Steph’s Note: This week, tl;dr is giving some pharmacy love to a heretofore less-traveled arena for us…retail. Luckily, we have a knowledgeable and passionate pharmacist on board who is eager to share his retail wisdom with you!

Lambert Peng graduated from Rutgers University Ernest Mario School of Pharmacy in 2015 and has been working at one of the three big chain pharmacies ever since. When he is not doing work-related activities, Lambert can be found writing (about other different topics), binge-watching Youtube videos, and taking long walks (to cool down from all the writing and Youtube-watching).

So whether you are a student intern at your local independent pharmacy or a practicing pharmacist at a large chain, take note of Lambert’s tips to help us all speak the same language when caring for our patients.

Newly hired staff frequently get tripped up by the computer system in a retail pharmacy. Retail companies, especially the big chains, provide minimal training and (quite honestly) basically “throw you to the wolves.” Having worked 8+ years at two of the three major pharmacy chains, I have some insights on why some of the things are the way they are, and in this post, I’ll address some of the most commonly encountered issues to try to give you a leg up.

Disclaimer: this article is not intended to be an “introduction” to retail. I am not going over the extreme basics, like how to resolve an out of stock issue. I’m focusing on the most common mistakes that I’ve seen people make when trying to resolve certain situations.

Retail Pharmacy Issue #1: Counting Refills

You would think that something as simple as counting refills would be a very straightforward thing to understand, right?

Not quite so much. I’ve seen countless new grads (and even veteran pharmacists, especially those who come from a non-retail setting) make embarrassing mistakes.

Let’s start with the number one most common mistake I’ve seen people make. “Total refills” must be subtracted by 1 to get the actual number of “refills.”

Let’s look at an example. A doctor’s office calls you and says, “I’m calling in lisinopril refills for patient John Doe.” You go into the patient profile, see that John Doe is indeed on #90 tabs of lisinopril, and say, “Okay, Doc, I’m ready. Go ahead.” Doc simply says, “Give him 5 refills.”

Pop quiz time! How do you enter this into the system? Do you enter:

A. 90 tabs with 5 refills

B. 90 tabs with 4 refills

If you chose option A, you are now in the same camp as said new grads and veterans who have made an embarrassing mistake!

If you chose option B, you are correct! In the “industry standard” speak, “adding X number of refills” is understood to mean adding a new prescription fill with X – 1 number of refills.

Here’s another scenario. You are transferring a script for amlodipine from another pharmacy. The pharmacist on the other line says, “This is for 30 tabs. There are 7 refills coming to you.” Do you put in:

A. 30 tabs with 8 refills

B. 30 tabs with 7 refills

C. 30 tabs with 6 refills

D. 90 tabs with 7 refills

E. 90 tabs with 6 refills

If you chose option B, then you have not been paying attention! If you chose option C, you are correct. If you chose option A, D, or E, I must ask you, “What planet are you from?”

To avoid problems like this, when I do transfer-outs, I always read the number of refills as “1 + X” refills. For example, if a patient has 6 refills, I always read the transfer out as, “You have 1 + 5 fills coming to you.” The pharmacist on the other end will always know exactly what I mean, and it is also an “industry standard” way that leaves no ambiguity. This is a best practice that I hope more pharmacists will take up.

Finally, let’s check out one last case. Doc calls your pharmacy and dictates a brand new prescription for a patient. He says, “Dispense atorvastatin 20 mg 1 po qd #90 with 2 refills.”

What do you enter?

A. 90 tabs with 3 refills

B. 90 tabs with 2 refills

C. 90 tabs with 1 refill

What it sometimes feels like working in pharmacy…

The correct option is B. Remember, the two examples I gave you previously are meant for counting refills. They do not apply to brand new prescriptions. Besides, in this case, the doctor literally just told you exactly what he wants.

Retail Pharmacy Issue #2: Filling for Less Than the Prescribed Amount

This is another one of the most common refill mistakes that I see people make. People fail to correctly count remaining quantities because the patient, for whatever reason, happened to fill less than the prescribed amount.

