USA Today news series:
Clarifying the issues and embracing community pharmacy safety
From the February 28, 2008 issue
Two weeks ago, USA Today published a series of articles, collectively called “Rx for Errors,” about medication errors occurring in community pharmacies (please see www.usatoday.com/money/industries/health/2008-02-11-prescription-errors_N.htm for details). Given the prior experiences of ISMP staff working in community pharmacy settings, observing and assessing current community pharmacy practices, and partnering with community pharmacy organizations to improve medication safety, ISMP reflects on the USA Today series of articles.
Summary of the articles
The 3-day series in USA Today emphasized what the reporters contend are the most common causative factors associated with serious errors, including:
- Periods of high workload: At times which may not be predictable, pharmacy staff may encounter a significant backlog of prescriptions to dispense, causing a stressful work environment (although one reporter noted that a lower volume of prescriptions also contributes to errors, and some of the larger chain pharmacies have established remote order entry capabilities to shift prescription entry from a very busy store to a less busy store to even out the workload)
- Fast pace of work: American consumers expect fast service, and pharmacists may feel compelled to work rapidly if they perceive that customers waiting for prescriptions are in a hurry
- Reliance on technicians: Technicians who have less training than pharmacists help fill prescriptions, and pharmacists don’t always catch technician’s mistakes
- Volume incentive awards: Financial bonuses may be provided to staff based on prescription volume (although the reporters noted this incentive is no longer offered by at least one large pharmacy chain)
- Consumer education gaps: Consumers are not consistently provided with meaningful education about their medications when picking up their prescriptions.
To drive these points home, some articles detailed several tragic dispensing errors that caused harm or death to consumers.
On day 3 of the series, two articles provided consumers with advice on how to minimize the risk of errors with prescription medications, including general safety tips and a short exposé on how pharmacist-provided consumer education can help detect errors before they reach the consumer.
ISMP believes that media interest in medication errors can help spur action that will improve medication safety, and we welcome the critical analysis such exposés often provide. The USA Today series, however, failed to identify or clearly articulate some important causes of medication errors in community pharmacies, which we have detailed below.
External factors have a profound effect on safety in community pharmacy settings. Pharmacists regularly dispense medications without important patient information that could help avert errors, such as the patient’s medical conditions, height and weight, and diagnostic monitoring results. Most consumers do not know how important it is to share information about their medical conditions and height/weight with their pharmacist, nor has this important risk-reduction strategy been widely promoted in consumer media. Additionally, most physicians are unwilling or reluctant to include the indication on prescriptions for the medications they prescribe. Thus, pharmacists often cannot match the prescribed therapy to the consumer’s medical condition to be sure it makes clinical sense. This clinical information is also useful when processing handwritten prescriptions for medications with look-alike names that are used for different indications. (Some errors described in the USA Today series might have been prevented if the indication for the drug had been included with the prescription.) Without an accurate height and weight, pharmacists may not be able to verify the drug’s dose, particularly for children. Also, community pharmacists rarely have access to patient laboratory results that would help identify an inappropriate dose or contraindicated medication.
Community pharmacists also may not know all prescription medications the consumer is taking, which prevents proper screening for drug interactions and therapeutic duplications among prescribed medications. In the pharmacy computer system, pharmacists can only view medications dispensed from their pharmacy. Most insurers require a co-pay for each 30-day supply of prescription medications dispensed from a community pharmacy. However, consumers can often receive a 90-day supply of medications from a mail-order pharmacy for the same monthly co-pay charged at a community pharmacy. This incentive fosters á la carte shopping for prescription medications. For insured consumers, this means that only the pharmacy benefit manager’s (PBM’s) computer system contains a comprehensive list of all medications submitted for coverage. This key information is not accessible to the dispensing pharmacist in a community pharmacy. While PBMs may offer some screening for drug interactions and duplicate therapy for insured consumers, generic medications purchased at low cost and not billed to the insurance company would be excluded from the PBM screening.
