How to reduce medication errors: Pharmacists weigh in (Web Extra)

July 1, 2009

So what is actually happening behind the retail counter? To get an idea, Drug Topics took a brief, unscientific survey of individual community pharmacists. All the respondents felt that pharmacist counseling reduces medication errors.

So what is actually happening behind the retail counter? To get an idea, Drug Topics took a brief, unscientific survey of individual community pharmacists. All the respondents felt that pharmacist counseling reduces medication errors.

We asked the following questions:

• How long have you been a pharmacist?

• Do you work for a chain?

• How many prescriptions do you process in a shift?

• How many techs do you supervise in a given shift?

• Do you counsel all patients? If not, why not?

• Does counseling make a difference in reducing workplace errors?

• Have you ever made an error because of workflow demands?

•What is your opinion of this statement: “A tired pharmacist is a dangerous pharmacist?”

• What would improve the rate of errors?

• What should your state board be doing about pharmacy working conditions in retail spaces?

Californian Jim Aichelman has been a pharmacist for seven years. He does not work for a chain. He supervises three to four techs per shift. He processes approximately 200 to 250 prescriptions in an 8-hour shift. “I counsel all patients, unless they don’t wish to have counseling. I do believe that pharmacist counseling reduces medication errors.”

What suggestions would you make for improvement in this area? “Eliminate multitasking. Create an environment in which a pharmacist can finish one task and move on to the next, instead of having five things going on at one time. The work environment [in the community pharmacy] does contribute to medication errors.” Has he made a medication error because of workflow demands? “I have no idea,” he said.

Comment on “A tired pharmacist is a dangerous pharmacist”: “It is important to understand how broadly being tired affects one at work. One way that doesn’t get a lot of attention is how it affects empathy. I’m less likely to go out of my way to help a patient if I’m tired. That could be dangerous.”

What should your state board be doing about pharmacy work conditions in retail spaces? “That is easy. Require a one-hour meal period in the middle of an eight-hour shift, with no exceptions.”

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Cathy Lane, RPh, has a PharmD degree from Purdue. Lane has been a pharmacist since 1988. She does not work for a chain directly. However, through her agency work, she does work in chain drugstores. Here is her story.

“I worked 16 years full-time in hospital pharmacy, then four years ago quit and went part-time at another hospital, picking up the balance of a 40- to 70-hour week from relief shifts for friends in clinics and hospitals, and agency work in retail - mostly at Wal-Mart. So I work in chain drugstores, but pretty much as my own boss, not working as a chain drugstore pharmacist per se.” Lane says her retail experience “amounts to about one retail shift every two weeks for 3-plus years.”

Lane supervises 4 to 6 techs (typically) “when I work at Wal-Mart, and this includes the cashier.” She also cited shifts “at Target, Osco, Genoa (specializing in mental health), grocery-store chains, and some hospitals. I have worked with as few as one tech, and as many as six (or seven, I think). It seems that there are usually two techs at intake, entering scripts into the system, two techs filling, and one or two handling the cash register and pick-up window.”

A typical workday, says Lane, can go something like this: “The shift I’ll be working Monday is scheduled from 9-6. It’s located 110 miles north and will take about 2.5 hours to drive there and then a little longer on the way back, since I’ll probably take the highway on the way home. It’s usually pretty busy, but at least it’s not the first of the month, so I’ll probably check in at 8:45 a.m., have 15 minutes at least for sitting down to lunch, and then get off at 6:45 p.m., unless they’ve hired some new techs.

“Seems like the last time I was there we did approximately 200 [prescriptions], just one tech and I, which was a lot for a Sunday. I have no idea of how many we’ll do, but will be wearing support hosiery and trying to get to bed early the night before in order to leave by 6 a.m.”

There is no such thing as a typical shift.

“It depends,” said Lane. For example, she processed “as many as 25 or so at a Wal-Mart two years ago on Mother’s Day. There were two agencies involved and they had inadvertently overbooked two other pharmacists, so not only were we more than adequately staffed but we were not busy. This could have been a problem, since all of us had traveled at least two hours to get to this shop, so we resolved the issue by taking turns working hard - it’s important to get into the ‘rhythm’ of filling, and not haphazard lollygagging inattentiveness, and then getting off early. We all took our allotted half hour lunch that day.

