Most of the time, when I talk about something related to how pharmacies work, it’s stuff that I wish people knew because it would make things actually better if more people knew it.

This time, though… I’m not sure telling anyone about this is actually gonna help anything.

But… screw it. I’ve decided that you still have a right to know.

And lots of you don’t.

So, for better or worse, here goes.

Behind the cut, in case you don’t need yet another thing to worry about.

This is about how pharmacy works– or doesn’t work – in regard to protecting patients who have allergies.

First, the very basics.

Some people have allergies to certain medications. They can be allergic to the active ingredient – the medicine itself – or they can be allergic to an inactive ingredient, like a color or a coating or a binding agent that’s used to make a pill stay together.

Different manufacturers produce their own versions of a medicine. All different brands of a medicine are required by law to be identical in terms of the active ingredients.

They are not required to have all the same inactive ingredients. So yes, a person can be allergic to one brand of a medicine and not a different brand of the same medicine.

Now, the complications.

If you tell the pharmacy that you cannot have the DystopiaPharm brand of Life Saving Heart Pills because it contains Poison Pink Horror Dye, to which you’ve had a bad allergic reaction– the best procedure is for the pharmacy to put that note in your profile, and make sure to follow it every time they fill your prescription, and always use one of the other manufacturers that you’ve told them you are fine with.

But in practice– even assuming the pharmacy has this as a standard procedure and is making every good-faith effort to follow it– there are still a gazillion ways it can go wrong.

1. Communication/awareness

The default process for filling any prescription, in the absence of such a profile note, is just to pick one of the brands the pharmacy has in stock. Any one of them, but usually whichever one has an open, sufficiently full bottle on the shelf already.

And your prescription is one of hundreds that they have to fill. Usually while very understaffed, and with constant distracting interruptions, within a very rushed timeframe. And unless they see the note, their muscle memory will tell them to follow the usual procedure on each one.

Amd the note is not always in the same place on the profile as the information a tech needs to access when filling a prescription. In many systems, it is scarily easy to miss this sort of note. So… there’s already a lot stacked against the pharm techs even remembering to give you the brand that’s not gonna poison you.

But even assuming they do remember, that is no guarantee that the right brand will even be in stock.

2. Availability

Pharmacy inventory is decided by some absolutely useless algorithm that I think is supposed to make sure we always order the brand of everything that’s currently the cheapest.

But in practice it just ends up meaning we order a different brand every week, and we usually have like 5 mostly-empty bottles that’ll never get used before their expiration date, and only 1 brand at most that actually has enough to fill any prescription, and that one won’t be the same brand from one week to the next.

If the only manufacturer of Life Saving Heart Pills currently in stock is the DystopiaPharm one with the Poison Pink Horror Dye that you’ve specifically asked the pharmacy not to give you for allergy reasons… and if they’re competent enough to remember this… then, they are going to set your prescription aside to wait until they have the correct brand to fill it with.

Which, ideally, will involve someone notifying you that there will be a delay, and someone notifying the inventory technician that a specific brand needs to be ordered, and the inventory technician actually doing this, and the supplier actually having it in stock, and everyone at the supplier’s location remembering and communicating the correct information to get the correct brand onto the shipment, and the shipment actually getting to the pharmacy, and the pharmacy technicians still knowing about your prescription that’s waiting for it, and your prescription finally actually getting filled with the correct brand, and you being notified about it, and you actually seeing the notification and coming in to pick it up before your 2-week time window runs out and it has to be returned to stock.

And any part of this chain of events can fail and prevent you getting the right med, or any med at all. People may not communicate the right information. People may be impossible to reach at all. And items may be unavailable at any level of the manufacturing and distributing process.

All these problems are especially impenetrable for me, as an overnight employee catching up on work from the day before. If the information that the day shift left for me is incomplete, I have nobody I can ask for clarification, except the rest of the overnight team (no more than 1 pharmacist and 1 other tech, both of whom have been left with the same incomplete information).

On my shift, in the middle of the night, I can’t call the patient, or the supplier, or any of my day-shift coworkers, or anyone unless I know they are available to be called at that hour.

Mostly I have to leave notes, as clearly as I can, and just… trust that the day shift will read, understand and follow them. Which they often do not.

But… let’s suppose that every single step of this process goes exactly according to plan, anyway.

There’s still the issue of what actually ends up in the vial.

3. Cross-Contamination

Now, for purposes of this example, we’re going to proceed under the assumption that you’re correct about what caused your earlier allergic reaction to this med, and that it really was the Poison Pink Horror Dye in the DystopiaPharm brand.

