Is it safer to use mail order or your local pharmacy?

Checker Drugs in Dearborn Heights is one of many pharmacies that have closed in Michigan

Is there a real difference between mail order pharmacies and community pharmacies when it comes to patient safety? It’s a question that’s thrown my way now and then. Just this Thursday, after The Inquirer published one of my recent blogs, Ann from Wayne wrote:

“It is ironic that I am reading the Inquirer article you wrote on Nov. 30, while waiting until 8 a.m. for my mail order pharmacy department to open. The prescription I take for blood pressure arrived but the shape and number on the pills are dramatically different than my last prescription, and there is no explanation. I have no idea if this is the same medication in a different form, or an error. In general, how does the error rate for mail order compare with neighborhood pharmacies?”

This question is especially germane in Pennsylvania. Health insurers give people incentives to use mail order pharmacy. They charge lower co-payments and allow up to three months of medication to be dispensed compared to medications dispensed by your local pharmacist for 2 months. Recently, health insurers have even begun to refuse to pay for certain chronic medications if you don’t get them from a mail order pharmacy after filling a new prescription for the medication once or twice at your local pharmacy for convenience. Community pharmacists have lost customers over the years, and for many, it’s become a hardship so they’re seeking parity in Harrisburg through a legislative fix. If successful, your local pharmacy would be able to fill your prescriptions with a 3-month supply and lower co-payments, just as mail order pharmacies do. So, patients would be free to decide where to have any of their prescriptions filled, and they would be able to fill all their prescriptions at one pharmacy. The Inquirer’s Stacy Burling recently covered this story.    

Actually, there doesn’t seem to be much evidence that one type of dispensing system offers greater safety over the other. The ISMP National Medication Error Reporting Program (ISMP MERP) receives many reports about pharmacy dispensing errors in both types of operations, but these are submitted voluntarily by healthcare professionals and consumers. The purpose is to learn about the nature of these errors so we can publish ways to avoid them.  Most dispensing errors are reported internally at the pharmacy or to corporate headquarters and not shared with national reporting programs. So there’s no accurate way to track error rates nationally. 

In fact, for pure dispensing accuracy, mail order might have a slight edge in some respects. These pharmacies take advantage of various technologies, tapping into experts in human factors to design systems that minimize failures. The check systems are superior, environmental issues are addressed, and they tend to cross-train and rotate employees through various work stations and tasks throughout the day. They also do a good job at monitoring “defects” and addressing them through avid use of six sigma methods.

That said, there can certainly still be errors, inconveniences to patients, and delays with mail order. With many prescriptions still handwritten, errors can happen when technicians or pharmacists are reading and interpreting the prescription and entering it into the pharmacy computer. If the prescription is misread, or if the wrong medication is selected on the computer screen, the mistake might go totally unnoticed and reach the patient. We also receive reports about prescriptions being mailed to the wrong person’s house. (I once got someone else’s Xanax, meant for a patient in Illinois.)

We also hear about problems with people not getting their critical chronic medications on time or not taking some doses because they ran out of their current supply and could not get a rapid enough refill (or replacement of lost medications) from a mail order pharmacy. Also, if you need an early refill because you are going on vacation, mail order pharmacies cannot help you the way your local pharmacist can. A very important issue, too, is the inability of mail order pharmacies to respond to acute illness needs and prescription emergencies. For that, you’ll need your local pharmacy.

I heard that Medco’s CEO, David Snow, recently remarked that the robotics (automated machines that fill prescriptions) they employ are “twenty-three times more accurate” than human pharmacists. A Medco study does exist to support Mr. Snow’s comments, comparing error rates at a Medco facility in 2003 with findings in a 2000-2001 study of 50 community pharmacies. These figures must be balanced, however, by the fact that, in more recent years since the study, many community pharmacies have also begun using robotic technologies. Many community pharmacies also now employ bar- coding to verify that the correct drug and dose has been selected from the shelf; they have computer screens that display pictures of what the pill looks like for comparison with the actual pills in the filled prescription vial; and they have computers that check for drug interactions and other technologies that are similar to those used in mail order pharmacies. More and more community pharmacies are also working to eliminate common interruptions of pharmacists, which is a key cause of human errors, by setting up call centers offsite and by having refills filled at a central pharmacy location and then sent back to the local pharmacy.

Unfortunately, another factor is that pharmacists in mail order pharmacies are faceless. You will never really get to know them. They’ll always be just a voice on the phone, and since you don’t know them, you may interpret their demeanor as uncaring. This is a major drawback compared to having a good caring pharmacist you can speak to directly, as I do at the local Acme Markets pharmacy near my house.

In a community pharmacy, the opportunity exists for more face-to-face communication and education, which is more effective when it comes to safety than just reading a drug information sheet. You can ask questions immediately, and contacting the pharmacist by phone is much easier and quicker than with a mail order pharmacy. With face-to-face contact, pharmacists have a chance to make sure patients know how to take their medicine using a strategy called “teach back”—the patient shows the pharmacist how they are supposed to take their medicine or states the directions for use for verification. Let me be the first to say, though, that not all pharmacists spend the time needed with patients to properly educate their patients so they know how to take their medications safely.

In many community pharmacies, staffing is slim, and interruptions are frequent because pharmacist are talking to patients who come to the counter and taking patient’s calls, doctor’s calls, insurance company calls, and so on.  In addition, you can add speed promises like the The Rite Aid 15 minute promise that could pressure pharmacists into taking short cuts when they believe problems are remote and think patient harm from an error is unlikely.  That in itself can lead to errors.

So, bottom line: whether its mail order or community pharmacy, both have plusses and minuses. Neither is perfect. Consumers still need to keep an eye out for issues like the one Ann asked about. I’d love to hear what you think.

By the way, after two phone calls, talking to four people, over 45 minutes, Ann had an answer to her question. The medication in her prescription vial was the correct medication—it just came from a different manufacturer so it didn’t look the same as her last refill. Should you have a similar question about a pill’s appearance, either do what Ann did (call the pharmacy), or save yourself some time by going to our website and using our free pill identifier.

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