Tag: dispensing error

A cautionary tale for Oregon retail pharmacists

Corporate retail staffing decisions and the Oregon Board of Pharmacy

Twice this year, I have represented relatively new pharmacists practicing their profession in the hustle and bustle of two different national corporate retail pharmacy chains. In both cases, the pharmacist needed or requested staffing that corporate management did not allow, and in both cases the practice of pharmacy suffered, dispensing errors and/or counseling errors occurred, and complaints were filed with the Oregon Board of Pharmacy. Not surprisingly, in both cases, the pharmacist sought to defend against the Board complaint by explaining the staffing decisions imposed by corporate management, but be forewarned: That justification is not considered an extenuating circumstance by the Oregon Board of Pharmacy.

What you need to know

Please know that the Oregon Board of Pharmacy expects you to protect the practice of pharmacy, even when to do so is at odds with decisions by corporate managers. While I am of the opinion that the Oregon Board of Pharmacy could do a better job of getting this message out to all new pharmacists, this is what I have experienced while representing pharmacists before the Board of Pharmacy. Simply put, your ultimate professional responsibility is to your profession – the practice of safe pharmacy – not your employer. See, e.g., OAR 855-019-0200 (pharmacist’s standard of care); OAR 855-019-0200(1)-(7) (responsibilities of the pharmacist); OAR 855-041-1015(1) (pharmacist required to be present in the pharmacy to supervise the pharmacy).

The tension between protecting your Oregon pharmacist’s or abiding your corporate employer

If you are practicing in a corporate retail pharmacy, you are surrounded by a sea of commercial activity, and all of it, including the staffing levels in your your pharmacy, is managed by business types. At times, you may be the only licensed healthcare provider on the premises.Your professional training, experience, and responsibilities as an Oregon pharmacist make you unique in that setting, leaving you alone to protect the practice of pharmacy throughout the day. In other words, you are uniquely liable to the Oregon Board of Pharmacy. Never lose sight of that fact, because the Oregon Board of Pharmacy has little sympathy for a pharmacist that defers to corporate management if that deference compromises the practice of pharmacy.

Expectations of the Oregon Board of Pharmacy

The general concern of the Oregon Board of Pharmacy is to ensure patient safety, the competency of every pharmacist, and the security of the drug inventory. If corporate management places you in a predicament where either corporate managers will be unhappy, or the practice of pharmacy will be compromised, the Oregon Board of Pharmacy will tell you it is your professional obligation to protect the practice of pharmacy, not the employer’s wishes. This is true even if it is necessary to take extreme action to temporarily close the pharmacy until adequate staffing arrives to ensure the safe practice of pharmacy. If you haven’t the authority take such extreme action when necessary to ensure the safe practice of pharmacy, it may be advisable to call a licensure lawyer, or an inspector at the Board of Pharmacy, to gain the perspective or assistance. In the end, you will have protected the practice of pharmacy, which is what the Board of Pharmacy expects of you as a licensed pharmacist. You will also have protected your license to practice pharmacy.


I am a licensure lawyer, not an employment law lawyer. An employment law lawyer might share very different observations with you, observations intended to protect your employment, not your Oregon pharmacist’s license. As a licensure lawyer, I am sharing what I have learned while representing pharmacists before the Oregon Board of Pharmacy. By sharing my observations here, I hope to help you protect your Oregon pharmacist’s license, while an employment law lawyer might provide very different observations intended to protect your employment. Indeed, this disclaimer reveals the very real tension occasionally faced by pharmacists while practicing in the large, corporate retail pharmacy chain stores.

For Pharmacists: Three medication errors could mean probation and loss of PIC

It is well accepted that dispensing or medication errors occur with some regularity in the practice of pharmacy. While most dispensing errors are never reported to the Board of Pharmacy, once they are, there are consequences for the dispensing pharmacist. For a first and second reported dispensing error, the dispensing pharmacist is at risk of professional discipline by the Board of Pharmacy, most likely a reprimand, and a fine ranging from $1,000 to $5,000.

During one recent case, however, it was revealed to me that the Board of Pharmacy is of the view that for a third reported dispensing error, the presumptive sanction is a fine, plus five-years of probation, and loss of pharmacist-in-charge (PIC) privileges. This is true even when pharmacy workload is a factor, and the prescription involves a look-alike or sound-alike drug.

What you need to know

You need to know that the Board of Pharmacy is imposing discipline upon pharmacists for dispensing errors even though pharmacists know, and the literature establishes, that dispensing errors cannot be fully prevented. For example, according to one study cited by the Institute of Medicine’s 2007 report, 1.7 percent of new and refill prescriptions are dispensed in error:

This more recent, large-scale study of both new prescriptions and prescription refills found an error rate of 1.7 percent (Flynn, et al., 2003). This dispensing error rate translates to approximately 4 errors per 250 prescriptions per pharmacy per day, or an estimated 51.5 million errors during the filling of 3 billion prescriptions each year. One study of medication errors at Medco Health Solutions, Inc., a large mail order pharmacy, carried out by Medco employees, found a dispensing error rate of 0.075 percent—16 dispensing errors among 21,252 prescriptions (Teagarden, et al., 2005).

Preventing Medication Errors: Quality Chasm Series (2007). Retrieved from: http://books.nap.edu/openbook.php?record_id=11623&page=113.

Applying the above error rate of 1.7% to a pharmacy filling 1,500 prescriptions per week indicates that 25 dispensing errors occur each week in that pharmacy. Dispensing errors are not, however, fully preventable, due to what has been described by Stuart R. Levine, et al., as a “latent failure” in the practice of pharmacy:

“Medication errors rarely occur from the failure of a single element or because of mistakes from a single practitioner. Rather medication errors are the result of the combined effects of ‚Äòlatent failures’ in the system and ‚Äòactive failures’ by individuals. Latent failures are weaknesses in the structure of the organization, * * * . By themselves, latent failures are often subtle and may cause no problems. Their consequences are hidden, becoming apparent only when they occur in proper sequence and are combined with active failures of individuals to penetrate or bypass the system’s safety nets. Many of the latent and active failures that were at the root of medication errors are not apparent until a root cause analysis is performed. [Footnote omitted] For this reason, providing an optimal level medication safety requires both recognition and correction of latent failures in the system. * * * . It is unrealistic to expect absolute perfection or error free performance from any person. * * * .”

Stuart R. Levine, et al., Guidelines for Preventing Mediation Errors in Pediatrics, p. 427.