COVER STORY

MAKE NO MISTAKE
ABOUT IT
Chain pharmacies are finding innovative ways
to combat medication errors

Sandra Levy of shrugging off medication errors and dismissing

them as the cost of doing business. But chain brass and

T
hese are undoubtedly nerve-racking times for pharmacy associations are quick to counter that patient
pharmacy chain executives—what with the re- safety is their highest priority and that they are contin-
cent “20/20” report and numer- ually seeking new measures to
ous stories in the lay press about pa- safeguard the public. So
tients suing pharmacy chains because DT CAPSULES what exactly are chains do-
of prescription errors. IOM estimates that 1.5 million people ing to prevent drug errors
The “20/20” exposé revealed that are sickened, injured, or die annually as from occurring in the fu-
an error made by a Walgreens techni- a result of med errors. ture? What new measures
cian allegedly resulted in a patient’s are being implemented to
suffering a stroke. Another Walgreens improve patient safety?
error occurred when a baby was allegedly given an
adult diabetes drug instead of phenobarbital, which re- Time to upgrade
sulted in brain injury. These days, many chains are upgrading their computer
Other pharmacies have also received negative publici- systems and work flow procedures to increase patient
ty. For instance, ApotheCure Inc., a Texas drug com- safety. Rite Aid spokeswoman Jody Cook said that last
pounding pharmacy, erroneously made the drug col- year the chain asked its pharmacists for ideas and feed-
chicine 10 times more potent than intended, which back in developing NexGen, its pharmacy dispensing
resulted in the recent death of three people who received system. “The new pharmacy system and pharmacy work
the drug at an Oregon clinic. At Rainbow Children’s Hos- flow procedures were guided by patient safety and giving
pital of Cleveland, Ohio, a pharmacy tech incorrectly the pharmacist the time to counsel patients,” she said.
mixed a child’s intravenous solution. Instead of receiving The NexGen system enables a hard copy of the pre-
0.9% concentration of sodium chloride, the child received scription to be scanned into the computer system before
A pharmacist scans a vial for a deadly 23.4% dose. pharmacists begin the filling process. “We make sure
the final check of the Rx The Institute of Med- we have the exact prescription saved in the computer
icine estimates that 1.5 system, and it can be pulled up onto the screen at any
million people are sick- time during the fill process,” said Cook.
ened, injured, or die The dispensing system shows a colored image of the
annually as a result of pill that is being dispensed, so that R.Ph.s can compare
medication errors. High the medication they’re filling with the one on the screen.
workload and unexpect- “Our system runs a drug utilization review [DUR]
ed consequences from against thousands of prescription drugs and OTCs, as
technologies that assist well as some vitamins and herbal supplements, to make
pharmacists in filling sure there is no possibility for a dangerous drug interac-
prescriptions and pro- tion,” explained Cook. “If a potential problem is found,
vide alerts about possi- Rite Aid’s pharmacists contact the patient’s doctor be-
ble drug interactions increase the potential for medica- fore going any further in the filling process.”
tion errors, according to a recent study published in Walgreens’ spokesman Michael Polzin reported that
Medical Care and funded in part by the Agency for every year the chain rolls out four major system up-
Healthcare Research & Quality. grades to its proprietary Intercom Plus pharmacy com-
Some industry critics have accused pharmacy chains puter system. “These upgrades and other improvements

