ASHP Response to '20/20' Report on Pharmacy Errors

The medication errors depicted in the ABC News 20/20 investigative report broadcast Friday evening, March 30, 2007, were tragic and regrettable. The American Society of Health-System Pharmacists (ASHP), which extends its deepest sympathies to the families involved, believes the following regarding the issues addressed in the program: 

Role of Technicians in Pharmacies

A fail-safe medication-use system depends on several key elements working in concert, including the use of properly trained and supervised pharmacy technicians. Properly trained and supervised technicians provide an invaluable service by allowing pharmacists more time to spend counseling patients and advising them about appropriate medication therapy. 

ASHP’s Position on Pharmacy Technician Training and Certification

ASHP advocates a model for training, credentialing, and regulating technicians that we believe optimizes patient safety. Although the pharmacy profession has not reached national consensus on this model,, ASHP strongly urges all sectors of the pharmacy field, including the chain drug store industry, to support this model and give top priority to its implementation.  ASHP believes that:

  • Pharmacy technicians should be educated and trained across all states and for all sites of practice in conformity with uniform national standards,
  • There should be a standard examination and certification process for pharmacy technicians, based on sound psychometric principles, that technicians must pass before they are granted permission to engage in the responsibilities authorized by a state, and
  • State boards of pharmacy should register pharmacy technicians, providing a means to regulate them and to eliminate from the workforce technicians who do not meet appropriate qualifications or performance requirements.

Preventing Medication Errors

Preventing medication errors requires a systems-based approach that includes checks and balances that anticipate and protect against human error. Pharmacy departments in hospitals and health systems, while not immune from the types of errors shown on 20/20, employ a number of safeguards, including double-checks of technicians’ work and the use of cutting-edge technology such as bar coding and automated dispensing machines, that can protect patients and ensure that they receive the right medicine in the right dose.  Technicians and pharmacists working in hospitals all must undergo regular competency assessments mandated by the Joint Commission, the accrediting body for hospitals, to ensure that they have the knowledge and skills to perform their job responsibilities properly.

Medication-Error Reporting

Serious medication errors that result in temporary or permanent harm, disability, or death should be reported to the appropriate regulatory agency or accrediting body.  ASHP has long been a champion for mandatory reporting of serious errors.  Errors that do not cause harm should be reported to voluntary reporting systems and used as part of quality-improvement efforts to ensure that similar errors are not repeated.

Pharmacist-Patient Counseling

All medications have the potential to harm if not used correctly.  Patients should speak to their physicians about the medicines that have been prescribed and always take advantage of the opportunity to speak with their pharmacist about their medications.