Advanced Pharmacy Technician Roles in Pharmacy Practice(Practical Considerations)Pearls Session #2

Frank P. Sosnowski, PharmBS, MSUnified Director of Pharmacy

Montefiore Medical CenterBronx, NY

September 18, 2015

Disclosures

• I have no relevant financial agreement with any individual or professional organization when discussing this topic

• I am a member of the New York State Board of Pharmacy

• I am a Past President of the NYSCHP

Objectives

Outline the similarities and differences of Pharmacy technician regulations in the Tri-State area

Define the benefits and concerns of a Pharmacy “Tech-Check-Tech” program in institutional practice.

Describe the requirements to implement a pharmacy “Tech-Check-Tech” program in institutional practice.

• Summit Recommendations February 1, 2011

• A. Imperatives for New Pharmacy Practice Models

• B. Optimal Pharmacy Practice Models: Characteristics, Requirements, and Challenge

• C. Advancing the Application of Information Technology in the Medication Use ‐Process

• D. Advancing the Use of Pharmacy Technicians

• E. Successful Implementation of New Pharmacy Practice Models

www.ashp.org/PPMI

Pharmacy Technicians Tri-State Comparison 2015State New York* New Jersey ConnecticutRecognize Technicians in Pharmacy Practice

Act

YesUnlicensed Persons

* Pending legislation

YesPharmacy Technicians

Yes Pharmacy Techniciansa) In Licensed Pharmacies

b) In Institution Pharmacies

Require Registration No Yes Yes

Require Certification No No/Yes (ICPT and PTCB)

Yes

Ratio

(Tech to Pharmacist Supervision)

2:1 2:1**provisions for greater

ratio (National PTCE+ P&Ps, job description)

2:1 outpatient(petition 3:1 IV, UD, bulk

compounding)2:1 Institutions

(petition inpatient/Sat. 3:1 or 5:1)

PTCB Technician # (2014) 7085 4452 1941

Cost to Register N/A $35 Application $25 Annual renewal

$100 Annual renewal

Requirements to Register

N/A At least 18 years oldHigh School Diploma or a GEDGood Moral CharacterPass National Tech Exam OR complete Board approved Nat.Tech Program

Have a certification from the PTCB or another program that is approved by Connecticut

Average Salary **(Google Trends)

$37,000 $33,000 $34,000

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. 9

NYS Pharmacy Technician Bill

PendingNYS Pharmacy Technician Bill• Requirements for Registration and Certification of

Pharmacy Technician:– 18 years old– High School Education or GED– Good Morale Character, no felony or drug related

convictions– Triennial Fee– Registration with the Board– Certification mandate by 1/1/18 (must file and have

successful completion of an educational or training program approved by the board)

– 30 hourrs CE every 3 years– Unless 5 years of employment within the last 8 years as a

pharmacy technician at a pharmacy and “directly” supervised “at all times” and perform only non-judgmental task.

– Individual enrolled in Pharmacy Tech training program will be exempt for a max of 2 years

– Board may adjust ratio if “All” technicians employed at the pharmacy are certified.In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. 10

Concept of a Pharmacy “Tech Check Tech” Program• Purpose:

– Allow pharmacists to practice at the top of their license

– Enable growth and development of clinical pharmacy programs and clinical pharmacists

– Most effective use of pharmacists as direct patient care providers

– Redeploy pharmacists to patient care areas to focus on safe and effective use of drug therapies

– Enhance patient satisfaction– Assure utilization of the most cost effective drug

therapy– Promote professional job satisfaction

Evidence Supporting the Practice of “Tech Check Tech”• 1989 Minnesota Society of Health-system Pharmacists collaborates

with State Board to develop guidelines for “Tech Check Tech” program

• 1991 Minnesota project demonstrated 99.94% accuracy rate by tech checking unit dose carts

• 2000 Ambrose et al, Cedar-Sinai Medical Center and Long Beach Medical Center in California, 99.89% accuracy rate

• Washington, Kansas, Kentucky, California implement the concept of TCT for unit dose medications

• AJHP Oct 2011 Adams et al “Tech-Check Tech”: A review of the evidence on its safety and benefits. Review of 11 published studies demonstrating comparable accuracy between pharmacists & technicians in performing the final dispensing check

• AJHP Oct 2011 Reed et al “Experience with a “tech-check-tech” program in an academic medical center. Allowed pharmacists to spend more time on patient care units.

• Woller et al. AJHP. 1991;48:1952-6.• Ambrose et al. Am J Health-System Pharm. 2002;59:1183-8.• Adams et al. Am J Health-System Pharm. 2011;68:1824-33• Reed et al. Am J Health-Syst Pharm. 2011;68:1820-3.

A comparison of technicians and pharmacists in checking automated drug cabinet medications in an academic teaching hospital: “Tech-Check-Tech”

Rachael Aletti, BS, PharmDMark Sinnett, PharmD, FASHPAlla Belovsky, MSEllen Rudnick, MSYvonne Gayle, PharmDFrank Sosnowski, MS

Residency Project 2012

Objectives

• Primary– To compare the error rates between unit

dose medications verified by a technician and those verified by a pharmacist

• Secondary– To assess data trends regarding error

occurrences, such as:• Type of error• Time of day error occurred• Campus (Henry & Lucy Moses or Jack D. Weiler)

Design

• Concurrent, quality-improvement study• Eligibility to participate:

– Attendance at a didactic training module– Participation in a practical session– Completion of a competency evaluation with a score of ≥

90%– National Pharmacy Technician Certification (Tech-Check

only)

