Continuing Education and Performance Evaluation: Essential Elements of Community Pharmacy Success

by Dewansia Sutton, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Grant M, Remines J, Nadpara P, Goode J. Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting. Innov Pharm. 2020;11(3): Article 11. https://doi.org/10.24926/iip.v11i3.3291

The Academy of Managed Care Pharmacy reports that medication errors affect at least 1.5 million people every year resulting in direct medical costs of at least $3.5 billion and result in significant morbidity and mortality.¹ I know that medication errors are a widespread problem, so I chose this study² because I was curious about the influence of training programs on the practice and whether they would be a beneficial addition to my future practice as a community pharmacist. This study assessed the benefit of live interactive training and also analyzed the impact of pharmacy prescription volume and the ratio of pharmacists to pharmacy technicians on the incidence of medication errors.

The study analyzed the incidence of medication errors at several Kroger pharmacies in one district before and after a live training program that addressed the most common types of medication errors reported in the previous six months. These errors occurred at reception, product dispensing, and during the final verification step. The topics of physical and mental fatigue, workplace cohesiveness, ways in which medication errors occur, strategies for mitigating errors, best practices for pharmacy workflow, and company policies and procedures were also addressed during a series of mini (8-minute) lectures. Following the lectures, teams of four consisting of both pharmacists and pharmacy technicians discussed examples of how they could improve their practice to reduce the occurrence of medication errors. These sessions were led by the same team of pharmacists on six occasions. Eighty pharmacists and 150 technicians from 20 different Kroger pharmacies completed the program. The pharmacies were classified as low, medium, or high volume based on their average number of prescriptions filled per week.

Comparisons of medication error occurrences before and after training and differences between the pharmacy categories were made. The ratios of pharmacists to certified pharmacy technicians and other demographic information was recorded. The results of the study are summarized in the tables below. There was a decrease in the number of errors overall and between the pharmacy classifications from pre and post-training but these differences were not statistically significant. The number of pharmacists and technicians based on pharmacy volume (low, medium, or high volume) was significantly different.  The authors concluded that the implementation of these live training programs helped streamline best practices and reiterate patient safety by focusing on medication error reduction.

Table 1: Pharmacy Characteristics

*Differences between groups p <0.01

Table 2:  Medication Error Rates at Baseline vs. Post-Training

This study is valuable because it highlights the fact that even in the most structured pharmacy practice systems, there is always room for improvement. It is also valuable because it shows the potential benefit of continuing education and analyzing medication error trends. I think more pharmacies should design programs similar to this one where pharmacists educate pharmacy technicians and other pharmacists on methods to decrease workplace fatigue and increase cohesiveness to decrease medication errors. The mean number of full-time pharmacists to certified technicians was 2:1 in low volume pharmacies and 2:2 in medium volume pharmacies. The mean number of errors in the medium volume pharmacies pre-live training was just over double the mean number of errors in the low volume pharmacies pre-training.  These results were interesting to me because they show that the number of pharmacists relative to pharmacy technicians may be an important factor in mitigating medication errors. It would be beneficial to employees and patients if the work environment was less stressful and had a smooth, structured workflow with a balanced workload. It is also valuable because it shows what difference can be made when the focus is put towards fixing systematic problems in the pharmacy instead of placing blame on individual employees.

A limitation of this study is the fact that it relied on the pharmacies to self-report the number of medication errors. Recall bias and underreporting of medication by pharmacies could give false confidence that the pharmacy made fewer errors after the training. It also failed to report a breakdown of the number of reported errors in each category before and after the training. This data would have been helpful to determine if the training is effective in minimizing a specific type of medication error. Another limitation is the fact that the pharmacies included in the study were all Kroger pharmacies and have similar policies and procedures.  Moreover, the pharmacists and technicians may not have had the freedom to make significant changes in the workflow or environment if it violated corporate policies. A sample including multiple chains and independent pharmacies would have provided a more accurate assessment of whether this training program leads to a reduction in medication errors and which kinds of practices benefit the most. A larger sample may have produced statistically significant results and more generalizable data. A longer observation period for data collection before and after the training would have increased the amount of data available to analyze and perhaps draw more precise conclusions. 

A similar study analyzed the impact of pharmacist-led training on the incidence of medication errors in an intensive care unit and post-surgical care unit.³ The educators in that program included a clinical pharmacist and a nurse.  The incidence of medication errors before and after the program, which included a lecture and ward-based hands-on instruction, remained high.  But the authors concluded that the program was effective because it changed the work environment to promote a safety culture. Another study published in the Journal of Pharmacy Technology evaluated the incidence of medication errors in the community pharmacy setting but collected data retrospectively.⁴ It attributed the number of reported medication errors to high prescription volumes and lack of adequate pharmacist coverage.  The authors concluded that increasing the number of pharmacists to accommodate the workload may help to minimize errors. The results of this study lead to a revision of pharmacy technician training requirements and certification in the state of New Hampshire. The results of these studies suggest that more work is needed to minimize medication errors and well-constructed training programs may be part of the solution.

Medication errors are expensive, harmful, and potentially deadly.  Live interactive training programs are a great method for delivering information.  I believe people are more likely to remember things when given the opportunity to interact with other participants and the instructor compared to when participants only hear or read about the material. More studies regarding the impact of live interactive training in community pharmacy are needed but the available data suggests they can make a difference in medication errors in pharmacy. Trial and error will be needed to figure out what elements are needed in the training sessions and whether periodic follow-up training should be implemented. Training sessions will also need to be adapted to fit different types and sizes of community pharmacies. Pharmacists should be aware of this study and similar studies so they can make informed decisions about employee training and different approaches to reduce medication errors. 

References:

1. Medication Errors. AMCP.org. https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors. Published 2019.
2. Grant M, Remines J, Nadpara P, Goode J. Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting. Innov Pharm. 2020;11(3):11. doi:10.24926/iip.v11i3.3291
3. Nguyen H, Pham H, Vo D et al. The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study. BMJ Qual Saf. 2013;23(4):319-324. doi:10.1136/bmjqs-2013-002357
4. Pervanas H, Revell N, Alotaibi A. Evaluation of Medication Errors in Community Pharmacy Settings. Journal of Pharmacy Technology. 2015;32(2):71-74. doi:10.1177/8755122515617199