The Blotter: ABC Report on Pharmacy Errors
I first stumbled across this 20/20 report when I saw a preview on the ABC investigative reports video podcast. Pharmacy errors are a major problem (see this story):
There are as many as 7,000 deaths annually in the United States from incorrect prescriptions, according to Carmen Catizone of the National Association of Boards of Pharmacy. He told The Washington Post that as many as 5 percent of the 3 billion prescriptions filled each year are incorrect.
In the ABC piece, they focus on Walgreens, although I'd suppose the conditions and processes are the same at other major chain pharmacies.
One former pharmacist was interviewed, talking about how he was fired for being too slow, the implication being that other employees rushed through their work to meet some sort of quotas and that he refused to work in a way that would have jeopardized patient/customer safety.
I think that leads us to a reminder about Lean and Standard Work. For one, nobody has accused Walgreens of using lean practices. The pressure that the former pharmacist described was probably an old Taylorist mass production approach of pressuring workers to work faster because management wanted better results.
With lean, Standard Work includes the steps in a process and the standard time required to do each step SAFETY and with high QUALITY. Sure, there might be variation in that time person to person. If someone is an extreme outlier, you would look at the Standard Work — are they following it? In a lean setting, you don't pressure people to work faster “just because” and you don't pressure people to work faster than they are able to safely.
The story also highlights how many Pharmacy Technicians are 16 year olds without any sort of degree. I've never seen this in the hospital pharmacies I've worked with, the Pharmacy Techs are always trained, experienced adults.
A high school-aged pharmacy technician at a Walgreens in Lakeland, Fla., made a typing error and dispensed a dose of the blood thinner Coumadin that was 10 times what the doctor had prescribed.
She was in high school. Her prior job had been cleaning a movie theater and serving popcorn,” said Karen Terry, a lawyer representing the patient's family.
The patient, Beth Hippely, suffered a massive stroke after taking the medicine she was incorrectly given, forcing her to stop chemotherapy for a treatable, stage II breast cancer. She died earlier this year.
That's a tragic story. There is some incredibly sad video of Ms. Hippely before she passed away. I don't think the problem would necessarily be a “young” employee, but isn't it likely Walgreens had a bad process with poor quality controls built in? The young tech dispensed the wrong dosage, but that happens a lot (unfortunately) at many pharmacies, which, to me, points to a systemic problem. Systemic problems are rarely solved completely by telling people to “be careful.” Is a 16 year old less likely of “being careful?” Maybe, but there's a higher responsibility on Walgreens: the supervising pharmacist as well as the leaders who are responsible for creating a solid, lean, error proofed process.
More on Walgreens management's role:
The high school student who made the error with Beth Hippely testified she had watched a video and was taking classes in school to learn about the pharmacy job.
Testimony in the Hippely case also revealed that stock boys and photo shop workers were also pressed into service behind the pharmacy counter when the store became very busy.
“They know mis-fills and errors are bound to occur because they're giving huge responsibility and important responsibility to people that aren't trained to perform those duties,” said Terry.
“This is an intentional, system drive for profits, for money. If it wasn't about that, they would hire more pharmacists,” the lawyer said.
Or they would spend more money on training their pharmacy techs better. We can try to throw a nurse into jail for making ONE error, yet the executives who oversee failed systemic processes are left to collect huge paychecks. I think the focus on “oh how shocking, it's irresponsible teenagers filling your prescriptions!!!” is misplaced. The shocking things are the lack of training and lack of standard work.
The industry seems to want to cover up the problem (2nd ABC page). 46 out of 50 states have no requirement for reporting pharmacy errors, even those that are fatal.
While some fear there is an unreported epidemic of pharmacy errors, there are no reliable figures to gauge the scope of the problem. And that's the way the industry seems to like it.
“I don't think it should be publicized,” said Mary Ann Wagner, the senior vice president of the National Association of Chain Drug Stores, in an interview to be broadcast Friday on “20/20.”
She says the industry fears the public won't understand the difference between minor and major errors, and that the figures could be used to punish drug stores.
We won't understand?? Of course the figures should be used to punish drug stores. We, as consumers, should be able to choose a pharmacy based on their safety record. Customers should run away, in droves, from those pharmacies that refuse to do a better job with patient safety. Notice I said “refuse to.” I don't think “can't” is the problem, I think it's a problem with “won't” fix.
