The entire pharmacy profession and all those interested in medication safety need to coalesce around the need for systemic change in community pharmacy workplace environments.
Authors' note: This commentary includes lyrics from Fire on the Mountain by the Grateful Dead in 1978. The song was written as California hills were engulfed in flames and the message has been suggested to be: “How come we’re doing the same old same old when disaster is at hand?”1
We think this song speaks to where community pharmacy practice is today. Why do we continue to practice in workplaces that we know compromise our own health and the health of our patients?
“Almost ablaze still you don’t feel the heat…It takes all you got just to stay on the beat”
Enter into the world of community pharmacy staff and you’ll often find individuals pushed to the edge to protect patient safety through the colliding responsibilities of prescription verification, insurance company requirements, answering phone calls, vaccine administration, counseling patients, and many other tasks. Community pharmacy practice is on fire and the flames are lapping at patient and health care worker health and safety.
Even before the pandemic, media outlets had taken notice of worsening practice environments in community pharmacies that threaten patient safety.2
Understaffing, resultant high turnover of support staff, unachievable performance metric quotas, consumer demands for fast prescription delivery above all else, and burned-out pharmacy staff feeling powerless to change these situations are all kindling for the fire.
“Caught in slow motion in a dash through the door…The flame from your stage has now spread to the floor”
The pandemic has only exacerbated these conditions, pouring fuel on a growing flame, with higher work demands such as COVID-19 testing and vaccines paired with fewer personnel resources and support.3 It’s raising the potential for medication and vaccine errors.4
We are at risk of losing the public trust that has been at the core of pharmacy practice for decades. The pandemic is also increasing stress levels among pharmacy staff and threatens to decrease the health care workforce as pharmacy professionals seek to escape to new opportunities. We are suffering at a critical point when we are needed the most.
“You gave all you had, why you wanna give more?”
Why does our profession take the heat? We care. We have a professional ethos that tells us that we must meet patient care needs. This ethos originates from the American Pharmacy Code of Ethics5 and is reinforced in the Oath of a Pharmacist.6 Through these documents, we solemnly vow to serve patients and the public. In practice, this has resulted in relegating our health and safety to these demands.
Moreover, these ingrained professional vows, coupled with crippling student loan debt, create situations in which many of us feel compelled to prioritize job security for the sake of ourselves and those we financially support. These twin factors allow the code and oath, which are appropriate and powerful, to be twisted to hold our feet to the fire to meet demands defined by corporate profit-seeking rather than meet patient needs defined by appropriate care.
“The more that you give, the more it will take…To the thin line beyond which you really can't fake”
Too often we lose sight of—or are blind to—our rights as individuals, employees, and professionals. Rights are inherent, inalienable, universal, and indivisible; they are not bestowed upon us and cannot be taken away from us.
Principles are foundational beliefs or behaviors that form our profession. Together, rights and principles must be the springboard for professional responsibilitiesand workplace policies and practices. It should not be the other way around; rights or principles are not derived from responsibilities.
Most importantly, we need to acknowledge our duty to ourselves and reject being seen as only, “a deliverer of service without his/her own existence, safety, or health given credence.”7
We must claim the right and corresponding obligation to take care of ourselves physically and emotionally so that we can safely care for patients. The duty to protect our health must be recognized as equal to our responsibility to protect patient health. A recognition that should reinforce the responsibility that employers have to provide safe and healthy work environments for pharmacists and pharmacy technicians.8
“You say it's a livin', we all gotta eat…But you’re here alone, there’s no one to compete”
As these workplace fires burn, who’s competing against the forces driving the flames? Too often, powerful stakeholders, such as professional pharmacy associations and state boards of pharmacy, are absent or offer only tepid replies to the urgent needs of practitioners. The popular call to be resilient, although important, doesn’t address the root causes of pharmacy chaos and carries an undercurrent narrative of “pick yourself up by your bootstraps.”
More recently, some stakeholders have used bolder rhetoric to acknowledge the “fire” but they still withhold strong, systemic action. The 2021 document titled, “Pharmacists Fundamental Responsibilities and Rights”9 describes pharmacist rights and responsibilities and recognizes the work environment challenges pharmacists face.
The sponsoring associations recommend resolution through individual employee-employer interactions. Such a “face the fire on your own” stance cannot compete with the blaze of corporate power that pharmacy staff endure. Few pharmacists or pharmacy technicians have the resources to overcome the significant imbalance in power that stands between them and their corporate employer.
Some national and state pharmacy associations and boards of pharmacy offer survey data as the answer to the chaos. The Pharmacy Workplace and Well-being Reporting (PWWR) portal10 requests voluntary pharmacist reporting of workplace conditions with the goal of informing best practices, education, and recommendations for change.
But what incentives do pharmacists have to report data? Can it be used to defend against their employers’ demands that compromise patient safety? Not likely.
Will it be reported for public consumption so that the public will demand safer pharmacy environments? No.
Will it provide a reliable view of what is happening in pharmacy workplaces? Only time will tell.
