A Review of the Evidence on Its Safety and Benefits

Alex J. Adams; Steven J. Martin; Samuel F. Stolpe


Am J Health Syst Pharm. 2011;68(19):1824-1833. 

In This Article


The wider use of appropriately structured and implemented TCT programs could reduce the technical functions that pharmacists perform, enabling them to redirect their professional activities to direct patient care activities. Research spanning three decades has demonstrated that specially trained pharmacy technicians can perform final verification in unit dose inpatient medication distribution systems as accurately as pharmacists, perhaps more accurately.[18] Research has also shown that TCT allows pharmacists more time for patient care activities, and a growing body of research links clinical pharmacy services to enhanced patient outcomes and safety.[49,50] In hospital settings, an increased pharmacist focus on clinically oriented activities may be key to a reduction in medication errors and associated consequences such as increased length of stay, mortality, drug costs, and overall health care costs.[49] One study reported a 51% decrease in medication errors (p < 0.05) when pharmacists accompanied a general medicine team on clinical rounds.[50]

Historically, misgivings about TCT have revolved around accuracy and safety concerns, neither of which is grounded in the published evidence to date.[13] Concerns about the safety of TCT may stem from infrequent but emotional reports of errors committed by pharmacy technicians and media reports noting that pharmacy technicians are less regulated than many other professionals even though they handle high-risk medications.[51,52] These arguments may be neutralized by noting that existing TCT programs do require specialized and advanced training for pharmacy technicians in addition to ongoing monitoring for quality assurance.

Concerns have also been raised about the potential effects of TCT on pharmacist job security. Ness and Grauss[13] argued that TCT "frees the pharmacist to roam the halls of the local unemployment agency," but that argument seems to reflect a minority opinion. In a survey of 543 hospital pharmacists, only one in five respondents cited concerns over job security related to TCT and more than half were in favor of TCT.[53] Recent data from the Pharmacy Manpower Project Aggregate Demand Index show that the demand for pharmacists exceeds the national average in more than half of the states that permit TCT (Table 4).[5] Furthermore, several states with TCT programs directly address pharmacist redeployment, with one explicitly stipulating that TCT may not be used as a strategy to reduce staffing.

A confluence of factors, including the ongoing health reform dialogue and emerging trends in health care delivery, has made this an opportune time for the consideration of the expansion of TCT nationally. Record investments in health information technology and other important advances in automation and technology, such as bar-code scanners and automated dispensing systems (many of which did not exist during the TCT studies summarized here) have added layers of safety and accuracy to the drug distribution process. Such technology has further enabled the safe delegation of dispensing functions to technicians.[16,54] Education and training within the pharmacy profession also continue to evolve and strengthen. Pharmacist training has transitioned to the entry-level doctor of pharmacy degree, which emphasizes direct patient care, and more practicing pharmacists than ever hold the doctor of pharmacy degree.[4,55] Similarly, more states have raised the standards for pharmacy technician practice, mandating licensing or registration, the completion of training courses, or certification.[56] As technician training becomes more formalized, it is possible that TCT could provide a career pathway for technicians; several of the studies reviewed here documented increased job satisfaction and professional growth among technicians in settings where TCT is used.[12,57] TCT may also give employers an incentive to invest in advanced technician training.

With regard to the prospects for adoption of TCT by more states, Fuller and Ness[31] noted that demonstration projects and the formation of task forces have been successful strategies in advocating for TCT. However, there is already adequate evidence that TCT demonstration projects in hospitals and other institutional settings would likely be redundant and unnecessary. Demonstration programs may, however, be a way to evaluate the use of TCT in practices beyond hospital and institutional settings. In addition, demonstration projects may be helpful in making the case for expanding the scope of TCT to include automated dispensing machines, which in many cases supplement or have supplanted cart fills. A number of states have already extended TCT to cover automated dispensing machines despite an almost exclusive focus on cart fills in published TCT studies.

In states that permit TCT, some evidence points to low adoption of TCT in actual practice. As one California pharmacist has noted, "Tech-check-tech has never really caught on in any significant way. Of the six hospitals that I've worked at … only one uses a tech-check-tech model."[58] A 2002 report on TCT in Canada painted a similar picture of slow implementation.[29]

Future research should assess the adoption of TCT in states that permit its use and identify barriers to implementation at individual practice sites. Both pharmacists and technicians will likely contribute to such barriers. Research has indicated that "work process changes, increased liability and responsibility, and heightened workplace stress without increased compensation" are areas of concern.[12] Increased liability will be another key issue to address. Medication errors have resulted in substantial fines, the loss of licensure, and, in some cases, jail sentences. Pharmacists have traditionally borne the liability for medication errors and may not feel comfortable operating in a TCT system, in which they would have to partially relinquish that area of responsibility. Similarly, with an expanded role for pharmacy technicians, liability could become a larger issue in technician practice. If TCT is to expand to noninstitutional practice settings, liability will be a primary concern, as the safeguards commonly used in institutional pharmacies (e.g., unit dose systems, medication administration by a licensed health care professional) will be difficult or impossible to achieve.

Pharmacists and pharmacy technicians function best when they work as a team. It will be difficult to expand clinical pharmacy services without an expanded scope of practice for pharmacy technicians. The profession faces a choice: to make better use of highly trained pharmacists and pharmacy technicians or waste the value of both.


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