Tuesday, June 7, 2011

Prescriptions per hour

I recently posted a poll that asked the following question:

How many prescriptions can a pharmacist fill safely per hour (including counseling)?

The results did not surprise me:
  • 0-10 (10%)
  • 11-15 (44%)
  • 16-20 (30%)
  • 21 or more (16%)
The majority felt that 11-15 scripts per hour was the safe level. At that rate, you have 4 to 6 minutes per prescription to verify the accuracy of the prescription label, check the patient profile for duplications/interactions, contact prescribers if any issues arise, call the insurer if needed, verify that the contents of the prescription vial are accurate, and counsel the patient on their medication.

Not included in this 4 to 6 minute span are the interruptions that a pharmacist must deal with. A patient asking for an OTC recommendation. Phone-in prescription from a prescriber's office. Phone ringing from a patient phoning in refills (I actually think that there is a rule somewhere that requires a pharmacy to have two more phone lines than people working in the pharmacy).

But back to what we actually do. We rely on the DUR software to help us check for interactions, but a recent study from the University of Arizona found that the software systems are flawed (link here). That means that we, as pharmacists, should dig through a patient's profile each and every time that we fill a prescription to check for interactions. That takes time.

Another part of the prescription process that take time is counseling. From my experience and observations, pharmacists fail at this horribly. I watch how pharmacists counsel patients on their prescriptions. 95% of the time "counseling" is simply the pharmacist reading the label to the patient. OBRA '90 gave us specific points that we are to cover when we counsel the patients.

OBRA ’90 Counseling Points:
  • Name of drug.
  • Intended use and expected action.
  • Route, dosage form, dosage, and administration schedule.
  • Common side effects that may be encountered,including their avoidance and action required if they occur.
  • Techniques for self-monitoring of drug therapy.
  • Proper storage instructions for the medication.
  • Potential drug-drug or drug-food interactions or other therapeutic contraindications.
  • Prescription refill information.
  • Action to be taken in the event of a missed dose. (source)
To inform a patient on all of these points, time is required. Two or three minutes, per prescription, is what I feel is adequate to ensure that the patient understands what I am saying. Then you need to allow time for questions from the patient.

* * * * *

So I found it amusing recently when upper management decided to change the guidelines for the number of prescriptions a pharmacist should fill on an hourly basis. I'll just say that, prior to the change, we were at the higher end of the volume spectrum of the poll. The new guidelines call for an increase of 25 percent.

I contacted my state board of pharmacy, whose mission statement states that it is to act...in the public interest to pursue optimal standards of practice through...legislation, licensing and enforcement to see what their take on my employer's changing guidelines were. The response from my pharmacy board was that no prescription volume limits have been or are being considered. Apparently my pharmacy board believes that a maximum time of two minutes, 24 seconds per prescription is the optimal standard of practice.

Eric Cropp lost his pharmacist license permanently due to a dispensing error. He was in a situation where there was too much work to be done with inadequate staffing. The little girl who was undergoing her last chemo treatment ended up dead from the error. So when he speaks about the rapid pace of pharmacy and the potential for error, I'm paying attention. He was quoted in a recent internet article as saying "We want to stress the fact that everybody's got to slow down and treat each patient like they're a member of your family...Healthcare is so fast and crazy sometimes we start to miss the fact that we're taking care of a human being, not running an assembly line."

If only the management of the pharmacy chains would think the same way.


Ju said...

Wow. Very interesting read.


Very interesting Eric.

Cropp reminds us that we're "...not running an assembly line.", yet that is exactly the case with a lot of central fill pharmacies where a RPh is expected to verify 800-1200 scripts/hr.

In the retail setting, advances in clinical decision support (eg., drug interaction checks) may ease the pressure, but if my latest experience with McKesson's EnterpriseRx is any indication, there is a ways to go.

15 minute or less mandates don't help either.

Anonymous said...

Unfortunately, all management is thinking is when they will have you increase volume by another 25%.

ElphiaDesigns said...

I love your blog! I'm a pharmacist at an independent (actually 2 indies) in St Paul, MN. I really have appreciated a lot of your topics. Obviously very "relatable" for my. Keep up the good work!

Anonymous said...

Eric--realize this blog entry is a bit dated but any idea where I can find more information on prescriptions filled per hour metric? Looking to do some forecasting/modeling.