Pharmacy – entrenched in outdated dogma

By | June 4, 2015

Dogma: belief or set of beliefs that is accepted by the members of a group without being questioned or doubted (Merriam-Webster)

I have opinions, lots of opinions. And like most, I believe my opinions are valid; it’s human nature. It’s not uncommon for me to find people within a group that agree and disagree with my opinions. However, once in a while I come across an entire group of people that stand in disagreement with my thoughts. That’s not crazy to imagine, but when that happens I’m forced to re-evaluate. Let’s face it, if everyone thinks I’m wrong, it’s possible that I am.

Such is the case with my thoughts on the use of technology and personnel in the i.v. room, which are on record at this site and are quite transparent. In a nutshell I believe that:

  • Technology can be used to improve both pharmacy operations and patient safety. Generally speaking people don’t disagree with this philosophy, but rather the details of type of technology and how best to use it. Tomayto, tomahto. There is good and bad pharmacy technology. With that said, some of the technology available for sterile compounding is quite good.
  • Pharmacies shouldn’t skimp on the technology they use. What does “good enough” mean anyway? I’m specifically speaking about comments I made recently in this post: “You’re literally getting one half of the functionality necessary to ensure accurate compounding [when using only bar-code scanning for verification]”. I’m not backing down on that one. If you’re using bar-code scanning to verify that you have the correct drug, that’s great. But if you’re only method for verifying accurate volumes is to have a pharmacist look at it, you’re wrong. I can’t put it any more plainly than that. “Good enough” simply doesn’t cut it in my mind.
  • Pharmacists are not the be-all end-all of the verification process. Many in my profession are stuck on the idea that a pharmacist must be the final check in any compounding process. Why? What makes pharmacists better at it then say, a technician? There’s data out there to suggest that technicians do a fine job in a verification role. In some instances as good, if not better than pharmacists. Here’s the thing, a pharmacist’s education includes many things, but checking isn’t one of them. I don’t recall a “verification” or “checking” class in pharmacy school.(1) I took a truckload of chemistry (organic, biocchem, PChem, etc), lots of anatomy (gross included – yes, I dissected a body), histology, enzyme kinetics, pharmacokinetics, more pharmacology than I can recall, etc. You know what I didn’t take? A class on how to verify that something was properly compounded or has the right label on it. All that came as on-the-job training when I went to work in a hospital. The first time I had to do a final check on a CSP I had no idea what I was doing. I put my initials on it because that’s what I was supposed to do. I had no idea if it was right or not. What makes the situation worse is that most pharmacists find checking to be a nuisance, and are often distracted by other “more important” things. No, pharmacists aren’t better at verification than a technician. The idea that a pharmacist must perform a final check on a CSP rather than a technician – or other qualified individual – is nothing more than ancient dogma.

In summary, after deep consideration, I’m not wrong. My opinions are valid: you should be using the most complete solution possible in the i.v. room, and you need to get over the idea that a PharmD is required for a “final check”.

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  1. I attended UCSF School of Pharmacy. UCSF is arguably the best pharmacy school in the country. That’s not bragging, it’s simply putting context to what “the best” includes – or in this case doesn’t include – in their curriculum.

One thought on “Pharmacy – entrenched in outdated dogma

  1. Ray Vrabel, PharmD

    Jerry,

    While I value your opinions, I think you may be misinterpreting the opinions of others, at least mine. My assumption is that I must be one of the people in the group that you feel “stand in disagreement” with your thoughts. Personally, I don’t think we are in disagreement, as much as we just view the facts differently.

    I totally agree with you that technology can, and should, be used to improve both pharmacy operations and patient safety. I view safety as the primary requirement and operational efficiency as secondary. I also believe strongly that automation technology should NOT be used to automate an existing manual process. The first step should be the reevaluate and optimization of the work process and then apply automation. Careful consideration also needs to be given to the risks of unintended consequences of automation (i.e., new risks actually caused by using automation).

    I think we both agree on the value of using barcoding scanning to ensure that the right ingredients (i.e., vials and bags) are being used to prepare an IV admixture. I also feel that the barcode scanning of IV admixture ingredients should be used for ALL IV’s for ALL patients. The degree to which automation technology is used for the remaining portion of the IV Admixture process appears to be a point of disagreement.

    The fact is that I strongly support the use of automation technology after the ingredient barcode scanning step. I’m just not certain that the optimal technology is yet available. I think that there are a number of unintended consequences with the existing automation technologies.

    You made the following comment that I have issues with:

    “…if you’re only method for verifying accurate volumes is to have a pharmacist look at it, you’re wrong.”

    Prior to the use of IV Workflow automation, the only way to verify the volume of a vial added to an admixture was to observe what the technician drew up in the syringe prior to adding to a bag or look at the “syringe draw-back” proxy for what the technician did, after the fact.
    In all of the new technologies that use images taken of the technician’s work, the pharmacist is still “looking at syringes drawn back with the drug volume”. What’s changed? In both cases, manual syringe draw-back or the image of a syringe drawn back, you still do not know exactly what was in the syringe, if the contents of the syringe was added to the bag, or if proper sterile technique was used. It’s all based on trust. The addition of gravimetrics automation to multiple steps of the IV admixture process (i.e., before and after of the vial, the syringe, and the bag) provides greater assurance of accuracy, but this adds a number of additional steps to the process. In addition, there is nothing to ensure “how” the admixture was performed (i.e., sterile technique).
    There is one automation technology that needs to be given more consideration: live, streaming video from the IV hood to the pharmacist. This would allow the pharmacist to review in real-time from outside the IV cleanroom what a technician is doing, both from an accuracy standpoint and the appropriateness of the sterile technique. Ideally, this technology would allow the pharmacist to capture a still image of what they are checking (mostly for documentation purposes).

    Our real major point of disagreement relates to your comment:

    “…Many in my profession are stuck on the idea that a pharmacist must be the final check in any compounding process.”

    You mentioned all of your pharmacy coursework that did not teach you anything about “verification”, but, you forgot to mention the one course that did: Pharmacy Law!

    On an individual basis a given pharmacist and a given technician may be equally good at the “checking/verification” step. The difference is that ONLY a pharmacist has a LICENSE to perform that step.
    Legal definition of License: The permission granted by competent authority to exercise a certain privilege that, without such authorization, would constitute and illegal act.

    I have a driver’s license, but that does not allow me to permit another individual who does not have a license to drive a car just because I trained them. The holder of a license does not have the ability to transfer the responsibility and accountability to someone else. Only the authority granting the initial permission (e.g., a Board of Pharmacy) can do that.

    You conclude saying,

    “…The idea that a pharmacist must perform a final check on a CSP rather than a technician – or other qualified individual – is nothing more than ancient dogma.” and that on this issue you feel that are “not wrong”.

    It is my opinion that in this particular case, you are WRONG! This has nothing to do with dogma, but is instead a matter of the law. The only way change it, is to change the law.

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