Overwork Threatens Druggists’ Accuracy

Pharmacist Randy Kautz asked Walgreens for help at least four times.

He warned that the drug counter’s busy pace might lead to errors. On June 15, 1994, he no longer had to make the point. That day one of his regular customers, Nathan Johnson, sank into a coma from which he never emerged.

“Oh my God,” Ruth Johnson remembers Kautz saying as he reexamined the prescription bottle that she brought back to the store. “I’ve given the wrong medication.”

A pharmacist’s task is now filled with more speed and more stress than ever before--and, studies suggest, less satisfaction. Pharmacists blame their workload, growing along with their worries. When that workload affects accuracy, the pharmacist’s worries become the patient’s.

The National Pharmacists Assn., a trade group based in Darien, Ill., recommends that, for safety’s sake, a pharmacist fill no more than 15 prescriptions an hour. Elizabeth Allan Flynn, a researcher at Auburn University School of Pharmacy in Alabama, says studies by her and others suggest that the rate of pharmacists’ errors increases after they fill more than 24 prescriptions an hour.

Whatever the number, pharmacists complain that they routinely have to exceed it.

Druggist J.F. Burnham warned Walgreens managers in 1991 that the frantic pace at his store in Arlington Heights, Ill., “enhances the chances for error.” Two pharmacists working separate shifts were filling up to 400 prescriptions a day --nearly 29 an hour.

“It’s not unusual for me to talk to pharmacists who are filling 300 prescriptions a day,” says Thomas J. Moore, a health policy analyst at the George Washington University Medical Center in Washington, D.C. “The job of the pharmacist is becoming nearly untenable. Management is putting on pressure to increase output and reduce waiting time. And it’s going to get worse.”

That stress has driven druggists like John Magaudda from their jobs.

“I’d see a bottle of thyroid medication on the counter and I’d say, ‘Why is this out here? I didn’t fill a thyroid prescription today,’ ” said Magaudda, who quit his job at a Rite Aid in Santee, Calif., in 1997 after 36 years. “If things went on, it was going to get worse, and I was going to make a mistake. A bad mistake.”

In a letter of warning to the California State Board of Pharmacy, Magaudda wrote that more pressure on pharmacists would inevitably lead to more errors.

Several of the 50 state boards of pharmacy that oversee the industry have begun to take complaints like Magaudda’s seriously. Some have linked understaffing to patterns of mistakes by the high-volume chains that dominate the industry.

In Oklahoma, Eckerd reached a settlement with regulators in 1998 after the state board of pharmacy found 23 prescription errors over one year at the chain’s Oklahoma stores.

In one of those instances, pharmacist Shirley Frame worked 67 hours over seven days before making a mistake that she attributed to “understaffed, overworked employees.” The state board said Eckerd didn’t employ enough pharmacists “to safely fill prescriptions,” and concluded: “The harm to the public is tremendous.”

Eckerd admitted no fault. “No inappropriate staffing was found,” the company said in a recent statement, and the settlement with regulators “did not include any changes in staffing.”

In Washington state, the state pharmacy board reached an agreement with Rite Aid last year after regulators fielded 134 complaints of dispensing errors over three years at various locations. The chain agreed to pay $50,000 in fines. It also agreed to review its staffing policies, but made no promises to change them.

Pharmacists in Short Supply Nationwide

Rite Aid made a similar deal with Oregon regulators last March, agreeing to pay $60,000 to resolve a pharmacy board investigation. The state alleged that the chain had shown poor supervision and violated state laws requiring pharmacists to counsel patients on how to take their drugs.

Rite Aid spokeswoman Jody Cook said the company has since taken action. In Washington state, Rite Aid put every company pharmacist through a revamped training program, installed automated dispensing machines at its busiest stores, and reduced the number of complaints last year from 95 in February to six in December.

In Oregon, the company appointed a new regional vice president to coordinate with regulators. It also increased staffing, automated some dispensing and reduced complaints from 22 in January to one in December.

Pharmacy owners say there are no easy answers.

An expanding array of innovative drugs and insurance plans that cover them has driven aging baby boomers--and Americans with conditions ranging from baldness to cancer--to the drugstore in record numbers. Consumers buy an estimated 3 billion prescriptions each year--two pills for every one they bought in 1989.

But pharmacy schools turn out about the same number of druggists as they did in 1989, creating what drugstore owners call a national pharmacist shortage.

President Clinton signed legislation in December to study the extent of the shortage. The National Assn. of Chain Drug Stores, a retail trade group, estimated that 4,000 of the 120,000 jobs at the nation’s major chains were open as of December.

The American Society of Health-System Pharmacists estimates a moderate to severe shortage of druggists at 90% of its hospital pharmacies, based on a survey of 350 of its directors earlier this year. Nearly half of the directors reported openings, with an average vacancy rate of 17%.

The group’s chief executive officer, Henri Manassi Jr., wrote to hospital pharmacy managers on Jan. 26 that the shortage is leading to overworked pharmacists and “error hazards” that threaten patient safety.

Many safety-related professions set limits on the hours worked. Air traffic controllers, for instance, take breaks every two hours. But pharmacists, like physicians, have no limit. Many complain that they rarely take lunch breaks or even bathroom breaks.

In some cases, that has changed. Walgreens generally schedules pharmacists for no more than 42 hours of work a week, spokesman Michael Polzin said. But the shortage often translates to extra hours at Walgreens and other chains.