18 DRUG TOPICS JULY 9 2007 www.drugtopics.com

COVER STORY
have resulted in Walgreens spend-
ing nearly $1 billion in the past
decade on pharmacy safety sys-
tems, safety training, and new tech-
nology,” he said. Intercom Plus’
safety features include alert mes-
sages for similar-sounding medica-
tions and certain dosing situations;
bar-code scanning of the patient la-
bel and the stock bottle for a match
before counting the medication;
color images of the drug provided
CVS has rolled out to the pharmacist during the verifi-
EasyRead Rx labels
with larger typeface. cation process; required documen-
tation of significant interactions
during the DUR; and an image of the original Rx provid-
ed onscreen next to the entered information for easy,
side-by-side comparison.
The tech issue
While critics charge that many recent drug errors have
been associated with inadequately trained techs, the
chains maintain that they are taking serious precautions
when it comes to hiring and training their technicians.
Rite Aid requires that pharmacy technicians be at least
18 years old. “All of our techs go through a Rite Aid cer-
tification on full counseling procedures and what their
jobs are,” said Cook. “They are trained to ask during
prescription pickups whether a patient has questions or
would like to speak to a pharmacist, and they are taught
to comply with state regulations wherever they work.”
Although the “20/20” exposé placed Walgreens in the
spotlight for an error made by one of its technicians,
Polzin said that Walgreens was one of the earliest backers
of the Pharmacy Technician Certification Board (PTCB).
“Walgreens encourages its pharmacy techs to become
certified,” he said. “Walgreens is the only national drug-
store chain with a tech-training program accredited by
ASHP. Walgreens also employs more techs certified by
the independent PTCB than any other pharmacy chain.”
CVS/pharmacy also strongly encourages all pharma-
cy support staff members to obtain national certification
through PTCB, reported CVS spokesman Michael DeAn-
gelis. “CVS pays the registration fees for eligible candi-
dates and provides employees with three study guides in
order to help them pass the certification exam,” he said.
Quality assurance
Yet another tactic to eradicate patient errors has chains
developing assurance checklists that employees are re-
quired to use. Rite Aid has a seven-point quality assur-
ance list that must be adhered to when pharmacists fill
scripts. The checklist includes confirming the patient’s
www.drugtopics.com
name, address, date of birth, and the prescriber’s name.
There is also a point that requires the medication name
and strength to be checked when the drug is pulled from
the shelf.
Cook said, “We also utilize bar codes and scanning de-
vices so we scan the stock bottle to verify that what prints
on the prescription label is exactly what is identified on
the stock bottle. We check the medication name and
strength against the hard copy prescription or the one in
the computer. We check the color image on the comput-
er screen and make sure it matches up with what is in the
vial. We look at the right advice monograph, which is the
paper that prints out with the script and check it against
the vial and make sure it is the correct patient and the
correct medication and that everything printed on that
monograph matches up with the label on the bottle.”
CVS also has a comprehensive quality assurance pro-
gram in place that is fully integrated into its prescription
fulfillment process. “The program utilizes organized
work flow, standardized processes, state-of-the-art tech-
nology, staff training, patient counseling, clinical sup-
port, and incident reporting/review to enhance patient
safety,” said DeAngelis.
Recent enhancements to CVS’ program include a new
bar-code accuracy scan process that matches the bar code
on the manufacturer package to the bar code on a pa-
tient’s prescription label receipt to minimize the possibil-
ity of dispensing the incorrect medication to a patient.
Another recent enhancement is a new quality assurance
verification computer screen for pharmacists that features
the following innovations: improved layout and presen-
tation of Rx information in an easy-to-read, organized,
and logical manner; translation of date of birth into age
and highlights for “infant” and “pediatric”; an electronic,