One pharmacist who was deemed responsible for an error in another case:
The pharmacist who admitted responsibility for the error, William Zaeske, continues to work at Walgreens and is now a pharmacy manager at another store near the one where the prescription error happened.
This might actually be the right approach, in a way. Should the pharmacist be fired for something that happened under his watch that was a systemic problem that's occurring in other pharmacies? Again, what about management? Why aren't we outraged that a VP or CEO wasn't fired? I guess $21m lawsuits aren't waking up Walgreens.
Final thought, Walgreens says:
In a statement, Walgreens said, “We deeply regret the few errors that have occurred among the more than 500 million prescriptions we fill each year at our 5,600 pharmacies.”
Instead of a sincere apology, we get a sales pitch from Walgreens about how big and popular they are. That's inappropriate. I guess they are saying that errors are inevitable because they're such a large company? That's an inappropriate attitude also. “Zero defects” really and truly needs to be the goal. We can't tolerate anything less, it's a matter of expectations. Put in error proofing methods and proper management oversight — that's how you work toward zero defects. A “Six Sigma” level in that industry is going to kill people. That's why we need zero defects.
It says it has invested nearly $1 billion in “redundant pharmacy safety systems” and training over the last 10 years.
And I wonder how much of this $1B investment was in “siren song” technology instead of investing in people and process??
So what can you do?
- Insist on better oversight and reporting mechanisms for pharmacy errors
- Ask your pharmacist what THEY are doing to prevent errors from occurring
- DOUBLE CHECK each and every prescription you bring home to make sure you have the RIGHT PILL and the RIGHT DOSAGE
ABC Video Link #1 “Prescription Errors”
ABC Video Link #2 “What Your Pharmacist Doesn't Tell You.”
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As you said, Mark, double check the prescription drugs you receive.In the end, we, or our loved ones, are at risk. To make the double checking possible and to help the pharmacy techs do a better job, Walgreen’s prints out a physical description of the pill that should be in the bottle. Some of the pharmaceutical companies have started making the dosages different colors, and many of the pills have different shapes. Visual management helps us protect ourselves, but the improvements in operations and logistics need to be extended through the entire supply chain to the customer/consumer.
This is somewhat akin to the issue with poor service at the Toyota dealership. Poor delivery of cars can harm you or kill you as well.
The entire program was focused on *chain* drugstores. If there is any evidence that the chains are worse than the individually-owned pharmacies, it wasn’t mentioned in the program. Which I would attribute to either the reflexive anti-corporate bias on the part of the legacy media, or to an attempt to make the program more relevant to audiences by focusing on drugstores that they would likely be familiar with. Or both.
It would be interesting to know if there are any people in executive positions at pharmacy chains who have studied the way things are done in other industries, specifically lean manufacturing and aviation.
What independent pharmacies? A yahoo yellow pages search shows that 38 out of the first 40 pharmacies (within 5 miles of my house) are chains: Walgreens, CVS, RiteAid, Albertsons, etc. etc.
The media might be biased against the big guy, true.
I’d think that BIG pharmacy chains should have better quality because there are more opportunities for sharing best practices and procedures, sharing “near misses” and turning those into better quality.
But I doubt that happens. I bet the store managers for all of the Rite Aids (to pick on someone else) are measured against each other. Are they given incentives to share information? Are they given incentives to keep labor costs to a bare minimum without balancing quality/service metrics??
We’ve got to start holding management accountable for quality systems.
Your comment about Six Sigma defect rates causing deaths reminds me of a plant tour I took 10+ years ago. It was a steering column manufacturer who shipped to Toyota, Honda, Subaru, etc. One of the people in my tour group asked “so what’s your defect rate….1 in a million?”. The tour guide said “oh no…if it was 1 in a million we would be out of business!”.
The amount of error proofing in this line was amazing. They had optical sensors on each parts bin to sense that the operator had removed the correct fastners in the correct order. And they had no flat surface on the machine where a washer or bolt could be set down.
Comparing this to a pharmacy, and I see nothing of the sort. There is no backup counting device, no system of catching key punch errors, no system for double checking the Docs poor handwriting, no system for peer review. The pharmacist is on their own, and somehow its up to them to never make a single mistake. That makes them superhuman in my book, or at least that’s what the system asks of them.