The lack of tangible actions to improve the practice environments of community pharmacy staff begs the question, “Why aren’t these stakeholders taking bolder actions to represent and uphold the rights of pharmacists and pharmacy technicians?”
“There’s a dragon with matches that’s loose on the town…Takes a whole pail of water just to cool him down”
The outcry from pharmacy staff around the country shows this is not just an isolated problem, it’s a public health crisis. Cooling the flames of current practice will require transparent, accountable, and equitable system-based approaches that incentivize medication safety and foster safe and healthy workplaces.
We can’t let the pharmacy profession become a tale of two cities; one in which pharmacists and pharmacy technicians advance their professional practices into new worlds and another in which some work in nearly servitude conditions. We can’t celebrate the former and be nearly complacent with the plight of the latter.
Community pharmacy staff cannot be abandoned to battle workplace environments that compromise their own health as well as patient safety. We need to pull together to ensure the health and safety of pharmacy staff, our patients, and the larger communities we jointly serve.
“Long distance runner, what you holdin’ out for? Get up, get up, get out of the door”
The entire pharmacy profession, in collaboration with other disciplines, and all those interested in medication safety, need to coalesce around the need for systemic change in community pharmacy workplace environments.
Table 1 lists actions to champion as a means to create safer and healthier community pharmacy work environments. None are quick fixes; all will require long-term consistent effort.
Many reflect the thinking of a national task force of public health pharmacists and medication safety experts that is delving into system-mediated medication safety issues.11
At this moment, the fire occurring in many community pharmacy workplaces is raging out of control. We need more momentum to quench the fire and prevent irreparable harm to our pharmacists, our profession, and our patients. Without concrete and concerted interventions, it threatens to engulf the pharmacy profession as we know it and our dignity as pharmacists.
The need is great. The time is now.
About the Authors
Audrey B Kostrzewa, PharmD, MPH, BCPS (corresponding author)
Associate Professor of Pharmacy Practice
Concordia University Wisconsin School of Pharmacy, Mequon, WI
Soosmita Sinha, RPh, Esq
Founder and President
Health Law Institute, Geneva, Switzerland
Nancy JW Lewis, PharmD, MPH
Adjunct Associate Research Scientist
University of Michigan College of Pharmacy, Ann Arbor, MI
Audrey Kostrzewa: Conceptualization, Writing - Original Draft, Writing - Review & Editing, Project administration. Soosmita Sinha: Conceptualization, Writing - Original Draft, Writing - Review & Editing. Nancy Lewis: Conceptualization, Writing - Review & Editing, Supervision
1. Dodd D. Greatest Stories Ever Told - "Fire On The Mountain". Grateful Dead. September 5, 2013. Accessed November 4, 2021. https://www.dead.net/features/greatest-stories-ever-told/greatest-stories-ever-told-fire-mountain.
2. Gabler E. How Chaos at Chain Pharmacies Is Putting Patients at Risk. The New York Times. January 31, 2020. Updated October 13, 2021. Accessed November 4, 2021. https://www.nytimes.com/2020/01/31/health/pharmacists-medication-errors.html.
3. Kaplan A, Nguyen V, Godie M. Overworked, understaffed: Pharmacists say industry in crisis puts patient safety at risk. NBC News. March 16, 2021. Accessed November 4, 2021. https://www.nbcnews.com/health/health-care/overworked-understaffed-pharmacists-say-industry-crisis-puts-patient-safety-risk-n1261151.
4. Mix-Ups Between the Influenza (Flu) Vaccine and COVID-19 Vaccines. Institute for Safe Medication Practices (ISMP). October 7, 2021. Accessed November 4, 2021. https://www.ismp.org/resources/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines.
5. Code of Ethics for Pharmacists. American Society of Health-System Pharmacists. Accessed November 4, 2021. https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/code-of-ethics-for-pharmacists.ashx.
6. Oath of a Pharmacist. American Pharmacists Association. Accessed November 4, 2021. https://pharmacist.com/About/Oath-of-a-Pharmacist.
7. Sinha S. Recognizing “duty to self” to save health worker lives. August 12, 2021. Accessed November 4, 2021. https://www.healthlawinst.org/post/recognizing-duty-to-self-to-save-health-worker-lives.
8. OSHA Worker Rights and Protections. United States Department of Labor Occupational Safety and Health Administration (OSHA). Accessed November 4, 2021. https://www.osha.gov/workers.
9. Pharmacist's Fundamental Responsibilities and Rights. American Pharmacists Association. Accessed November 4, 2021. https://www.pharmacist.com/pharmacistsresponsibilities.
10. Pharmacy Workplace and Well-being Reporting (PWWR). American Pharmacists Association. Accessed November 4, 2021. https://www.pharmacist.com/Advocacy/Well-Being-and-Resiliency/pwwr.
11. Task Force on System-Mediated Medication Safety Issues. Addressing Community Pharmacy System-mediated Medication Safety Issues. American Public Health Association (APHA) Pharmacy Section. October 2021.