scanned image of hard copy Rxs; computer messaging
for look-alike drugs and other high-alert medications;
comprehensive, streamlined DUR messaging and resolu-
tion; and medication product image and description.
Walgreens is not sitting on the sidelines. The chain
has implemented 14 new quality controls in the past
year, and there are another 10 controls being developed.
“Quality assurance is an ongoing project at Walgreens,”
said Polzin. “Over the past decade, we’ve invested ap-
proximately $1 billion in redundant pharmacy safety
systems, safety training, and new technology toward
the goal of a zero error rate. We also have a quality as-
surance division in our Pharmacy Services department
Photo: Courtesy of CVS/pharmacy
that is dedicated to improving pharmacy operations.”
New measures
One new technology some chains are using to reduce
errors is biometrics. Although biometric technology,
which includes fingerprint scanning, is primarily de-
DRUG TOPICS JULY 9 2007 21
COVER STORY
Chains
signed to ensure security, this technology may system that is used on a daily basis. The system
be used to curb drug errors.
are automatically knows when one pharmacy is get-
Rite Aid is employing this technology. Noting upgrading ting busy and another pharmacy is slower. The
that the same technology is used by the Depart- their system can switch some of the work from the
ment of Defense, Cook said, “It ensures that only computer busy pharmacy to the slower pharmacy.
the pharmacist can complete the filling process systems “When a pharmacy at one location is experienc-
because the pharmacist has to scan his or her fin- and work ing a very high volume of scripts coming in and
ger for our computer system to move on to the flow there may be another pharmacy across town that
next screen. Not only do they have to scan to fill procedures. has a lower than typical prescription volume, we
the Rx, but if any DUR alert comes up, the only can send some of the new scripts over to that slow-
way to get past that screen is to scan a fingerprint.” er pharmacy where the staff there can enter the in-
So any techs working on filling Rxs can’t pass by those formation from the prescription into our system. That in-
DURs or complete the fill process. A pharmacist has to do formation is sent back and forth electronically between
that with a fingerprint. the stores,” said Polzin, adding, “Workload balancing
Chains are also making improvements to their medica- moves some of the prescription-filling process to pharma-
tion bottle labels. In April, CVS completed the national cies with more capacity. This allows the workload to be
rollout of its new blue EasyRead Rx labels, which feature spread out more evenly among our stores and provides
larger typeface, a change from yellow to blue highlighting more time for patient counseling and education.”
for easier reading, and a cleaner layout. The labels also in- Walgreens piloted the workload-balancing computer
clude a physical description of the pill prescribed to help system almost two years ago in Florida. “We implement-
customers identify their medications. “We have also re- ed that in an emergency circumstance right after Hurri-
designed the medication monograph with medication cane Katrina hit to help out stores in Texas and Louisiana
product image and description,” said DeAngelis. and a few other states where a lot of evacuees were com-
Balancing workload is yet another measure chains can ing in and overwhelming the pharmacies. We were pilot-
use to increase patient safety. Polzin explained that Wal- ing the system at the time in Florida and after Katrina hit,
greens has implemented this measure. It is a computer we turned it on in those other states. We got special per-
mission from the pharmacy boards to turn the system on
in some of those states in order to help out our pharma-
cies there.”
And if these measures are not enough to reduce med
errors, the use of electronic prescribing is also gaining mo-
mentum. According to Cook, all of Rite Aid’s stores are
equipped to handle e-prescriptions. “This is something
we support and are working with the rest of the industry
to have doctors sign on for,” she said. “It completely elim-
inates the problem of poor physician handwriting.” Wal-
greens is also working to expand the use of e-prescribing,
said Polzin.

