This initiative is designed to get TPA members to participate in a singular project.  That is get the state boards to act to protect the public from dangerous pharmacists.  The state board will never allow a pharmacist who is impaired by a couple cocktails at lunch to practice pharmacy.  Why do they keep blind to pharmacists who are impaired after 12 hours straight, no meal or rest breaks, 300 Rxs in the pot and still two hours to go with no technician help?

The state boards are mandated to regulate pharmacy so that the public is not put in jeopardy.  Let us demand that they do their job.

I am asking all members to get onboard.  The more hands and brains aligned, the more significant our initiative will prove to be.   This will be almost exclusively Internet driven.  After we have compiled the evidence, I will ask our attorney, Paul Garbarini, to prepare documents to be entered into the record that hopefully will pucker up some assholes.

Demanding that the state boards of pharmnacy accept that a tired pharmacist is a dangerous pharmacists is what we will focus on.  This is the turd in the punch bowl.  Everyone sees it, but too many board members represent retail chains.  Board members know that this is a problem, but they will continue to try to ignore it.  Our job will be to put it right on the table where they have to see it.  Statements from pharmacists will mean something, but statements from the public, demanding that the state boards do their job wil be huge.

Of course, dignity, self-respect and integrity will remain our foundation.

Now is the right time to join The Pharmacy Alliance.

Jim Plagakis

Our Boy Hubert Humphrey, the turncoat.  The lackey of the doctors’ lobby and Pharma.

You may not be familiar with the term counter-prescribing.  Some pharmacists still believe that this is as important in 2011 as it was in 1965. It is unfortunate that younger pharmacists do not think that it is part of the job.

I remind them as often as I can that OTC medicines are real drugs and that OTC counseling is real pharmacy.

The Golden Days of Counter-Prescribing

Well Before Durham-Humphrey

          Counter-prescribing is the prescribing of Over The Counter medicines by the pharmacist.  I do not use the word prescribing flippantly.  People did not consistently get their medical care for minor illnesses like colds, coughs or gastric hyperacidity at the doctor’s office.  They came to the druggist, the man they called “Doc”.  Pharmacists made a substantial part of their livings from counter-prescribing.

            Counter-prescribing is a carry-over from before the Durham-Humphrey Amendment.  There weren’t that many drugs in those days.  We relied heavily on the official formulas of drugs that were found in the USP and the NF. Pharmacists were still compounders and we were medical practitioners separate from doctors.  That is probably hard for you to get.  We are so accustomed to following the doctor’s lead even when it is not in the best interest of the patient that the idea of a pharmacist being independent is unbelievable.

                 Why would anyone go to the doctor for a headache when his best shot was surgery?  The pharmacist could give you cocaine or heroin.  No prescription needed,  Amazing.

The original, with cocaine

            The Durham-Humphrey Amendment of 1951 changed the game.  It formally distinguished between prescription and over-the-counter drugs.  Until that time, all drugs could be legally dispensed by pharmacists.  No prescription necessary.  Hence: Counter-Prescribing.  It took more than a decade, but by 1965, my first year as a Registered Pharmacist, we had relinquished our independent role and had securely landed below the nurse in the medical hierarchy.  It would take us decades to get back to where we are recognized as an important contributor to the patient’s health and we have not gotten back to our rightful spot yet.

The preceding was lifted from “The Comfort Demands.  Occupy Pharmacy” by Jim Plagakis, RPh, available January 2012.

Here is an email from one of our members to his state board.

            The nature of the RRRRRRR program’, one of XXXXXXXs business practices that is an automatic refill service, created numerous instances of unintended polypharmacy.  I do not have records of these instances, because when I noticed them, I corrected them.  The ones I didn’t notice were not corrected, because the system has no set way to make a pharmacist aware of them.  We simply must catch them as they appear, and use our best judgment at the time.  This can be very difficult due to the horrendous pressure the pharmacist is under to do things quickly.  Every action is timed, how quickly you get prescriptions done, how fast you answer the phone, how quickly you get drive through customers handled and move to the next one.  Failing to meet these targets results in discipline or even termination.  This pressure puts the pharmacist in an untenable position: Do I satisfy company demands even if I feel in my professional judgment this may do harm, or do I take the legal and ethical path and possibly lose my job?  Can a pharmacist comply with the mandates of counseling as defined by 21NCAC 46.2504, if they only have 2 minutes 30 seconds to do it in at the drive through?  Why is there a ‘target’ number of automatic refills we must achieve every week, if the pharmacist honestly feels that a patient would not benefit, or possibly be harmed by this service, do we not have the ethical and professional obligation to act in the way that defends the patients interests, and not the company bottom line, no matter how that ‘shakes out’ on our weekly RRRRRRR report?

