nyrxman's blog

Harold E. Cohen, R.Ph. Publisher & Editor-in-Chief of U.S. Pharmacist, blogs on current issues facing pharmacists.

Pharmacy Technicians: Truth and Consequences

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With the flu season quickly approaching, imagine an absolutely unbearable workday in your pharmacy. Anticipating the worst, you call in extra pharmacists and pharmacy technicians to help fill what are expected to be some of the busiest prescription days of the year. Sure enough, on a typical day during the flu outbreak, a line starts early at the prescription drop-off counter and continues to build throughout the day. Cars are stacked up at the drive-through prescription window as though McDonald’s were giving out free Big Macs.

As physicians’ offices open, the pharmacy’s phones ring incessantly with new prescription orders and permissions to refill older prescriptions. Everyone is working to their fullest capacity, which necessitates extra effort from all pharmacy personnel. Pharmacists’ and technicians’ fingers are furiously tapping the computer keyboards trying to input data as quickly as possible while making sure important information is accurately recorded into patients’ medical records. Medication stock bottles are being pulled from every shelf in the pharmacy, with their tablets and capsules ready to be poured out into the smaller prescription containers and bottles lined up on the prescription counter, each awaiting a label with instructions to be affixed to it. Once filled, the prescriptions will be checked by a pharmacist before being dispensed to the patient. The pharmacy counter is a mess and resembles the trading floor of the New York Stock Exchange after a busy day, with notes on scrap paper strewn everywhere. Pharmacy technicians and pharmacists line up to fill the waiting prescription bottles and vials like a General Motors assembly line.

And then it happens...a pharmacy technician prepares a prescription that contains a fatal dose of the medication. Because of the craziness in the pharmacy, the error gets passed over by a pharmacist who is supposed to check each and every prescription before it is dispensed.

A doomsday scenario, you say, that would never happen in your pharmacy? Maybe, but the truth is, it does happen, and it is more than likely that the pharmacist, not the technician, will pay the consequences of any error. Depending on its severity, the error could result in a hefty fine and prison time for the pharmacist. While the above scenario may be fictitious, a case reported by U.S. Pharmacist’s legal contributor, Jesse C. Vivian, BS Pharm, JD, in this month’s Legal Considerations column (page 66 in the print edition or at www.uspharmacist.com ), is unfortunately all too real.

In that case of a fatal error, the technician was charged with negligent homicide but was given a “get out of jail free” card by the court, wasn’t even fined, and actually went back to work in a retail pharmacy. The pharmacist, however, was found guilty of involuntary manslaughter and faced up to 5 years in prison and a $10,000 fine. His license was revoked, and he will probably never work again as a pharmacist. All this because he did not check the accuracy of a prescription filled by the technician.

The column should be a wake-up call for every pharmacist who works closely with one or more pharmacy technicians. While it is true that each case of negligence involving a technician will be judged on the merits of the case, the message is clear. The truth is that if a pharmacist is not diligent about checking a technician’s work, the consequences could be dire.

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Paul Badger's picturePharmacy TechnicianPaul BadgerJoined: Dec, 2009
Location: Mechanicsville, VA
Posts: 11

I have to agree on virtually everything PharmacistSteve said, especially the "work environment" issues.

Here's the deal from my (a Lead Technician's) point of view:
Unless you are operating a highly profitable independent pharmacy where you can hire the people you want, pay them what you feel they are worth, and answer only to your patients and the state pharmacy board, you are going to have less-than-excellent technicians foisted upon you. This is a sad fact of our lives.

When a pharmacist has to "remind" an experienced technician that "q.i.d." is not a viable dose of fluoxetine 40mg, how much stress has just been added to that pharmacist's day?

When two pharmacists, in a 12 hour period, are verifying 800 prescriptions, does anyone else see the increased likelihood of errors? I watch my pharmacists struggle on a daily basis with incoming calls, calls for copies, patient questions, verifying the hieroglyphics that pass for physician script, trying to deal with technicians for whom this is a job not a career, helping the customer from the front store who needs advice because her son has a cough, trying to grab a bite to eat, and then deal with field management's visits, all while trying to control payroll in a pharmacy filling 4,000 prescriptions a week. Stressed? Nah.

I again have to agree with PharmacistSteve's assessments. Do I make mistakes as a technician? I am sure I do. I do everything in my power to verify my own work before it gets to the pharmacist(s). I catch my own foolish errors (ointment vs cream, capsule vs tablet), and sometimes even catch my colleagues's data entry mistakes. But my diligence is the result of knowing its MY PHARMACIST'S license on the line. My challenge to pharmacists though is to ask: Do your technicians understand this?

nyrxman's picturePharmacistnyrxmanJoined: Mar, 2009
Location: Lyndhurst, NJ
Posts: 80

Pharmaciststeve, I could not agree with you more. Mistakes happen and the person who is the center of this case had a history for making more than his share. I agree that mistakes can be minimized with proper procedures in place. Unfortunately, most retail pharmacists today are multi-tasking on a daily basis and even with solid SOPs in place, there are enough distractions in many pharmacies that mistakes are tragically inevitable.