Another external influence on safe dispensing of medications rests with the failure to educate consumers about their medications. As the USA Today series points out, many consumers don’t understand the immense value of consumer education (often referred to as “patient counseling”) and its role in patient safety; to this point, healthcare providers have rarely stressed its importance with consumers. Thus, consumers decline the opportunity to speak to a pharmacist or are in too much of a hurry to accept the offer of education, without understanding that they are missing an important safety checkpoint. If consumers were routinely provided with education about their prescribed medications, many dispensing errors would be detected at the point of sale and never reach the consumer. Another problem is that few consumers realize how much of the pharmacy team’s behind-the-counter activities revolve around ensuring the safety of the prescribed medication. As it stands today, many consumers demand convenience and rapid turn-around for prescriptions without recognizing that their expectations may drive pharmacy personnel away from strict adherence to the safest practices.
Community pharmacies are clearly on board when it comes to patient safety. While much of the attention regarding patient safety in the last decade has focused on inpatient settings, ISMP has observed that many community pharmacies have also stepped up to the plate in this regard, particularly in the last 5 years. Today, some of the large community pharmacy chains have established full-time positions for patient safety officers and recruited well-prepared staff to fill the positions. Many pharmacies provide subscriptions to the Community/Ambulatory Care edition of the ISMP Medication Safety Alert! for their staff. The National Association of Chain Drug Stores, in partnership with ISMP, recently launched an ongoing, nationwide initiative to provide education about medication errors to community pharmacists and technicians using the ISMP Ambulatory Care Action Agenda.
Community pharmacies, particularly large chains, have spent billions on technological solutions, including bar coding, pill imaging, robotics for dispensing, sophisticated drug interaction software, electronic prescription receipt and processing, call centers, and remote order entry. These technological advances are helping pharmacists safely manage the ever-increasing volume of prescriptions. Data from reported medication errors are being used to help determine system weakness and drive improvements. Some community and chain pharmacies and other individual community pharmacists consistently share error reports with ISMP to promote collective learning.
ISMP has also witnessed a perceptible increase in proactive risk reduction efforts among some of the larger pharmacy chains. In fact, Walgreens and CVS are working with ISMP as a research partner in an AHRQ-funded study to identify community pharmacy high-alert medications, model the risks associated with these drugs, predict the frequency of harmful errors with a subset of high-alert medications, and predict the effectiveness of targeted risk reduction strategies.
Prior lawsuits may not reflect the current state of risk in community pharmacies. The media tends to highlight patients and families of patients who have suffered great harm from medication errors, even when the information was obtained from lawsuits involving errors that occurred years ago. Fortunately, fatal or life-threatening errors such as these represent an extreme minority given all the prescriptions dispensed safely every year. Equally important, lawsuits from 5 years ago or more may reflect system problems that have since been resolved. Since organizations continually change, the potential to glean useful information about the causative factors of errors from lawsuits is frequently lost in the lengthy, often secretive litigation process. In many cases, by the time useful information is made public, new technologies or procedures have already been implemented to reduce the risk of similar errors.
Our comments made here about the USA Today series on community pharmacy errors are not offered as a rebuttal, nor are they meant to minimize the seriousness of medication errors or the scope of the problem in community pharmacies today. Instead, we hope to broaden and clarify issues, and portray the current state of risk in community pharmacies more accurately. We stand firm in the belief that healthcare providers should not accept even one harmful medication error as a tolerable consequence of the healthcare process. As such, the series of articles in USA Today should serve to strengthen the resolve of the patient safety community to:
- Educate consumers about the value of prescription education and sharing medical information with their pharmacists
- Communicate critical patient information among all healthcare practitioners seamlessly and effectively
- Maintain workload at a manageable, safe level
- Reduce the external influences that negatively impact safety when dispensing medications
- Reduce incentives based on prescription volume and increase incentives for safe practices and consumer education
- Facilitate transition to electronic prescribing
- Change reimbursement systems to compensate for the time pharmacists spend performing clinical review of prescriptions and educating consumers
- Develop technician training and certification standards
- Improve the ability to assess risk and engage in proactive risk reduction efforts in community pharmacies.