A community pharmacy survey conducted this summer demonstrates how policies and procedures related to pharmacy guarantees to fill prescriptions within a specified time are implemented and how pharmacists’ link these pharmacy time guarantees to medication errors. While such a link may come as no surprise to many, the severity of the problem and the intensity of sentiments from pharmacists (see Table 1) who work within such an environment call for a more in-depth exploration of the issue and discussion regarding how time guarantees impact patient safety and diminish the role of pharmacists in all practice settings.
The Community Pharmacy Time Guarantee Survey was developed by our 2011-2012 ISMP Fellow, Stacy Carson, PharmD, BCPS, and was conducted cooperatively by ISMP and the American Pharmacists Association (APhA) between June 9 and July 7, 2012. The survey comprised a total of 22 questions, nine related to respondent demographics and the remaining 13 questions related to time guarantees and their effects on pharmacy practice and prescription accuracy. The survey was sent via email to a subgroup (N=10,248) of community pharmacists using an APhA mailing list.
A total of 673 pharmacists responded to the survey, most of whom worked in a chain pharmacy (45%), independent pharmacy (20%), or grocery store/mass merchant pharmacy (25%) as a staff pharmacist (49%) or pharmacy manager (32%). The pharmacists worked in pharmacies with diverse weekly prescription volumes (range 0 to 5,000 prescriptions per week, median response 1,001 to 2,000 prescriptions per week). The pharmacists were also diverse in regards to years of experience as a community pharmacist (range 0 to more than 15 years, median 0 to 5 years) and total years of experience as a pharmacist (range 0 to more than 30 years, median 6 to 10 years).
Almost two-thirds (62%) of the responding pharmacists reported that their pharmacies have policies and procedures related to the time it takes to fill prescriptions. More than a quarter (27%) of respondents reported that their pharmacies advertise a time guarantee to patients. Of these, 49% do not have provisions that allow pharmacists to exceed the time guarantee expectation. These time guarantees ranged from one prescription per hour to 10 prescriptions in 10 minutes (i.e., 1 minute per prescription), with the most often (75%) cited guarantee of 15 minutes to fill one to three prescriptions. In 21% of pharmacies with time guarantees, patients receive a reward or incentive, such as a pharmacy coupon if the time guarantee is not met.
Nearly half (49%) of the pharmacists said they are penalized if they do not meet the advertised time guarantee expectations, which most often is due to multiple causes including adjudicating insurance issues (87%), encountering prescription volumes that exceed resources (77%), clarifying the prescription with the prescriber (77%), and providing patients with information or other services such as immunizations (61%). Twenty-three percent said they were incentivized through salary bonuses for meeting the time guarantees.
Of the respondents whose pharmacies advertise time guarantees, most pharmacists (71%) felt they were able to fulfill the promise about 75% to 95% of the time, and another 20% of pharmacists felt they were able to fulfill the promise between 50% and 74% of the time. Respondents were then asked whether they could handle the workload associated with meeting time guarantees and whether they feel supported by management if they are unable to meet the time guarantees:
- 17% said they are able to handle the workload generated by time guarantees and have management support if the guarantees are unmet.
- 22% said they are able to handle the workload generated by time guarantees but do not have management support if the guarantees are unmet.
- 22% said they are challenged to handle the workload generated by time guarantees but have management support if the guarantees are unmet.
- 39% said they are challenged to handle the workload generated by time guarantees and do not have management support if the guarantees are unmet.
Eighty-three percent of pharmacists working at pharmacies with advertised time guarantees reported that the time guarantee was a contributing factor to dispensing errors; almost half of them (49%) felt this contributing factor was significant. In fact, 44% of pharmacists working in pharmacies with time guarantees reported a dispensing error they were personally involved in, which was directly attributed to rushing to fulfill the time guarantee. Of the pharmacists who were involved in dispensing errors related to time guarantees, 37% did not report the error or errors that resulted.
At the end of the survey, all respondents regardless of whether they worked in pharmacies with time guarantees, were asked if they favor or oppose regulations from state boards of pharmacies that would prohibit the use of time guarantees or promises. Overall, the majority of respondents strongly (71%) or somewhat (16%) favored such regulations, and the remaining were neutral (6%), somewhat opposed (3%), or strongly opposed (4%) to the regulations. Comments from several respondents who opposed board regulations suggested that these pharmacists may not necessarily support time guarantees but rather do not feel the boards have responsibility to regulate the practice.
