Buy Viagra Blog

On August 25th, CBS News’ show 60 Minutes did a report on a serious drug overdose given to two newborn infants. The infants survived, but similar problems have occurred in other hospitals with tragic outcomes. The reporters kept asking “how could this happen?” and made the point that three people had responsibility for checking the dose. The report didn’t go into enough detail to answer some of the obvious questions about responsibility, but several thoughts came to mind, not about this specific incident, but about drug therapy in hospitals in general.

1) How rushed was the staff? There are serious staff shortages in just about every health care profession, even while the need increases. There’s an estimate that by the year 2020 there will be 157,000 unfilled pharmacist jobs. By 2025, there may be a shortage of 500,000 nurses – in 2007 the immediate shortage of nurses was estimated at 116,000. So far, the answer to the problem has been to increase work-load, increasing productivity. It also increases the risk of error.

2) Was the computer system set to prevent errors? A well designed computer program would stop an adult dose being ordered for an infant – it’s not a major bit of programming. Was it?

3) Was there a pediatric pharmacy, preferably with a pediatric pharmacist on duty? If there’s an overall staff shortage, it may be hard to recruit suitable specialists, but it’s a lot simpler to set aside a space on the unit and only stock it with appropriate drugs. That isn’t an infallible system, because older children may requite adult doses, but it helps.

There’s no way to completely avoid human errors; there will always be tragedies like this one. As we become more reliant on drugs therapy, and as the aging population means that more people will require drugs, we’ll need more professionals and better systems, and we should address the problem as soon as possible. Right now there’s a shortage of over 700 faculty positions in nursing schools, which means that we’re losing the ability to train nurses to make up the shortage. Pharmacy schools report 417 vacant faculty slots, and dental schools need about 400 more professors. That’s going to be a problem, very soon.

Byetta – there are two important reports about Byetta, the generic name is exenatide, an injectable drug used in treatment of diabetes. On one side the Food & Drug Administration is giving sterner warnings about the risks of exensatide, that in rare cases, it can cause inflammation of the pancreas, and this has occasionally been fatal. At the same time, a study presented at a meeting of the American Diabetes Association reported that patients treated with exenatide actually had longer survival than patients using other anti-diabetic drugs. The results of this study will need more examination, since there doesn’t seem to be a cause and effect relationship, and sometimes this type of thing shows up in a study result simply by chance. It will take additional examination, both of the results of this study, and probably additional large studies, before any conclusions can be drawn. In view of the known risks of pancreatitis, patients shouldn’t be switched from other drugs to exenatide unless there’s a compelling reason to do so.

In the New York Times health blog, Tara Parker-Pope draws attention to a blog by Dr. Robert Lamberts, an Augusta, Georgia primary care physician. The blog (http://www.musings.org) is usually informative, often funny, and occasionally infuriating. Dr. Lamberts has created lists of rules for physicians and for patients (how to be a better patient.) In his honor, here are some rules for physicians dealing with pharmacists:

1) Write either legibly or illegibly, not in-between: http://www.musing.org,legible prescriptions are best, but if it’s completely illegible, then I’ll call. Too many prescriptions are semi-legible, look like one thing, but were supposed to be another. That’s how mistakes get made. The extra few saved by scribbling aren’t worth it.

2) Come to the telephone: telephone communications are supposed to be between physician and pharmacist, but too often, the physicians assign these calls to their office staff. In many states, telephone prescriptions dictated by anyone but a licensed prescriber are illegal. What’s particularly annoying is when we call to alert the physician to a prescribing error, and they still won’t speak to us directly.

3) Don’t say “I’ll take responsibility”: The pharmacist is an independent professional, and filling a prescription is effectively a collaboration between two colleagues. Our responsibility is to the patient, not to the prescriber. If we feel that a drug or a dose is unsafe, we can’t fob off responsibility and liability if something goes wrong. Part of the problem is that we can refuse to fill a prescription if there’s enough evidence to convince us that it’s dangerous, but we can’t counterprescribe. So, if the physician orders penicillin for a patient with a penicillin allergy, the pharmacist has an obligation not to dispense the drug, but that leaves the patient with an infection that’s not being treated.

4) Talk to your patients: This is a serious problem, and it’s built into the system. Physicians and pharmacists are both pressed for time, and what gets cut out may be the most important part – the counseling. Maybe physicians assume the pharmacist will do it, and pharmacists assume the physician will do it, and too often the patient never gets counseled. Neither one should rely on the other.
There are more rules, but these would be a good start.

A recent review in the journal Spine, evaluated the use of non-steroidal anti-inflammatory drugs for treatment of low back pain. The reviewers concluded that these drugs, which include ibuprofen, naproxene, fenoprofen, meloxicam, nabumetone and lots more, do have some benefit, but don’t expect much from them. They also looked at the studies to try to answer the question that has been asked often enough – which is best. There really doesn’t seem to be a best, they’rr all about the same once the dose is adjusted for differences in potency. The best choice is the cheapest, used in the lowest effective dose in order to minimize side effect. As the doser gets higher, the side effects, particularly the effects on the stomach, become more common and more severe.

The American population is getting older, and manual dexterity declines with age, but for some reason tablets keep getting smaller and harder to pick up. Kitchen tools are made with fatter handles that are easier to hold, and clocks have larger numbers that are easier to read with aging eyes, but pills keep shrinking. They may be easier to swallow, but only if you can get your fingers on them. If the people who have the trademark “Good Grips” came out with a line of pills, they would probably find a market with no trouble at all.

