More Than Half of Pharmacies Fail to Inform Customers of Dangerous Drug Combinations
Out of 255 pharmacies, fifty-two percent sold dangerous drug pairs without mentioning potential interaction
Fast Food Pharmacy at Chain Stores
Mayuri Patel is a pharmacist working at a Wal-Mart in Northlake, Chicago. She estimates that in a typical nine-hour shift, she usually fills 200 prescriptions. That's one prescription every 2.7 minutes.
Patel said that it was even busier at a different Wal-Mart where she was trained. "We were doing 600 a day with two pharmacists with 10-hour shifts," she said: one prescription every two minutes.
Patel passed CT's test. She noticed a potentially fatal combination of drugs and warned the reporter: "This is a common interaction."
It is hard to say why so many other pharmacists failed where Patel succeeded, but interviews and studies may provide an explanation: the pressure for speed.
Many of the stores tested filled prescriptions for risky pairs of drugs without providing any kind of warning about the danger in less than 15 minutes. It was 12 minutes at a Kmart in Valparaiso, Indiana, and at an independent pharmacy on Chicago's North Side, it was five minutes.
The reporters discovered that pharmacists often either hurry through drug safety reviews that they are legally required to provide or just skip them completely. Illinois law requires pharmacies to make several safety checks, including whether or not the dose is reasonable and if the drug might interact with other medicines the patient is taking.
In CT's tests, however, pharmacies rarely asked which other drugs the reporters were taking.
Bob Stout is the president of the New Hampshire Board of Pharmacy, which reviewed data from two of that state's retail chains and found that pharmacists were spending only 80 seconds on average on safety checks for each prescription that they filled.
"They're cutting corners where they think they can cut," Stout said. "What happens, I found on the board, is people stop doing [safety] reviews. They're not going in looking at patient records."
Although most pharmacies use computer software that is meant to show a red flag for drug interactions, experts say that alerts from the software are so common that pharmacists can get "alert fatigue" and ignore many such warnings.
At the same time, however, pharmacies in chain stores are promoting fast service more and more. Many now have a drive-through window, and services like the walk-in MinuteClinic at CVS are attractive to customers who want speedy service.
Services like these, however, might be sending a message to patients that speed is more important than quality healthcare. People have taken that message to heart, according to pharmacists, and so they think they should have a short wait time.
"The patient will get mad if you call the doctor and take time," said Sadia Shuja, a pharmacist at Skypoint Pharmacy in Schaumburg, IL. Shuja flagged a dangerous drug pair to pass CT's test. "Sometimes they think it is fast food."
Most pharmacies employ technicians for tasks that don't need as much medical knowledge in an attempt to ease the workload on pharmacists.
Arsen Mysllinj is another pharmacist who passed the test. He works at a Kmart in Rockford, IL, and he said that the technicians working at his store and others often screen for interactions after they enter a patient's order into a computer. If any interactions come up, he said, the technicians have been trained to print out the warning and hand it to a pharmacist. Mysllinj believes that it would be better for pharmacists to do the screening themselves.
In light of the results found by CT, Kmart said that it will review its relevant policies, computer systems, and training programs. Most Kmart pharmacists failed the test without providing a warning about the possible interactions. However, several did take the time to try to get the reporters to enroll in the company's savings program.
Grades and Rankings
Timely service is not just a goal at CVS. Records and interviews show that the company measures it carefully and, together with other assessments, uses it as a metric to grade and rank its pharmacies.
Many current or former CVS pharmacists were critical of this practice. They said that it put pressure on them to focus more on meeting the company's criteria than on safety checks like drug interactions.
Chuck Zuraitis is one such pharmacist. He is the head pharmacist at a CVS in Park Forest, IL, though his pharmacy was not included in the test.
"You get stressed, and it takes your mind away from the actual prescriptions," he said.
Such metrics of performance and business are common at large chain pharmacies. Supporters claim that using metrics makes companies more efficient and responsive to their customers.
The nonprofit Institute for Safe Medication Practices conducted a national survey of 673 pharmacists in 2012. Roughly 25 percent worked at a company that guaranteed a short wait time for customers. Out of that 25 percent, four in 10 said that they had ended up making a medication mistake as a result of hurrying to fill a prescription within a certain set time.
CT was able to get internal CVS records showing that the company keeps track of several different tasks that pharmacists do. One such task is whether or not they fill prescriptions in the time promised to customers.
"Every prescription is timed," said Deepak Chande, a former head pharmacist at a CVS in Worth, IL, "and this is the worst of the pharmacist's nightmares."
According to Chande, if a pharmacist gets behind schedule, the backlog pops in in a colored window on their computer screen.
"It's an unreal pressure," he said. "Your mind is kind of frantically trying to obey it."
In response, CVS stated that prescriptions do not have to be filled quickly, but that it does expect pharmacists to have patients' medications ready by the time they promised the patient.
"Just trying to keep their pharmacies afloat"
Independent pharmacies are under a different type of pressure: intense competition from big chains.
B.M. Patel has been working as a pharmacist for 40 years and owns Riteway Pharmacy on Chicago's Northwest Side. He failed the test but made no excuses.
"It was a mistake," he said. "Maybe I should be paying more attention."
Patel also said that small pharmacies know they if they don't or can't fill a prescription, the patient might just go to a nearby chain store. The business at his pharmacy "is not good," he said. "I can still survive, but not too long. We don't really know how long it's going to last."
At a Mexicare Pharmacy in the Pilsen neighborhood of Chicago, independent pharmacist Audrey Galal passed her test. However, the store is closing, she said, partly because of competition from chains.
She said that she did not think that small pharmacies would knowingly sell harmful drugs, but they might not want to turn away business.
"These pharmacists are acting like businesspeople, just trying to keep their pharmacies afloat instead of being clinicians," she said. She now works at another Mexicare location.
The number of independents that failed the test was surprising to many people, including Andy Politis, pharmacist and part-owner of Oakmill Pharmacy in Niles, IL. Politis himself passed.
"The independent guys should be better because they don't have the same pressure as the big stores with so many prescriptions," he said.
Many independent pharmacies said that their test results caused them to make changes. Summit Medical Pharmacy in Chicago, for example, improved internal checks after it failed, and it also worked together with a software company to make sure that even minor interactions between drugs are found.
Since that time, said head pharmacist Pankaj Bhalakia, their new system has found several interactions that led to a consultation with doctors and patients.
"We changed the whole system," he said. "I don't think there could be a problem in the future."