I know that, at least in my company, labels on the prescription bottles don’t have enough room to print an exact quantity of drug remaining. So it prints something ambiguous like “2+ refills” or “partial refills remaining.”

So, for example, if a doctor wrote a prescription for 90 tabs with 2 refills (so the total prescribed quantity is 270 tabs), and the patient chooses to get only 30 tabs, the bottle would say that there are “1+ refills” remaining. Do not go off of that number!

If you verbally transfer the script to another pharmacy and tell them that there are 90 tabs with 1 refill remaining, then the patient just lost 60 tabs into thin air thanks to your mistake. Instead, the best practice is to enter the patient’s profile and look up the “quantity remaining.” That number should be 240.

By the way, if you’re the pharmacist receiving the transfer, how do you enter 240 tabs into your system? The answer is this: you literally just write it as #240 with 0 refills. Unfortunately, there is no way around this. The computer system, at least at my company (and most likely in most companies), is not sophisticated enough to make room for special situations like this.

My advice to you is to get familiar with where your system tells you the total number of pills left on the script. Be able to access it using muscle memory. If you can figure that out, believe it or not, you will be ahead of the game.

If you have no retail experience, you might be thinking, “Wow. What is the big deal? It’s just friggin’ refills. Did this guy really just type an entire section about how refills are calculated?”

To which I will simply say this… I have seen (and been in) arguments that lasted over 30 minutes due to issues like this. Most patients trust the pharmacy to handle their prescriptions, but there are some who religiously keep track of their refill amounts. And they will argue with you and waste your time if they feel that they are being cheated. When it comes to dealing with the general public, no issue is too small to argue about!

Plus, that patient who just lost 60 tabs into thin air will likely run into a sticky wicket down the road. The filling pharmacy is eventually going to request a renewed script from the prescribing provider, who isn’t going to understand why that patient needs a new script so soon. Shouldn’t they have at least 2 months left on the previous script?

So that faxed request to the provider for a script may end up file 13’d (sometimes repeatedly) until the patient, now completely OUT of medication, has to coordinate, request, and explain multiple times in order to not miss doses. Or they miss doses…all because of a miscommunication, which is just awful.

Retail Issue #3: Calculating Refill Due Dates

When you’re dealing with refills for controlled substances, calculating the next refill due date is a whole skill set in itself. Bear with me, but this concept is best illustrated using lots of examples.

Example 1: Patient picked up 30 tabs of alprazolam, taken once daily, on April 10. You choose to refill it 2 days early. How do you calculate it?

Most people, especially those with experience, just sort of “eyeball” it. In this case, if you said May 8, you would be right. However, “eyeballing” it causes people to make tons of mistakes, especially if the numbers are not so “clean” like they are in this example. And so, it’s important to understand exactly how you got there, mathematically!

Here is how I calculate it:

April 10 + 30 tabs = April 40. The refill runs out on April 40.

But there is no such thing as April 40. There are only 30 days in April. Thus, you subtract 30 from April 40 to move into May.

April 40 – 30 days = May 10.

Since you’re refilling it 2 days early, you would subtract that from May.

May 10 – 2 = May 8, your final answer.

If you keep this simple “formula” in mind, you will get adept at navigating tricky situations where the numbers are not so simple.

Example 2: Patient picked up a 30 day supply of zolpidem on May 19. If you fill 4 days early, what date is it due?

May 19 + 30 days = May 49

There are 31 days in May, so you subtract:

May 49 – 31 = June 18, the day they run out.

If you refill 4 days early, you subtract 4:

June 18 – 4 = June 14, your final answer.

Example 3: It gets really complicated when you start working with larger numbers. Patient picked up a 90 day supply of clonazepam on September 6. You want to refill 2 days early.

September 6 + 90 days = September 96

There are only 30 days in September:

September 96 – 30 = October 66

There are 31 days in October:

October 66 – 31 = November 35

There are 30 days in November:

November 35 – 30 = December 5, when the refill runs out.

Refill 2 days early:

December 5 – 2 days = December 3, your final answer.

Example 4: This calculation method becomes absolutely critical when you start working with otherworldly numbers.

Patient gets 420 tabs of phenobarbital, which lasts 84 days. (Yes, I have seen this in real life.) It was picked up on January 17. You want to refill 3 days early.