• Didactic training topics include:– Background relevant to the study– Detailed overview of the study process– Components of the checking process / Quality Assurance– Definition and examples of high-risk medications– Look-alike Sound-alike (LASA) medications

The Players

• Carousel-Tech– Rx Specialist operating the carousel dispensing

technology (CDT; e.g., TalystTM) • Serve as first check in the quality assurance (QA)

process• Check-Tech

– Board certified (CPhT) Rx Specialist – Verifies accuracy of drugs selected from CDT

• Serves as Second check in the QA process• Auditor

– Pharmacy manager or PGY1 Pharmacy Resident– Documents the demographics of each CDT stock fill– Assesses for errors among all double-checked drugs

• Documents and corrects any errors before drug is sent to floor

The Process ( 2 study arms)

• Arm 1: Pharmacist checks a Tech (control arm)– Will tell us the baseline error rate of a pharmacist

acting as second checker on the drug

• Arm 2: Tech checks a Tech (study arm)– Will tell us the error rate of a Technician acting as

second checker on the drug

• Artificial errors– Will be randomly introduced by the Auditor at a

rate of 0.2% in order to maintain the error rate seen in past studies

Woller et al. AJHP. 1991;48:1952-6.Reed et al. Am J Health-Syst Pharm. 2011;68:1820-3.Ambrose et al. Am J Health-System Pharm. 2002;59:1183-8.

Bin: T-1Check-Tech verifies that the

contents of each bag are accurate

-Check-Tech initials each bag-Check-Tech places verified bags into Bin T-2

Bin: P-1Pharmacist verifies that the

contents of each bag are accurate

-Pharmacist initials each bag-Pharmacist places verified bags into Bin P-2

Bin T-2: Contains all unit doses

verified by the Check-Tech

Bin P-2: Contains all unit

doses verified by a Pharmacist

Carousel-Tech picks drugs from CDT, picking station, or remote stock

-Mark an X on the bag if drug was chosen from picking station or remote stock

- Alternate bags into Bin P-1 and Bin T-1- Place all patient-specific drugs in Bin P-1

CDT: Carousel Dispensing Technology

All double-checked and audited bags are placed into Bin D

-Bags in Bin D are delivered to respective hospital units and filled into the ADC stations

Auditor assesses the accuracy of drugs verified by

the Check-Tech (Bin T-2)-Documents stock fill demographics and the number of unit doses in each bag on the data collection sheet-If an error is detected, documents error type and then rectifies error

Auditor assesses the accuracy of drugs verified by the Pharmacist

(Bin P-2)-Documents stock fill demographics and the number of unit doses in each bag on the data collection sheet (excludes patient-specific items)-If an error is detected, documents error type and then rectifies error

ADC: Automated Dispensing Cabinet

Statistics

• Based on previous data, with a technician error rate of 0.11% and a clinically significant difference of 0.3% between groups, approximately 5,165 unit doses per group are required in order to meet 80% power with a two-sided α of <0.05

• We plan to audit a minimum of 6,000 unit doses per group, with a goal of 20,000 unit doses per group

• Statistical analyses will be performed for categorical data utilizing the Chi-Square analysis with Yate’s correction

Woller et al. AJHP. 1991;48:1952-6Reed et al. Am J Health-Syst Pharm. 2011;68:1820-3.Ambrose et al. Am J Health-System Pharm. 2002;59:1183-8.

Conclusion

• This study received approval from the Pharmacy & Therapeutics Committee 12/2011

• Technician training completed and data collection began in late January 2012

• Plan: If no statistical difference observed, the State Board will be petitioned with evidence to approve a TCT Program at our institution

• Policies and procedures to be developed regarding the audit process and validation of technician accuracy– Follow-up validation of accuracy will be scheduled in 3 to 6

months– ADC audits and interdisciplinary involvement with nursing

will occur to see if errors are observed on the floors

Results • Total of 61,746 unit doses were audited

intermittently (Jan 24 to March 15,2012) • Audit showed accuracy rate of 99.87% for

pharmacist vs 99.98% for technician)• Pharmacist n= 28,566 doses Tech n=30,118 excluded doses 3062

• No statistical difference in accuracy rates– Wrong strength missed was most common error in both arms – Larger variety of errors in pharmacists group

• Conclusion: Pharmacy Technicians are highly accurate at checking unit dose medications picked via Carousel

• Results presented at a NY State Board of Pharmacy in 2012

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. 23

WHAT HAPPENED ?• NYS Board of Pharmacy - mixed view points (we are

putting the “Cart before the Horse”)• Awaiting for approval of pending Technician Legislation

to pass (with certification) x 3 years• Pharmacy Operation Directors (SPs) preferred State

Board approval before initiation• Directors felt not enough qualified techs to be a

success 24/7• PTCB Tech turnover increased (1199 upgrade fund

program) + FMLAs• Competing Priorities on several Pharmacy Technology

projects (DoseEdge, Pyxis ES, Sentry, Sentri 7, Kit Check, Alaris smart pumps, Epic)

• Carousel Technology failures with software and hardware

• No Operation Manager “Champion”• Institution in Expansion and Acquisition Phase• No letter written petitioning the State Board by

Director

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. 24

Lessons Learned• Review Literature (don’t re-create the wheel”)• Incorporate right qualified technicians + build

excitement• Educational Program with testing to assure

competency• P&Ps and QA process• Communicate with “all” staff within and out of

Dept. • Build Momentum and stay on course.• Time consuming to do study and initiate

correctly • Review Technician “job descriptions”• Find Manager Champion and “Just do It!”• Petition the State Board earlyIn response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. 25