were like 10x larger - 30 feet or so of visible machine each, and I have no idea how far back they went.

  3. Regarding counting out pills vs. pre-packaged - if a medication is frequently prescribed in different quantity, would you want to be told “sorry, your prescription is for 30 days, but we only have these in 14-day packages and can’t sell you two of those”? If it is something that is frequently refilled, they’ll often order that size in, but they’ll also have it in bulk.

  4. There are a bunch of no-show customers, which lead to RTS (return to stock). Then the pills have to be re-counted back into the stock bottles, insurance claims reversed, etc.

  5. Sometimes things just make no sense at all. I have a $10 / prescription co-pay. Insurance denied one medication refill due to insurance feeling I didn’t need it every month, so I asked what the “cash price” was - $7.99. Why even bother processing it through insurance month after month if it a) costs the customer less to direct pay, and b) reduces the time the pharmacist or tech spends dealing with insurance when they could be doing actual pharmacy stuff instead of sitting on hold with insurance, being told “Your call is important to us…” by a machine?

73

If I get a prescription that doesn’t have to be re-bottled, I get the package insert stuck to the bottle. But oftentimes, they’re in very small print to save space and are difficult to read. There may also be a lot of scientific information that most people don’t understand. That’s why pharmacies have a database with patient-friendly information. I’ve never left the pharmacy without one of those printouts, even for drugs that I’ve taken for years.

Prescription labels seldom, if ever, have the condition the drug is intended to treat. I’ve got a couple of labeled prescription bottles in front of me, and neither has the condition on it. In fact, one of them is prescribed for a number of conditions from bipolar disorder to migraine to seizure disorder to chronic pain. Just looking at the label won’t tell you which I have. The other is a standard non-steroidal anti-inflammatory drug that is generally prescribed for pain, but again, the bottle doesn’t say specifically where the pain is. (I got it after I sprained my ankle this spring.)

In the US, prescription labels are required to give the patient’s name, the name of the drug, the dosage, the number of pills dispensed, the prescriber, and, of course, the pharmacy that dispensed the drug. This information is required by federal law, and having all that information in one place facilitates getting refills if you’re traveling. And, frankly, if your friends are snooping in your medicine cabinet, you need a better set of friends. (Or you need to keep them in a more private place, which is what I generally do.)

To repeat what Hirka T’Bawa said, pharmacists are specifically trained in the uses and effects of drugs, both prescription and non-prescription. They are not trained monkeys who only count pills. Besides, my primary doctor knows what she prescribes, but she may not know what the specialist I saw prescribed until I see her again, which may not be for a while. My pharmacist knows everything I take. Doctors also make mistakes on dosing and scheduling; if I’m taking one drug and she prescribes another, she may not know to adjust the dose of the second one to take the first one into account. My pharmacist knows that it should be done, and will call the doctor to get a new prescription based on his recommendation. He may also recommend another drug entirely that will do the same thing but with less risk of interaction, or recommend a different schedule.

Finally, not every patient is well-informed. Because my father is a pharmacist, I know to ask the pharmacist if there is anything I need to know in terms of food and over-the-counter medications to avoid, and whether I need to do anything special before and after I use it. But not every patient does that. A good pharmacist volunteers this information and makes sure the patient understands before he leaves the pharmacy. All of these come from years of education and professional experience.

I love my pharmacist. :slight_smile:

74

But all those differently coloured bottles in the pharmacy, the identically-looking small white tablets are then put in identical plastic orange jars for the patient, yes? Or are the jars for the patient in different colours, too?
Also, the pharm. tech takes one bottle with a blue label from the shelf and counts out 30 tablets, and then the pharmacist proper has to controll it. If jars get switched at this point, before the label is stuck on, how would you know?

Um, that’s what I meant! They need a sighted person to tell them whether it’sa 5 or 1$ bill, only then can they fold it. By contrast, the Euro bills are all different sizes (the bigger the value, the bigger the bill), plus lowered printing of the value in one corner, plus brightly different colours for hard-of-seeing people. Thus, blind people here don’t need the help of other people figuring out the value, and sighted people can’t trick them by telling a false value (as apparently happend to blind musician Ray for example, as shown in the movie).