Time magazine has an interesting report on counter-detailing, focusing on South Carolina’s SCORxE program: South Carolina Offering Prescribing Excellence (yes, that’s the way Time reports it, not SCOPE which seems more logical.) The idea is that the state funded program has pharmacists visiting physicians, offering objective information about drug selection and countering the efforts of corporate representatives to promote more expensive drugs when a generic drug can do the same job at a lower price. The report estimates that every dollar spent on the program saves $2 in drug costs. While South Carolina tends to be a conservative state, and opposition to a program of using state money to counter corporate effort was expected, the program seems to be popular.

But according to Time, there is a major debate going on – should the people doing the counter-detailing work bring pizza?

It’s amazing how many parents child-proof their homes, put in latches so that kids can’t get to cleaning supplies, put plugs in electrical outlets and gates in front of stairs – but don’t have a proper medicinal teaspoon. When a prescription calls for giving a child one teaspoonful of a liquid, it does NOT mean take a teaspoon out of the kitchen drawer – it means use an accurate measure. A medicinal teaspoon has 5 milliliters, while household teaspoons may have anywhere from 3 to 6 milliliters.

The best medicinal teaspoons are the ones that look like test tubes with marks on the side. They can be a little bit harder to use, and a lot harder to clean, than some other designs, but they give a more accurate measurement than either the ones that look like spoons or the ones that are packaged with bottles of pediatric medicine.

As you may have noticed, there are thousands of Internet pharmacies where you can order and buy Viagra online. Allowing web users to order Viagra online from the privacy of their homes has been a great boon to both consumers and sellers, creating a cottage industry of Viagra vendors. Some actually deliver what they promise… [...]

2008 Pet Hall of Fame Award Honoring our Animal Companions Every year these awards are presented to honor the outstanding contributions our animal companions make to human lives...

The purpose of this column is to offer advice about saving money on prescription drugs – which usually reduces to asking questions of your physician and pharmacist. But, there are two other questions you should ask that can save more than money – they may save your life. These are the questions that may prevent prescription errors, and they should be asked before you say good-bye, before you leave the physician’s office, before you leave the pharmacy.

When your physician hands you a prescription, look at it, and read it. If it isn’t clearly written, so that you can read it with no difficulty, as “would you please rewrite this legibly?” You may not recognize the word, you may not be familiar with quadragintesimal either (it means “in forty parts” according to the Hutchinson Dictionary of Difficult Words) but you can read it, and that’s what’s important. Read the prescription aloud to your physician, to be sure you’re reading it correctly. If you can’t read the prescription, don’t assume that anybody else can, because an illegible prescription increases the risk that your pharmacist will make a mistake.

Physicians’ handwriting has been the subject of a lot of jokes – but when it leads to medication errors it’s not funny. Too often, drug names, when written, can look alike. One of the classic examples was Lasix (a diuretic) and Losec (to reduce stomach acid). Amrinone has been confused with amiodarone, hydroxyzine with hydralazine. A well written prescription should really have a lot more information than most of them do. Ideally, the prescription should have the patient’s name, gender, age and diagnosis. You want the pharmacist to have enough information to do a proper double check on the physician, to confirm that the MD didn’t order an adult dose for a child, didn’t put a decimal point in the wrong place, didn’t confuse two drugs with similar names. Some day, there may be a computer system that will give the pharmacist all that information, and print the prescription legibly, but until then, just make sure that you can read the prescription yourself. Sloppy handwriting can turn OD (once a day) into QID (four times a day), or QOD (every other day). It takes just a few extra seconds to make sure that the prescription is legible, and if it isn’t, to ask your physician to rewrite the prescription to prevent an error.

***
When your pharmacist hands you a filled prescription, and this applies mostly to refills, take it out of the bag, open the vial, look at the tablet or capsule, and if it doesn’t look familiar, ask him to double check that it was filled correctly. You can even ask him to show you the stock bottle, the one that he dispensed from, to verify that it’s the right drug.

One of the most important advances in keeping drug costs down was generic dispensing. Generic drugs are as good as their brand name equivalents, and a lot less expensive. The disadvantage is that because the same drug from different manufacturers won’t look alike, you can’t identify a drug by its appearance. One month, a drug may be a round tablet, and the next month an oval tablet. One month, it may be a blue capsule, and the next month it may be red. Most of the time these changes in appearance will be the result of buying the drug from different manufacturers – but every now and then, it will be because the pharmacist grabbed the wrong bottle from the shelf. The prescription may have been perfectly legible, and given the pharmacist all the information needed to double check that its’ an appropriate drug in the right dose, but that won’t help if he grabs the 10 milligram tablets instead of the 5 milligram ones. You may not know what the drug looks like the first time, but if it looks different when you go back for a refill, ask the pharmacist to double check. Most of the time, hopefully all of the time, it will be because the drug came from a different manufacturer – but check anyway. If the drug comes in the original manufacturer’s package, compare the manufacturer’s label with the pharmacy label, make sure they agree. An increasing number of pharmacies are using bar code readers to do this step, but do it yourself anyway.

***

Most of the time, both physicians and pharmacists do everything right, and that’s good – but there are still going to be exceptions. Asking some questions can save money. Asking other questions can save your life.