Pharmacists on the Front Lines
EMR-associated prescribing errors are just one of a number of new stresses that retail pharmacists on the front lines face. Many pharmacy chains now track pharmacist productivity, tying bonuses tightly to the number of prescriptions filled.
A community pharmacist may work a 12-hour shift, during which they may be asked to fill 30 prescriptions every hour. If you do the math, that means the pharmacist must fill one prescription every two minutes.5 That includes the time needed to counsel patients, which is mandated by law.6 If we factor in the time the pharmacist needs to check the insurer’s formulary, look for drug interactions, speak to physicians calling in prescriptions and counsel patients, the amount of time left to fill prescriptions drops precipitously.
Some pharmacies tie pharmacists’ bonuses to other activities, such as the number of patients agreeing to automatic refills or the percent of 30-day prescriptions converted to 90-day prescriptions; each of these activities, in aggregate, leads to increased revenue.7
Many pharmacies now rely heavily on pharmacy technicians, who may help fill prescriptions without a solid understanding of the potential interactions and risks of the drugs they are placing in the bottles.8 In many states, pharmacy technicians must be registered, licensed or certified by examination. That said, because these technicians must be supervised, their presence does not necessarily decrease the stress placed on the pharmacist.
Not surprisingly, these higher workloads are associated with a higher rate of dispensing errors. In 2015, Christy Gorbach, PharmD, et al. conducted a retrospective study of medication errors by 50 pharmacists who worked in a tertiary care hospital. Among pharmacists who verified fewer than 200 prescriptions per shift, 2.58 errors per 100 shifts were noted. Pharmacists who verified more than 200 prescriptions per shift had a threefold increase in errors.9
These errors have the potential to affect our patient’s lives: In 2016, the Chicago Tribune had reporters walk into 255 pharmacies in the Chicago area with prescriptions for both clarithromycin and simvastatin. Over half of the time, the reporter walked out with both drugs in hand, without anyone warning him about the potential drug–drug interaction.10
Also not surprisingly, these higher workloads are associated with a higher rate of burnout among pharmacists. A 2017 survey found that nearly half of health system pharmacists had symptoms of burnout, on par with the rate of burnout experienced by physicians.11 In the 2014 National Pharmacist Workforce Study, 66% of respondents characterized their workload as high or very high, and 45% indicated this workload negatively affected their emotional and mental health.12
Where is all of this increased pressure coming from? The answer, in part, may be pharmacy benefit managers (PBMs).
For the uninitiated, PBMs started as middlemen between insurers and pharmacies, taking a small fee for processing claims. Now, three PBMs manage the drug benefits for 85% of all Americans.13 With this ubiquity comes the ability to influence all aspects of drug delivery; PBMs now have a hand in determining which drugs are included in a plan’s formulary, which pharmacies are included in a plan’s network and how much to charge pharmacies for their services.
That last point is the key: PBMs squeeze pharmacies to increase their profit margins; in turn, pharmacies push pharmacists to do more with less. So how can patients protect themselves from pharmacy-generated errors?
