Doing a Druggist’s Job--Without the Training

PORT RICHEY, Fla. —  Deborah Hoffman wanted to know why the nausea drug for her 5-year-old came with a special warning about giving it to children.

Even now, three years later, she remembers the words of the woman in a white coat behind the counter at Walgreens: It’s OK “because all children can use Compazine.”

That was disastrously bad advice. Moreover, the woman in the smock was a pharmacy technician --not a pharmacist. She had no pharmacy degree, and she didn’t notice that the bottle contained an adult dosage--10 times what the doctor had prescribed.

The next morning, Hoffman found her daughter “all crumpled up,” unable to move or talk. Little Brittany vomited for two days. She couldn’t speak a complete sentence for three.

Since her overdose, according to court records, Brittany attends school with children with learning disabilities and for short spells can’t think clearly. “I’ll ask for an ashtray, she’ll give me the phone,” Hoffman said.

Increasingly, the person greeting Americans from behind the drugstore counter is a pharmacy technician. In most states, the job requires no license or training. California requires techs to be registered, and to qualify they must have some experience, education or training. For $6 to $12 an hour, these assistants shoulder much of the pharmacist’s job. Druggists, who earn $30 to $35 an hour, are then free to double-check their dispensing work and counsel customers.

That low-cost help is a mixed blessing: Technicians lack the pharmacist’s expertise, face little regulation and sometimes--amid the crush of the nation’s increasingly busy pharmacies--dispense drugs with little oversight from pharmacists.

Techs, as they’re known inside the pharmacy, have helped the nation’s drugstores to flourish despite shrinking profit margins. In most states they are allowed to call the doctor to authorize prescription refills, to pull drugs off stock shelves, to put pills into prescription bottles, to enter prescriptions into the computer, to type labels and to ring up sales. In California and 36 other states, as well as the District of Columbia, they can also mix drugs from raw chemicals.

Pharmacists are responsible for supervising the technicians’ work, dispensing drugs, checking for dangerous interactions with other drugs and explaining how to take the medication.

To ensure that drugstores hire enough pharmacists to safely dispense drugs, most states, including California, limit the number of technicians each pharmacist can supervise. But as technicians reach the legal limits of their tasks, pharmacies are pressuring state regulators to expand those limits.

They are succeeding.

Since 1990, at least 10 states have increased the so-called pharmacist-to-technician ratio: Alabama, Arkansas, Colorado, Florida, Indiana, Kansas, New Mexico, North Dakota, Oregon and Tennessee.

A 1998 study by the Virginia Board of Pharmacy found good reason for pharmacists to supervise technicians closely: Pharmacists were catching an average of 6 1/2 technician mistakes a week.

The study questioned pharmacists-in-charge at the state’s 1,590 drugstores, and more than half answered. Of the technician errors found in the study, 55% involved the wrong drug; 22%, the wrong instructions; and 16%, the wrong dose or quantity.

Druggists elsewhere say they see similar problems.

“I might find in a day five, six, maybe seven errors,” said Lowell McNichol, a pharmacist in Petaluma, Calif.

Many pharmacists and regulators complain that pharmacists have trouble monitoring the technicians they have now. The Virginia study was prompted in part by complaints from Virginia pharmacists such as June Carpenter of Lynchburg, who said technicians are given responsibilities that should be reserved for trained druggists.

“We have lost control of our profession,” she wrote to the board in 1996. “We must rely on technicians to do the work because the pharmacist only has time to quickly check behind them.”

The pharmacist, not the technician, is legally liable for mistakes in every state. But often, according to dozens of pharmacists interviewed, they don’t check the tech’s work. Druggists complain that because they dispense nearly twice as many drugs as they did in 1989, they simply don’t have time.

One nonprofit group, U.S. Pharmacopeia of Rockville, Md., collects voluntary reports from health care practitioners. The group’s Medication Errors Reporting Program received 314 reports of pharmacy errors in the year ended Oct. 31. Half were made by technicians and undetected by pharmacists; the other half were presumed to have been made by pharmacists.

Pharmacists aren’t the only ones concerned about oversight.

“Sometimes the pharmacist gets so comfortable that they get lax and don’t check it,” Houston tech Kelly Fash said. “I had that happen, and I said, ‘Don’t do that. I’m human. I err.’ ”

Texas regulators have increased oversight. Fash started working in pharmacies 21 years ago, when techs were simply called support staff. Now she has passed a certification test, as most Texas technicians will be required to do under state law by next year. It’s made a difference, she said: Certified techs are, by and large, more qualified.

“For the majority of the technicians that are hired off the street, certification is needed, because they’re taking anybody and letting them work in the pharmacy department,” she said. “You have the photo department and you have makeup. If a technician didn’t show up, pharmacy managers would pull someone from another department and let them work in the pharmacy.”

But techs are still allowed to do tasks best left to the pharmacist, Fash said, such as putting the label on the prescription bottle--a final step that requires a pharmacist’s knowledge.

In most states, technicians face little regulation. Only four states-- Alaska, Utah, Washington, Wyoming--license technicians, according to the National Assn. of Boards of Pharmacy. Two states--Louisiana and Wyoming--require a certification test, and 19, including California, simply register their names. Many states set no requirements at all.

With few prerequisites for the job, most technicians receive only on-the-job training.

“You could become a technician today, walk into a pharmacy and start filling prescriptions,” said Ralph Vogel, president of the Guild for Professional Pharmacists, a California labor union. “That’s the problem.”

That’s no longer the case in Utah, where wages have risen since regulators in 1998 required technicians to be licensed. Some employers in the state now pay starting technicians nearly $10 an hour, compared with as little as $5.75 in some California pharmacies. Those with more experience can earn as much as $13 an hour. Utah requires technicians to pass an exam on drugs and state pharmacy regulations.

