Articles Posted in Pharmacy Legislation

According to reports, the U.S. Food and Drug Administration (FDA) receives approximately 100,000 medication error reports annually. In 2010, the FDA received only 16,689, but by 2018, the agency was receiving more than 100,000 reports per year. Experts point out that medication error reports are submitted on a voluntary basis, meaning that true medication errors are likely even higher.

Dr. Randall Tackett, a clinical and administrative pharmacy professor at the University of Georgia College of Pharmacy states “What’s reported to the FDA usually only accounts for 1 to 10 percent of what actually occurs.” Dr. Tackett went on to theorize that most medication errors result from the extreme workload that pharmacists are faced with. In an effort to combat this issue, some states have implemented prescription shift limits for pharmacists, limiting them to filling 150 prescriptions per shift. A recent news report describes a first-in-nation pharmacy safety bill recently passed by the California legislature.

What is the California Pharmacy Act?

California state lawmakers recently passed Assembly Bill 1286 or the Stop Dangerous Pharmacies Act after months of negotiations with chain pharmacies, labor groups, and regulators. The measure will now be sent to Gov. Gavin Newsom’s desk to be signed. The bill is the first state-level regulation in the nation to crack down on understaffed chain pharmacies making medication errors, setting up California to be a national leader in pharmacy safety if it is passed. The proposed law requires corporate chain pharmacies to report all medication errors as well as provide baseline pharmacy staffing rules to ensure that California pharmacists are receiving the support they need as they fill prescriptions, and give injections.

After a patient is prescribed a medication by their doctor, they assume that the medication provided by the pharmacy will help their condition. However, statistics show that there are a frightening number of pharmacy errors each year. Indeed, according to the World Health Organization, it is estimated that nearly 50 percent of all patients will experience a pharmacy error at some point in their life.

As is the case with most accidents, there are several causes of pharmacy errors. One cause that has garnered significant attention over the past few years is the lax reporting requirements following a pharmacy error. In most states, including Maryland, a pharmacist who discovers that he made an error is not required to report the error. It is only in certain, limited situations that the error must be reported. Experts believe that implementing stricter reporting requirements may bring to light common errors, as well as ways to improve patient safety.

Some states are working to create stricter pharmacy error reporting requirements. According to a recent news report, Ohio lawmakers recently passed a law requiring pharmacists to report prescription errors that harm or kill patients because of reckless behavior or unprofessional conduct. In determining whether to pass the law, lawmakers reviewed data suggesting that there were two deaths and 31 cases of serious injuries in the state over just the past four years. Under the new law, a pharmacist’s failure to report an error could result in disciplinary action, a suspension of their license, required additional coursework, monetary fines, and potentially the revocation of the pharmacist’s license.

A significant number of Maryland prescription drug injuries are caused by opioid use and abuse. Over the last decade, the number of deaths that were related to opioid medications has dramatically increased from about 35,000 in 2007 to over 70,000 in 2017. In an effort to curb these stark statistics, experts began to consider why opioid abuse has become more prevalent over the past few years and what new law or policies could help decrease opioid abuse.

One idea that is starting to gain traction is the concept of partial-fill prescriptions. Under a partial-fill prescription policy, patients who are prescribed certain high-risk opioid medications are given only a few days’ worth of medication at a time. The idea behind the policy is that if patients are given fewer pills they will be less likely to take more than they need. Additionally, proponents of a partial-fill policy hope that it would reduce the number of people who sell some or all of their medication.

According to a local news report, Tennessee recently enacted a partial-fill policy under which patients would only be provided some of their medication on their first visit to the pharmacy. Patients could obtain the rest of their medication, if needed, by returning to the pharmacy once they run out of medication. Under the new policy, pharmacies are responsible for inputting patient data into a state-wide database.

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Medical errors, including Maryland pharmacy errors, are commonly believed to be one of the leading causes of death in the United States. However, the actual number of pharmacy errors is up for debate because, as is the case in Maryland, most states do not require pharmacists to report the vast majority of the errors that occur.