            This constant pressure creates an unnecessary distraction that is a breeding ground for errors.  I do not have records of actual patient harm, but the assumption that a harried pharmacist is more prone to make errors is a logical one.  I do know that XXXXXX has a policy that any misfills are to be reported online via the company channels.  I obviously cannot acquire these now, but I would imagine that should the Board inquire these records would be turned over.  Then one could backtrack to see if XXXXXX policies led to these errors.  Several pharmacists and store managers in the district may have other information as well.

            I am curious, however, how this relates to my original complaint?  I had initially stated that XXXXXXX’s involvement of a non-pharmacist manager – who is not even registered as a tech on the NCBOP website – in countermanding my authority in the filling and dispensing of prescription orders constituted an unlawful violation of 21 NCAC 46.1804 ( a ):

            “The pharmacist-manager of the pharmacy shall be ultimately responsible for the safe, lawful and secure receipt of prescription orders and delivery of prescription drugs.” – to be responsible for something, yet unable to exert authority, cannot be the intent of the law.  Such would be ludicrous. and ( b ):

            “In filling or refilling prescription orders, the pharmacist shall not be required to deal with parties, including managed care companies and insurance providers, outside the practitioner-pharmacist-patient relationship.”  – I can’t imagine that the store manager or district manager, both non-pharmacists, as agents of the permit holder, are included in the practitioner-pharmacist-patient relationship.

            I would also point out that this behavior was incongruent with the “Practice of Pharmacy” as defined by 90-85.3-( r ):

“the responsibility for: interpreting and evaluating drug orders, including prescription orders; compounding, dispensing and labeling prescription drugs and devices; properly and safely storing drugs and devices; maintaining proper records; and controlling pharmacy goods and services.”

            These are clear violations of the law.  The fact that I left the pharmacy in protest of being forced to work in an environment I had repeatedly announced to management and staff was unsafe is irrelevant.  Whether I stayed or left, a non-pharmacist usurped my authority as provided by the law.  This action created a magnified potential for patient harm as the pharmacist in charge was no longer able to control the delivery of pharmacy goods and services to best benefit the public.  To say otherwise, would be to admit that the public the Board is charged to protect is at the mercy of non-medical management who do not have the training to practice pharmacy, and whose loyalties will be to the good of corporate profits and not the patient.

            To my mind, this is a cut and dried situation.  Either a pharmacist manager is in charge, as the law would seem to imply, or they are not, in which case the law needs clearer language.  I must admit that as a pharmacist of 12 years, over half of which has been as managing pharmacies, I find the notion of a non-pharmacist manager walking into a pharmacy and telling the pharmacist manager what she/he will or will not do in regards to any aspect of the pharmacy appalling.  The fact that the legality of it seems to be up for debate is unconscionable.

The Royal Pharmaceutical Society

The Pharmaceutical Journal

Law and Ethics Bulletin

This organization, I believe, is the United Kingdom’s equivalent of the APhA.

Since the powers at our APhA would never dirty their hands or soil their reputations

with such a mundane, and non-important issue, where do we look for an organization that will?

This may be like a national board.  Who wants to find out?  Regardless, we need statements

like this from official organizations that carry weight.  Is that APhA?  Yeah Sure!

 Making adequate provisions for pharmacists to have appropriate rest breaks

 Pharmacists’ prime concern must be for the safety and well being of patients and the public.  Working for extended hours without taking appropriate rest breaks can adversely affect a pharmacist’s ability to practice safely and may compromise patient care.  Pharmacists, pharmacy owners and pharmacy managers should therefore ensure that provisions are in place to allow pharmacists to have appropriate rest breaks.

 The Code of Ethics supports this requirement by stating that pharmacists should ensure that they do not work in conditions that they do not work in conditions that do not enable them to comply with the key responsibilities of a pharmacist.  Similarly, there is a professional requirement for pharmacy owners, pharmacists and pharmacy managers to ensure that they do not seek to impose conditions on pharmacists that may adversely affect their ability to comply with their professional and legal duties.  It is essential to encourage pharmacists to take appropriate breaks, and requiring an employee pharmacist to work for extended periods without adequate provision for rest breaks could constitute a breach of the Code of Ethics.

