Out of Stock on a Friday: Partial Fills and an Emergency Oral Order
Friday, 4:50 p.m. at a single-pharmacist independent pharmacy in rural Kentucky. The wholesaler will not deliver until Monday. Three problems arrive at once.
(1) A hospice patient's daughter brings a new prescription for morphine sulfate ER 30 mg, quantity 60, "one tablet every 12 hours." The patient is enrolled in hospice and is terminally ill. The shelf holds 22 tablets.
(2) A regular patient presents a new prescription for oxycodone 5 mg, quantity 60, from a local surgeon. The pharmacy has 30 tablets. The patient is not in hospice, a long-term care facility, or terminally ill.
(3) At 5:05 p.m., an urgent care physician telephones in an oral prescription for oxycodone 5 mg, quantity 40, for a patient with an acute fracture, stating the written prescription will follow. The patient is in the store, in pain.
1. For the hospice patient, what may the pharmacist do tonight, how must it be recorded, and what is the outer time limit?
Read the worked answer
This patient falls within the exception in 21 CFR 1306.13(b): a partial fill is permitted for a patient in a long-term care facility or one who is terminally ill, and the prescription may be partially filled in this way for up to 60 days from the date the prescription was issued.
Practical consequences:
- The pharmacist may dispense the 22 tablets tonight and supply the balance when stock arrives, provided the total dispensed never exceeds the prescribed 60 tablets and the balance is supplied within the 60-day window.
- Each partial fill is a dispensing event. It must be recorded on or with the prescription: the date of each partial fill, the quantity supplied, and the identity of the dispensing pharmacist.
- The supplies are separate dispensings, not refills - the prescription's refill status does not change.
- Because each is a dispensing, each must be reported to KASPER as the state requires.
- No new prescription is needed to complete the balance inside the 60 days; a new prescription and a new 60-day clock are needed if the balance would fall outside it.
The pharmacist should also confirm and document hospice enrollment or the terminal-illness status, since the exception turns on that status, and should tell the daughter clearly when the balance will be ready.
2. For the surgeon's patient (no hospice or long-term care status), what are the options and the deadline? What must happen if the deadline is missed?
Read the worked answer
This is the ordinary partial-fill rule of 21 CFR 1306.13(a). The pharmacist may supply 30 tablets tonight, but the remaining 30 must be supplied within 72 hours of the partial fill. The partial fill must be recorded on the prescription - date, quantity, and dispensing pharmacist.
The deadline is Sunday evening. If the wholesaler cannot deliver by then, there is no lawful way to complete this prescription under the partial-fill rule. The pharmacist must:
- Notify the prescriber that the full quantity could not be supplied within 72 hours, and
- Supply no further quantity after the 72 hours have elapsed without a new prescription from the prescriber.
It is a mistake to treat the leftover 30 tablets as an informal refill or a "pick up Monday" arrangement. It is also a mistake to dispense the whole 60 if only 30 are on hand, and to "borrow" tablets from another patient's stock - that creates an inventory and recordkeeping problem that will follow the pharmacy into its next controlled-substance audit.
A practical step the pharmacist should take tonight: call the prescriber proactively, explain the shortfall, and ask whether to supply 30 with the balance due in 72 hours or to refer the patient to a pharmacy with full stock. Document the conversation.
3. What are the requirements for the oral emergency oxycodone order, and what is the pharmacist's obligation if the written prescription never arrives?
Read the worked answer
Under 21 CFR 1306.11(d), an oral Schedule II order is permitted only in a genuine emergency - the prescriber must be unable to provide a written prescription at that time, and the emergency must be real, not an administrative workaround. Before dispensing, the pharmacist should:
- Verify the prescriber's identity (confirming callback number, DEA registration, and that the caller is authorized), and
- Reduce the oral order to writing promptly, including the date and time it was received.
Quantity limit: the amount dispensed is limited to the quantity needed to cover the emergency period. Forty tablets on a two-tablet-a-day regimen is twenty days, which is not an emergency period and should prompt a call back to the prescriber to reduce the quantity.
Follow-up: the prescriber must furnish the written prescription within 7 days of the oral order. If it does not arrive within 7 days, the pharmacist must notify the nearest DEA field office and should document the notification.
Repeated emergency oral Schedule II orders from the same prescriber or for the same patient are themselves a warning sign; the emergency mechanism is not a standing substitute for written or electronic orders. If the 7-day clock expires, the pharmacy's file should show either the written prescription or the DEA notification - an empty file is the finding an investigator will cite.