“I think the record for me in checking prescriptions is a little more than 500 for a shift ... I would say generally that 90 percent of the time when I work I check at least 250 scripts and probably 50 percent of the time, it’s 325 scripts.”

Do you counsel all patients? “If there’s opportunity, I counsel all patients. When I first started agency work, it was difficult to even get the work done without attempting to answer extra questions. Techs could sense (or I told them, when asked) that I didn’t have much retail experience, and in some shops, the aggressive techs sort of ‘took over’ in telling me what to do next, so that they could get their breaks on time.

“As I gained more experience, I was able to point out how the workflow might be improved so that I was able to coordinate the work in dealing with patients and with checking prescriptions.

“To me, the counseling is the last chance and step in ensuring that the patient has received the correct medication and will take it for treating the diagnosed problem.

“I do have to say that one of the pharmacists I ‘trained’ in hospital became the manager at one of the Wal-Mart shops where I fill in occasionally, and his shop was the most efficient, organized, and well-run operation I’ve encountered. He had it set up so that the pharmacist runs the entire length of the counter between the intake and pick-up, so that he can supervise what’s going on from when scripts are left off to what’s going on out front, to ensuring that every prescription is handed out by a pharmacist to a patient before the cashier takes care of the payment.”

If you don’t counsel all patients, why not? “In times where I’ve not been able to counsel patients, I notice that it’s usually a factor of 1) how the pharmacy is set up, combined with 2) how skilled, experienced, and smooth the techs are at keeping up with providing insurance support, answering phone calls not critical to being handled by the pharmacist, and 3) the ‘attitude’ of techs or others in the pharmacy.

“I have to state for the record that in some places where the tech ‘assumed’ that I was not going to counsel each patient (because of the unfavorable layout: i.e., pharmacist couldn’t easily get around the counter, or the scripts were placed in bins away from the pharmacist with a doorway in between the pick-up and pharmacy filling area, or there was simply too much junk in the way to see over the counter to patients), I would hear the technician say explicitly, ‘Here is the phone number on your bottle, and you call us if you have a question when you get home’, which of course is not a replacement for the legal mandate, but it gave the patient a chance to put in their mind that they might have a question, that questions are okay, and that the phone number is on a specific place on the label if they want to call the pharmacy.

“Sometimes, the ‘attitude’ seems to be derived from the work habits of regularly staffed pharmacists, i.e., I overhear comments about how they would handle a situation or interact with a client, or that I’m taking ‘too much time’ in explaining something, or that I have ‘work to do,’ i.e., patients are waiting in line so there’s no time for me to answer a question, etc.

“In one job at a [store with a pharmacy] to which I used to drive 2.5 hours for several months, they were looking, but no one was interested in working for them, it seemed. I took turns filling in with the chain floater and the person that quit. There were four or five regular techs that knew the limits of their roles, and then there was one who seemed overeager to help and was always rushing here and there to help out (and not always skillfully - so that I was usually the one in the end who had to solve the sticky problem with my authorization), and because of the lack of smooth workflow, she ended up offering the patients ‘coupons’ or $25 gift certificates, because patients had to wait more than 15 minutes for their prescriptions.

“At first I was bothered, as if it were a comment on how I fulfilled my job duties, but then I shrugged it off, as I was new and hadn’t fully realized that this tech’s dys-rhythm was the most time-wasting problem. After several weeks, I tried to get her to get her to complete tasks before going on tangents, and I found I had a chance for more helpful interaction with patients.

“However, that ... setup (which seemed to be the same at all their shops) was the gnarliest workflow I’d encountered - and I recognized it later at [another national store with a pharmacy] and independents where I filled in.”

Do you think that pharmacist counseling reduces medication errors? “Yes, of course. Not only does counseling reduce medication and prescribing errors, but it helps ensure that the patient might possibly take the medication as it was intended.”

Do you feel that your work environment is a potential contributor to medication errors? “The work environment is always a factor in contributing to medication errors, by levels of noise and interference or nonfocused tasks, as well as sense of urgency and smoothness of workflow. The key is allowing a smooth, focused workflow.

“If someone has to stop what they’re doing to do something unrelated to the matter at hand, they’ll have to reinvent their attentiveness when they come back to the situation. Some matters that contribute to poor workflow include placement of restroom, sink, stock, and secretarial supplies, i.e., where the scissors are, being able to access drug references on the computer screen, etc.