 A pharmacist’s capacity to undertake his or her professional duties safely for specified periods, without a break, will differ between individuals.  It will also depend on various factors such as the tasks being undertaken, the complexity of patients’ needs, the level of trained support staff on duty, prescription volume and the level of over-the-counter business.  Pharmacists and their employers should give particular consideration to the provision of appropriate rest breaks for pharmacist who work extended hours pharmacies, provide on call services or travel long distances to their place of work.

 When agreeing working hours and breaks be taken during the working day, employers and employees should take note of the Working Time Regulations 1998.  These state that if an employee is required to work for more than six hours at a time, he or she is entitled to a rest break of 20 minutes.  The break should be taken during the six-hour period rather than at the beginning or the end, but the exact time at which breaks are taken is left to the discretion of the employer.  Employees are entitled to have a minimum 11 hours rest between working days and cannot be forced to work more than 48 hours a week on average.

 While the Working Time Regulations can provide a useful benchmark, more frequent breaks may be required, for example, where high volumes of prescriptions are being dispensed.  Employers are responsible for making sure that their employees can take a rest break, but they are not required to make sure that the break is taken.

 The right to rest breaks does not apply where a job requires round-the-clock staffing, such as in hospitals, and exceptions can be made for emergencies or busy periods. 

 The above principles and guidelines also apply to Registered Pharmacy Technicians.

 While a pharmacist is taking a break, robust standard operating procedures should be in place to ensure that no activities take place that require the pharmacist’s personal involvement or oversight.  All pharmacy support staff should be aware of these procedures and patients should be advised of when a pharmacist is not available and when he or she is due to return.

Pharmacists make dispensing errors consistently closer to the end of a 12 hour shift then in the morning.  The most serious error I have ever made was on the label of a prescription for Dexamyl Spansules.  This was in 1966.  The product was a diet “pill” manufactured by Smith Klein & French.  It was a Spansule, a sustained release product designed for once a day use, in the morning.  The ingedients were 15 mg of Dextro-amphetamine Sulfate and 3o mg of amobarbital to “take the edge off”.

I came to work that day at 8:00 AM and my day ended at 10:00 PM.  Fourteen hours with no uninterrupted meal breaks or rest breaks.    The prescription was presented at around 9:00 PM, thirteen hours after I came in to work.

Of course,  I knew that the Sig was “One capsule once a day”.  Still, being well compromised, tired and hungry, I, inexplicably, put “One capsule FOUR times a day” on the label.

Three days later, the patient’s husband came in with the bottle.  “What the hell is this stuff?” he demanded.  “My wife can’t sleep.  She is up all night doing hippie love dances to loud music in the living room.  Last night she was dancing topless with the shades on the windows wide open.  The music is so loud that a neighbor called the police.  What the hell did the doctor give her?”

My heart sank and my stomach churned when I looked at the label.  I had to tell this guy what I had done.  I can confidently state that that error was 90% due to my being exhausted.  I am a careful and competent pharmacist now and I was attentive in 1966.

We must present our argument in such a compelling manner that the members of the fifty state boards of pharmacy are forced to take action.

The  chain drug store companies won’t make changes unilaterally.  They would perceive giving the pharmacists any concessions a competitive disadvantage.  However, I don’t see much argument if they are all forced to obey pharmacy laws.  The wait for the chains to act on their own would be long and drawn out.

Send your horror stories to TPA for cataloging.  Be complete.  Details, details details.  Send your stories to thepharmacyalliance@hotmail.com

Changes will come at rocket speed if a patient has a story of getting errors in their prescription because the pharmacist was tired.  Urge your patients to tell their stories.

The pharmacy boards do not care about your lousy working conditions.  They are mandated to regulate the profession of pharmacy in a manner that prevents danger to the public.  They boards have been looking the other way for decades.  They are NOT doing their job.  The boards must be compelled to step up and do the right thing.

This is the only issue that TPA is focused on.  Join us.

Sixteen members created TPA in two days.  The cornerstone is detailed in “About TPA” above.  The “Sixteen Principles” can be read by clicking above and the “DSI Agreement” is a suggested contract that new pharmacists ask their employers to sign.  Take a good look.  These are what make TPA the only pharmacy organization dedicated to the health and welfare of pharmacists.  Nothing else. 

