Patient Safety Alert
Debate continues: Is pharmacist shortage creating risks?
More pharmacy schools opening, but that’s not a short-term fix
Some industry experts fear the pharmacist shortage eventually will threaten patient safety as the demand for prescriptions increases from 3 billion to 4 billion by 2004. And while there is a growing need for pharmacists, the number of students entering pharmacy schools essentially remains the same year after year.
Carmen Catizone, executive director of the Park Ridge, IL-based National Association of Boards of Pharmacy, says the nature of the job creates a potential for danger. "Any time you dispense a prescription as a pharmacist and you make an error, patient safety is at risk. The volume [of prescriptions] certainly adds to the risk."
To reduce the chances of compromising safety, Catizone says there is a need for more pharmacists and better-trained technicians. But that isn’t likely to happen within the next few years.
Pat Minard, PharmD, pharmacy manager at Shawnee Mission (KS) Medical Center, says there’s no doubt that the shortage creates a risk for patients, particularly in the retail setting.
Minard says there are cases where retail pharmacists are under a lot of pressure to meet a bottom line. "Sometimes they end up working to the point where they are ignoring information screens where there could have been an interaction or they are asking technicians to do things that the pharmacist should be doing," he says.
Retail pharmacists also face a time crunch, Minard says. "Patients are more tolerant in a hospital," he says. "If it takes 30 minutes to fill a prescription, usually the patient doesn’t know because he’s upstairs in a bed. The nurse might get a little irritated. But standing around waiting in a drug store for 30 minutes is completely different."
He fills about 150 prescriptions during an eight-hour shift.
Lisa Abrams, MD, an internist at Lake Forest Hospital in Deerfield, IL, began working as a pharmacist in the early 1980s. Back then she would easily fill 600 prescriptions a day.
"This problem is not new," she says. "There’s been a shortage for years even when I was starting out. I don’t think patient safety is at risk because, by nature, pharmacists have compulsive and obsessive personalities. "I would check and re-check a prescription, and I think other pharmacists do the same thing."
Patients suffer when pharmacists too busy
When pharmacists are under pressure to "lick, stick, count, and pour," the patient is the one who suffers, Minard says. "We are trained in pharmacy college to spend a lot of time counseling patients," he says. "You don’t have time to do that in the retail setting."
Taking an extra few minutes to talk to a patient can dramatically reduce the likelihood of an error, most pharmacists agree. And indeed, a growing number of retail pharmacies are focusing more on patient care, says Dan Kidder, spokesman for Alexandria, VA-based National Association of Chain Drug Stores. "Chain stores are getting away from having pharmacists [getting stuck] behind the counter."
Kidder says no one doubts pharmacists need to spend more time with patients. "Approximately 50% of prescriptions are taken improperly by the patient. The time spent with the patient is crucial."
But even Richard Penna, executive vice president of Alexandria, VA-based American Association of Colleges of Pharmacy, concedes that a pharmacist with the best intentions can inadvertently put a patient at risk. "I have no information to say the lack of pharmacists puts lives in danger. But you could make a case, similar with a physician in his residency who spends 36 hours on call. The last five or six hours are crucial time when errors occur.
"The same thing would hold true of pharmacy situations," he says. "They may not have time to double-check the order. One issue that does need to be dealt with is the amount of time pharmacists are spending with insurance companies," he says.
The solution to the pharmacist shortage seems obvious — recruit more pharmacy students. But that’s easier said than done.
"In pharmacy, just like medicine, dentistry, and nursing, fewer and fewer people are entering the fields, and I don’t know why," says Penna.
Some experts say careers in the medical field are taking a backseat to technology-based careers. "That has been mentioned by a variety of people and it sounds logical, but I don’t know if it is the real reason." Pharmacy may not be as popular as technology because the hours are not regular and the salaries are not as high as in some computer-related positions.
New technology, however, can help support pharmacists in the delivery of better and safer care. One example is Excalibur Patient Safety Net, a software package and information system from Safety-Centered Solutions Inc. (SCS) in Tampa, FL. Excalibur includes reporting, analysis, and trending capabilities, as well as medical error and adverse drug reaction taxonomies to assure reliable data. Pharmacists using Excalibur have been able to significantly reduce the incidence of errors," says David Spencer, founder and CEO of SCS.
Pharmacy schools are doing their best to keep up with the demand. The 82 pharmacy schools across the country graduated 8,000 students in spring 2000.
New pharmacy schools are opening every year, but most graduate less than 100 students at a time. Meanwhile, there are 7,000 openings in drugstore chain pharmacies alone, and 94,000 pharmacists are employed nationwide. That doesn’t count hospitals, community pharmacies, HMOs, and drug companies.
