Are accuracy checking technicians being used as cheap pharmacists?

By PDA Union locum membership group

The accuracy checking technician, or ACT, is a reality in an increasing number of community pharmacies today. But what, precisely, is an ACT, and what is the reality of working with one? We sought the views of users of internet pharmacy discussion forums LocumVoice, Pharmacy Forum, PJ Online and the Royal Pharmaceutical Society general group, and have drawn from our own pool of experiences. A number of issues were highlighted in response.

Pros and cons of ACTs

The advantages of using ACTs were cited mainly by proprietors as a means of reducing the number of pharmacists needed to run busy dispensaries with high prescription turnovers, and by pharmacist managers as a means of relieving pressure with regard to routine activities, particularly in the provision of regular repeat prescription collection services and monitored dosage systems.

Concerns were raised by pharmacists of different backgrounds but, in particular, by locum pharmacists who are often required to work alongside ACTs of whose competence they lack the evidence and first-hand experience that would reassure. Locums and relief employee pharmacists are finding themselves in invidious positions on arrival at unfamiliar pharmacies when, often, an ACT may be introduced without an available and up-to-date reflective error log, and even without certificatory testimony to document the credentials and currency of the accreditation. This is despite the introduction of the responsible pharmacist legislation, which requires a responsible pharmacist to be satisfied that tasks are delegated to support staff of known specified levels of attainment in accordance with standard operating procedures (SOPs). In our experiences, there are ACTs who will expect to commence accuracy checking duties without first having ensured that the responsible pharmacist is thus satisfied for this to proceed.

Less-than-ideal scenarios

Anecdotal evidence is indicative of a problem wherein staff employed to act as ACTs may become prone to misconceptions about the importance of a pharmacist’s duties in the clinical checking of prescription medicines and in the supervision of the sale of pharmacy medicines (ie, to intervene whenever necessary in the course of medicine supply).

Our members have encountered such ACTs, who have become accustomed to performing final accuracy checks on dispensed items without a pharmacist’s clinical assessment. For example, in the provision of regular repeat prescription collection services and monitored dosage systems, the ACT would offer rationale such as “nothing has changed since last time” and is apparently oblivious to the circumstances of any safeguards designed to ensure that medicines cannot be supplied to patients without the exercise of a pharmacist’s professional judgement. This has led to scenarios, including:

• ACTs making decisions on whether or not to “lend” prescription-only medicines to patients without a legally valid prescription
• Discontinued medicines — which, due to error at the doctor’s surgery, have been “revived” on a repeat prescription — being erroneously dispensed (eg, resulting in multiple corticosteroid inhalers being prescribed by asthma nurses) “because they’ve had them before”
• Inappropriate non-bioequivalent preparations that could compromise patient therapy (eg, the supply of Adalat Retard tablets od to a patient stabilised on the corresponding strength of Adalat LA tablets) being supplied in error
• Seemingly minor changes made in the transcription of a prescriber’s dosage instructions onto a dispensing label being overlooked, thereby introducing potential semantic errors that could jeopardise medication adherence and patient safety (eg, a doctor’s instruction on warfarin 1mg tablets of “Do not mix up with 5mg tablets” being labelled as “Do not mix with 5mg tablets”).

These scenarios, in which ACTs have acted beyond the scope of whatever instruction they may have received, remind us of Alexander Pope’s warning that “a little learning is a dang’rous thing”. The dangers inherent in such practice becoming commonplace — not least that prescription medicines are supplied to patients before a pharmacist can undertake a clinical check to ensure safety and appropriateness — are such that further investigation should be undertaken as an imperative.

Qualifications and regulation

Major questions remain unresolved with regard to the criteria that define ACTs. There is no nationally standardised accrediting qualification in the community sector. Legislation and the General Pharmaceutical Council do not recognise accuracy checking technicians while registered pharmacy technicians must be trained to a minimum equivalent to NVQ level 3 pharmacy services.

There remains no requirement for dispensary staff performing final accuracy checks on dispensed medicines to be registered pharmacy technicians. As such, the prevalence of “in-house” accreditation (ie, by their own work colleagues) of accuracy checking dispensers seems to have emerged within corporate bodies, and the intake for this accreditation process need be no more qualified than dispensing assistants trained to the equivalent of pharmacy service skills NVQ level 2. For example, candidates may need only to undertake a short correspondence course and then to complete a log of 1,000 items, which have been checked by the candidate and then further checked by a designated facilitator, who could be a checking technician or a pharmacist. One of our group has encountered such a dispenser recently who was proud to be qualified to accuracy check, but could not distinguish between Fucidin and Fucibet creams.