January 17 + 84 days = January 101

There are 31 days in January:

January 101 – 31 = February 70

Remember there are fewer days in February! Assuming no leap year, that would be 28 days:

February 70 – 28 = March 42

March 42 – 31 days = April 11 is when it runs out

April 11 – 3 days early = April 8, your final answer

Example 5: And finally, one last curveball example.

Patient picked up a 6 day supply of Percocet on March 27. Assuming you fill 2 days early, what is the due date?

March 27 + 6 day supply = March 33

March 33 – 31 days in March = April 2, the date it runs out

April 2 – 2 days early = April 0???

If you end up with 0 or a negative number, that means you need to backtrack. Here, let’s go back to March 33.

Take March 33, and simply subtract 2 days directly from that.

March 33 – 2 = March 31, your final answer. Whew!

See, not soooo bad. These controlled substances refills just require a little bit of extra consideration - and math. But that’s ok, we’re pharmacists, we like math, right? Hopefully these examples make it a little easier to determine correct refill dates!

Retail Pharmacy Issue #4: Inventory Issues

Picture this: A customer in the drive-thru hands you a script. You take it in and enter it in the system. It goes through insurance. The inventory tells you that there is more than enough on hand. Satisfied that everything is cleared and good to go, you cheerfully say, “Okay! It will be ready in 30 minutes!” Customer comes back in 2 hours. Prescription is still not finished. Go over to the shelf right away to fill it.

The prescription is out of stock.

You drag your feet back to drive-thru, be the bearer of the bad news, and proceed to get screamed at by the customer about how you guys just wasted their time, how incompetent the pharmacy is, blah blah blah. They demand to have their script back. You give it back to them. They snatch it out of your hand, and you get an earful about they are going to report you to the board of pharmacy and the local news outlets, etc. They speed off.

What went wrong?

Why did the inventory system lie to you?

As it turns out, especially in a busy chain pharmacy, it is actually very difficult to maintain an accurate inventory. Even if you accurately count the inventory of a particular drug and enter it in the system successfully, chances are there is still something you missed. Remember, the pharmacy is open to the general public, so literally anyone can walk up at any time and order anything. And all this is occurring while pharmacy staff members are performing background tasks that affect inventory. At any given moment, any or all of these factors could simultaneously be happening:

People filling prescriptions; this depletes inventory.
The “delete” or “return to stock” list: pulling finished prescriptions from the bin that have been sitting there for several days, to put them back on the shelf. This adds drugs back to the inventory.
Inventory counts: a staff member logs the inventory of a drug at a given moment, which resets the on-hand counts to whatever number that staff member enters at that exact moment.
A truck full of totes gets delivered from the supplier’s warehouse, and when they get scanned in, all the drugs inside the totes instantly get added to the inventory, even though the staff members have not had time to open the totes and put the drugs on the shelf properly.
Patients (and sometimes prescribers) cancelling finished orders. Sometimes the cancel order comes in right when you’re doing 5 things at once, so you don’t have time to pull the finished product from the bin. You decide to just clear it from the system and make a note to yourself to physically pull it later. Meanwhile, that drug just got added back to your inventory.
Lost prescriptions: you can’t find the bag in the bins to save your life, so you have no choice but to “re-do” the prescription for a customer that’s standing there. This reduces the number of pills on the shelf, but the inventory does not get updated.
Bottles get misplaced. This is very common in high volume pharmacies, because there is simply not enough room on the shelves.
Bottles are sitting on the filling counter - and not on the shelf - because someone is about to use them shortly. Those easily get missed when assessing inventory.