However, this blog is not just about errors, but errors made by pharmacy technicians that are not being caught by a supervising pharmacist. While there is no question that there are some very dedicated and well-trained technicians working in high traffic pharmacy settings, it is incumbent on every licensed pharmacist that he or she check the technician's work every time or be held personally responsible for any errors.

edsonrph's picturePharmacistedsonrphJoined: Aug, 2009
Location: clackamas, OR
Posts: 968

I have very good techs and also some mediocre techs. I train my eyes to treat each rx as if it was done by a bad tech. That forces me to double and/or even triple check each rx that passes thru my hands before the patient see it.

nyrxman's picturePharmacistnyrxmanJoined: Mar, 2009
Location: Lyndhurst, NJ
Posts: 80

I like your approach. Every pharmacist who is supervising a technician should adopt it. It would definitely lead to less errors.

edsonrph's picturePharmacistedsonrphJoined: Aug, 2009
Location: clackamas, OR
Posts: 968

Thank you! It also helps me not to be complacent.

pharmaciststeve's picturePharmacistpharmaciststeveJoined: Jul, 2009
Location: New Albany, IN
Posts: 220

I agree that the Pharmacist SHOULD BE ultimately responsible for all errors..but there are more "players" in this game than just the Pharmacist... In one state that I am licensed in - KY - it has NO tech/RPh ratio limit. So corporate pushes the numbers as hard as they can... where was the Board's or bureaucrats collective brains when this was permitted to become the law of the land? How does this protect the public's health?

I only work as a temp/per diem RPh working in community (both chain & indys) as well as closed door LTC Pharmacy. I have had to threaten to shut down a pharmacy dept in a chain store because there was not a full tech staffing because I wanted the drive-thru window shut down because I didn't have - imo - enough staff to adequately & safely fill rxs.

I was recently in a new store in a privately held grocery store chain in the south east and their pharmacy is so designed that the pharmacist has virtually no place to hide or even focus. The counter is slightly above waist level... a open invitation to be interrupted. Is the corporation or the board going to share in the blame for a mistake that this open work environment and the interruptions that it permits by patients is going to cause... I doubt it !

I have Pharmacists that work for the largest retailer in the country who tried to put up a sign }.. please hang up your cell phone ..." was told to take it down because it was not "an approved sign"

The new Rphs coming out of school are given the example from the preceptor Pharmacist that capitulating to the patient and the corporation wims is what is expected.

With this particular Pharmacist.. did anyone address previous mistakes.. was the technicians provided him adequately trained... did he have enough tech manhours for the volume he had to handle.

Until Boards take the permit hold at task for the work environment and until Pharmacists individually and collectively stiffen their backs and or get "a pair" and say "this is how I work safely" and "tell the store manager he/she has no authority in/over the Pharmacy dept".. patients will continue to be harmed and all the other players will do the finger pointing at the Pharmacist...as the sole reason the round brown smelly stuff hits the fan.

pharmaciststeve's picturePharmacistpharmaciststeveJoined: Jul, 2009
Location: New Albany, IN
Posts: 220

I feel for the parents of the little girl who died.No "train wreck" of this magnitude is triggered by just one cause. Blame should be shared with the college who passed this person.. to the state board that licensed him which is a presumption of confidence to the hospital who hired him.

In this particular incident... the board sanctioned its own "mistake"... the hospital simply "pays" in $$$ to be absolved of any guilt. The technician was basically "untouchable" because there was no state/fed body with an legal authority over her.. Is the board/state bureaucrats partially guilty for not being pro-active in mandating technician licensing/credentialing? Could this lack of pro-activity be a direct result of lobbying from corporate pharmacy ... because credentialed techs would raise payroll cost of operating a pharmacy?

how would his employer have dealt with him if he processed orders at a pace that he was comfortable with - to reduce the possibilities of errors? Been given a reprimand because orders were not provided on time to be given at the prescribed time? What would have been the consequences if a pt was harmed because of missed/late dose?

How many times have we or in talking to our fellow Pharmacists experienced one or more days or S.O.P. that the work environment is at best described as "organized confusion" Yet if/when a Pharmacist tries to get extra help and/or fill Rxs at a pace that will keep errors at a minimum... management suggests that they need to prioritize better....or other stores are doing as many or more Rxs/hr with the same staffing level.

The pharmacy regulations that we have to live with today were written primarily in a time when the majority of Pharmacist and the store owner were one and the same. They controlled staffing levels and their business was their reputation and their reputation was their business.

That cannot be said today... In today's corporate work environment the list of importance starts with making "the market" & stock holders happy.. one unhappy customer is more important that any employee and P&P's are written is such a verbiage that the corporation can absolve itself of nearly any guilt at the store level and place blame on the employee.

The computer industry strives for the ultimate goal of a computer being up 99.999% of the time .. called FIVE-9's

If pharmacy was able to achieve this goal .. we would still have FOUR MILLION errors a year. That means that the typical Pharmacist would make two mistakes a month.

Virtually all pharmacy boards have elected not to get involved with work environment/demand/staffing issues.. so how do they protect the public health?

They wait until someone get harmed or killed and then they take action against the pharmacist involved... do they then take a look at the work environment? Probably not... does the license holder have any other consequences than maybe a fine or settle a claim? Probably not !

Some people refer to this type of enforcement as regulating via "tomb stones"... once the tomb stone count gets high enough the regulatory body takes action, and normally just enough response to make it appear that they are actually doing something.

Nothing is going to change until either Pharmacists get a "back-bone" and stand up for a work environment that they control instead of being controlled by the work environment and/or boards get involved with work environment/staffing issues and make the license holder at least partially responsible for errors and harm/death to the patients in their stores and Rxs filled by their staff.

edsonrph's picturePharmacistedsonrphJoined: Aug, 2009
Location: clackamas, OR
Posts: 968

What steps can RPh take to control their work environment?