番茄社区

In this Instagram Live clip, Jeremy Faust, MD, editor-in-chief of 番茄社区, and pharmacist Shane Jerominski, PharmD, the activist behind The Accidental Pharmacist, discuss how increasing workloads at U.S. pharmacies have increased the opportunity for medication errors.

The following is a transcript of their remarks:

Faust: I think people are really interested in the question of safety, and this is an area that you really raise concerns about. Can you tell the average person watching what are some of the safety concerns that you have seen crop up over time? And give us a sense of why it might be getting worse.

Jerominski: Sure. So I think that safety has gotten worse, especially during COVID.

COVID was really -- we were going to this place where immunizations were the biggest margin driver for Walgreens and CVS. So they were always about let's make sure we have a flu shot season that makes the year, let's make sure we do that. And then when they realized that, they started adding all these different vaccinations, and COVID pushed it over the edge.

So every time the pharmacist steps away from their normal job -- the job of a pharmacist is to safely and accurately check prescriptions. When you work at a high-volume, or even a medium-volume Walgreens or CVS, you are tasked with filling a lot of prescriptions and making sure those prescriptions are typed accurately and making sure there are no drug interactions. So, I need to be focused on that. I need to be focused on the screen, what the technicians have typed. I need to make sure I'm checking drug interactions, answering doctor calls, transferring prescriptions, and checking prescriptions, physically checking prescriptions.

But every time you step away to give a vaccine, to do any of these other ancillary duties that they've added, you introduce the opportunity for a medication error to occur.

That's the reason why Walgreens and CVS are having what they call a "shortage" of pharmacists or people willing to work in that practice setting. It's not a shortage of pharmacists, it's a shortage of pharmacists willing to put their license on the line.

What's at stake for a pharmacist when a medication error happens is far more concerning than what's at stake for CVS or Walgreens. They're comfortable with a certain level of medication errors happening in their store, especially since in almost every state they don't have to report it. They're under no obligation to report it to the boards of pharmacy or anyone.

Faust: I have a question about maintaining that safety, and I hope the question will enlighten the viewer in terms of how this plays out.

When I prescribe a medication, I might go to Drugs.com or some kind of outlet that tells me about all the drug interactions that might happen, but the list is long. It could pump out dozens and dozens of interactions and sometimes the patient's on the drug, and honestly, a lot of them are nothing. They're nothing burgers. So it ends up being this firehose, and you're like, "Well, I'm just going to avoid the hose altogether."

My question for you is: how do you, when you're doing your job, distinguish the noise and the signal. Like, "Oh, this is a real one, I really got to take care of this one," as opposed to the dozens and dozens of stuff that like, ah, it's kind of hypothetical.

Jerominski: Yeah. I think that when you see the monograph, it's overwhelming for everyone.

The first thing about that is it's listing the drug, it's not listing its delivery, whether it's IV. There are a lot of drugs that if you're taking it orally, those interactions are not really going to be that serious or much of a concern, but if you're on long-term IV antibiotic therapy for a fluoroquinolone versus a 7-day course of therapy for a Cipro [ciprofloxacin] or something like that, it's a different animal.

What we're talking about with medication errors are really simple things that every pharmacist is going to take. It might not be those drug interactions, but if I don't have time to counsel a patient -- you figure a very high-volume store can be doing a thousand prescriptions a day. If I'm not counseling patients on new prescriptions, an easy medication error can happen and occur. And if we're not adequately staffed, those things ... you're triaging everything.

A very common medication error that occurs a lot of times in a retail setting is hydroxyzine and hydralazine. It's easy to catch if I counsel a patient. So say all those things, we missed all those steps, and that first initial counseling, if I have the time to do it -- which I'm supposed to do on every prescription -- but if it doesn't occur, you've lost your chance. And you could save a medication error like that.

There are countless lookalike/soundalike drugs that that happens with, and that's when the pharmacist is worried about something else and they're like, "Oh, that's fine. We got it through. We'll let it out." That's how medication errors happen. They seem like little things, but they're not.

Faust: Are we making any progress on lookalikes and labels, because I've seen talks given by pharm people who show me, look, these two vials, they look so alike or these two drugs look so alike and one of them is going to cure them and one of them is going to kill them. So, it would be nice if they didn't look alike. Are we making any progress on that?

Jerominski: Well, I think there are a lot of things that they do to catch those things. There are a lot of stopgaps within the workflow to be able to catch that.

The problem is that when you're understaffed, sometimes things get through. All of these safety concerns start with adequately staffing the pharmacy, and technicians are the key component to that. If we don't have well-trained, adequately-staffed technicians, that makes a pharmacy way less safe.