“Those technicians come in with a little more perspective than someone who doesn’t know anything about pharmacy,” said Ryan Lee, a member of the Utah Board of Pharmacy who said he is the only technician to sit on a state board.

Before 1998, some Utah companies offered their own tests, as many outside the state still do. But those tests aren’t always a good measure of a technician’s knowledge.

“I thought it was too simple,” said Lee, who took a test administered by a mail-order pharmacy. “It took me 20 minutes and I was done with a 100-question exam. . . . They were so desperate. If you had a pulse, they’d hire you.”

Utah began licensing technicians largely because the board had no authority to discipline unlicensed workers, Lee said.

In states that don’t even record the names of technicians, regulators can do little to stop technicians who violate pharmacy regulations from taking jobs elsewhere, across the street or across the nation.

In its 1998 study, the Virginia board noted that technicians there can continue to work “even if they have diverted or abused drugs, have been convicted of a felony or have willfully acted negligent[ly] while working in a pharmacy in the past.”

Despite that concern, a Virginia task force studying the issue made no recommendation, and the board of pharmacy declined to regulate technicians.

Thirty-six states, including California, limit the number of technicians each pharmacist can supervise. Eleven of those states allow no more than one technician per pharmacist, but some have ratios of 4 to 1. (California requires a 1-to-1 ratio, but allows exceptions.)

Raising those limits is a priority of the National Assn. of Chain Drug Stores, an industry trade group that contends 1-to-1 ratios are unacceptable.

“Why should pharmacy, unlike other health care settings, be limited in its staffing decisions? Hospitals aren’t limited in the number of nurses they have assisting a surgeon,” said NACDS chairman Frank A. Newman.

For decades, many pharmacies have had helpers. But it’s unclear how many, because support staffers of the past were only recently dubbed technicians. Technicians are now so popular that the majority of drugstores and hospitals use them. The journal Occupational Outlook Quarterly reported some 130,000 pharmacy technicians in 1996.

Keepers of state statistics predict the number will grow. The Kansas Board of Pharmacy expects a 40% increase between 1993 and 2005--as Americans increase their prescription drug buying.

“The rising cost of health care, the increasing complexity of insurance programs and the growing number of patients make it necessary for pharmacies to try to become more efficient,” Eckerd officials stated in writing.

As the number of technicians increases, so do their responsibilities. Eighty percent of the 600 pharmacists surveyed in the November edition of Drug Topics magazine reported that techs’ duties had increased in the last two years.

Margaret Cozzone, business manager of a union representing 750 Walgreens pharmacists, agreed. In a recent malpractice suit against the retailer, she testified that Walgreens in the early 1990s had “a different staffing philosophy . . . where they start substituting pharmacist help with technician help.”

Pharmacy chains say they are working to improve technicians’ training. Some 55,000 techs--two of every five--have passed a voluntary certification exam designed by a nonprofit trade group. Walgreens, for example, gives its certified techs a $1,000 annual raise. That program, said Walgreens spokesman Michael Polzin, has encouraged 60% of its technicians to pass the exam.

But problems remain. The Associated Press analyzed disciplinary records for all 50 states in 1998, the most recent year for which data were available. Those reports show that state pharmacy boards disciplined druggists and drugstores more than 75 times for letting techs do jobs reserved for pharmacists. Limits on techs’ duties vary by state, but nowhere can a technician dispense a drug without the pharmacist’s approval.

In Illinois, the pharmacy board found that a Wal-Mart technician dispensed drugs for 1 1/2 hours, unsupervised.

A Washington state pharmacist repeatedly allowed technicians to fill prescriptions.

In Arkansas, four Fred’s Pharmacy locations were fined a total of $10,000 in 1998 for allowing technicians to exceed their duties.

Sometimes it’s unclear whether a technician or a pharmacist dispensed a prescription.

Pharmacist Randal Prince’s name was on the bottle of Carolyn See’s antidepressant prescription--with 10 times the correct dose inside. But at the time the prescription was filled, Prince was nowhere near his base in Parkersburg, W.Va. He was visiting the Ohio headquarters of the Phar-Mor chain, nearly 200 miles away. As Prince explained in a deposition, “a tech logged my initials in.”

Jack See found his wife on the kitchen floor, unable to move. Because pharmacists remain legally liable for any errors, a druggist in the store at the time took the blame. In 1996 the drugstore settled the case for $272,750. Seven years later, Carolyn See remains disoriented, unable even to dress herself.

Deborah Hoffman had never thought about whether special training was required for those working behind Florida drug counters in January 1997, when she picked up the prescription that allegedly led to Brittany’s seizure.

Today, Hoffman is suing Walgreens and waiting for her daughter to recover. The technician’s words, she said, still haunt her: “ ‘There are a lot of medicines that say you can’t give them to children, but they do anyway.’ ”

With regret, Hoffman added: “I assumed that she knew what she was talking about.”

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California’s Registration Requirements

California requires pharmacy technicians to be registered. Applicants must submit an application and have completed any one of the following:

* Experience: Must have worked 1,500 hours in a pharmacy performing clerk duties, such as entering prescriptions in the computer and calling in refills.

* Education: Applicants could have an associate of arts degree in health, biological or natural science.

* Training: Must complete at least 240 hours of theoretical and practical instruction.

Registered pharmacy technicians’ duties in the state include removing drugs for stocking, placing product in containers, and fixing labels for packaging and repackaging. They are allowed to count, pour and mix pharmaceuticals, said Patricia Harris, spokeswoman for the California Board of Pharmacy.