Pharmacists have voiced their apprehensions and lack of confidence in delegating the final accuracy check to community pharmacy support staff whose proficiency may be questionable. There is a considerable cause for concern, doubt and distrust where accuracy checking dispensers have been “facilitated” by familiar work colleagues who may feel uncomfortable about being objectively critical in the event of errors being made in the collation of a 1,000-item log. Alternatively, they may cherry-pick particular items to be checked at certain times as a consequence of commercial pressures such as the interest of a company in getting its staff accredited.

The concept of using ACTs in community pharmacy is one which seems to have draw inspiration from their employment in hospital pharmacy, and a contrast is discernible in comparing the two sectors. There is an “NHS nationally recognised framework for final accuracy checking of dispensed items” that is used to accredit registered pharmacy technicians only.

However, even this framework may not be as robust as the interests of patient safety necessitate, in that candidates are assessed and reaccredited by their employer, and in that a candidate is required to check successfully only 1,000 items, and is allowed a maximum of three less-serious errors while no serious errors are allowed. When judged against the work of Ashcroft et al¹ in their prospective study of the incidence, nature and causes of dispensing errors in community pharmacies, finding from over 125,000 dispensed items that, “on average, for every 10,000 items dispensed, there are around 22 near-misses and four dispensing errors”, the evidence is clear that the checking of a mere 1,000 items could not possibly confer the breadth of experience in accuracy checking. Also, it could not demonstrate sufficient proficiency in spotting potential errors on performing the final accuracy check before supply to patients.

Responsibility and due diligence

A principal issue in the use of ACTs is that of responsibility for supplied medicines. This has become a legal grey area because, since the enactment of the responsible pharmacist Regulations, a responsible pharmacist in charge of a pharmacy premises must, under the new section 72A of the Medicines Act 1968, “secure the safe and effective running of the pharmacy business” so far as concerns the sale and supply of medicinal products. One of our group has highlighted, in letters to the PJ (17 July 2010, p82, and 25 September 2010, p333), the potential need for a responsible pharmacist to be able, in the event of a dispensing error, to demonstrate that all due diligence had been exercised in order not to be apportioned with criminal culpability and liability for delegated work.

The GPhC manifestly has refused to address our calls for clarification on the apportionment of professional responsibility, on whether accuracy checking must be restricted to registered pharmacy technicians as a minimum standard, and on what (if any) training in accuracy checking is necessary (PJ, 24 September 2011, p367). It has stated no intention to recognise ACTs via register annotation, as another author has called for in a joint letter (PJ, 18/25 December 2010, p714). It follows, therefore, that corporate SOPs, by which accuracy checking may be delegated as described, may not withstand the scrutiny of risk-assessment, and so demonstrating the exercise of due diligence might be a daunting prospect.

Furthermore, Joy Wingfield has elaborated in detail the lack of clarity over where accountability will now be distributed in criminal, civil and regulatory proceedings (PJ, 3 September 2011, p246).

It could be argued that typical current pay levels for ACTs are incommensurate with any significant assumption of responsibility for dispensed medicines. And, although employers claim that their indemnity insurance will cover the work of an ACT, it is unclear how this would translate into practice in the event of an insurer and its legal counsel representing both an employer and a dispenser between whom a conflict of interest arises not dissimilar to the recent case in Prestatyn (PJ, 31 October 2009, p471). There is also the issue of locum ACTs emerging who are not yet known or encouraged to carry their own individual indemnity insurance cover.

Worrying conclusions

From the issues that have been highlighted, we can only conclude that the trend of ACT employment in community pharmacy practice to date has been executed in the manner of a cheap substitute to avoid the cost of employing an adequate number of pharmacists for a given workload. The notion that the employment of ACTs should pave the way for fewer pharmacists to be employed is discredited by the duty of pharmacists to perform professional pharmaceutical assessments, which cannot be undertaken by less qualified staff, on volumes of prescription throughput that continue to increase in excess of 5 per cent year-on-year. Thus, this exposes that notion to be no more than an expedient exercise in commercial cost-cutting.

Moreover, the restriction of the title “pharmacy technician” to GPhC registrants does not appear to have put a stop to the delegation of accuracy checking to non-technicians, a subject on which the GPhC’s silence is now deafening.

The views expressed here are those of the PDA Union locum membership group and do not necessarily reflect those of the Royal Pharmaceutical Society Assembly or national pharmacy boards, on which some group members sit.

Reference

1. Ashcroft DM, Quinlan P, Blenkinsopp A. Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies. Pharmacoepidemiology and Drug Safety 2005;14:327–32. Available at: www.ncbi.nlm.nih.gov (accessed 5 December 2011).