Abstract and Introduction
Abstract
Objective. The published evidence on state-authorized programs permitting final verification of medication orders by pharmacy technicians, including the programs' impact on pharmacist work hours and clinical activities, is reviewed.
Summary. Some form of "tech-check-tech" (TCT)—the checking of a technician's order-filling accuracy by another technician rather than a pharmacist—is authorized for use by pharmacies in at least nine states. The results of 11 studies published since 1978 indicate that technicians' accuracy in performing final dispensing checks is very comparable to pharmacists' accuracy (mean ± S.D., 99.6% ± 0.55% versus 99.3% ± 0.68%, respectively). In 6 of those studies, significant differences in accuracy or error detection rates favoring TCT were reported (p < 0.05), although published TCT studies to date have had important limitations. In states with active or pilot TCT programs, pharmacists surveyed have reported that the practice has yielded time savings (estimates range from 10 hours per month to 1 hour per day), enabling them to spend more time providing clinical services. States permitting TCT programs require technicians to complete special training before assuming TCT duties, which are generally limited to restocking automated dispensing machines and filling unit dose batches of refills in hospitals and other institutional settings.
Conclusion. The published evidence demonstrates that pharmacy technicians can perform as accurately as pharmacists, perhaps more accurately, in the final verification of unit dose orders in institutional settings. Current TCT programs have fairly consistent elements, including the limitation of TCT to institutional settings, advanced education and training requirements for pharmacy technicians, and ongoing quality assurance.
Introduction
The Patient Protection and Affordable Care Act (PPACA), signed into law in 2010, provides a variety of opportunities for pharmacists to expand their responsibilities in direct patient care, a role for which national pharmacy associations have long advocated. However, the implementation of the PPACA will also impose additional demands on the nation's drug distribution system; it is estimated that an additional 30 million Americans ultimately will gain health insurance as a result of the law. Thus, while the pharmacy profession will gain new opportunities to increase the clinical role of the pharmacist, its ability to do so may be constrained by an increased dispensing workload.
In a 2009 survey, full-time pharmacists reported spending an average of 55% of their workdays performing tasks related to dispensing while devoting only 16% of their time to direct patient care services. More than two thirds of actively practicing pharmacists rated their workload as "high" or "excessively high" and indicated that workload issues negatively affected their contact time with patients, the quality of care they provided, and their opportunities to solve drug therapy problems and reduce potential errors. Moreover, survey respondents reported that heavy workloads take a toll in reduced job satisfaction, performance, and mental and physical health.
Workload issues are exacerbated by shortages in the pharmacist work-force, a problem expected to persist for decades. Even in the challenging economic environment, reports indicated that 18 states had difficulty filling available pharmacist positions, while 31 states reported an even balance of pharmacist supply and demand. The Health Resources and Services Administration has projected a shortage of pharmacists of 11% (38,000 positions) by 2030. As one pharmacist aptly put it in a recent Drug Topics article, pharmacies are "understaffed and overwhelmed."
Ensom and Tierney described pharmacist services as a "scarce human resource" that should be provided in the most efficient and cost-effective manner possible. The staggering costs of avoidable medication-related problems warrant a careful reassessment of the roles and responsibilities of pharmacists and their support staffs to help ensure that the skills and talents that each brings to the health care team are used to full advantage. Studies have shown that most medication errors occur at the prescribing and administration phases of the medication-use process, not at the dispensing stage. This suggests that pharmacists' time could be spent more effectively by focusing on error-prone aspects of medication use and delegating many dispensing functions to pharmacy technicians. This is not a new concept. In 1977 Whitney stated, "The lack of the use of technicians and technologists for preparing and dispensing drugs is one of the prime impediments of the expeditious development and growth of the clinical pharmacist."
One concrete strategy for increasing the role of pharmacy technicians in dispensing is the use of "tech-check-tech" (TCT) programs, i.e., the checking of a technician's order-filling accuracy by another technician rather than a pharmacist. TCT allows specially trained pharmacy technicians working in "tightly circumscribed practice situations" to perform final verification on refill medications. TCT has at times been considered a polarizing issue within the pharmacy profession. As an example, TCT was once widely practiced in California, but vocal opposition led the state board of pharmacy to restrict its use in 1996. A decade later, TCT was reimplemented in California after convincing evidence of its benefits from demonstration projects influenced the board to rethink its earlier decision.
The purposes of this article are to review the published data on the safety and accuracy of pharmacy technicians performing final verification and to evaluate reports of gains in clinical pharmacy services resulting from TCT. The core operational elements of TCT programs will be identified by reviewing applicable state laws and regulations. This information will be used as a framework to make recommendations regarding future TCT programs.