Seems like a market opportunity for someone, say Mark Graban for example, to start a company that develops point-of-use pharmacy systems that do the kind of error proofing we are all used to seeing in well design lean production lines. It seems like with some thoughtful process mapping, much error proofing could be accomplished at a relatively low cost and with minimal impact on “fill time”. The total package might even be faster, as we commonly see in production lines when they are properly analyzed for waste.
I believe most of the problems can be solved by looking at the prescription that you get from the Doctor. Can you read it? Are the letters and numbers clear? If you can’t read it how do you expect anyone else to? If I can’t read it I tell my Doctor to give a new prescription that I can read.
I know it’s LONG, but the following is a recitation of what happened to me over the last six months at the individually-owned, neighborhood pharmacy I have been going to years. I won’t name names, but thought it might be interesting to some of you. FYI – a huge Walgreen’s store went in practically in this pharmacy’s back door about a year ago; I would have expected service at the “old” one to get better, but it got much, MUCH worse, even though the remodeled and have twice as many techs and pharmacists working there as they did before.
Anyway, here goes:
1. I always call my prescription refills in ahead of time so that they will be ready for me to pick up; I work full time and do not have a lot of spare time to spend waiting around. On one occasion last fall, I called at 10:30 a.m. for a refill. The person I talked with asked me when I wanted to pick it up. I told her “between noon and 1:00.” She said that would be fine. I actually got there at 1:20, and it was not ready. I waited 20 minutes for it to be filled.
2. About three months ago, I needed another refill. I again called ahead, at about 11:00 in the morning, and was again asked when I would be in to pick it up. I said “tomorrow.” I arrived the next day, at 2:00 in the afternoon, only to be informed that the prescription was not ready. Also, they seemed to have no record of me having called at all. They apologized and told me it would take “a few minutes” so I agreed to wait. I waited half an hour, with no response and no attention. I went to the desk and asked how much longer it would be, as I could not wait a whole lot longer. I was told “not too much longer.” So, I sat back down … I watched the pharmacy tech going back and forth behind the counter, picking up bags of filled prescriptions and putting them in the alphabetical bins, several of them in the “L” bin, which is where mine would be. I waited for someone to call me up to the counter and tell me mine was ready. After ten more minutes (now a total of 40 minutes) no one did. I went back up to the counter and asked about it, and was again told it was not ready. I asked the woman to please check the “L” bin, as I had seen several prescriptions going into that bin. I watched as she went through all of the bags there, one by one, until she got to the very back of the bin and found mine. Obviously, it had been there all along. I wasted 45 minutes sitting there waiting for a prescription that had been filled the day before, but no one seemed to be able to find.
3. I thought about transferring to another pharmacy after the above incident, but decided to give this one another chance, as I have been a customer for many years. I needed another refill a month ago. Once again, I called it in ahead of time and went through the same routine (“When will you be picking it up?” “Between noon and 1:00 today.”) I called at 10:00 a.m. I actually did not get to the pharmacy until 2:00 p.m. When I arrived, I was informed that the prescription was not ready, because it required authorization from my doctor. I was told that they had “sent him a fax, but we haven’t heard back.” I understand that sometimes doctors need to be consulted on refills. My complaints are two: first, why didn’t they CALL the doctor, instead of sending a fax; and, second, why didn’t they call me to tell me that the prescription had not been filled yet and tell me what the problem was, so I didn’t make an unnecessary trip? I told them I would be back the next day to pick it up. The next morning I called to make sure that the prescription had been filled. The man I talked with assured me that it had been but, you guessed it, when I got to the pharmacy that afternoon, it had NOT been filled; I waited 20 minutes for it to be filled and THEN was told that they had to give me an “IOU” for 90 of the pills (the prescription was for 135), as they didn’t have enough to fill the prescription. I paid for the entire prescription, and said I would be back to pick up the other 90 in a few weeks.