Teamwork
Still another way for chains to eliminate med errors is to
collaborate with industry associations. Chains report that
they’re working with other organizations to foster pa-
tient safety. According to DeAngelis, the Institute for Safe
Medication Practices (ISMP) has been providing ongoing
consulting services to CVS to ensure continual quality
improvement in the chain’s Rx fulfillment process.
“Our quality assurance program functions on the
principles of continuous quality improvement,” said
DeAngelis. “Our processes, procedures, and technology
undergo constant review and improvement independ-
ent of media reports. We have reinforced our patient
counseling policies with all pharmacy staff across the

22 DRUG TOPICS JULY 9 2007

COVER STORY
CVS chain. Because of the systems robots hasn’t changed, “robots have
and processes we put into place and Today, 50% to 60% of scripts gotten faster, more accurate, and more
our continual efforts to identify op- are filled by automation. affordable.”
portunities to further enhance quality, In addition to increasing safety and
our error rate has decreased even as the accuracy, Coughlin said, when robots
number of prescriptions we fill continues to rise.” do the mundane tasks, they free up pharmacists to as-
Like CVS, Walgreens has hooked up with other sume a cognitive role and interact with patients and look
groups to reduce errors. “For a number of years, we’ve for potential problems. “The errors the robot can avoid
had strong working relationships with ISMP, the Na- are avoided by the robot, but there are still potential er-
tional Association of Chain Drug Stores, SureScripts, rors in prescription entry, failure to catch drug interac-
the National Council on Patient Information & Educa- tions, errors in failing to counsel the patients properly, or
tion, and PTCB,” Polzin said. labeling mistakes,” he said. “If you look at all the differ-
ent steps in filling a prescription—from receiving it from
Banking on new technology the patient to inputting it, getting it filled, checked, veri-
Pharmacy chains, which have been embracing technol- fied, and counseling—any one of those steps is under
ogy such as automation and robotics to ensure a safe pressure. The robotic part of it is right there in the mid-
and predictable outcome when filling scripts, have dle where the filling is actually done.”
some new products at their disposal. Coughlin said that robotics also enables pharmacies to
Thomas Rhoads, executive VP of sales and marketing use technicians more reliably. “There are controls built
for North Carolina-based Parata Systems, a leader in au- into the robotic filling system. You have a very organized
tomation and robotics, predicted, “More and more elec- process in which you handle that manufacturer stock bot-
tronic and automated processes and products will come tle when it comes in from the distributor. You bar-code
into play. Over the years, we’ve seen a high adoption scan it and take the cell it’s supposed to go in the robot
with semi-automation and now we are moving even one and you scan that, and the com-
step further and closer to full automation with robotics.” puter shows that there is a
In most pharmacies today, he said, 50% to 60% of Rxs are match between the exact drug
filled by automation. He predicted, “As pharmacies called for in that cell and what’s
grow, a higher percentage of them will be fully auto- in that bottle, according to the
mated and will fill 95% of the scripts coming out.” manufacturer bar code on it. The
Parata’s recent acquisition of the assets of Distributed stock bottle is handled once in a
Delivery Networks (ddn) related to Automated Product very controlled way. In a manu-
Machine (APM) technology may also be a boon to phar- al situation that stock bottle may
macy chains in their quest to improve patient safety. Al- be handled 20 or 30 times.
though the APM’s primary objective is to offer conven- There’s a lot of potential for hu-
ience to customers by allowing them to pick up their man error.”
refilled prescriptions during a pharmacy’s operating ScriptPro initially released the
hours or after hours, the kiosk also connects patients to SP 200 robot, which handles 200
a pharmacist for counseling, even after hours. drugs, and has since created the
ScriptPro’s robotic Rx
According to Rhoads, 21 states permit utilization of a SP 100 and SP 50. “We started dispensing system
kiosk for Rx refills. He hopes that state pharmacy boards addressing the problem with the
will allow kiosks to dispense drugs containing the ingre- highest volume pharmacies that needed 200 drugs cov-
dient pseudoephedrine. This would free up pharmacists ered,” said Coughlin. “Then we saw that pharmacies in
who currently have to administer these products from the next tier down didn’t want to spend as much money
behind the counter. “You could still have a secured ac- on the 200, so we developed the 100 and then the 50, so
cess model, where the person purchasing it is fully we really can cover any pharmacy in all size ranges.” He
tracked and monitored,” he said. “It reduces the burden said robots range in price from $700 to $900.
on the pharmacy staff who are overburdened today.” Coughlin said that his firm is also working on devel-
oping more powerful systems for building messages and
Robots growing up alerts into pharmacy operating systems. “There are sev-
Chains are also embracing robotics in order to wipe out eral common occurrences that give rise to problems—
medication errors. Michael Coughlin, president/CEO of patient injuries and lawsuits,” he said. “There are ways
ScriptPro, which introduced the first robot for retail phar- to identify these occurrences with computer analysis.
macy in 1997, explained that while the basic design of the And bringing these to the fore is necessary so the phar-

