Technicians checking technicians: Is it really a non-issue for pharmacists?

That depends on how willing or able you are to change

How to manage and train pharmacy technicians are two of the prickliest problems to grow out of the managed care revolution. In almost every state, pharmacy regulators and industry groups are debating pharmacist/technician ratios and technician training requirements. But no one issue has polarized the industry more than the liability arising from technicians checking technicians, or "tech-check tech," a phrase that — depending on your disposition — either makes your blood boil or elicits a shrug.

So quickly has this issue come about, in theory and in practice, that the 1996 white paper on the "functions, training, and regulation" of technicians endorsed by the American Society of Health-System Pharmacists and the American Pharmaceutical Association makes no mention of it. However, the paper does place the responsibility for technicians squarely on the shoulders of pharmacists.

Created in 1995, the Pharmacy Technician Certification Board takes no official stand on the issue and defers to the American Pharmaceu-tical Association (APhA). APhA, says director of policy and legislation Susan Winckler, approves of technicians checking technicians provided that "the pharmacist is responsible for the technicians, and acknowledges that, and is responsible for dispensing, and is comfortable with the system in the hospital." If that sounds vague, it’s probably meant to. And it certainly fails to address where pharmacists could find relief if they don’t feel "comfortable."

Critics of technicians checking technicians, such as Phillip Grauss, PharmD, staff pharmacist at Kaiser Permanente in Petaluma, CA, say holding the pharmacist liable for medication errors that result is ludicrous. It’s putting economics ahead of better pharmaceutical care, he says. (See Status of Pharmacy Technicians charts, pp. 148-150.)

"The reason administrations want this is to save money. Replace the pharmacist and save $50,000," he explains, alluding to the average pharmacist salary. Technicians can be paid as little as $12,000 to $14,000. Kaiser maintains a one-to-one ratio of pharmacists to technicians in its outpatient pharmacy.

"The biggest single thing we’re seeing come out of this is drug errors," Grauss asserts. He argues that adverse drug reactions, cross-sensitivities, or side effects may not always be caught by a technician, and cutbacks in nursing staffs leave another hole in the medication oversight process. And finally, he warns, the proposed federal Safe Medi-cations Act of 1997 would send the pharmacist, not the technician, to prison in cases of fatal medication errors.

Aggravating this situation is the changing landscape of pharmaceutical care, which is making the dispensing-only role obsolete "Pharmacists now filling prescriptions have to do something else," Grauss points out. "In California, we’re looking at 600 to 700 pharmacists with less to do. Match that with the Pew [Commission] report, which states 40,000 less pharmacists will be needed by the year 2005 as automation and technicians take over our roles, and if you ask, ‘Are we being squeezed out?’ the answer is yes."

Kaiser, like most health care organizations, is moving pharmacists into greater clinical roles, but are there enough such jobs to go around? As past president of the Marin County Pharmaceu-tical Association, Grauss has fought against the implementation of tech-check-tech by California’s Department of Consumer Affairs, which runs the state’s pharmacy board. Since 1995, changes in technician duties have come before the department only to be stifled by opposition or procedural fights.

But for every Phillip Grauss in the debate, there’s a Joe Ness, MHA, RPh, pharmacy director at Grays Harbor Community Hospital in Aberdeen, WA. "I’m clearly on the side of a greater role for technicians, and I do not see that as a threat. If you do view it as a threat, you need to take a hard look at the fact that you’re being paid a lot of money to do what a technician or an automated system can do. And I think the tech-check-tech issue will fade as automation increases. You don’t need tech-check-tech with PYXIS machines," Ness maintains. "Hospitals are hiring more pharmacists to do clinical work, and I think that will happen with or without tech-check-tech."

Without growth in technician roles, Grays Harbor could not have have developed the multidisciplinary teams it now has to enhance disease management, patient education, dosing consultation, pain relief regimens, and drug therapies, Ness explains.

"Just directing the patient on how to take medicine is a huge need, and physicians are crying for more of that. I think that techs checking IVs is a risk mainly because something could go wrong quicker, but we need to acknowledge that there is no inherent genius that gives us exclusivity on being a checker." Grays Harbor’s technician-pharmacist ratio is about two to one.

Over the past two years, VA hospitals underwent a reclassification effort that expanded the duties of technicians. Kathryn Fowells, director of pharmacy services, has begun tech-check-tech at the Syracuse (NY) Veterans Affairs Medical Center and has technicians process all narcotics for the inpatient unit. At the same time, she says, quality controls were set up throughout the pharmacy to ensure pharmacists are not spread too thin.

Automation, she says, also is playing a major role. Along with the use of PYXIS machines, the Syracuse VA is using the ACT2 12 computer system to download bulk tablets into unit doses, as well as the consolidated mail outpatient dispensing system — CMOP, located in Bedford, MA, and one of seven regional sites in the U.S. — for the automated filling of 15,000 prescriptions a day.

"Our philosophy is that the technicians are freeing up pharmacists to get involved in patient care, and I think that over the two years I’ve been here, our staff is increasingly embracing that," Fowells says. A recent staff survey backs up that notion. "The monitoring we set up is the same we would do if a pharmacist were handling these duties."

A study by the Minneapolis Medical Research Foundation compared accuracy rates of technicians checking technicians with those of pharmacists checking technicians in syringe preparation for dialysis at that state’s Regional Kidney Disease Program (RKPD).1 The RKPD covers 10 Twin Cities dialysis units and about 700 patients and prepares about 20,000 syringes a month.

In the study, conducted from November 1995 to April 1996, 10,608 syringes were checked by both technicians and pharma-cists, with very similar results. Accuracy rates in checking the tech-prepared syringes was 99.86% for the pharmacists and 99.83% for the technicians.

Study technicians recorded 167 errors, while pharmacists recorded 87. Much of the differ-ence is explained by 70 syringes that technicians recorded as errors but were within standard limits. The pharmacists noted just four syringes out of standard. Overall, 69 errors were detected by both the techs and the pharmacists. The techs missed 17 errors, the pharmacists 14.

Based on this study, the Minnesota Board of Pharmacy allowed the RKPD to proceed with a tech-check-tech program. As part of the program, random audits are done monthly; they require a technician to maintain a 99.75% accuracy rating to continue to check syringes.

[For more information, contact any of the following: Susan Winckler, Director of Policy and Legislation, American Pharmaceutical Association, 2215 Constitution Ave., Washington, DC 20037. Telephone: (202) 628-4410. Phillip Grauss, PharmD, Staff Pharmacist, Kaiser Permanente of Petaluma, 3900 Lakeville Hwy., Petaluma, CA 94954. Joe Ness, Director of Pharmacy, Grays Harbor Community Hospital, 915 Anderson Drive, Aberdeen, WA 98520. Telephone: (360) 532-8330. Katheryn Fowells, Chief of Pharmacy Services, Syracuse VA Medical Center, 800 Irving Ave., Syracuse, NY 13210. Telephone: (315) 476-7461.]

Reference

1. Andersen S, et. al. Accuracy of technicians versus pharmacists in checking syringes prepared for a dialysis program. Am J Health-Syst Pharm 1997; 54:1,611-1,613.