Although the rate of response to the survey was low (6.6%), ISMP believes there is a sufficient number of responses to suggest that time guarantees are common in community pharmacies and are sometimes used in marketing efforts, presumably to attract customers to the pharmacy. We also heard from pharmacists that operating under what is perceived to be unrealistic time guarantees has resulted in rushed pharmacy dispensing practices, during which pharmacists have made mistakes—some of which go unreported.
Pharmacists responding to the survey are sometimes given incentives for meeting time goals, but more often they are punished for not meeting them. Yet, the reasons for not achieving the goals are clearly associated with confirming prescription accuracy, educating patients, providing wellness care, and maximizing pharmacy benefits to promote patient adherence to prescribed drug therapy—all crucial elements to ensure patient safety.
Further, if past experience has taught us anything, it is that incentives for perfect performance and punishment for imperfect performance results in underreporting of errors, practice barriers, and risks. This is a significant threat to patient safety because unreported errors, barriers, and risks perpetuate the conditions that lead to adverse patient outcomes. Also, if patients are rewarded when time guarantees are not met, it sets the tone for an adversarial relationship between the pharmacist and the patient, when a collaborative relationship is needed to promote safety.
Of course, one can’t overlook the fact that timeliness is an important value. However, think about the message that time guarantees are sending to patients, pharmacists, and other healthcare providers at large.
- To patients, while the message rightfully communicates that their time is important, it can promote unrealistic expectations implying that speed is always possible without sacrificing accuracy. It can also perpetuate an undervaluing of the pharmacist and his or her role in safety. It is already disheartening that patients have little understanding of what a pharmacist does to ensure the appropriateness and safety of prescription medications. It is also clear that patients undervalue patient counseling and do not perceive this as being crucial to their safety. Time guarantees further such opinions and suggest that the pharmacist merely needs to fulfill what the doctor prescribed, and to do it quickly.
- To pharmacists and other healthcare providers, time guarantees explicitly send the message that timeliness is the primary value in the pharmacy. By setting incentives for meeting timeliness goals and punishing those for not meeting the goal, pharmacies are loudly conveying the message that this primary value should not be breached. Again, while timeliness is certainly an important value, overzealous pursuit of timeliness requirements risks achievement of other values, such as safety, in this case. Instead, safety should be the primary value in all healthcare organizations, and most if not all other values should be subservient to safety.
- To pharmacy practices, inflexibility with time guarantees also sends a mixed message to pharmacists about safety in the work environment. Forcing pharmacists to work quickly leads to the development of at-risk behaviors that can quickly become unsafe practice habits where the perception of risk has faded. Each time a corner is cut to ensure a time guarantee, if the outcome is successful (i.e., correct and appropriate prescription dispensed within the specified time), the successful violation leads to a faded perception of the risk that accompanies the shortcut. Over time, with enough successful violations, the unsafe practice becomes the way work gets done to ensure time guarantees. Given enough time, these at-risk behaviors will result in medication errors—some harmful, particularly if they involve high-alert medications.
Helping patients to recognize what the pharmacist does behind the scenes and to accept, even demand, patient counseling is crucial to our collective efforts to improve patient safety. Time guarantees are made by pharmacy organizations because they perceive timeliness to be the primary value upon which patients measure community pharmacies. We need to change this perception with patients, and it is our belief that every healthcare provider needs to be part of the effort to address the adverse effects of time guarantees on safety.
The adverse effects of time guarantees in community pharmacy practice spill over into inpatient pharmacy practice by perpetuating a largely diminished role for pharmacists in general. Thus, we believe it is crucial for hospital pharmacists, nurses, and physicians to promote the important role of both hospital and community pharmacists when teaching hospitalized patients about their medications. This is even more important as we begin to rely on community pharmacists to assist with medication reconciliation.
While ISMP advocates for changes on a national level, we hope that all healthcare providers can help the effort by promoting the important role that pharmacists play in patient safety whenever the opportunity arises, and to educate patients about the danger of time guarantees. In the end, the unrushed pharmacist will be the accurate pharmacist, and the unhurried patient will be the safe patient.