We have been stunned by the number of mistakes that occur in pharmacies. A few years ago we asked the question: how many errors occur annually in drug stores? What we discovered was beyond shocking. One study found that the average pharmacy fills four prescriptions incorrectly each day. The researchers estimated that this would add up to 51.5 million errors annually (Journal of the American Pharmaceutical Association, March-April, 2003). Another study carried out with trained secret shoppers uncovered an even higher rate of mistakes. One out of five prescriptions dispensed deviated from the physicians’ written orders (Journal of the American Pharmacists Association, March-April, 2009). Using that calculation, hundreds of millions of errors occur annually in pharmacies.

Such numbers are unbelievable. And yet most patients hardly bother to look at the little bag of medicines they receive from the pharmacist before heading out the door. Dennis Miller, RPh, is a retired pharmacist. He provides an insiders perspective on this huge problem in the article below.

Dennis Miller, RPh, Compares Banks to Pharmacies:

I admit up front that I am not an expert on the frequency of bank errors. I’ve never worked at a bank. I’m basing this article on my perception of banks from the perspective of someone who is 65 years old and has relied on banks like most people.

How often has your bank given you the wrong amount of money when you cashed a check? I don’t recall a bank ever short-changing me or giving me too much cash.  Most people trust their bank teller, but they almost always count the cash to verify that no mistakes were made.

Patients are Far More Trusting of Pharmacies:

My impression is that pharmacy customers assume that the incidence of pharmacy errors is similar to the incidence of bank errors, i.e., a pretty rare occurrence.

I suspect that pharmacists are far less confident about their own accuracy in comparison to the confidence our customers have in us. The difference is that pharmacists know the infinite number of things that can go wrong at the pharmacy.

Let’s contrast banks with pharmacies:

The most obvious thing about pharmacies is that they have thousands of products on their shelves. In contrast, there are no products on bank shelves. Banks deal primarily with one product: money.

Bank managers have a much better way to precisely gauge the accuracy of tellers than pharmacists have to gauge their own accuracy and that of technicians. That is largely because bank tellers must balance their drawers at the end of their shift. If the teller is over or short by a significant amount of money, there is likely to be an intensive investigation by that teller, the head teller, and/or a bank officer.

In contrast, with the notable exception of some controlled or “scheduled” substances (like Ritalin, Percocet, Oxycontin, etc.), pharmacies do not “balance” or reconcile their inventories at the end of each pharmacist’s shift.

At the pharmacy chain I worked for, we were required to maintain a running balance of each Schedule II drug. In effect that forced us to count the remaining inventory of the specific Schedule II drug after we dispensed some quantity of that drug.

Keep in mind that Schedule II drugs account for only somewhere around 5 per cent of the total pharmacy inventory (just a guess). There are far more pills in the pharmacy that are not controlled substances. That includes drugs for blood pressure, cholesterol, type 2 diabetes, depression, skin problems, seizures, as well as oral contraceptives, antibiotics, acid suppressors, etc. There is no running inventory kept of drugs in these non-scheduled categories.

Grabbing the Wrong Drug:

Pharmacists aren’t able to “reconcile” their inventory of non-scheduled drugs in any way similar to the way that bank tellers “reconcile” (balance) their cash drawer. Whereas there is only one product that bank tellers handle (money), there are thousands of products that pharmacists and technicians handle.

Due to understaffing, simple carelessness, look-alike / sound-alike drugs names, poor handwriting, and other factors, we mistakenly grab the wrong drug far more often than you would believe.

Pharmacies use technicians because it is much less expensive to hire techs than it is to hire additional pharmacists. These technicians vary in ability from those that are super-competent to those that are an accident waiting to happen.

One Pharmacist vs. Lots of Bank Tellers:

Customer wait time is directly proportional to staffing levels. The big chain drug stores want to keep the number of pharmacists on duty at one time down to one if at all possible, since they are so expensive to hire. In contrast, banks can have multiple tellers on duty because they earn much less pay than pharmacists.

Corporate management at the big chain drug stores pressures pharmacists and technicians to fill prescriptions quickly. There are lots of production metrics in chain drug stores (for example, the number of prescriptions filled per hour and the amount of payroll utilized in the process).

Speed vs. Accuracy:

A pharmacist’s speed in filling prescriptions is a major factor used by supervisors in evaluations of pharmacists. A pharmacist who always has long lines at the pharmacy whenever the district supervisor is in the store is likely to be admonished by that supervisor and/or be given a poor evaluation by that supervisor.