"Pharmacists are in demand by a lot of companies because of their knowledge of drugs," Penna says. "And that’s all a part of it."
For more information, contact:
Carmen Catizone, executive director, National Association of Boards of Pharmacy, Park Ridge, IL Telephone: (847) 698-6227.
Pat Minard, PharmD, pharmacy manager, Shawnee Mission (KS) Medical Center. Telephone: (913) 676-2110.
Lisa Abrams, MD, internist, Lake Forest Hospital, Deerfield, IL. Telephone: (847) 535-8333.
Dan Kidder, spokesman, National Association of Chain Drug Stores, Alexandria, VA. Telephone: (703) 549-3001.
Richard Penna, executive vice president, American Association of Colleges of Pharmacy, Alexandria, VA. Telephone: (703) 739-2330.
University study identifies problems with IOM report
The Institute of Medicine’s (IOM) report on medical errors is faulty because it does not include a control group and all the patients studied on average were very sick, according to researchers at Indiana University School of Medicine in Indianapolis
"If you take their figures literally, you have to assume that patients never die if they do not suffer an adverse event," says Clement J. McDonald, MD, director of the Regenstrief Institute and Distinguished Professor of Medicine at Indiana University School of Medicine.
McDonald is referring to the study released by the IOM in November 1999 that stated "prevent-able adverse events are a leading cause of death" and "at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors."
Indiana University’s report "Deaths Due to Medical Errors Are Exaggerated in Institute of Medicine Report"1 was published July 5 in The Journal of the American Medical Association (JAMA). Lucian L. Leape, MD, adjunct professor of health policy in the Harvard School of Public Health in Boston, published a rebuttal piece, which ran in the same issue.2
McDonald and his colleagues at Indiana University, Michael Weiner, MD, MPH, assistant professor of medicine, and Siu L. Hui, PhD, professor of medicine, said that it is wrong for the IOM to assert that all deaths in the study group were caused by adverse events without reporting any kind of comparison or control group.1
Leape’s colleague, Thomas Nolan, PhD, a statistician at the Institute for Health Care Improvement in Boston, says there was no control group because the IOM study is an analysis of other literature.
The IOM report is based on a Colorado and Utah study that implies that at least 44,000 Americans die each year as a result of medical errors, and on a New York study that suggests the number may be as high as 98,000.
In its high-severity group of 1,278 patients for whom an adverse event was identified, the IOM’s study reported that 173 patients (13.6%) died, at least in part because of an adverse event.2
"Indeed, an assertion that adverse events caused death in 13.6% of the patients who experienced adverse events is tantamount to the assertion that there would be no deaths in a group with similar baseline risks who avoided all adverse events. Clinical experience tells us that is not true," McDonald wrote in JAMA.
Nolan says Leape’s study eliminated people who were at high risk of death. "The analysis that Dr. McDonald did was not appropriate because Dr. McDonald did not take that into account. The whole issue comes down to whether they excluded the very sick — they did," he says.
Leape wrote that the group screened included people who were not very sick. Patients who had major surgery, acute myocardial infarction, pneumonia, or stroke or were terminally ill, extremely ill, or with a do-not-resuscitate order were eliminated.2
According to Leape, three reasons suggest that the IOM report did not exaggerate the extent of medical injury and death. First, despite the limits of record reviews, it is unlikely the reviewers found adverse events that did not exist. Second, neither of the large studies examined the extent of injuries that occur outside of the hospital. Finally, when prospective detailed studies are performed, almost invariably, error and injury rates are much higher than indicated by the large record-review studies.
Louis H. Diamond, MB, ChB, FACP, vice president and medical director of MEDSTAT Group Inc. in Washington, DC, and member of the board of directors of the Chicago-based National Patient Safety Foundation, says, "Although this has raised some methodological questions, it doesn’t detract from the fundamental fact that errors are occurring at a rate higher than they should, and patients are harmed by these errors."
Nolan agrees, saying there’s no question that people are dying from medical errors, "despite whether it is 98,000 or 40,000 or 20,000. Come look at some of these cases; we need to work on this."
The research team’s analysis will not change the message of the IOM report nor will it change future legislation or the way the private sector responds to the IOM report, Diamond says.
The IOM report concludes with a list of recommendations that includes creating a Center for Patient Safety within the Agency for Healthcare Research and Quality. Initial funding of $30 million to $35 million would permit the center to conduct activities in goal setting, tracking, research, and dissemination, according to the report.
Another component of the plan is mandatory reporting of errors. While 23 states (18 of which require hospital reporting) currently have mandatory reporting systems to track medical errors, President Clinton’s plan will have a nationwide, state-based system in place within three years.
