Pharmacies miss half of dangerous drug combinations

Sam Roe, Ray Long and Karisa King, Pharmacies miss half of dangerous drug combinations. Part 3 of “Dangerous Doses.” Chicago Tribune, 15 December 2016. “The [Chicago] Tribune reporter walked into an Evanston [Illinois] CVS pharmacy carrying two prescriptions: one for a common antibiotic, the other for a popular anti-cholesterol drug. Taken alone, these two drugs, clarithromycin and simvastatin, are relatively safe. But taken together they can cause a severe breakdown in muscle tissue and lead to kidney failure and death. When the reporter tried to fill the prescriptions, the pharmacist should have warned him of the dangers. But that’s not what happened. The two medications were packaged, labeled and sold within minutes, without a word of caution. In the largest and most comprehensive study of its kind, the Tribune tested 255 pharmacies to see how often stores would dispense dangerous drug pairs without warning patients. Fifty-two percent of the pharmacies sold the medications without mentioning the potential interaction, striking evidence of an industrywide failure that places millions of consumers at risk.”

CVS, the nation’s largest pharmacy retailer by store count, had the highest failure rate of any chain in the Tribune tests, dispensing the medications with no warning 63 percent of the time. Walgreens, one of CVS’ main competitors, had the lowest failure rate at 30 percent — but that’s still missing nearly 1 in 3 interactions.

In response to the Tribune tests, CVS, Walgreens and Wal-Mart each vowed to take significant steps to improve patient safety at its stores nationwide. Combined, the actions affect 22,000 drugstores and involve additional training for 123,000 pharmacists and technicians….

Dangerous drug combinations are a major public health problem, hospitalizing tens of thousands of people each year. Pharmacists are the last line of defense, and their role is growing as Americans use more prescription drugs than ever. One in 10 people take five or more drugs — twice the percentage seen in 1994….

The [Chicago] Tribune study, two years in the making, exposes fundamental flaws in the pharmacy industry. Safety laws are not being followed, computer alert systems designed to flag drug interactions either don’t work or are ignored, and some pharmacies emphasize fast service over patient safety. Several chain pharmacists, in interviews, described assembly-line conditions in which staff hurried to fill hundreds of prescriptions a day….

In the fight to protect patients from dangerous drug interactions, doctors shoulder significant responsibility. They are the ones who write the prescriptions.

But one physician may not know what another has prescribed, and research has found that doctors’ knowledge about specific interactions is often poor.

In filling prescriptions, pharmacists are uniquely positioned to detect potential drug interactions, warn patients and prevent harm. Pharmacists themselves say that is one of their primary duties.

Yet little data exists about how well they perform in real-world situations.

The Tribune set out to find the answer. To select drug pairs to be used in the tests, the newspaper enlisted the help of two leading experts on drug interactions: pharmacy professors Daniel Malone of the University of Arizona and John Horn of the University of Washington. Five pairs were chosen, three of which posed life-threatening risks. Another could cause patients to pass out. A fifth included an oral contraceptive and could lead to unplanned pregnancies.

According to the two experts, all of the drugs had been on the market for years, and the pairs presented well-established interactions that pharmacists should easily catch….

Writing the prescriptions was Dr. Steven C. Fox, a Chicago physician who treats many elderly patients on multiple medications. He knew the risks of interactions firsthand.

The reporters tested 30 stores at each of seven leading chains as well as numerous independent pharmacies. Most stores were in the Chicago area; some were in Indiana, Wisconsin and Michigan.

Reporters presented the prescriptions together or a couple of days apart, then waited to see if the orders would be filled.

In Illinois, pharmacists who detect a serious interaction must contact the prescribing doctor to see if the order is correct or if an alternative therapy is available, according to the Illinois Department of Financial and Professional Regulation. Pharmacists are then supposed to alert the patient.

Carmen Catizone, executive director of the National Association of Boards of Pharmacy, said the professional standard is clear. “Anytime there’s a serious interaction, there’s no excuse for the pharmacist not warning the patient about that interaction,” he said.

In the Tribune study, a test was considered a pass if the pharmacist attempted to contact Fox about the interaction or warned the reporter.

Drug information leaflets placed inside the bag or stapled to the outside were not considered sufficient to warrant a pass. Illinois regulators said these materials typically are not adequate replacements for verbal warnings; some of the materials don’t warn about specific interactions, and experts say patients frequently throw out the leaflets without reading them.

After the tests, reporters called many of the pharmacists to inform them of the results and to discuss the findings.

Why were so many pharmacies missing dangerous drug combinations?…

It is difficult to say why so many pharmacists failed the same test, but interviews and studies point to a possible explanation: the emphasis on speed….

The Tribune found that pharmacists frequently race through legally required drug safety reviews — or skip them altogether. According to Illinois law, pharmacies are required to conduct several safety checks, including whether the dose is reasonable and whether the medication might interact with other drugs the patient is taking.

But in the Tribune tests, pharmacies rarely asked what other medications testers were using….

Most pharmacies use computer software designed to flag drug interactions. But experts say computer alerts are so common that pharmacists can get “alert fatigue” and ignore many of the warnings….

At CVS, prompt service isn’t just a vague goal. It is a carefully measured metric that the chain uses, along with other assessments, to grade its pharmacies and rank them against one another, records and interviews show.

Several current or former CVS pharmacists criticized the practice, saying it pressures them to focus more on corporate criteria than on drug interactions and other safety checks….

Performance and business metrics are common at big chain pharmacies and in other industries. Supporters say they make companies more efficient and responsive to customers.

In 2012, the nonprofit Institute for Safe Medication Practices conducted a national survey of 673 pharmacists and found that nearly two-thirds worked at stores that track the time it takes to fill prescriptions. About 25 percent worked at companies that guaranteed short wait times….

In 2013, the National Association of Boards of Pharmacy called on states to prohibit, restrict or regulate company policies that measure the speed of pharmacists’ work. But, the association says, little has changed in state law.

Internal CVS records obtained by the Tribune show that the company tracks numerous pharmacist tasks, including whether prescriptions are filled in the time promised to customers and whether voicemails are retrieved in a timely fashion….