Efficiency metrics in the pharmacy include things like answering the phone by the third ring and regularly informing any callers placed on hold as to the status of their call.

Racing the Red Light:

Some pharmacy chains have a red light on the computer screen which alerts the pharmacist that it has taken a long time to fill a prescription once it has been entered into the system. Pharmacists derisively refer to this as “racing the red light.” I did not work for a chain that had such a red light, but I am told that pharmacists would be admonished by their district supervisors when the red light frequency became excessive.

Thus I suspect that there is far greater pressure on pharmacists to fill prescriptions quickly than there is on bank tellers to complete customer deposits or cash checks.

I suspect that most pharmacists perceive corporate management at banks to be more concerned about accuracy than corporate management at chain drug stores. Bank tellers must be careful to dispense the correct amount of cash, whereas pharmacists have to be careful that we dispense the right drug, the right quantity, the right directions for use (once a day, twice a day, every 4 hours, etc.). We also have to screen for potential drug interactions and for drug allergies.

Drive Thru Disasters:

Whereas bank tellers don’t need to tell customers how to spend money, pharmacists often must advise customers about the optimal use of drugs, including adverse effects to watch out for, the best time to take medications, foods to avoid, the need to avoid alcohol or excessive sunlight, and the fact that a medication can make driving or operating machinery dangerous.

Banks have had drive thru windows for a very long time. Many pharmacists feel that the drive thru window is the worst thing that ever happened to our profession. Drive thru windows cause the public to think that drug stores are no different from fast food outlets, where speed is the primary objective.

One of the banks I use is not very busy and, at times, there is only one teller on duty. He or she must wait on customers inside the bank as well as those at the drive thru window. I am sure that this is stressful to the teller. But that teller has to balance his/her drawer at the end of his/her shift. Thus the manager at that bank knows when the teller has made an error or errors.

In contrast, pharmacists don’t necessarily know precisely what errors we make unless, for example, a customer returns to the pharmacy asking why the pills we dispensed look different from what they are accustomed to.

Pressured by Patients:

I don’t know whether bank customers are more (or less) impatient than pharmacy customers. I know that pharmacy customers routinely increase the stress level on the pharmacy staff by clearing their throat, by clanking their keys on the counter, by honking their horn at the drive thru window, and by asking “Why does it take so long to put a few pills in a little bottle?”

Understaffing is the key concept that explains why working at chain drug stores is so stressful. The big pharmacy chains have chosen understaffing as their road to financial success. Understaffing forces all employees to work at break neck pace. But understaffing unquestionably increases the incidence of pharmacy mistakes.

Most of the pharmacists I know believe that the big pharmacy chains have made the cold calculation that it is more profitable to pay customers harmed by pharmacy mistakes, rather than have adequate staffing on duty so that pharmacy mistakes are a rarity rather than a common occurrence.

Do you rush your bank teller when he/she cashes your check or processes your deposit?  Do you rush your electrician when he is rewiring your circuit breaker?  Do you rush your mechanic when he is working on your brakes? Do you rush your barber or hairdresser when he/she is working on your hair? Do you rush your dentist when he/she is filling your teeth?  Do you rush your accountant when he/she is working on your taxes?  Do you evaluate your cardiac surgeon based on the amount of time he/she takes to complete a triple bypass?

My point is that, for some reason, pharmacy customers seem to feel it is no different to rush one’s pharmacist than it is to rush a clerk at McDonald’s, Burger King, or Wendy’s. Many pharmacists feel that our customers’ impatience originates from the addition of drive thru windows at pharmacies.

A Pharmacist’s Dream:

My hope is that pharmacy customers have as much patience with pharmacists as they do with bank tellers, electricians, barbers, mechanics, dentists, accountants, plumbers, etc. The consequences of a pharmacy mistake can be far more serious than an error caused by most other workers in our economy.

Pharmacy mistakes are far more common than you would believe. The solution to this problem requires that pharmacy customers be more patient, that chain management be less obsessed with production metrics, and that state boards of pharmacy exercise courage in standing up to the immense legal and political clout of the mighty chain drug stores. State boards of pharmacy are doing a miserable job in protecting the public safety by failing to mandate safe pharmacy staffing levels.

Please keep all of this in mind the next time you are tempted to rush your pharmacist. Please don’t forget that pharmacies are not like banks or fast food restaurants. The worst thing you can say to your pharmacist is to hurry up because you have ice cream sitting in your car because you’ve just come from the grocery store.

Written by Dennis Miller, RPh

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