I first stumbled across this 20/20 report when I saw a preview on the ABC investigative reports video podcast. Pharmacy errors are a major problem (see this story):
There are as many as 7,000 deaths annually in the United States from incorrect prescriptions, according to Carmen Catizone of the National Association of Boards of Pharmacy. He told The Washington Post that as many as 5 percent of the 3 billion prescriptions filled each year are incorrect.
In the ABC piece, they focus on Walgreens, although I’d suppose the conditions and processes are the same at other major chain pharmacies.
One former pharmacist was interviewed, talking about how he was fired for being too slow, the implication being that other employees rushed through their work to meet some sort of quotas and that he refused to work in a way that would have jeopardized patient/customer safety.
I think that leads us to a reminder about Lean and Standard Work. For one, nobody has accused Walgreens of using lean practices. The pressure that the former pharmacist described was probably an old Taylorist mass production approach of pressuring workers to work faster because management wanted better results.
With lean, Standard Work includes the steps in a process and the standard time required to do each step SAFETY and with high QUALITY. Sure, there might be variation in that time person to person. If someone is an extreme outlier, you would look at the Standard Work — are they following it? In a lean setting, you don’t pressure people to work faster “just because” and you don’t pressure people to work faster than they are able to safely.
The story also highlights how many Pharmacy Technicians are 16 year olds without any sort of degree. I’ve never seen this in the hospital pharmacies I’ve worked with, the Pharmacy Techs are always trained, experienced adults.
A high school-aged pharmacy technician at a Walgreens in Lakeland, Fla., made a typing error and dispensed a dose of the blood thinner Coumadin that was 10 times what the doctor had prescribed.
She was in high school. Her prior job had been cleaning a movie theater and serving popcorn,” said Karen Terry, a lawyer representing the patient’s family.
The patient, Beth Hippely, suffered a massive stroke after taking the medicine she was incorrectly given, forcing her to stop chemotherapy for a treatable, stage II breast cancer. She died earlier this year.
That’s a tragic story. There is some incredibly sad video of Ms. Hippely before she passed away. I don’t think the problem would necessarily be a “young” employee, but isn’t it likely Walgreens had a bad process with poor quality controls built in? The young tech dispensed the wrong dosage, but that happens a lot (unfortunately) at many pharmacies, which, to me, points to a systemic problem. Systemic problems are rarely solved completely by telling people to “be careful.” Is a 16 year old less likely of “being careful?” Maybe, but there’s a higher responsibility on Walgreens: the supervising pharmacist as well as the leaders who are responsible for creating a solid, lean, error proofed process.
More on Walgreens management’s role:
The high school student who made the error with Beth Hippely testified she had watched a video and was taking classes in school to learn about the pharmacy job.
Testimony in the Hippely case also revealed that stock boys and photo shop workers were also pressed into service behind the pharmacy counter when the store became very busy.
“They know mis-fills and errors are bound to occur because they’re giving huge responsibility and important responsibility to people that aren’t trained to perform those duties,” said Terry.
“This is an intentional, system drive for profits, for money. If it wasn’t about that, they would hire more pharmacists,” the lawyer said.
Or they would spend more money on training their pharmacy techs better. We can try to throw a nurse into jail for making ONE error, yet the executives who oversee failed systemic processes are left to collect huge paychecks. I think the focus on “oh how shocking, it’s irresponsible teenagers filling your prescriptions!!!” is misplaced. The shocking things are the lack of training and lack of standard work.
The industry seems to want to cover up the problem (2nd ABC page). 46 out of 50 states have no requirement for reporting pharmacy errors, even those that are fatal.
While some fear there is an unreported epidemic of pharmacy errors, there are no reliable figures to gauge the scope of the problem. And that’s the way the industry seems to like it.
“I don’t think it should be publicized,” said Mary Ann Wagner, the senior vice president of the National Association of Chain Drug Stores, in an interview to be broadcast Friday on “20/20.”
She says the industry fears the public won’t understand the difference between minor and major errors, and that the figures could be used to punish drug stores.
We won’t understand?? Of course the figures should be used to punish drug stores. We, as consumers, should be able to choose a pharmacy based on their safety record. Customers should run away, in droves, from those pharmacies that refuse to do a better job with patient safety. Notice I said “refuse to.” I don’t think “can’t” is the problem, I think it’s a problem with “won’t” fix.
One pharmacist who was deemed responsible for an error in another case:
The pharmacist who admitted responsibility for the error, William Zaeske, continues to work at Walgreens and is now a pharmacy manager at another store near the one where the prescription error happened.
This might actually be the right approach, in a way. Should the pharmacist be fired for something that happened under his watch that was a systemic problem that’s occurring in other pharmacies? Again, what about management? Why aren’t we outraged that a VP or CEO wasn’t fired? I guess $21m lawsuits aren’t waking up Walgreens.
Final thought, Walgreens says:
In a statement, Walgreens said, “We deeply regret the few errors that have occurred among the more than 500 million prescriptions we fill each year at our 5,600 pharmacies.”
Instead of a sincere apology, we get a sales pitch from Walgreens about how big and popular they are. That’s inappropriate. I guess they are saying that errors are inevitable because they’re such a large company? That’s an inappropriate attitude also. “Zero defects” really and truly needs to be the goal. We can’t tolerate anything less, it’s a matter of expectations. Put in error proofing methods and proper management oversight — that’s how you work toward zero defects. A “Six Sigma” level in that industry is going to kill people. That’s why we need zero defects.
It says it has invested nearly $1 billion in “redundant pharmacy safety systems” and training over the last 10 years.
And I wonder how much of this $1B investment was in “siren song” technology instead of investing in people and process??
So what can you do?
- Insist on better oversight and reporting mechanisms for pharmacy errors
- Ask your pharmacist what THEY are doing to prevent errors from occurring
- DOUBLE CHECK each and every prescription you bring home to make sure you have the RIGHT PILL and the RIGHT DOSAGE
Thanks for reading! I’d love to hear your thoughts. Please scroll down to post a comment. Click here to receive posts via email.
Now Available – The updated, expanded, and revised 3rd Edition of Mark Graban’s Shingo Research Award-Winning Book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. You can buy the book today, including signed copies from the author.