And even amongst these factors, there are “sub-factors” at play that make it even more complicated. For example, filling a prescription depletes it from the inventory, but at what point exactly do you specify that the system should make the necessary deduction? Is it at the point of order entry? Is it at the point where the pharmacist verifies the order? Is it at the point where the tech actually opens the bottle and starts counting the pills? All of these have problems:

If the system deducts the inventory at the point of order entry, you run the risk of possibly making a mistake. For example, if you enter #30 pills of alprazolam, but the handwriting was bad and the reviewing pharmacist determines that the script was actually for clonazepam, then you just deducted #30 alprazolam from your inventory without actually taking out the pills. No bueno.
If you deduct at the point of pharmacist verification (or any time afterward), you run the risk of shorting someone. For example, your inventory says you have #30 tabs of Belsomra. A patient comes in, drops off an rx for Belsomra #30, and the tech successfully enters the rx without any issues. The patient decides to come back for it in a few hours. A few minutes later, before the pharmacist has had a chance to verify the rx, a second patient drops off another rx for Belsomra #30 and wants to wait for it. That second prescription gets pushed through—entered, verified, and printed, all ahead of the first patient. That second patient receives the Belsomra, but the first patient has now been shorted.

Other factors add yet MORE complications…

Lag time is very common when updating inventory. In many companies, the inventory management system is a completely separate database from the prescription processing system, so it takes time for the data to be transmitted back and forth between the two systems.

These two systems are also separate from the inventory ordering system, which is almost always a different company that has a completely different website! For example, Walgreens contracts its orders from Amerisource Bergen, and CVS gets theirs from Cardinal. That adds yet another layer of necessary coordination in which things can easily go wrong.

Not to mention, staffing shortages make it extremely challenging to accurately perform background inventory tasks while simultaneously helping every customer that walks up to the counter.

The point here is that it is almost impossible to have perfect inventory. All the pharmacies I’ve ever been in that have near-perfect inventory are either extremely slow stores or well-managed independent pharmacies with strict protocols in place for managing inventory.

The best thing you can do for yourself is to make it a habit to physically check the shelf every time a patient orders a prescription, if you are anything less than 100% confident that you have this in stock. Tell the patient, “Lemme just make sure I have this in stock.” Then go to the shelf and check it. It takes less than a minute, and the patient will never get annoyed at you for doing so.

Retail Pharmacy Issue #5: Automatic Refills…and Running Out of Refills

Automatic refills cause a whole host of problems. How many times have you encountered a patient who got angry because something was “supposed” to be filled today but wasn’t - because it ran out of refills? Or what about when the refill request never reached the primary care provider because the system generated the refill request based on the previous refill, which just happened to be a one-time prescription by a temporary covering doctor? Or how about the prescription that was successfully renewed by the doctor’s office, but the quantity, directions, strength, or even the prescriber was (intentionally or unintentionally) altered?

Automatic refill problems are the result of two factors:

The general public expects automatic refills to be a smooth, ongoing process. Kinda like setting up your credit card for automatic recurring bill payments each month, and
A prescription is a finite resource that eventually gets depleted, and it requires human intervention to renew properly.

The law does not allow for a prescription with unlimited refills that lasts forever. This disconnect between expectations and reality, if you think about it, is basically what causes every single customer service problem you can think of with automatic refills (barring insurance and out of stock issues).

Unfortunately, since automatic refills are handled by the computer system, the quality of your experience with automatic refills pretty much depends on how good or crappy your company’s computer system is. However, even if you have an amazing computer system, there is little you can do to save yourself from a provider who, say, prescribes 3 pens of Lantus today instead of the usual 3 boxes, or who doesn’t get back to you until the patient has been out of Lantus for a week.

Some independent pharmacies take (at their own risk) matters into their own hands by basically using their judgement and approving the refills themselves. This is the part where people start talking about pharmacist prescribing privileges and “provider status.”

I won’t go too much into prescribing privileges or provider status today because that is a whole other topic that deserves an entire dedicated article. I will say this, though… There is one, small intervention that you can apply today to try to make this problem a little less burdensome.

Did you know that most states, insurances, and pharmacy computer systems allow for “PRN refills”? Instead of prescribing, say, #90 losartan with 3 refills, you can just ask the doctor to prescribe #90 losartan with PRN refills. This grants the patient unlimited refills for a full year. Then you won’t have to worry about giving emergency supplies, arguing with the patient over lost medication, etc. Not enough prescribers and pharmacists, at least in my area, utilize this feature (or are even aware of it).