Under the laws of most states, pharmacists need only report errors that end up causing an “adverse medical event.” Essentially, this means that an error does not need to be reported unless the patient suffers some kind of harm as a result of the error. Thus, errors that are caught before the medication is delivered to the patient do not need to be reported.

It is widely believed, however, that the best way to reduce errors is to learn from common mistakes. In most professions, the industry can learn from many common errors as a whole, meaning that pharmacists in Maryland may develop a better way to prevent an error and can share that new method with other pharmacists nationwide. However, in order for that learning process to work, pharmacists must be open about the number and types of errors.

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Maryland medical errors – including misfilled prescriptions – are one of the leading causes of death in the state and across the country. Indeed, a 2016 study by Johns Hopkins concluded that, if properly tracked, medical errors would be the third-leading cause of death in the United States. However, due to the fact that the law allows for voluntary reporting of most errors, many Maryland pharmacy errors go unreported.

According to a recent industry news report, Chicago is taking affirmative steps to combat the growing number of pharmacy errors. The city’s actions follow a report by a local paper indicating that of the 25 pharmacies surveyed, over 50% committed at least one error. The city’s attempts are premised on the longstanding and verified belief that the more prescriptions a pharmacist fills per shift, the higher is the chance that the pharmacist will make a medication error in the type, dose, or administration of a drug.

In an attempt to reduce future errors, Chicago lawmakers have proposed a number of pharmacy regulations. For example, one proposed regulation limits the total number of prescriptions a pharmacist can fill by hour to 10. Another regulation requires that pharmacists who have been working in excess of eight hours notify patients as they fill their prescription. Lawmakers have also proposed that pharmacists be required to take one 30-minute lunch break and several 15-minute breaks per eight-hour shift.

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Chances are anyone who has followed the news over the past few months has noticed at least one serious pharmacy error occurring at either a hospital or a retail pharmacy. Indeed, the Food and Drug Administration estimates that there is on average one death per day in addition to approximately 1.3 million people harmed per year by pharmacy errors. However, these statistics are only estimates because the real number of errors cannot be determined, due to discretionary reporting requirements.

As the law stands now, pharmacies are not required to report most of the errors that their pharmacists make. While some errors come to the public’s attention due to widespread press coverage or because a pharmacy error victim files a personal injury lawsuit, many errors go unreported. Thus, the true number of pharmacy errors is unknown.

According to a recent article, our neighbors to the north in Ontario, Canada have begun to implement mandatory reporting requirements. Evidently, the change in the law was spurred on by the death of an eight-year-old boy last year. The report indicates that the boy suffered from sleeping problems and was prescribed tryptophan by his pediatrician. The boy’s mother called in the prescription and went to pick up what she thought was tryptophan, but what she was given was actually baclofen, a powerful muscle relaxer. After the boy’s death, the coroner reported that “logic would dictate that baclofen was substituted for tryptophan at the compounding pharmacy in error.”

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The U.S. Food and Drug Administration (FDA) recently issued draft revisions of pharmaceutical industry guidelines regarding “off-label” promotion of drugs. “Off-label” refers to information about uses of a drug that have not been formally approved by the FDA and are not included in its approved labeling. The agency has treated off-label promotion as “misbranding,” which can carry both civil and criminal penalties under the Food, Drug, and Cosmetics Act (FDCA). The Second Circuit Court of Appeals struck down the conviction of a pharmaceutical sales representative for conspiring to introduce a misbranded drug into interstate commerce, finding that the off-label promotion rule violated his First Amendment right to free speech. United States v. Caronia, 703 F.3d 149 (2nd Cir. 2012). The FDA’s proposed revisions, published in the Federal Register at 79 FR 11793 (Mar. 3, 2014), seek to apply a narrower set of restrictions on off-label promotion.

The FDCA generally prohibits “misbranding” of an approved drug. In a “Guidance for Industry” document published in January 2009, the FDA addressed the distribution of medical literature and other scientific publications regarding off-label uses of approved drugs. The FDA has strict labeling requirements for all approved drugs, including risks of side effects and complications and instructions for use. Off-label marketing of a drug, the FDA stated in the guidance document, constitutes unlawful misbranding of a drug because the drug’s label does not include “adequate directions for use,” as required by the FDCA. 21 U.S.C. § 352(f), 21 C.F.R. § 201.100(c)(1).