After a 1997 incident in which an Eckerd pharmacist in Wilmington, N.C., dispensed the wrong drug during a 16-hour shift, Eckerd started guaranteeing lunch breaks for druggists in selected regions.

Wrong Prescription Can Be Fatal Mistake

As they grow busier, pharmacists are coping with more paperwork than ever. The chain drug association cites an industry-funded study done last year by the Arthur Andersen accounting firm, which found that pharmacists spend 20% of their time dealing with insurance.

The workload crunch has left druggists struggling to keep up.

At the Daytona Beach Walgreens where Ruth Johnson picked up her husband’s fateful dose, the pace was picking up. In June 1991, the pharmacy averaged 162 prescriptions a day. When she picked up her husband’s prescription in June 1994, it was open 24 hours and averaging 247 prescriptions.

Kautz was scrambling to supply customers with their drugs within 15 minutes. He meant to give her Coumadin, a blood thinner to prevent blood from clotting. Instead, he gave her Cycrin, a female hormone that can have the opposite effect.

Two weeks later, Johnson suffered a stroke that left him comatose. He died last year, never regaining consciousness. His widow won a verdict of $6 million.

Between October 1991 and June 1994, when Ruth Johnson arrived, the Daytona Beach pharmacy reported 27 other errors to Walgreens headquarters, according to store records revealed in Johnson’s lawsuit.

In a deposition, Kautz recalled three or four occasions before the June 15 error when the same mistake happened--Cycrin placed in a bottle labeled “Coumadin.” But he caught those mistakes before they left the store.

Along with reports of errors came store reports of chronic understaffing. In February 1994, store managers warned of “current staff being stretched to the limit.” Kautz had asked for more help at least four times, according to testimony from Kathryn Correia, the pharmacy’s manager.

Kautz said he asked for another pharmacist to work with him but was told one “wasn’t in the budget.” He said he never took lunch or other breaks because the store was too busy and he had no one to relieve him. And between 1993 and 1994 the store added six hours of pharmacist time per week, but not a second pharmacist, according to court records.

The now-relocated store has added pharmacist and technician hours since then, but a spokesman declined “for competitive reasons” to say how many.

Walgreens’ director of pharmacy operations, Phil Burgess, testified that he’d heard pharmacists at various Walgreens stores complain “forever” about inadequate staffing and excessive workload.

Walgreens officials would not say how many errors the company’s pharmacists make, but spokesman Polzin said mistakes make up a “minute percentage” of the prescriptions the chain’s pharmacists fill. The chain recently paid $150 million to revamp its computer system, replacing computers handling 250 prescriptions a day with those that can manage more than 400.

“There is more business coming into the pharmacy, no doubt about that,” Polzin said in a recent interview. “But we’ve made a very concentrated effort to deal with that workload efficiently and allow our pharmacy staff to handle that business without it becoming overwhelming.”

The expanding workload has left many pharmacists frazzled--and unhappy. In 1998, Drug Topics magazine asked 870 pharmacists whether they would still choose their profession. Only 45% responded yes, a drop of 10 percentage points over six years. For many, high stress is a daily part of the job.

Pharmacist Jim Ellison manned the Daytona Beach Walgreens counter a few years before Randy Kautz took over. He also had tried to cope. He asked for more help but, he told his brother David, “It doesn’t do any good.” He rejected a promotion that meant more work and eventually transferred to a slower store. He even gave up bathroom breaks.

To calm down after work, his brother said, Ellison jogged, lifted weights and started drinking four or five beers a night.

Anxiety was Ellison’s unshakable companion, even in his final moments. In March 1995, he had chewed the nail on his middle finger to the nub. Bite marks cut into the plastic tube that he hooked to the tailpipe of his Honda Civic inside his garage.

No one will ever know for certain why Ellison killed himself. But his brother and his widow think they know:

“His job.”

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Protecting Yourself From Error

Some safety guidelines for buying and taking prescription drugs:

* Know your drugs: Tell your doctor that you want to know the name of each medication and why you are taking it. Then check the pharmacy labels to make sure that’s what you’re getting.

* Check your pills: Write down the dose and how often to take each drug on your medications list. Describe the color and imprint on each pill. If pills look different from those you usually take, ask your pharmacist why. It could be a generic drug, or it might be the wrong drug.

* Inform the druggist: Tell your doctor that you want the purpose for the medication written on the prescription. Many drug names look alike when written poorly; knowing the purpose helps you and the pharmacist double-check the prescription.

* Warn of potential problems: Tell your pharmacist about any allergies and any drugs--including over-the-counter medications--you’re taking. Don’t assume they know.

* Insist on counseling: Talk to the pharmacist, especially the first time you pick up a drug. Remember that when you sign for the drug, you may be signing away your right to be counseled on how to take it.

* Read the label: Do this each time you take a dose to make sure you have the right drug and that you are following the instructions. Make sure the label agrees with what your doctor has said you should take.

* Beware of samples: If your doctor gives you samples, make sure that he or she checks to be sure there are no interactions with your other medications. Pharmacies have computers to check for drug interactions and allergies, but when your doctor gives you samples, this important check may be missed.

* Store carefully: Don’t store medications in direct sunlight. Humidity, heat and light can affect medications’ potency and safety.

Associated Press / The Institute for Safe Medication Practices, a Warminster, Pa., nonprofit organization