“Sometimes [it’s the case that] a step might be missed or a risky shortcut taken when you’re stepping back into what was happening before the interruption. As an example, if you’re checking the accuracy of order entry and a thought crosses your mind about how a signature was written and you don’t think to send it back through for reinterpretation, and then you’re interrupted and you don’t see it again for a while [because] another overriding thought is a priority, when it does come back you miss checking whether the patient had the script before with that same sig or it’s a different doc, so you miss a different way to think about its relevancy.

“For example, in one nearly dead grocery-store pharmacy, I kept catching myself in inattentiveness because it was set up with very unfriendly computers, so that I couldn’t check any information for myself about previous treatment regimens and other factors, and the sink (where I wanted to wash my hands) did not have accessible paper towels nearby or a place to sit near the dispensing counter, and the phone and fax machines were way out of the way of being able to see the patients at the window, and the dispensing counter was at a low height so I couldn’t lean against it. I had to stand when we weren’t busy, or sit away from the workflow, so missed being able to talk with patients (even as the techs entered the prescriptions in the computer). I ended up standing at an awkward position when we weren’t busy, and going to the OTC section to straighten drugs just to get off my feet, running to the window to take the prescriptions and grabbing the bottle off the shelf to fill it when processing the scripts, then talking with the patients while the bills were processed.”

What suggestions would you make for improvements? “I would suggest a Wal-Mart model. Not all Wal-Marts are the same, but the shops that allow the pharmacist to oversee and carry-through the operation in a smooth flow and promote the pharmacist intervention at pick-up, ideally at intake as well, seem to ensure some completion of filling scripts for individuals. To me, the matter is not the speed of an assembly line, but that all the steps are done smoothly and consistently, i.e. all the steps get done.”

Have you made a medication error because of your workflow demands? “The biggest problem with work flow that I’ve encountered, and the situation in which errors were made, had to do with abruptly changing the job. For example, in the hospital, having to go from inpatient order entry to covering for lunch in the outpatient pharmacy.

“Another situation in which an error was made was being asked to come after the shift had started so that I missed out on the change-of-shift report, then missed important information about where some drugs were located and how they were to be compounded. (Plus all the other things that I might not know about what was going on, but hadn’t yet realized that I didn’t know.)

“I made an error in one shop by putting one patient’s prescription in another patient’s bag, because something happened in the work flow, and I found myself setting unbagged medications on the counter, then grabbing them and bunches of generated paperwork to place in a sealed bag, and some of the paperwork got stapled to the bag with someone else’s prescription in it.

‘I try to avoid errors by allowing myself to depend on a routine, then altering the routine in my mind as often as I am able and it is practical to do so, in order to think of things in a ‘fresh perspective.’”

Comment on “A tired pharmacist is a dangerous pharmacist”: “A pharmacist so tired as to not realize they’re not making the necessary triple checks, or filling the scripts in their mind, is in quite a dangerous situation.

“Sometimes, if the routine is smooth and the techs are skilled enough, the pharmacist can get a chance to relax from the focus during ‘breaks,’ but if there is no let-up, there is often much risk that something will be missed, that the pharmacist might yield to temptation to do two things at once, or try to handle things like an assembly line. Invariably, it is simply a matter of luck that no error is made in an inattentive situation when a pharmacist who is supposed to be in charge of their corner of the world is fatigued.”

What should your state board be doing about pharmacy work conditions in retail spaces? “The biggest thing is providing accurate information about and ensuring standard staffing expectations in any given area. For example, regular inspections and reports should be available. If it is understood that illegal activities (especially disrupting normal workflow) will be investigated, then there might be less inclination to engage in irregularities that disrupt the job at hand.”

Any other comments? “I think errors occur with experienced pharmacists when there are disturbances in work flow that promote a less-diligent focus on the task at hand.”

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Brandon Eldridge, PharmD (as of May 16, 2009), started his career in retail at age 16. He has worked in pharmacy for seven years. He currently works for Super D Drugstore in Sikeston, Missouri. Super D is a chain of approximately 250 stores. When we queried him, Eldridge was still a student.

How many technicians do you supervise in a shift? “Currently I am working as a student pharmacist/intern until I can take boards sometime in June. I do help with the supervision and training of technicians, and we usually have about six or seven techs during our 9-to-5 shift and three to four younger high school and college students during our evening shifts from 2 to 8pm or 4 to 8pm.”