But apparently, the pharmacy doesn’t help them with Braille labels in that.

Um, I don’t doubt at all that the blind are capable of managing their lifes! I just meant that , if it requires little effort, the official places should to do their best to help them.

Um, I did say that on the foil itself the expiration date is stamped, so it’s not that we don’t know when to throw things out. It’s just that they last longer.
As for only 90 day supply: many people have chronic conditions, and the insurance doesn’t care for how many days. The only limit is the N3 is the biggest size, but how long that lasts depends on the concentration and number of tablets per package.

As for why the tablets should last longer than one year, I can think of two reasons: chronic illness, and general things like paracetamol. Every winter when I catch a cold (I try my best, but sooner or later I get it), my doctor prescribes me paracetamol against headache and fever (plus throat tablets). These are taken as-needed, so from a 30 tablet package, half might be left over at the end. When I get the next cold, I can tell my doctor and don’t need a new package.

So what’s the reason for this federal law? All the fear about “controlled substances”? Over here, that would violate grossly patient’s right and citzen’s right for privacy.
As for refills while traveling: you either take enough to last, or you take a recipe with you from your doctor if you are travelling.

I’m not saying my friends do that, I’m talking about how easy it generally is.

75

The pharmacy-supplied containers are all the same color - a yellowish-brown, designed to filter out light for pills which are photo-sensitive. For prescriptions that are dispensed in manufacturer packaging, that packaging can vary - opaque white bottles, foil blister packs, etc.

However, each pill has a unique combination of size / shape / color / imprint. On the prescriptions I get, that info is repeated on the label the pharmacy puts on the container. If they change suppliers, for the next month or two, they also put a sticker on the bottle that says “This is the same medication you have been taking, just in a different form”.

My understanding is that the vast majority of prescription errors come from mis-reading or mis-understanding what the doctor wrote, or transposing different prescriptions before filling them, not from putting pills in the bottle that are different from what the label says. Given that a pharmacist can lose his license over this, there aren’t that many errors. But when you hear about one, it is usually a whopper.

Just curious - why? The only people that are going to see that are the pharmacy employees and the person it was prescribed for. Even if there’s no label on the bottle whatsoever, there exist many web sites that will tell you what a pill is based on its characteristics. Plus, most of the “notorious” ones are well-known. For example, I’ve never seen a Viagra pill in person, but I know that they’re a funny-shaped blue pill.

76

Who said you get a kickback? But if you stall me a while ,I might buy something else and the store makes more money.

77

Maybe so, but that isn’t something us in the pharmacy care about. However, I’ve only worked in chain pharmacies (Rite Aid, CVS, wallgreens, etc). The other places that don’t depend on the pharmacy such as Walmart, grocery stores, etc, might be different. However in that case it isn’t by telling the pharmacist to go slower, as much as not giving them the tech hours they need… either way, the people in the pharmacy don’t care. Do you really think we take longer then needed when you’re right in front of us staring us down? We want to get rid of patients like you as fast as we can!

78

Now that you’ve mentioned Walmart, Hirka T’Bawa…

My longest wait ever was at a recent trip to WallyWorld.

I desperately needed to fill two new allergy prescriptions and had some shopping to do as well. So I decided to kill two birds with one stone and use WallyWorld.

I dropped off two prescriptions at the Drop Off Counter and was given a 20-30 minute wait, so I went off to shop.

30 minutes later I return only to be told my prescriptions were not ready and would need another 10-15 minutes, so off I went to get something to eat.

15 minutes later I return again only to be told my prescriptions were still not ready and would need another 10 minutes. Slightly miffed, I decided to wait at a nearby bench.

15 minutes later I am finally able to get my prescriptions, or so I thought.

