The Quantity That Was Written Over
Monday, 20:15, a busy community pharmacy. A man you have not seen before hands over a hard-copy prescription for hydromorphone 2 mg tablets, '1 tablet PO every 4 hours as needed,' quantity 60, dated three days ago and written on a pad from a walk-in clinic two cities away. He says he has just moved to the area, is in significant pain, and has no other pharmacy. While entering it you notice the '6' in '60' has been written over - the ink is darker and the stroke does not match the rest of the prescription - and the signature differs from the prescriber's usual hand. The prescriber's office is closed and the after-hours line goes to voicemail. The pharmacist is counselling another patient.
1. What do you do at the counter, and what must you not do?
Read the worked answer
At the counter - neutral, not accusatory: take the prescription, tell him it needs to be verified with the prescriber before it can be filled, and give a realistic timeline rather than a vague 'sometime.' He may be entirely legitimate; the document is the problem, not necessarily the person.
Do not:
- Alter, correct, initial, or annotate the quantity - a suspected alteration is not something you fix with a pen.
- Accept a verbal order to 'confirm' the quantity; most provinces require a written narcotic prescription.
- Dispense, partially fill, or promise to fill it.
- Hand the prescription back if you suspect forgery - retain it and follow policy.
- Accuse him, or discuss the suspicion within earshot of the queue.
Do:
- Scan/copy the prescription; note the time, the appearance of the document (ink, overwriting, signature), and exactly what he said.
- Confirm identity as your policy requires and check whether he has a profile anywhere in the system.
- Get the pharmacist - this decision is theirs, not yours.
2. The prescriber cannot be reached. How do you and the pharmacist proceed?
Read the worked answer
Checks before deciding:
- Provincial monitoring program: other prescribers, other pharmacies, recent fill dates, any red flags.
- The clinic's on-call or after-hours number, and whether the pad is a genuine current pad for that clinic.
- Whether that prescriber's pads have been reported lost or stolen (the college or clinic will know).
The pharmacist decides. If it cannot be verified tonight, it is not dispensed. The pharmacist - not the technician - explains it to the patient, without accusation, and offers real alternatives for pain: urgent care, a walk-in, or the emergency department.
If it is judged forged:
- Retain the original document; do not destroy it.
- Report as provincial requirements direct - police and/or the college/registrar - and notify the PIC.
- Do not confront the patient alone or follow him out.
- Record the time, who was notified, and what was said.
Technician role: evidence and process. Not the refusal decision, and not the confrontation.
3. Next morning the prescriber's office confirms 60 tablets. What now?
Read the worked answer
The clinical question is settled; the document problem is not. You still have a prescription that appears altered, and that does not become clean because someone confirmed the number by phone.
Do:
- Ask the office for a new prescription - fax or secure electronic - rather than annotating the suspect one.
- Record who confirmed it: name, role, direct phone number, time, and what exactly they confirmed.
- Have the pharmacist verify the prescriber is registered and the prescription is valid, and re-check the monitoring program.
- Dispense with pharmacist counselling: sedation, constipation, alcohol, driving, no sharing, safe storage, and return of unused medication.
- Document the original concern and its resolution in the file - date, time, who you spoke to, what was decided.
If the clinic instead says they never issued it, stop and proceed with the forgery report. The two outcomes look identical at the counter and could not be more different.