How long are your shifts? “I work 8- or 10-hours shifts now, and that will stay the same once I become a pharmacist.”

How many prescriptions do you process in a shift? “We fill about 800 to 900 on a busy Monday over 12 hours from 8 to 8. A lot of that is front-loaded - the vast majority is done from 9 a.m. to 5 p.m., and we really drop off after 5p.m. We usually have three pharmacists, with me counting as what, 3/4s of a pharmacist?

“I’d say I probably type/run through 100-150 scripts (mix of refill/new orders) during a 10-hour shift. Of course, a lot of the counting is done by the technicians. I process the order and usually get the drug from the shelf for them. I also ‘check’ the prescription before it is sent to the pharmacist. It’s a way of me practicing before all of the responsibility is laid on me upon graduation.”

Do you counsel all patients? If not, why not? “I do a LOT of the counseling at my store - mostly because I am available, still practicing and honing my pharmacist skills, and able to work under the wing of the licensed pharmacists at this point. [Also] I like to handle the questions, counsel, and select and recommend things.”

Do you think that pharmacist counseling reduces medication errors? “I believe it can. I honestly believe that the main benefit of counseling is maximizing benefit that patients get from their prescriptions/OTC products. I have caught a few things through the counseling session, but usually it’s something minute like incorrect address, birthday, or spelling. Major errors haven’t been a factor yet. It could be due to the fact that my store is very efficient and our pharmacists are very thorough. Not to say that errors don’t occur (that would be a ridiculous statement), but we are very fortunate to have minimal reports of errors.”

Do you feel that your work environment is a potential contributor to medication errors? “Absolutely. I also believe that the computer system used is a MAJOR factor. Some of the larger companies have computer systems that require scanning and a ‘four point’ check of the Rx after it is typed by a technician prior to a label being generated for filling. I think this is very inefficient and actually does little in preventing errors, regardless of what [chain stores] scream from the mountaintops. I have seen too many errors slip through this little stopgap and also seen too many pharmacists merely blow through that little stop, only to rely on the final check as is the case in a traditional pharmacy program.”

What suggestions would you make for improvements? “I think mandatory accredited technician certification needs to be initiated over the course of a few years (unfortunately we would have to grandfather in those already in the workforce). I believe this certification can allow some accountability to be given to the technician [which would] be shared with the pharmacist.

“It also would allow us to pay our technicians more as their level of expertise and responsibility is higher. Finally, age requirements need to be instituted. I don’t think that 16-year-olds have any business behind the counter unless they are only working as a cashier. Those under the age of 18 or 19 cannot understand the gravity of their actions, nor can they adequately take some sort of personal pride in accurate, efficient work as they have yet to mature to a level where a job well done is a reward in itself.

“I’ve read it kicked around on the pharma blogs - some sort of degree beneath pharmacist and above certified tech, like a two- or four-year degree ... It’s something to consider. It will never happen, but I believe it to be a good idea.

“I also believe that laws need to be consistent from state to state. I realize that state laws are different for a reason - the federal government allowed the states to govern themselves in some aspects. I believe that’s silly in this regard. I don’t understand why we cannot be consistent from one state to the next.

“For instance, I live in Missouri. [Certain drugs that] are not controlled can be prescribed by FNPs without a DEA license. However, in the bordering states of Kentucky and Arkansas, they are controlled. Therefore, if a patient wishes to transfer [certain] Rxs from Missouri to Arkansas or Kentucky, they are out of luck if the scripts were written by an FNP. They are also out of luck if they wish to transfer them back after a fill in these states, since controlled drugs are limited to one move. I live literally 30 minutes from Arkansas - what could possibly be so different, to require such differing laws?

“I know [the issue] would only end up in the Supreme Court, but I just think things would be a lot easier for the profession. I could go work in any state without spending thousands in reciprocations. Same for techs - it would make things simple.”

Have you made a medication error because of your workflow demands? “We adequately staff, with ample technicians and pharmacists. These types of issues are usually a result of corporate counterparts limiting hours of pharmacist overlap and technician hours. I believe that if errors are due to understaffing, the chain/store should be fined in triple. That’s a horrible reason/excuse for an error causing someone’s death or injury: ‘Sorry, Ms. Jones, you got penicillin to which you are deathly allergic because we, a multinational corporation, refused to splurge on another technician making eight dollars an hour ...’”

