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February 13, 2020

Pharmacists are feeling overwhelmed. Is that jeopardizing patient safety?

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    Pharmacists in recent years are voicing more concerns to state regulatory boards about their work environments being disorderly and understaffed, which they say makes their jobs more difficult and heightens the risk of medical errors that put patients at risk, Ellen Gabler reports for the New York Times.

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    Pharmacists say they're spread too thin

    In at least two dozen states, pharmacists at CVS, Rite Aid, Walgreens, and other companies have raised concerns to state boards and pharmacy associations about patient safety, understaffing, and workloads, according to records and interviews with officials, Gabler reports.

    And the complaints in some states are pouring in, according to Gabler. For instance, Michael Jackson, EVP and CEO of the Florida Pharmacy Association, said he's received an "overwhelming" number of complaints from pharmacists in the past year about staffing cuts and patient safety concerns.


    According to Gabler, pharmacists in letters to state regulatory boards have described untenable work conditions, which they say make them feel spread too thin. Pharmacists have noted that their jobs require them to juggle multiple responsibilities, including answering telephones, administering flu shots, calling providers and insurers, counseling patients, manning the pharmacy's drive-through, and operating the pharmacy's register—all while dispensing prescriptions.

    One pharmacist in a letter sent to the Pennsylvania Board of Pharmacy in February 2019 wrote, "The amount of busywork we must do while verifying prescriptions is absolutely dangerous. Mistakes are going to be made and the patients are going to be the ones suffering."

    Pharmacists in the letters also raised concerns about the performance metrics they are expected to meet. According to Gabler, the metrics can vary by pharmacy chain—and even by store—and they are not publicly disclosed. But some of the metrics pharmacists have flagged in letters to boards include meeting certain quotas for automatic refill prescriptions, switching patients to 30- or 90-day supplies of medications, contacting physicians with refill requisitions, and reaching out to patients. According to Gabler, pharmacists are evaluated by the number of patients they speak to and the number of patients who agree to the pharmacists' requests. CVS and Walgreens documents reviewed by the Times show the companies tie bonuses to certain metrics, Gabler reports.

    Pharmacists have described their performance metrics as burdensome and said they've faced backlash for either failing to meet the metrics or suggesting the goals are unsafe and unrealistic, Gabler reports. For example, one pharmacist in a letter sent last year to the South Carolina Board of Pharmacy wrote, "Any dissent perceived by corporate is met with a target placed on one's back."

    Similarly, a pharmacist in a comment submitted to the Missouri Board of Pharmacy wrote, "Metrics put unnecessary pressure on pharmacy staff to fill prescriptions as fast as possible, resulting in errors."

    Pharmacists say staffing cuts also are causing them to make mistakes, Gabler writes. In letters to state boards and interviews with the Times, pharmacists have noted how staffing shortages have led to them work longer shifts without breaks.

    Wesley Hickman, a former CVS pharmacist, said he once worked a 13-hour shift without taking a lunch or dinner break. Hickman said he was the only pharmacist on duty that day, and he had to fill 552 prescriptions—which Gabler reports amounts to one about every minute and 25 seconds—while also administering flu shots, counseling patients, making calls, and staffing the drive-through. The next day, Hickman resigned. He told his manager, "'I am not going to work in a situation that is unsafe.'"

    What does this mean for patient safety?

    The result, pharmacist say, is an increase in errors that can put patients' at risk. In a letter to the South Carolina Board of Pharmacy, one pharmacist raising concerns about reduced staffing levels wrote, "I had two misfills in three years with the previous staffing and now I make 10-12 per year (that are caught)."

    The errors pharmacists say they're making as a result of the strain vary, Gabler reports. For instance, pharmacists might hand a patient the wrong prescription drug but staple the correct information and directions on the bag it is placed in. Other times, pharmacists might give patients the wrong medication dosage. In one case, a patient received a chemotherapy instead of an antidepressant, and she died two weeks later, Gabler writes. Other patients who've received and taken incorrect dosages or medications said they had to seek emergency care or be weaned off of the incorrect drug.

    But the exact extent of the problem isn't clear. According to Gabler, there isn't publicly available data on errors being made by pharmacists—as a majority of state boards do not require pharmacies to report mistakes. In addition, Gabler writes that pharmacy chains declined to release requested data on pharmacist medical errors.

    Further, Gabler writes that some state boards and legislatures have struggled to regulate pharmacies. Though some states have implemented laws to improve conditions for pharmacists, they haven't resulted in significant progress in part because the laws fail to address broader issues or are difficult to enforce, Gabler writes.

    Pharmacy chains say concerns are unwarranted

    But pharmacy chains say patient safety is their top priority and they have taken steps to address pharmacists' concerns.

    CVS and Walgreens representatives said the metrics they have in place for pharmacists are intended to provide patients with better care and are not intended to penalize pharmacists. And Gabler notes that some of the performance metrics are tied to reimbursements from insurers and the federal government.

    According to Gabler, a CVS representative said the company has cut its performance metrics in half over the past 18 months.

    The pharmacy chains also noted that staffing levels are set to ensure prescription drugs are dispensed accurately, and technologies such as e-prescribing have improved the safety and efficiency of prescribing, Gabler reports.

    Walgreens said it has made it "clear to all pharmacists that they should never work beyond what they believe is advisable."

    Further, the pharmacy chains note that pharmacists have internal outlets to anonymously voice their complaints. For instance, Walgreens has a confidential employee hotline that pharmacists can use to raise concerns, Gabler writes.

    CVS said, "When a pharmacist has a legitimate concern about working conditions, we make every effort to address that concern in good faith" (Gabler, New York Times, 1/31).

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