And we’ll assume that the pharmacy, at this point, is correctly filling your prescription with the brand you’ve requested – let’s call it the Dye-Free Pure White Lifesaving Heart Pills from TotallyFine Pharmaceuticals.

But as you’ll see, there are also any number of other allergens that absolutely could end up in any bottle of your medicine. And choosing a specific brand can’t always do much to stop it.

Now, there are various ways your medicine can get from the stock bottle on the shelf into the bag you end up taking home. The safest method, with the least risk of cross-contamination, is probably when we just stick your label on an unopened bottle or package from the shelf and hand it to you still factory-sealed. But that only happens if we have supplies in stock that come prepackaged in the exact quantity your prescription allows you to get at a time.

After that, the next safest methods are probably the ones where pills are automatically dispensed from pre-filled cartridges in a machine. Most pharmacies I’ve worked in have at least one automatic dispensing machine. And there’s very little risk of those cartridges contaminating each other with residue from different medications, since they’re all very separated.

But when they need refilling, they get filled from bottles on the shelf… and if anything has already happened to cause cross-contamination in those bottles, then it can make it into the machine.

Which brings me to the least safe method: manual filling of prescriptions on a table or counter, with a tray and spatula.

This is what we have to do for every medicine that doesn’t come prepackaged in the perfect quantity and also isn’t among the super-common meds that get stocked in the machine.

(And we also do it any time one of those common meds can’t be dispensed from the machine, for whatever reason. So it absolutely can affect the stock bottles that are used to refill the machine.)

The tray is a little plastic thing with a flat surface, a pour spout on one side, and a compartment with another pour spout on the other side. The spatula is a sort of blunt knife. The technician sets the tray on the table, pours pills from an open stock bottle onto the flat surface, uses the spatula to count and push the correct number of them into the compartment, pours the rest back into the stock bottle, and then pours the counted ones from the compartment into the vial you’ll end up taking home.

You can probably see the cross-contamination risks here already. If the tray doesn’t get fully cleaned of all pill residue every single time it’s used, then there are already at least 2 ways Poison Pink Horror Dye might be getting into your supposedly safe Dye-Free Pure White Lifesaving Heart Pills:

1. This tray hasn’t been cleaned since the last time it was used to fill someone else’s prescription. The pills in that last prescription were ones that contained Poison Pink Horror Dye. Traces of it are still on there, and it’s getting onto your pills as they’re counted in the tray.
2. This tray has just been cleaned, but this stock bottle of Dye-Free Pure White Lifesaving Heart Pills isn’t a fresh unopened one. Another prescription was filled from it earlier. That prescription was counted onto a tray that hadn’t been cleaned since the previous prescription was counted on it. And that previous prescription was one that contained Poison Pink Horror Dye. So, when the last prescription of Dye-Free Pure White Lifesaving Heart Pills was counted, and the excess pills were poured back into the bottle after counting, they brought Poison Pink Horror Dye into the bottle with them. And now traces of that are being dispensed into the vial you’re gonna take home.

4. Current Safety Measures

Now, I’m not claiming there are no precautions ever taken to stop this sort of cross-contamination.

There are not as many precautions as I think there should be.

Pharmacists and techs often seem to treat the whole thing casually, believing that patient claims of allergies to a specific brand are unfounded or exaggerated in the first place, and that the amount of contamination likely to happen wouldn’t even be enough to cause actual harm.

Which sometimes may be true.

But I, personally, feel that it’s safest to make a habit of treating it… well, more seriously than we’re ever allowed to treat it, as things stand now.

Pharmacy techs are expected to use alcohol wipes to clean the trays and spatulas from time to time. And medicines that are known for being hazardous, or being common allergens, will often have their own dedicated, labeled trays and spatulas that aren’t supposed to be used for anything else.

But even assuming these rules are followed flawlessly, there is not usually a rule requiring cleaning of trays after absolutely every use.

In a busy pharmacy’s workflow, that would slow things down unacceptably. Especially considering that a tray has to be allowed to dry for a while after being alcohol-wiped, or else pills will start to dissolve on it as they’re being counted.

At most, trays are cleaned whenever the technician has some downtime. Or after they’ve been used to count something that leaves a noticeable, concerning amount of residue.

Cleaning them more often would result in slower work… and ultimately customer complaints about delays, and disciplinary action against the employee.

So, if Poison Pink Horror Dye isn’t a conspicuously visible powder that’s left on the tray, and if it isn’t well-known as a common allergen or hazard… then most technicians would never feel they can or should clean a tray just for being exposed to it.

…Which, from your perspective as an allergic patient, unfortunately means that any prescription you pick up could have traces of the stuff in it. There’s no way to be sure.