Dignity, Self-Respect & Integrity 

Drug Topics has stepped up and had the guts to publish essays by myself, David Stanley, Dennis Miller, Tom Hanson and number of other pharmacists who have a need to address the soul-crushing working conditions in the job of working in retail pharmacy.  Drug Topics magazine is, once again, the go-to news source for all pharmacists.  There was a tough patch when the old New Jersey editorial crew seemed to want to make the magazine just another clinical rag.  How many of us want to read another article about filiariasis in the Asian community of San Francisco when we can read about 14 hour shifts with only a giant Snickers bar, Cheetos and a big bag of Nutter Butter cookies washed down by multiple Mountain Dews?  Advanstar, the company that owns Drug Topics stacked the sand bags, sent editorial to North Olmsted, Ohio and started brand new.  The editorial staff was inexperienced, but eager to put out a quality new magazine for pharmacists.  They relied heavily on pharmacists for the opinion pieces that drive a magazine.  The people I mentioned above came through.  I commend the publisher and the editors for trusting pharmacists in the trenches.  Take advantage of Drug Topics.  Click on the red Drug Topics below.  Find the link to “Subscribe” and sign up for the magazine free of charge.  You can get the print or the Digital edition which is every word of the print edition.  This is YOUR magazine.   JP 6/6/2011

David Stanley will be a rock star in our industry.  He wrote this a few months ago, “You talkin’ for me?”, which was published by Drug Topics, by talking about a tale of two organizations. He could just as easily be talking about the dream world of pharmacy and the real world of pharmacy. On the one side, we find the pharmacy schools and the pharmacy organizations pushing their “dream world”. On the other side, there are only a few scattered organizations, a few blogging pharmacists, and the mass of working pharmacists. In David’s lattest article, “Understaffed and overwhelmed”, he takes us deeper into the “real” world of pharmacy. I don’t have to tell you what it is like in the real, working world of pharmacy. David gets right to the heart of the matter: understaffed and overwhelmed.

It is quite refreshing to finally see a pharmacy magazine talk about real world pharmacy, and I commend the folks at Drug Topics for taking on the less than glamorous side of pharmacy. The Pharmacy Alliance was born in April, 2008, by a group of pharmacists that saw the real world side of pharmacy. It was their contention that pharmacists should stand firm on their principles, and that pharmacists should be treated as professionals. You will have to look far and wide to find another pharmacy organization that promotes these things. Find me one pharmacy organization that talks about the real world of pharmacy as described by David Stanley. The simple fact is that all us pharmacists are finding ourselves facing more and more prescriptions to fill in a day. Despite the enormous responsibility of our job, most of us work in an almost circus like environment.

One major chain drug store company routinely expects their full-time pharmacists to work three 12 to 14 hour shifts every week with no lunch or rest period.  No bathroom breaks.  The timers give no time to counsel.  Patients have suffered harm.  This company is lucky to still be in business.  Every pharmacist they have is a dangerous pharmacist. 

Read and re-read the principles of The Pharmacy Alliance a number of times. Each time you will come back with a greater appreciation of those principles. We believe those principles should be the foundation of every pharmacists personal guidelines. In life, we need guidelines to keep us on track and to prevent us from making bad mistakes. In the practice of pharmacy, we need guidelines that set the goals of our job and the boundaries of what we do. In this article, we will talk about principle number 4:
 

4. Pharmacy professionals will counsel patients when appropriate and will advocate for a professional environment and for patient safety.

The number one guideline of every pharmacist should be based on patient safety. No matter how you try and frame your job, you are a professional and it is your responsibility to dispense medications to a patient in the safest possible manner. Now, I am going to outline what happens when you fail at this task.

Results of a dispensing error:

1. Patient harmed or killed.
2. Patient may be hospitalized and incur a huge medical bill.
3. Patient’s family suffers.
4. You must deal with the emotional agony of what you have done.
5. You are fired.
6. Your reputation is ruined.
7. You can no longer find employment in pharmacy.
8. You are sued and lawyer expenses lead you to bankruptcy.
9. Your pharmacy loses its profit for the year.
10. Your company incurs a lawsuit and an enormous court loss.

 

 

 

 

It does not take a genius to realize that a single bad mistake can completely ruin a pharmacists life. This is why patient safety should be every pharmacists number one priority! It is in the benefit of everyone involved for you to be careful, take your time, and do your best to dispense the right drug to the right patient. It is in the patients best interest, your best interest, and the companies best interest.