My first stop is at the Pick Up Window. I am able to view and confirm one of the two requested prescriptions (the second needed to be ordered, I asked for the script back so I could get it somewhere else sooner). I also had to sign for the script on a computer pad similar to a credit card machine.

My next stop is down the counter at the Pay Here Window where I pay for my script at a different register. At this point my script that I have waited almost an hour for is fully paid for but apparently not yet mine. The tech places the bottle back in the special little bag it had been pulled out of just moments before.

Huh sez I?

At this point I am instructed that I cannot have my prescription until I have first spoken with the one pharmacist on duty so she can answer any of my questions. This will occur at the Consultation Window, again further down the counter.

I let her know as politely as I could that I was in a bit of a hurry, had taken this medication before, had absolutely no questions, and would please like to just have my prescription.

No sez she. I must talk to the pharmacist.

So off I go to wait in line at yet another window. The pharmacist is with another woman discussing the pros and cons of a particular yeast infection medicine, how to determine if she actually needs said medicine, etc. etc. I wait for a few minutes more and finally just snapped.

I went back to the Pick Up Window and basically demanded my prescription. What should have taken 20 to 30 minutes had now taken well over an hour, I had been to FOUR different “windows”, and yet I was being asked to wait for no real reason while my PAID FOR prescription was being held hostage.

I finally got my filled prescription along with the unfilled one and left, never to use WallyWorld again to fill a prescription.

:smack:

79

Ha-- I knew it!

[Jerry Seinfeld Paraphrasation] Hey, stand back. I’m taking pills from a biiig bottle. And I’m putting them… in a little bottle. That’s why I’m up here, an extra foot off the ground. I can’t be down there with YOU people…" [/Jerry Seinfeld Paraphrasation]

80

The bottles I get from my pharmacy are all green unless the pills are dispensed in the same package they shipped in.

Not all pills are little and white. The two prescriptions I have look completely different. I can tell immediately which is which. Also, most drugs look different from dosage to dosage; a 5 mg may be green, a 10 mg may be blue and a 20 mg may be pink, and they may all be different sizes. For that matter, pharmacists know which drugs they stock and can generally tell at a glance what’s in the bottle, and even if they can’t tell right off, they have reference books and databases to tell them. Packaging is a significant cause of medication error, so this is something that manufacturers are working on.

Official places do help them, but Braille equipment is expensive and space-consuming and not worth the cost given that it wouldn’t be used much. Blind people can and do figure out schemes that work for them. They ask the pharmacy for help if they need it.

Doctors in the US write prescriptions based on a particular supply. For example, the medication I take is 200 mg taken once a day. The doctor writes for 30 pills, and the pharmacy dispenses 30 pills at one time. If that medication were for 100 mg taken twice a day, the prescription would be for 60 pills, and the pharmacy would dispense 60 pills. That’s an advantage of bulk supply; the doctor can write for as many tablets as may be required without worrying about the limitations of a foil-backed package.

Most drugs are good for a lot longer than one year. However, the manufacturer can’t guarantee the safety and efficacy past a certain period. Having a one-year expiration date means the patient assumes the risk if he takes a pill that’s been sitting in his medicine cabinet for five years. The pill should still be good, but the manufacturer can’t take responsibility. (In the US, paracetamol is an over-the-counter drug, so it’s generally not prescribed.) And for prescriptions for chronic illness, it’ll be long gone before the one-year expiration date anyway.

If privacy really matters that much to you, you’re free to take the label off the bottle, or cover it up when you get it home. However, that information is there for the patient’s benefit, as well as the benefit of a patient’s caretaker; I can look at a bottle and know instantly what’s in it, who it’s for, and when it should be taken. Thus, I can’t take the sprog’s allergy pill or give him my pain medication, as long as I read the label beforehand. It also makes the prescription easy to trace, should the need arise.

Sure. But having a full label with refills does the same thing as carrying a paper prescription, which would need to be verified as well.

I’m not saying my friends do that, I’m talking about how easy it generally is.
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