4. A few weeks later, when I needed the rest of the IOU, I called at 10:30 a.m. to tell them that I wanted to do this, and asked them to check and make sure they had these in stock so the prescription could be filled. I was assured that they did, and I said I would be in “in a couple of hours” to pick up the prescription. I arrived at 12:50 to pick it up and, LO AND BEHOLD it was actually READY! I picked it up and left to run some errands. While running them, I decided to just check out the pill bottle, to make sure everything was okay with it. The IOU/prescription was for 90 tablets of Paroxetine 10 mg. I looked at the bottle, and that’s what the pharmacy label said it was. However the bottle was a “manufacturer’s” bottle, and it was a bottle for Pravastatin Sodium. I opened it and discovered that the pills looked vastly different than the Paroxetine I had been taking. I had my cell phone with me, so I pulled over and called the pharmacy to ask about it. The woman I talked with said I would have to talk to a pharmacist about it, and she put me on hold …. for five minutes. I didn’t want to wait any longer at that time, so I hung up. I called back 15 minutes later and said that I had been holding for the pharmacist but had to hang up, and would they please let me talk to him. I was put on hold AGAIN …. and AGAIN hung up after five minutes with no response. At that point I decided to just go back to the pharmacy in person. When I got there I walked up to the counter with the bottle and said “Since apparently no one wants to talk to me on the phone, I decided to just come back.” The woman actually laughed – ! I then handed her the bottle and asked her to have the pharmacist check it, as it did not appear to be right. Of course … I was right; it was the wrong medicine.
As an experienced, ADULT pharmacy technician, I have a little different perspective on the recent 20/20 interview. According to federal law, any and all prescription work that is done by a technician MUST be double-checked by a pharmacist. I have never worked in or heard of a pharmacy where the pharmacist did not check technician’s work. Legally, if a medication error leaves the pharmacy, it is the responsibility of the pharmacist, not the technician. That’s why they have licenses, malpractice insurance, 6+ years of schooling, and make 5 times more money than technicians do.
A technician’s job is to type your prescription, count the pills, and process it on your insurance. It is the pharmacist’s job to check for drug interactions, check our typing and pill counting, and make sure your doctor didn’t order something that might potentially kill you.
In my opinion, more quality control standards have not been implemented because they would tame more time. The average American already does not want to wait 15 minutes for their prescription to be filled, much less adding on any more time, even if it would increase safety.
Pharmacy employees also catch many drug errors that are written by the doctor. Cases like writing a dosage too high for a child, prescribing a drug the patient is allergic to, writing for a fatal dosage, and writing for drugs that do not even exist are errors that we catch and fix on a daily basis. An experienced pharmacy technician may not be able to tell you exactly what the proper medication dosage is for a particular drug, but we can tell when something looks off, and we bring it to the attention to the pharmacist, who has the authority to make the proper changes to the prescription.
In direct response to Carla F’s previous post, many doctor’s offices are experiencing staff shortages just as pharmacies are. In my area, doctor’s offices prefer us to fax them refill requests, rather than call. Many people do not realize that most of the people who call in prescriptions from doctor’s offices are NOT nurses, but simply an office staff member who can read a chart. Most of these staffers cannot even pronounce the medication correctly, much less be able to recognize when an error is being made. A typed, faxed refill request allows the request to go directly from pharmacist to doctor, without the chance of an error being made thru a misunderstood telephone message.
This may sound cold, but the vast majority of pharmacy employees simply do not have the time to call patients to let them know whether or not their medication is ready. My pharmacy fills 500-600 prescriptions each day, and we’d have to hire 2 full time people to do that job! Every prescription label is required by law to have printed on it the number of refills. If the prescription does not have refills left on it, your bottle will reflect that. It also has on it the date that your prescription expires. No matter what, we absolutely CANNOT refill your prescription after that date; it is against federal law. It is the patient’s responsibility to keep up with the number of refills, and the expiration date. If you think that your prescription may not be ready when you go to pick it up, call first! This will prevent you from making an unnecessary trip.
In this era of healthcare worker shortages, increased usage of PBM’s, and the scores of new drugs that are being released yearly, pharmacist’s and pharmacy technician’s jobs are becoming more complicated. We still have a long way to go to improve technician training and patient safety standards.
Thanks, anonymous, for your post. That give a very interesting “behind-the-scenes” insight. I understand that everyone is overloaded, which is why I kept going back (and, am actually STILL a customer of this pharmacy … )
As a side note, the prescription that they had to “consult with my doctor” on was not expired; it had two refills remaining, and that was printed clearly on my bottle. I am always aware of my prescription expiration dates.
Again, thanks for your comments.
