Pharmacy mistakes, Part 3: State BOPs and public safety

Dennis MillerWe all make excuses from time to time, but rarely do our excuses cost lives. In my opinion, the favorite excuse used by state boards of pharmacy is costing lives.

State BOPs love to claim that they can’t do anything about pharmacy understaffing because it is an employer-employee issue. They have been trotting out this pathetic excuse for decades.

Give me a break. State boards of pharmacy exist to protect public safety. When people are injured by pharmacy mistakes, it is a public safety issue. Where are the state BOPs?

The No. 1 issue

I’ve been writing commentaries for Drug Topics for more than 10 years. Judging from the e-mail I’ve received, I don’t think there’s any topic that gets pharmacists more lathered than the inaction of state boards toward pharmacy understaffing. 

Dangerously understaffed pharmacies are a threat to public safety. What’s so hard for state boards to understand?

Pharmacists resent the fact that the state boards have the power to discipline us for mistakes we feel are a direct result of dangerously unsafe staffing levels in retail chain stores. The state boards act as if they have the moral high ground in this matter, when in fact they are failing to do their own job of protecting the public safety.

Okay, politics

I realize that state BOPs have more freedom and independence in some states than they do in others. And I realize that each board of pharmacy must be mindful of the political climate in its state.

A regulation on pharmacy staffing levels probably has a better chance of passing in a blue state than in a red. But passing such a regulation in any state would be difficult.

The retail chains are likely to fight back tooth and nail. And I’ll bet that the strongly pro-business interests in the red states would make passing such a regulation even more difficult.

But that doesn't mean the BOPs should turn their backs on this issue.

Where are the  BOPs?

From my perspective, the Oregon Board of Pharmacy seems to be the most progressive in the country. In July 2011, and again in July 2013, the Oregon BOP sent pharmacists a questionnaire on working conditions. It asked about issues such as understaffing and pharmacy mistakes, and it publicized its findings. Have other state BOPs done even this much? I haven’t heard of any.

To my way of thinking, the primary cause behind the epidemic of pharmacy mistakes at the big chains is the dangerous understaffing of pharmacies. Understaffing increases productivity, but it also increases pharmacy mistakes. It’s a lousy business model.

The state boards may claim that they can't intervene in employer-employee issues in the private sector. Nonetheless, understaffing is a public safety issue that, in fact, screams for state BOP involvement.

How it was in North Carolina

The BOPs probably have different levels of regulatory authority depending on what state they’re in and their position in state government.

As I recall, when the North Carolina BOP first proposed a maximum scripts-per-hour or per-shift rule, the state rules committee said that the board was overstepping its authority. I believe that this BOP proposal was also opposed by lobbyists for one of the major merchants' associations in that state.

When I worked in North Carolina, we routinely filled more scripts per hour and per shift than the recommendation/guideline indicated. My employer simply ignored the recommendation.

One day a fire marshal cited the chain store where I worked because boxes in our stockroom were stacked too close to the ceiling sprinklers.

The fire marshal did not say, "Well, it's up to each chain to determine how high to stack boxes in their stockrooms."

The fire marshal evidently determined that protecting the public from fires is more important than giving the chain the prerogative to fill the stockroom shelves as high they like.

Understaffing is not an employer-employee issue. It is a public safety issue.

Yes, it’s hard to write a rule

I will grant one thing to the state boards of pharmacy. It is very hard to write a regulation mandating safe staffing levels. And it is very hard to write a regulation mandating a maximum number of scripts per pharmacist per hour or per shift.

Why is it hard to write such a rule? In my opinion, one of the biggest variables is the quality of technicians present in the pharmacy at any given time.

In my experience, techs vary tremendously in terms of their speed, accuracy, and basic knowledge. Some techs are absolutely fantastic, while other techs are an accident waiting to happen.

The big chains, on the other hand, seem to view any warm body off the street as equivalent to a seasoned tech.

The tech factor

One proposal I’ve seen calls for a limit of 150 scripts per 8-hour shift. I think that might be reasonable if there were at least one seasoned tech on duty for the entire shift and not just for part of the shift.

I've worked in many stores where no techs showed up for work the day I worked at that store. At other times, the techs who did show up were a threat to public safety.

Many techs are, indeed, true superstars. Working with them is an absolute delight. Filling an endless cascade of prescriptions per shift can be almost bearable in some chain stores with the help of superstar techs.

On the other hand, filling that same number of scripts per shift with a rookie tech can be your worst nightmare and a genuine threat to the public safety.

With a seasoned tech present for the entire shift, 150 scripts per 8-hour shift might be reasonable. Unfortunately, many pharmacists end up filling 150 prescriptions per 8-hour shift with no techs present.

That’s dangerous. The pharmacist would be filling about 19 scripts per hour (almost one every three minutes) without any tech assistance.

In my opinion, it is impossible to specify a safe number of scripts per pharmacist per hour or per shift without very seriously considering the caliber of the tech(s) present and, indeed, whether there are any techs present.

Untrained clerical help

Sometimes pharmacists are able to pull a clerk off the sales floor if the nonpharmacist store manager is cooperative. Very often, all the clerk is able to do is ring the pharmacy cash register and possibly count pills.

So, an attempt to determine the maximum number of scripts per pharmacist per hour or per shift also requires a consideration of whether the pharmacist has to ring up the prescriptions himself at the pharmacy cash register because there are no techs or clerks available for part of - or all of - the pharmacist's shift.

The drive-through window

Another factor in determining the maximum number of scripts per pharmacist per hour or per shift is whether or not the pharmacy has a drive-through window. Drive-through windows can be very convenient for customers but they are extremely burdensome and dangerous at understaffed pharmacies.

A chain pharmacist who closes a drive-through window because of unsafe staffing levels is likely to encounter the full wrath of the nonpharmacist store manager. Even pharmacy district managers are likely to criticize the pharmacist for closing the drive-through window at times of dangerous understaffing.

What pharmacists don’t say

When local newspaper and TV reporters interview pharmacists about pharmacy mistakes, I wish those pharmacists would talk about how intimidated the state BOPs seem to be by the immense political and legal clout of the big retail chains. When state BOPs fail to mandate safe staffing levels, it has to be fear that is holding them back.

It’s no secret that chain people constitute a large proportion of pharmacy board members. This, in my opinion, is an example of what’s known as “regulatory capture.” The industry that’s supposed to be regulated by a governmental regulatory body ends up controlling that regulator.

Meanwhile, pharmacists remain under intense pressure, accidents happen, and nothing is done to address the underlying cause.

Pharmacists need to hold their state BOPs responsible until this critical issue is adequately addressed.

After watching state BOPs over the last few decades, I’m not holding my breath. How about you?

Dennis Milleris a retired chain-store pharmacist living in Delray Beach, Fla. He welcomes feedback at dmiller1952@aol.com. His books "Chain Drug Stores are Dangerous" and "Pharmacy Exposed" are available at Amazon.com.