For more information, contact:
Clement J. McDonald, MD, director of Regenstrief Institute and Distinguished Professor of Medicine, Indiana University School of Medicine, Indianapolis. Telephone: (317) 630-7070.
Louis H. Diamond, MB, ChB, FACP, vice president and medical director of MEDSTAT Group Inc. in Washington, DC, and member of the board of directors, Chicago-based National Patient Safety Foundation. Telephone: (202) 719-9843.
Thomas Nolan, PhD, statistician, Institute for Health Care Improvement, Boston. Telephone: (301) 589-7981.
References
1. McDonald CJ, Weiner MJ, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA 2000; 284:93. http://jama.ama-assn.org.
2. Leape L. Institute of Medicine medical error figures
are not exaggerated. JAMA 2000; 284:95.
http://jama.ama-assn.org.
Billing for drugs could become safety issue
A rule implemented Aug. 1 by the Health Care Financing Administration (HCFA) has some pharmacists and other industry insiders concerned about the increased potential for medical errors.
Under the new outpatient prospective payment system, the government will reimburse Medicare services based on the type of procedure performed.
According to Judy Smetzer, RN, director of risk management services for the Institute for Safe Medication Practices in Huntingdon Valley, PA, some medications used in affected procedures will be eligible for "pass-through" reimbursement using HCFA J-codes corresponding with specific drug quantity billing units.
Smetzer says that to use the new billing process, some pharmacies may need to change their computer billing and inventory systems in a way that could compromise patient safety.
Pat Minard, PharmD, pharmacy manager at Shawnee Mission (KS) Medical Center, says about 300 drugs will be impacted by the new rule, and depending on a pharmacy’s computer system, there could be some problems.
For the 300 or so drugs affected, Medicare will reimburse based on specific doses. For example, Medicare will pay for meperidine in 100 mg units. It is produced in units of 25, 50, 75, and 100, and is typically prescribed in units of 50 mg. "But we have to bill them in 100 mg units so we have to charge them for 100, even though we might use 50," he says.
The problem occurs if the patient returns for a refill and the pharmacist or technician reads the bill rather than the prescription, the patient could receive an overdose. In other cases, Minard says there are drugs that Medicare will reimburse in 5 mg doses. "If you prescribe 30 mg, you have to bill them six times," he says.
Smetzer says multiple billing could desensitize nurses and pharmacists to an important error-prevention rule, "always check when more than two or three units are required for each dose."
The new system could create a problem for automatic software pricing and clinical updates as systems are automatically updated through a software system tied to each drug’s national drug code (NDC). "If hospitals create new inventory items to match billing units, it may not be possible to load important software updates since the HCFA dosing units will not have an NDC," Smetzer said.
Since adding or changing drug files and the related units of measure may increase the risk of error, Smetzer recommends finding other ways to accommodate the new billing system. "It may be possible to work with your information system vendor to develop rules by which affected drugs will be intercepted between the clinical and financial sides and the units will be converted into compatible units of measure for billing purposes," she says.
For more information, contact:
Judy Smetzer, RN, director of risk management services, Institute for Safe Medication Practices, Huntingdon Valley, PA. Telephone: (215) 947-7797.
Pat Minard, PharmD, pharmacy manager, Shawnee (KS) Mission Medical Center. Telephone: (913) 676-2110.
To read the rule, visit the HCFA Web site at www. hcfa.gov.
Safety-Centered Solutions, hospital win software award
Safety-Centered Solutions Inc. (SCS) and one of its clients, University Community Hospital (UCH) of Tampa, FL, recently won the Healthcare Innovations in Technology Systems (HITS) "Partnership in Technology" Award for a system to improve patient safety by identifying, quantifying, and measuring the cost of adverse events.
The HITS Awards were established in 1992 by Henry Ford Health System, a leading managed care provider in the United States, and honor both inpatient and outpatient facilities in two categories for each classification based on size — small or large.
SCS and UCH were chosen in the large facility category based on their development and use of Excalibur Patient Safety Net, a proprietary software and information system that recognizes systemic causes of medical errors and subsequently reduces their frequency and associated costs.
"We are delighted that our collaboration with University Community Hospital was recognized by our industry at the national level," says David Spencer, founder and CEO of SCS. "Once again it proves that putting good tools into the hands of good people offers endless possibilities for permanent improvement in quality."
For further information on Safety-Centered Solutions Inc., contact:
7650 W. Courtney Campbell Causeway, Suite 400, Tampa, FL 33607. Telephone: (813) 626-0299 or toll-free (877) 739-6751. Web site: www.scCARE.com.
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