Also … note that in my “situation #3” I did call to make sure that it was ready before I made the trip, and they told me it was … but, alas, that was not the case …
I’m actually getting data (and need more), of people getting incorrect number of pills in their prescription. 1,5, & even 10 pills missing at a time meaning earlier filling of a prescription. The pharmacy gets the money a little earlier. Anyone have this problem?
20/20 is so sensationalized
1) any errors are REQUIRED to be reported to the state board of pharmacy
2) the actually frequency of errors is 3.4%. All patients have electronic profiles and all meds are barcode checked in nearly all pharmacies
3) pharm tech are licensed and certified by examination. The average “mature” person would fail it…many can’t even do simple math
4) can you wait hours to get your meds? how much is a physician visit and do you know how much a pharmacist counsel costs? do you know how much insurance companies pay the pharmacy for 1 prescription? it takes $10 for the service but they’re not even paying 1/6 of it
5) pharm tech are not trained and are legally prohibited to offer medication advice…so the aspirin bottle “investigation” was pretty pointless. Might as well ask a grocery cashier if aspirin can be taken with your meds
6) signatures…everything is explained on the form why can’t people just read. The MAIN reason for signature is for insurance purpose to prevent reimbursemnt of Rxs that have not been paid for.
Responding to anonymous above, the fact that the report might be somewhat sensationalized doesn’t mean there aren’t issues to be solved. What’s your angle in defending the drugstores?
1) It might be REQUIRED, but does it always happen? You’ve got to be kidding me if every error is really reported. What about near misses? Are near misses reported? That’s where your real opportunities for problem solving come from.
2) 3.4%? That’s something to brag about? That’s horrible. If errors and near misses were really being communicated and shared, processes would be improved and defect rates would be lower than 3.4% Don’t tell me it isn’t possible to do better.
3) Not sure what your point is. Old people can’t do math?
4) If being a pharmacy was such a horrible business, Walgreens and CVS wouldn’t be opening new locations on every corner. The actual pharmacy service is a loss leader for all of the other stuff they sell. I don’t want to hear them whine that they aren’t getting paid enough. That’s no excuse for not providing better quality control.
As I said before, I think the 20/20 report was misguided in blaming the 16 year-old pharmacy tech. It’s the system and management that are to blame.
carla its great that you are understanding patient. Let me clear some of your earlier points:
It’s impossible to get everyone’s prescription filled in 20minutes. In some pharmacy chains fast refills are for those who have an urgent need. It was good for you to allow the pharmacy extra time to get it filled and the reason they filled it so fast was because they messed up and “bumped” you up in line. They are able to get a few patients out in short notice at any given time but its impossible to do this for everyone
Filing in the correct bin is sometimes not even done by technicians…but either way they messed it up. Nowadays, filling with the wrong medication is not much of an issue as everything is barcoded + photo checked
true 6 sigma is achieved by mail order pharmacies which are fully automated, BUT you dont get any service. Dell is running at 3 sigma with their production which is not too far from the average pharmacy. The greatest error a person can make is to think that one can learn NOT to make errors. One needs to make the prescription system error absorbant.
for refills nearly all doctors use faxes. most medications are called in by the nurse, physician assistant, or nurse practitioner
a consultation with the doc is not always about refills and expiration. There are many reasons such as suspicious refill habits with controlled substance, prior authorization with insurances, ambiguous regimen etc etc
mark,
sorry if i sounded cold. i simply copied one of my earlier discussion w a friend (we’re still friends :)
while its required its true that few (very few) get reported and if they get reported the cause is rarely relayed to other pharmacies. Healthcare in general has a report rate of 5% largely because health professionals are afraid of the punitive consequences.
here’s a the general formula for pharmacy payment by insurance companies
avg wholesale price of Rx- 15% + dispensing fee
the pharmacies are making money off the avg wholesale price on their Rxs. That’s why they want you to get generic medications because they can negotiate lower prices than AWP-15%. This is feasible for large chains who have a lot of buying power and very difficult for the independent pharmacies.
For the fee of service for 1 Rx (staff salary, utilities etc ) the pharmacy gets payed less than 1/6 of what they should get payed. It takes on avg $10 to fill an Rx. This service cost is nothing compared to physician office visits
Yes they are getting payed enough to expand but not for the right reason
most pharmacies are about quality but often at the cost of its staff
So, where can i find really not bad online pharmacy?