US Pharm. 2009;34(11):3.

With the flu season quickly approaching, imagine an absolutely unbearable workday in your pharmacy. Anticipating the worst, you call in extra pharmacists and pharmacy technicians to help fill what are expected to be some of the busiest prescription days of the year. Sure enough, on a typical day during the flu outbreak, a line starts early at the prescription drop-off counter and continues to build throughout the day. Cars are stacked up at the drive-through prescription window as though McDonald’s were giving out free Big Macs. As physicians’ offices open, the pharmacy’s phones ring incessantly with new prescription orders and permissions to refill older prescriptions. Everyone is working to their fullest capacity, which necessitates extra effort from all pharmacy personnel. Pharmacists’ and technicians’ fingers are furiously tapping the computer keyboards trying to input data as quickly as possible while making sure important information is accurately recorded into patients’ medical records. Medication stock bottles are being pulled from every shelf in the pharmacy, with their tablets and capsules ready to be poured out into the smaller prescription containers and bottles lined up on the prescription counter, each awaiting a label with instructions to be affixed to it. Once filled, the prescriptions will be checked by a pharmacist before being dispensed to the patient. The pharmacy counter is a mess and resembles the trading floor of the New York Stock Exchange after a busy day, with notes on scrap paper strewn everywhere. Pharmacy technicians and pharmacists line up to fill the waiting prescription bottles and vials like a General Motors assembly line.

And then it happens...a pharmacy technician prepares a prescription that contains a fatal dose of the medication. Because of the craziness in the pharmacy, the error gets passed over by a pharmacist who is supposed to check each and every prescription before it is dispensed.

A doomsday scenario, you say, that would never happen in your pharmacy?  Maybe, but the truth is, it does happen, and it is more than likely that the pharmacist, not the technician, will pay the consequences of any error. Depending on its severity, the error could result in a hefty fine and prison time for the pharmacist. While the above scenario may be fictitious, a case reported by U.S. Pharmacist’s legal contributor, Jesse C. Vivian, BS Pharm, JD, in this month’s Legal Considerations column (page 66), is unfortunately all too real.

In that case of a fatal error, the technician was charged with negligent homicide but was given a “get out of jail free” card by the court, wasn’t even fined, and actually went back to work in a retail pharmacy. The pharmacist, however, was found guilty of involuntary manslaughter and faced up to 5 years in prison and a $10,000 fine. His license was revoked, and he will probably never work again as a pharmacist. All this because he did not check the accuracy of a prescription filled by the technician.

The column should be a wake-up call for every pharmacist who works closely with one or more pharmacy technicians. While it is true that each case of negligence involving a technician will be judged on the merits of the case, the message is clear. The truth is that if a pharmacist is not diligent about checking a technician’s work, the consequences could be dire.

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