5. Solutions?

So. I don’t want to end this on a note of “you’re screwed and can do nothing"…. but to be honest, everyone in this scenario has limited options.

Guess I’m going to break them down according to who’s the audience. Because there’s lots of people who have some responsibility in this. And it’s best if all of them, or as many as possible, are aware of the problem and at least give some thought to it.

What can I do as an allergic patient trying to avoid contamination of allergens in my medicine?

• Make sure you tell the pharmacy techs what you need. Make sure they have an effective way to contact you, and sufficient information on when, how, and with what information it’s okay for you to be contacted. Make sure they know if you want to be notified right away of things like "your required brand is not in stock,” or “it’s back in stock now.”
• If possible, request that your medicine be filled in an unopened, factory-sealed container, or from the machine. It might not be available that way, but you can at least ask.
• Call for updates if you don’t hear back from the pharmacy when you expected to. Come in and pick up your prescription as soon as you are notified that it’s ready. This allows time to resolve any issues before you run out of meds.
• Allow time, in general. Don’t come to the pharmacy assuming your prescription will be ready within minutes. Don’t make complaints about slowness when the slowness may be due to technicians trying their best to be careful with your prescription.
• When picking up, check to make sure your requirements were followed before you leave the pharmacy. If they weren’t, ask for the fill to be redone.
• This won’t eliminate the chance of cross-contamination, but it will at least help minimize the chance of you being actually sold a medicine you’re allergic to.

What can I do if I’m working in a pharmacy and trying to avoid contamination of allergens in patients’ medicine?

• Make a habit of checking for patient profile notes about required brands of medicine.
• Add notes when patients ask you to.
• Learn the optimal way to add notes in your pharmacy’s computer system so that your colleagues can most easily notice them.
• Use sealed, unopened packages when possible, especially for patients with known allergies.
• Keep at least 2 trays and 2 spatulas and a supply of alcohol wipes within easy reach at your workstation. Clean your trays and spatulas after use, as often as possible. Alternate trays each time you fill a prescription, to give the recently cleaned one a chance to dry.
• (In my case, I had to do this by using my own money and time to purchase and bring my own trays and spatulas and alcohol wipes. No damn way can I trust the pharmacy to always have those things available where I can find them. And I’m lucky to work in a pharmacy that lets me buy and bring my own supplies from home, and doesn’t make me use the too-scarce and worn-out official company supplies that any coworker could come and steal from me at any moment.)

What can I do if I’m a manager in a position to make decisions about how a pharmacy is run, and I want to avoid contamination of allergens in patients’ medicine?

• Listen to your employees when they tell you what’s making the task difficult for them.
• Figure out standard ways for info about patient allergies to be communicated in ways that everyone in the process will be able to see and notice. Train employees in doing this.
• Make more frequent cleaning of trays a standard procedure. Train employees in doing it, and make sure they always have adequate supplies to do it.
• Make sure they also have adequate time to do it. And adequate room to focus, without interruptions that will break their workflow and cause mistakes.
• Yes, this will mean hiring more people. You cannot expect a low rate of errors when every tech on duty filling prescriptions is also having to interrupt that task whenever there’s a phone call or a patient at the front. If you actually want to reduce errors (any kind, including ones involving patient allergies) you must hire enough people for each task to get done uninterrupted.
• Yes, this will sometimes mean that there are times when your pharmacy seems overstaffed. Yes, you can’t predict when things will get busy and when they’ll be slow.
• No, you should not tell your technicians that they “always need to be doing work” and they always need to “find something to do” whenever there’s downtime. If they start doing any make-work to fill the time, this will prevent them seeing when new tasks show up in the computer, and may be difficult to interrupt for phone calls and patients at the front. This will cause errors. You need to become okay with technicians sometimes doing nothing but waiting and being ready for the next busy rush.
• You know those security guards that you put at the front of the building, who spent 99% of their shift just sitting at a desk doing absolutely nothing, just in case something happens that needs a security guard? The ones who have never in their lives been told they are doing too much nothing and need to help out with, like, janitorial tasks or whatever, when things are slow?
• Yeah. That. It’s time to apply that kind of philosophy to the technicians inside the actual pharmacy, who need to focus on protecting people from actual leading causes of death (untreated disease), instead of “protecting” them from, like, a homeless guy who might want to spend the night in the building when it’s negative-40 degrees outside.
• And yes. It’s going to cost more money to staff the pharmacy this way. Errors will go down, but I know that’s not what you care about. You want profits to go up. Not just stay profitable, but become more profitable every quarter. That is the only thing that matters to you.
• You don’t actually want to avoid contamination of allergens in patients’ medicine.
• Which is why you won’t be doing any of this.

grrr.