Comment on “A tired pharmacist is a dangerous pharmacist”: “A loaded question/statement. A tired anything is a dangerous anything. Driver, doctor, carnival-ride worker. You’re trying to put blame where it shouldn’t be placed. Tiredness is not an excuse when sleep is free.”

What should your state board be doing about pharmacy work conditions in retail spaces? “Limiting lengths of shifts and hours worked per week. Requiring the certification I spoke of.”

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Colin Price and his wife, Sarah Price, are pharmacists in Utah. Colin says he has “worked in about 40 different retail pharmacies for several different companies over the years, so I’ve seen many different operational systems.” Specifically, he has been a pharmacist for seven years and he currently works for a chain.

How many techs do you supervise in a shift? “I supervise three by law per RPh, but we have two to three RPhs on, so we may have six to nine techs on-site during a busy Monday. Our shifts run 12 hours and we process approximately 200-plus scripts in a shift.”

Do you counsel all patients? If not, why not? “No. At my current pharmacy we have a steady stream of patients picking up meds, and it’s not possible to counsel everyone and still check 200+ scripts in a day. We rely on our techs to get our attention if a patient is receiving new meds and may have questions. When our pace slows a bit and one pharmacist can handle all the Rx checking, I do prefer to stay at the register and talk with patients.”

Do you think that pharmacist counseling reduces medication errors? “Definitely! Pharmacists, though training and experience, should have a knack for probing bits of information from patients that may signal a red flag. If the patient seems at all confused or hesitant upon the pharmacist’s initial inquiry, it probably means further counsel is needed. So, the pharmacist either has to be with the patient to sense this confusion about their meds, or we need to rely on good techs who can sense this to call us over for counseling.”

Do you feel that your work environment is a potential contributor to medication errors? “Maybe. Most of the errors I’ve seen made over the years are due to carelessness and lack of concentration. My current pharmacy is very well staffed with techs, so I rarely feel harried by other tasks left undone. I am free to concentrate on accurately filling prescriptions and counseling. In a work environment that is poorly staffed, a pharmacist’s concentration is inhibited and mistakes seem to follow.”

What suggestions would you make for improvements? “We seem currently to be holding a double-edged sword. I believe new filling technologies can help us reduce error by scanning prescriptions and bar codes, but these technologies are also usually slower. We seem to be in a situation where we are filling prescriptions more accurately, but more slowly, and this loss of time may be making us feel more rushed at other tasks, such as counseling. The answer seems simple: more staff to run the new computer stations. But that costs more money.”

Have you made a medication error because of your workflow demands? “Yes. I can remember some very ‘wild’ pharmacies over the years where I was provided little help and our wait time approached ‘Tomorrow.’ This is when mistakes usually happen.”

Comment on “A tired pharmacist is a dangerous pharmacist”: “True. Most retail pharmacies are open 12 hours, and it’s difficult to staff that time period. Most everyone chooses to work a 12-hour day. It’s better than coming in for four hours on a day that you could have off. We’d all be better workers to end our day after eight to 10 hours, however. I believe the solution lies in exactly where capitalism isn’t taking us. We should not be open until the latest hours of the night.

“Call me old-fashioned, but 10 hours of operation is sufficient to serve the community.”

What should your state board be doing about pharmacy work conditions in retail spaces? “Banning the use of transfer coupons, because they waste our time and increase the chance for error. I’ve written to the board about this, with no response. This is a topic that deserves an entire article. It’s legal in most states for patients (non-government plans) to jump around chasing coupons while we try to keep track of potential drug interactions.”

Any other comments? “Thanks for contacting me. My wife is also a pharmacist, and we have some unique views about the field. I’d love to see some articles about taking on not just work conditions, but also the entire pharmacy paradigm. I greatly question the ubiquitous quest for money that so many pharmacists are pursuing.

“So many pharmacists are working 60-70 hours a week, getting burnt out and making too many errors. Perhaps we need to be promoting work moderation. Naturally we want to blame the corporations who have taken over pharmacy for our errors and burnout, but we also need to take some responsibility for our lives. If all pharmacists would only work half-time, we’d still live on a comfy 55K, we’d have even more work opportunities, less stress and burnout, fewer errors, and perhaps more power to bargain with executives about our working conditions.

“This is exactly where pharmacy isn’t going, but I believe there are eyes out there that would love to read about the possibility of a simpler, more peaceful career, and those of us who live it.”