Now, it should be noted that not every prescription is a candidate for this magical PRN refill business. Controlled substances and acute meds are the obvious exceptions. But in addition to these types of medications, there are also providers who simply don’t want their patients to have unlimited refills, even for chronic maintenance meds, because they want to keep closer tabs on their patients. Needing medication refills is one way to incentivize patients to keep their appointment dates.

Still, “advocating” for PRN refills is easier than you think. Like I said, you don’t have to do it for every prescription, especially if you’re busy. But it’s such an easy intervention if the provider calls you first to phone in a year’s supply of maintenance medication. Use this opportunity to throw them this pitch: “Do you wanna do PRN refills instead? That way, the patient has unlimited refills for a year. So if the patient accidentally drops the pills in the toilet or something, we can just resupply him ourselves and won’t have to bother you about it.” Boom. If you pitch it like that, they will always say yes. It takes like less than 10 seconds to say this, you have nothing to lose, and you will benefit yourself, the patient, and the provider.

Birth control is the best candidate for PRN refills. Most birth control patients have annual follow up anyway. Many are young women, or teenagers, and it’s not uncommon for them to accidentally lose their medication. It’s definitely a medication that should not be skipped. It’s not a controlled substance, and I don’t know of any pharmacists who would dispense an emergency supply for birth control. Sounds like a pretty good PRN refill scenario to cover the bases.

Transferring prescriptions

Since we’ve touched upon advocacy, let us end on this note here. There is one issue with retail pharmacy computer systems that nobody seems to talk about but that we need to start advocating more for, because it affects our day-to-day work.

Why are we still doing paper transfers?

Patients expect transfers to go as smoothly between pharmacies as their money goes between banks. Yet, as anyone who has worked retail at the beginning of the New Year knows, transfers take a long time and can really, really slow you down!

Last time I checked, we are living in the year 2022. E-scripts are a thing. Providers can transmit prescriptions—even for oxycodone—electronically to a pharmacy. There is no law that prohibits electronic prescription transfers. In fact, even the DEA allows electronic transfers of CII prescriptions! (Nobody does it, but it’s technically allowed.) So why are we still faxing and verbally transcribing transfer prescriptions like it’s the year 1972?

The reason for this is very simple.

Companies have no incentive to implement smooth transfer technology. Why do you want to make it easier to give your business to your competitors?

We need to advocate for a law that incentivizes pharmacies to transfer prescriptions electronically. We need to pitch it as patient advocacy—and it really is - because the patient is the one that suffers if there is a delay or mistake in getting their prescriptions transferred. We need the law to say, “If your pharmacy is capable of receiving electronic prescriptions, then it needs to be capable of transmitting electronic transfer prescriptions. Said electronic transfers are a perfectly valid substitute for written/faxed transfers.”

We can bundle this law into one of the many packages that are already swirling around in Congress, perhaps one of the bills that is attempting to address high drug prices. (We can even frame our request as making competition easier between companies).

Plus, reducing fax and paper waste is good for the environment. APhA is already talking their tail off about advocating for “provider status,” which is something that still has not materialized at the federal level. Why not give them some lower-hanging fruit - a success that they can sell to their constituents?

The tl;dr for Avoiding Retail Pharmacy Computer Mistakes

So there you have them - my biggest tips for keeping your “i”s dotted and your “t”s crossed in the world of retail pharmacy.

Pay attention to the lingo for counting refills.
Know where your computer system reports the total quantity remaining on a prescription (not necessarily the number of refills remaining).
Learn how to calculate refill due dates and practice this until it’s second nature.
Strategically advocate for the use of “PRN refills” when appropriate to allow for a year’s worth of refills without contacting the provider.
For the love of Pete, please walk the 10 steps to the shelf to check stock if you have any doubt whatsoever of inventory accuracy. (This saves literally everyone.)

If we retail pharmacists (and our student interns) can band together and work on speaking the same language, as well as advocating for common goals like electronic prescription transfers, my hope is that we can make this practice oh-so-much smoother. Which would only make our days that much more pleasant and patient care that much higher quality.

And if anybody needs less stressful days especially now, it’s retail pharmacists, am I right?

So let’s do this!

How to Prevent Common Retail Pharmacy Computer System Mistakes