The problem is that if you have a highly-skilled technician, which there are many of them out there, they need to be paid appropriately. Right now, the Bureau of Labor Statistics has technicians at the median wage of $18.17 an hour.

For the stress level and the amount -- I mean, they're the ones on the front lines. Pharmacists are there and they're responsible for everything that goes out, but generally the technicians are the ones that are fielding all the complaints for insurance issues, dealing with patients at the register who are very unhappy because they just learned that the insurance that they pay for is still going to have them charge a medication as $500 as their out-of-pocket expense this month. So the one that's face is getting screamed, those are the technicians, and they deserve to be compensated for the stress level and the skillset.

Faust: One of the things that a lot of my readers on 番茄社区 and on Inside Medicine, my newsletter, are really concerned about is the masking issue during cold and flu season in pharmacies.

This is actually a true story. My spouse and our kid were in the pharmacy the other day and the guy in front of them in line is literally on the phone saying, "Hey, you'll never believe it. I got influenza A, so I got to pick up a prescription," which is probably Tamiflu. And my spouse is looking at this guy, he's got no mask on, and we're like, "OK, let's go. Let's walk away now."

But people come to the pharmacy when they're sick. So what do you think about requiring masks during certain times of year from staff or even just guests and customers?

Jerominski: I think it probably would help a little bit, but there's going to be a pushback. I mean, we were in the middle of a giant worldwide pandemic and people were getting pushback on masks. So if we required people to wear masks to pick up their Tamiflu or anything, you'd probably get a lot of pushback on it.

I am in total agreement. My wife works at a high-volume Walgreens that does not only the COVID boosters, but also COVID testing. So this little, tiny she-shed that they put up in the waiting area to administer vaccines is also the same place they swab for COVID. So if you go there for your COVID vaccine and you didn't have COVID when you started, you might have it when you leave. It happens all the time.

Faust: Right. We see this in the ER, especially in the patients who are what's called "boarding" -- they're admitted to the hospital, but they haven't yet gotten a private room. I've heard stories of patients getting COVID while they're waiting for their bed.

Now, one thing I'll always say is that, if you're really worried, one-way masking is pretty good if you are wearing the right mask. A N95 or even a KN95 will really reduce a lot of risk. So I always tell people, look, you can't control other people's actions, but you can control your own. I think you're right. I think that there's a question of pushback, but it's a scenario where I get it. I get the concern.

Jerominski: And the one thing you were talking about, like being overburdened with the amount of work -- you're supposed to sterilize between each patient. But if I have tons of work and I have one technician or two technicians in a place that has hundreds of prescriptions and hundreds of vaccine appointments for the day, that's going to be one of those things -- you're not really going to thoroughly sanitize in between each patient.

Faust: If I heard you correctly, it's that you have pharmacists and techs who are keeping the public safe and then they're being overworked, and on top of that, oh we're going to run a vaccine clinic here. So they're getting pulled out in multiple directions. But people love to get their vaccine at the pharmacy.

My question for you is: do you think that it's just a matter of yeah, it can happen at the pharmacy, but you have to staff for it differently? Or do you feel like, no, it's the wrong place for it?

Jerominski: Yeah, that. You're exactly right. I want pharmacists to practice at the top of their license. I want them to be able to do any of these things, not just vaccinating, but you do need to staff appropriately.

I mean, they're always trying to innovate, to be able to do more quickly, like virtual verification, when you have pharmacists remote verifying prescriptions. That I'm totally against. It doesn't matter how quickly you can do it, checking prescriptions is tactile. You understand if you're holding a prescription in your hand whether there are 90 pills in there sometimes or 30. So medication errors can occur a lot easier under virtual verification. That's just one little thing.

I would love to do all those things if they staffed appropriately. And it's not just those two main tasks and vaccinating -- sorry, my dog's barking in the background.

Faust: That's a very passionate dog you've got. They agree.

Jerominski: So vaccinating and checking prescriptions, but they have all these other ancillary duties that increase their bottom line, but don't do much to help with the workload that's there. PCQ [patient care queue] calls trying to hound patients to come pick up prescriptions before they have to return them, save a trip where they try to sync all their prescriptions, medication therapy management -- which I'm all for, but that's another thing is we have to have time allocated to do those things.

But Walgreens just wants as much revenue as possible with as little investment in resources and personnel to do that.

Faust: Alright. Outstanding. I'll just say safety is number one and people take it for granted, but they miss it when it's gone. So thank you for the advocacy.

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