24 DRUG TOPICS JULY 9 2007 www.drugtopics.com

COVER STORY
macists and techs are reminded or ror and what is the right thing
alerted to the fact that this is one of for the pharmacist to say.”
those situations that can blow up and The toolbox also features
cause a problem.” two patient safety videos
that can be viewed on-line
What else is new? and used for staff training.
KeyCentrix, a Wichita, Kan., pharma- To access the toolbox, visit
cy software company, is offering www.nacds.org, click on phar-
RxKey, a work flow solution that al- macy, and click on the patient
ScriptPro’s SP 200 handles 200 drugs.
lows the pharmacy to choose which safety section. You can also
components they want to make mandatory. For example, find links to the Food & Drug Administration’s Patient
there’s an option that allows techs to type new Rxs but Safety News (PSN), a monthly video for healthcare pro-
they can’t generate a label until a pharmacist has verified fessionals, the AHRQ Patient Safety Network, and ISMP.
that the Rx has been typed correctly. Another option al- “We do have some potential partnerships coming up
lows the pharmacist to call or fax details from the phar- with ISMP regarding patient safety that will be an-
macy software straight to the doctor’s office so the staff nounced shortly,” said Hauser.
there can share medication information. This is especial- It’s impossible to tell whether medication errors will
ly helpful if a patient has been prescribed medications by ever be completely eliminated. This much is certain:
more than one physician. Pharmacy chains are thinking out of the box when it
ScriptChek Visual Verification Systems, Weston, Fla., comes to employing innovative measures to combat the
offers ScriptChek, a label that provides additional drug problem. Meanwhile, pharmacists may want to heed
information and a space where consumers can write the words of Kasey Thompson, Pharm.D., director of
their own reminder notes. The new labels extend out patient safety for ASHP: “Patients are a part of the team.
from the drug bottles, providing nearly five inches of ad- They need to view themselves as part of the team. If
ditional space for more information about medicines they can’t act as their own advocate, they need someone
contained in the bottle. The extended tabs can also be who can—family or friend. The patient-physician phar-
torn off for easy refilling. macy team is something that can’t be overemphasized.
Stacy Kaufman, founder and president of ScriptChek Patients should ask, if not demand, to speak to a phar-
Visual Verification Systems, said, “The opportunity to dis- macist. They should demand to know what medication
play more information about contents will help improve they are being given, what its intended purpose is, and
not only readability, but also consumer education about what potential adverse effects there may be and certain
the prescription medicines people are taking today.” things to look for. As pharmacists and professionals,
our responsibility is to proactively seek the patients out
On-line safety toolbox to educate and inform them.”
NACDS has an on-line Patient Safety Virtual Toolbox John Gans, Pharm.D., American Pharmacists Asso-
for chain pharmacies. Ronna Hauser, NACDS director ciation’s executive VP/CEO, echoed Thompson’s sen-
of pharmacy practice and operations, said the toolbox timents in his response to the “20/20” report: “For the
features samples of members’ continuous quality im- past three years, APhA has concentrated a great deal
provement programs. There is also a section called of effort on emphasizing the need for pharmacists and
“build your own program” from which pharmacies can patients to develop a relationship. We believe that
pick and choose certain components of programs that conversation and getting to know one another are es-
they like. sential to improving medication
ScriptChek’s labels extend out from the
In addition, a section offers tips vials, providing more room for information. use. Never before have we had
on work flow. “It shows ways to such an opportunity as this to
structure the intake window, out- strengthen that link and build
take, and the role different phar- upon the trust that the public has
macy staff members can play at in us.” DT
each point in the work flow,” said
Hauser, who added, “There’s a For more on how hospitals
section on incident management are reducing drug errors,
that gives advice for a situation in as well as some tips for patients,
which an error has occurred—how please check
the pharmacist can handle that er- Drug Topics’ Web Exclusives.

