Should boards of pharmacy set hourly dispensing quotas?

Ken BakerA friend e-mailed me about the failure of employers today to provide enough pharmacists and pharmacy staff to properly and safely handle high prescription volumes in pharmacies.

He believes this is a major cause of prescription medication errors and proposed that boards of pharmacy essentially set quotas for the number of prescriptions that should be filled in a given time by a calculated number of pharmacists and staff. 

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Inquiry, not mandate

I applaud his desire to increase safety and reduce medication errors. I disagree with his assignment of blame. It is not practicable or feasible for the government to determine how many pharmacists and how many technicians are required to fill one prescription or 100 prescriptions.

North Carolina is often cited as having such a rule, but North Carolina’s rule is retrospective, not prospective.

When an error is submitted to a state board, it may be reasonable for the board to inquire into the prescription volume and the staff available at the time of the error. This is not the same as setting a quota.

Pharmacist, not boss

Professional practice does not lend itself to quotas. Instead, each pharmacist and each technician, regardless of the number on duty, must make the professional decision as to the amount of time required to fill this one prescription. The responsibility rests with the professionals filling the prescription.

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The pharmacist, not the pharmacy, is the professional. Professional decisions can be made only by the pharmacist, not by the boss. 

It is up to pharmacists and technicians to guard against and reduce the risk of medication errors. The pharmacy’s job is to assist them and to provide the tools as may be necessary, such as a CQI workflow plan, scanners, a safe environment, etc. The pharmacy can suggest times required and can decide how many technicians are hired. The pharmacy cannot make a professional judgment.  

Protect and guard

There could be a role for boards of pharmacy: to protect the pharmacist and technician from undue pressure and to guard against interference. A statute or regulation in each state could provide that a pharmacy may not interfere with the pharmacist’s professional duties or judgment.

For example, look at Arizona law. Under the Arizona Revised Statute 32-1901.01, Definition of unethical and unprofessional conduct; permittees; licensees, we see: “A. In this chapter … for the purposes of disciplining a permittee, "unethical conduct" means … 24. Overruling or attempting to overrule a pharmacist in matters of pharmacy ethics or interpreting laws pertaining to the practice of pharmacy or the distribution of drugs or devices.”

Similarly, requiring an employee pharmacist to work faster than he or she considers safe may be an exception to the “at-will employment doctrine.”¹

This means that courts could rule that a pharmacist may not be fired for taking what time he or she decides is necessary to fill a prescription and protect his or her patients.

Economics, not safety

Failure of the pharmacy to provide enough staff should be an economic problem for the pharmacy, not a safety problem for the patient. If customers believe it takes too long to fill a prescription at a given pharmacy, they will go somewhere else. Eventually the boss will hire more staff.

An answer to my friend’s question may be for each pharmacist and technician to say, “I will work as fast as I safely can, but no faster.”  If we fill prescriptions too fast, we cannot blame the boss. We, the pharmacists and technicians, are the professionals. If we are to assign blame, perhaps we should look at ourselves. To quote a famous line from Walt Kelly’s Pogo cartoon, “We have seen the enemy and it is us.”  

I told my friend he would not like my answer.

Endnote

1. For example, see the case of Carl v. Children's Hosp., 702 A.2d 159 (D.C. 1997), in which a nurse was wrongfully discharged because of her advocacy for patients' rights before the legislature and the courts. This was ruled an exception to the at-will doctrine. Also see the case of James Liberatore v. Melville Corporation (D.C. 1998), in which a pharmacist was fired for threating to report safety concerns to the FDA. The court ruled this an exception to the at-will doctrine of employment.