The defendant in Caronia was charged with conspiracy to introduce a misbranded drug, and introducing a misbranded drug, into interstate commerce. 21 U.S.C. § 331(a). If a defendant had the “intent to defraud or mislead,” the offense carries a maximum penalty of three years in prison, a $10,000 fine, or both. 21 U.S.C. § 333(a)(2). The case involved Xyrem, a central nervous system depressant with only two FDA-approved uses. The drug contains GHB, a powerful depressant commonly known as the “date rape drug,” making it one that the FDA closely watches.

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Pharmacies often rely on a team of medical professionals to meet the demands of customers. These teams consist of pharmacists, who must meet educational and licensing requirements in all U.S. states and the District of Columbia; and pharmacy technicians, who are not always subject to such strict credentialing requirements. Some states set a maximum ratio of pharmacists to pharmacy technicians, while others simply require that the pharmacist have adequate support from staff and technology to perform their professional duties. Pending legislation that would increase the number of technicians that can work under a pharmacist has raised concerns about patient safety.

To obtain a pharmacy license, an individual must obtain a degree from an accredited pharmacy school, pass several examinations, and maintain continuing education requirements. Many states do not require as many credentials to work as a pharmacy technician. Maryland requires a person to have a high school diploma or equivalent, complete a 160-hour training program or obtain certification from a national pharmacy organization, and complete annual continuing education. Supervision of pharmacy technicians by licensed pharmacists is critically important to patient safety.

According to a report by Tampa’s WFTS on pending legislation in Florida, errors occur in an estimated 0.09 percent of all prescriptions filled in the United States. While this seems like a small number, the Kaiser Family Foundation estimates, based on data from 2011, that doctors write more than 59 million prescriptions per year in Maryland alone. That means that more than 53,100 pharmacy errors may occur per year in this state. Most of these errors do not cause any harm, but injuries from pharmacy misfills can be severe.

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Last month, the Florida House of Representatives passed a bill, by a vote of 101 to 16, that would double the number of pharmacy technicians each pharmacist can supervise from three to six.

The pharmacists remain responsible for signing off on all of the medication orders, regardless of whether they fill them personally or a trained pharmacy technician fills them under supervision.

Opponents of the bill argue that it puts corporate profits at more of a priority than patient safety.

Under current law, pharmacies have to petition the State Board of Pharmacy in order to have each pharmacist supervise more than one, up to three, technicians. But the bill would allow up to six techs per pharmacist without any prior board approval. Thus, the bill is essentially eliminating the current oversight, and creating the opportunity for a six fold increase in the number of techs without requiring any special application process.

Critics further point to the incidences of pharmacy error that are occurring with the 1:3 ratio, and imply that this would only become more prominent with less oversight.

Major pharmacy retailers, such as Walgreen’s, CVS and Publix, support the bill, claiming that they operate in several states which do not have any mandated ratios, and according to their statistics do not have a difference in quality across these different states. If pharmacies are able to hire more pharmacy technicians, who are paid much less than pharmacists, their potential profits could rise because they could sell more medicine in the same amount of time.

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The lack of comprehensive regulations regarding compounding pharmacies is cause for great concern. For example, records and otherdocuments show that grave safety lapses, such as that which occurred at a Massachusetts pharmacy last fall linked to a deadly meningitis outbreak, was not an isolated occurrence. Alarming revelations predate the New England Compounding Center’s contaminated steroid shots, which were linked to 45 deaths and 651 illnesses.

Compound pharmacies are entities which compound certain drugs for use in hospitals and the like, which are then used to treat patients. Examples of such compounds include intravenous fluids used to treat various conditions. Compound pharmacies evolved out of the need for hospitals to have readily available intravenous drugs, that couldn’t conveniently and accurately be compounded on site.

A Washington Post analysis reveals unsanitary and loose practices at large specialty pharmacies that have in turn been linked to illnesses and deaths over the past 10 years. The Post reviewed hundreds of documents, including lawsuits and FDA documents, and found serious issues with at least three of the fifteen large scale compounding pharmacies that dominate the industry.

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