26 DRUG TOPICS JULY 9 2007 www.drugtopics.com

 RUNOVER FROM DXMEDERROR07A

Some tips for patients

P harmacists may want to pass the following advice •Report any adverse effects immediately to your doctor
along to their patients. It comes from James O’- and strictly follow the guidelines of the doctor and R.Ph.
Donnell, Pharm.D., associate professor of pharmacolo-
gy at Rush University Medical Center in Chicago and a
frequent expert witness in drug error trials. T he Connecticut Pharmacists Association (CPA) rec-
ommends pharmacists ask patients to become
their partner in patient safety. CPA recommendations
•Read the prescription back to the doctor before leav- for pharmacists and patients include
ing the exam room. Make note of the drug name and the following:
dosage instructions.
•Get to know your pharmacist. He or
•Ask for Rx drug counseling from the pharmacy. Don’t she is your biggest ally in making sure
sign the pharmacy log for the Rx until the pharmacist that you are taking your mediations
has given counseling and clear directions. properly.
•Read the label on the Rx bottle while at •Use one pharmacy. Your pharmacist
the pharmacy. Make sure that it is what the will be able to monitor for drug interac-
doctor prescribed. tions and side effects if he or she knows all
•Inform the R.Ph. of all the meds being tak- the meds you are taking. When in doubt,
en and any chronic health conditions. call first. You aren’t bothering the pharma-
•Allow time for the pharmacist to fill the Rx. cist when you have a question.
Don’t expect the pharmacist to rush. •Follow up with what you have done to cre-
•Research the drug on the Internet ate as safe an environment as possible
before taking any new medication. ScriptChek provides labels for your patients: investment in technol-
Pictures of the pills on the Web will that extend out from the drug ogy, e-prescribing, how you deal with
help verify that the correct med has bottles providing additional space
for information look-alike/sound-alike drugs, and what
been filled. Directions and precau- process you have in place for tracking
tions are also on many pharmaceutical Web sites. errors and educating staff?
•Talk with your doctor or pharmacist if you have any For fact sheets to give to patients, visit www.ctphar-
questions. macists.org.
 Blocking bloopers on the hospital side
H ospitals have had their share of drug errors and
attendant bad publicity. What is the industry do-
ing to prevent errors?
Kasey Thompson, Pharm.D.,
director of patient safety at ASHP,
believes that training and educat-
ing pharmacy technicians is cru-
cial in order to reduce med er-
rors. Pointing out that ASHP is an
an accrediting body for techni-
cian education programs through
community colleges as well as a
key stakeholder in the Pharmacy
Kasey Thompson Technician Certification Board
(PTCB), he said, “We have a very longstanding com-
mitment and interest in improving the quality and pro-
ficiency of the technician workforce. Our goals have
been to ensure that techs are adequately educated to
work in hospitals and that they are adequately trained
within those hospitals to deliver the services and pro-
vide the technical support they are expected to and
that they are certified through PTCB.”
Emphasizing that having well-trained, educated,
and certified techs frees pharmacists up to spend
more time in a cognitive role of counseling and edu-
cating patients, Thompson added, “That’s the real
goal—to have this highly competent technical work-
force that handles a vast majority of the distribution
and to have pharmacists spending the majority of
their time speaking to the patient, educating the pa-
tient, answering questions for the patient, and work-
ing with physicians and other providers to make sure
the medication use is safe and effective.”
Praising hospitals for embracing technology such
as automation, robotics, and bar-coding in an effort
to improve patient safety, Thompson cautioned,
“Technology can serve as the source of verification
that the product you have is correct, but it doesn’t re-
place the need to have a highly competent workforce,
trained through accredited programs, and certified
through PTCB. Ultimately the techs are the ones who
are managing the technology.”
Thompson said that ASHP also believes hospitals
should ensure that pharmacists and techs aren’t
working excessive hours, since fatigue could lead to
errors and harm befalling patients.
Here are some resources from ASHP:
•ASHP’s Web site, www.ashp.org, has a patient
safety resource center.
•The society lists community colleges that offer ac-
credited technician programs on its Web site.
Thompson said ASHP advocates reporting of med
errors and providing a safe haven for practitioners
and organizations that report so that the system can
improve. “We’re starting to see a greater commitment
to reporting and lesser focus on punishing people
who report or who make errors,” he said.
ASHP has also been an advocate of making names
of drug products more distinguishable. “We’ve long
advocated to the FDA and pharmaceutical industry to
change practices in naming, packaging, and labeling
to minimize confusion,” said Thompson.