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Tragic community pharmacy error - one year after owner talks about workload stresses to NY Times



From the August 23, 2000 issue

PROBLEM: Typically, pharmacies have well-established, redundant systems to monitor the accuracy of the dispensing process. But today, pharmacy work is increasingly stressful and these checks and balances are being strained beyond capacity. The rapidly rising number of prescriptions and shortage of qualified pharmacists are creating unsafe working conditions - long hours without breaks; multitasking between phones, patients and prescription dispensing; and ever-increasing time spent verifying insurance coverage. Errors are the inevitable result even in the best pharmacies. A Virginia pharmacy knows this all too well after a five-year-old boy died as a result of an order entry and compounding error that was not caught by the usual check system. In this case, imipramine was dispensed in a concentration five times greater than prescribed. Imipramine is a tricyclic antidepressant used to treat adults, but it is also used to treat childhood enuresis. A technician entered the concentration into the computer as 50 mg/mL instead of 50 mg/5mL, along with the prescribed directions to give 2 teaspoonfuls at bedtime. He then mixed the solution using the incorrect concentration on the label and placed the prescription in a holding area to await a pharmacist's verification. The high workload made it impossible for the pharmacist to check the prescription right away. When the child's mother came in to pick up the prescription, the clerk was unaware that it had not been checked and gave it to the mother without telling a pharmacist. At bedtime, the mother gave the child two teaspoons of the drug (500 mg instead of the intended 100 mg) and found him dead the next morning. An autopsy confirmed imipramine poisoning. While the proximate causes of this error include inaccurate order entry and inadequate checks before dispensing, high workload issues also contributed to the error. The pharmacy now dispenses about 10,000 prescriptions per month versus 7,000 per month last year. Yet, there had been no increase in staffing. Also, one of the two pharmacists on duty was at lunch when the prescription was dropped off and filled, which made it hard for checks to occur in a timely fashion.

While this error underscores a growing problem in healthcare, the handwriting was on the wall at this pharmacy a year ago. The owner was interviewed for an article, "Store's Pharmacists Tell Tales of Overwork," published in June 1999 in the New York Times. The article described the pharmacists' frustrations with how little attention is paid to workload difficulties faced in today's healthcare environment. On the day of the interview, 49 prescriptions were in the process of being prepared and about a dozen patients were standing in line or milling about the store waiting for prescriptions. Yet this was a slow day. The owner also said that, while managed care had reduced profits considerably over the past three years, prescription volume had increased 50% and medications and drug interactions were more complex. To overcome these barriers, the owner installed private consultation areas for patients who have questions; installed a $175,000 robot that accurately dispenses the 200 most common drugs; and diversified sales to offset full time pharmacists' salaries. Yet, despite these efforts, one year later (June 2000), almost exactly to the day, a Washington Post article reported this tragic fatal error at the same pharmacy! The Board of Pharmacy placed the staff pharmacist on duty the day of the error on probation for six months, citing that he bears ultimate responsibility for the technician's error. On a more positive note, the Board is also drafting legislation that sets minimum education levels, specialized training classes, and supervision requirements for pharmacy technicians.

SAFE PRACTICE RECOMMENDATION: The environment and demands placed on health professionals significantly affect their ability to provide safe service. While technology such as robots can help, overstressed professionals cannot consistently perform at the maximum level of safety. Therefore, it's important that the public and healthcare leadership understand this problem so they can be more open to tradeoffs, such as working with one patient at a time and incurring longer turnaround times, which are necessary to enhance patient safety. With a shortage of qualified professionals, we need to demand more rapid adoption of computerized prescribing to reduce time spent with prescription transcription. We also need to spend time thinking about creative staffing patterns and centralized prescription filling centers that can provide capable support while minimizing staff fatigue. We should identify the biggest distractions that occur in the workplace and eliminate or reduce the source by batching common interruptions and reorganizing work areas. Fail-safe processes to ensure an independent double check before dispensing medications and other critical processes is a must. The pharmacy where this error occurred now requires two pharmacists to check every prescription. This level of vigilance is typical after a patient has been harmed from an error. In other pharmacies, especially where there's only one pharmacist on duty, technicians may be involved in the checking process. A few other strategies can also help prevent similar errors. Do not fill prescriptions using only the label because the order input may be incorrect. Fill from both the original prescription and label and keep the prescription, label and product together all the way through the process to help detect order input errors. It's also more likely that order entry errors will be detected if the person entering the prescription into the computer is not also preparing it.

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