Counseling is important because it not only helps the patient understand their medication, but it is also a last check to make sure the right patient is getting the right medication. I cannot tell you the number of times that I have counseled a patient only to discover that something was wrong. It was not what the patient was suppose to get because the doctor wrote for the wrong drug, the patient was allergic to the medication, or directions were not correct. It is our job to take the necessary care to take care of the patient. It is in everyone’s best interest for us to do this. The number of prescriptions we fill in a day should not be our number one priority. The number of people standing in line at the cash register or the number of prescriptions we have to fill should not be our number one priority. What is our number one priority? PATIENT SAFETY!

Many of us work for chains and we often feel that the chain is primarily interested in the number of prescriptions we fill per hour. Whether this is the real case or not, I cannot say. However, I can say that a few big lawsuits will wipe out the profits for the pharmacy for one or two years, and it is in the best interest of the chain for us pharmacists to do a good job, take care of the patient, and not make any serious mistakes. We should never hurry at our task. We should always take diligent care in the things we do. Again, it is in everyones best interest, whether they realize it or not. The design of pharmacies are often not the best. They can sometimes be too noisy. Sometimes the nature of the job creates too many distractions. Wherever we see problems, we should contact corporate to make them aware. Yes, it is our duty to do so. Remember, the patients safety is our number one priority, and it should be the chains number one priority. A professional environment is not only good for the pharmacist, but it is good for patient safety, and this means it is good for the patient. It is good for the company because it helps keep down prescription errors. We are the pharmacy specialists…not the folks at corporate. We are the pharmacy specialists….not that non-pharmacist DM. We are the pharmacy specialist…not the store manager. And, we better hold our ground, and keep the patients best interests at heart.

It is easy to get “caught up” in work and a job. It is easy to lose sight of our number one priority. That is why we need to place before us our guidelines and read them anew each day. You might want to print out the pharmacy principles and read them each day before retiring and before going to work. Just remember that no matter how bad the circumstances may seem to be, it is you, that in the final analysis, check that last prescription for that patient and you better get it right. If you have any doubts about what I am telling you, then go back up and read what the results can be of a bad dispensing error. One bad error can ruin someones life, can even kill them, and it can ruin your whole life in the process. Taking chances with peoples lives is like rolling the dice with everything you own sitting on the table.

You are not a south side of Chicago single mother with no food for her children, no money and no prospects. You are not an eighty year old widower whose breakfast every morning is the one egg that the manager of the Safeway store lets you steal.

You are a pharmacist. A member of a proud and dignified profession. Start acting like it.

Your neighbor had his McMansion foreclosed. You watched the moving trucks. The family drove away before the first light of the day. The wife grim-faced. The two teenage girls crying.

You are a pharmacist.

You have your house paid off. Your biggest expenses are insurances and taxes. You won’t lose your job. The wife wants to take that long weekend at the south shore of Lake Tahoe. You told her that you’d rather take advantage of the very cheap flights to Cabo. You want different things. What a great problem to have.

You are not the poor kid who fought for his Ph.D. in Philosophy. He keeps trying to publish, but works nights at Borders to supplement the income from days checking groceries.

You are a proud pharmacist and have earned the right to have self-respect.

When you started, you thought that it was always going to be rewarding, that each day would be an adventure. Can it be possible that a profession is just working too? None of us will get laid off, chances are. The paycheck will always be there every Friday. Most of us will always have the tip money for the valet parking at the club. It can’t be that bad. You are spoiled like a teenage kid who got bored with his Play Station and now whines about Wii.

You are not an attorney. In tough times, they get put down at the bottom of the priorities list. You are not an electrical engineer. Shazam. That degree is outmoded in only 8 years. You aren’t working selling Barcaloungers because nobody wants Hummers and the dealership you sunk every penny of the wife’s inheritance into went bankrupt.

Integrity is what separates a professional from trades job like TV repair. Start acting like a professional. Demand Dignity, Self-Respect & Integrity in your job.

You are not a 19 year old, trudging down a close-in, dirt track between houses in a dark midnight neighborhood of Baghdad, Iraq, scared to death of an explosion any second.

You are a pharmacist in the United States of America. Life is terrific. But, we have work to do.

Take Pharmacy Back

Join TPA today.