The Growing Burden on Community Pharmacies

Community pharmacies in Ireland, much like their counterparts globally, are facing an unprecedented escalation in workload. This isn’t merely a fleeting challenge but a systemic issue, intricately linked to an aging population with more complex medical needs, the increasing array of patient services offered, and an ever-growing administrative burden that takes valuable time away from direct patient interaction. This escalating workload has far-reaching consequences, extending beyond just patient access to clinical pharmacy services. It significantly impacts the well-being of our dedicated pharmacists and pharmacy staff, contributing to increased stress, burnout, diminished job satisfaction, and even a higher rate of job turnover.

Within this demanding environment, a pervasive yet often unquantified phenomenon known as ‘rework’ further exacerbates the pressures on pharmacy operations. Rework, in essence, is any activity during the medication dispensing cycle that necessitates a return to a prior procedural step for correction. It represents an inefficiency, a deviation from the ideal flow, and a significant drain on resources. My recent research, a pioneering observational study into the cause and frequency of prescription rework in community pharmacies, has unveiled the startling reality of its prevalence. This study, the first of its kind to comprehensively evaluate a wide variety of prescription reworks in this setting, found that on average, at least five instances of prescription rework occur every single day in community pharmacies. This figure, based on self-reported data, is likely a conservative estimate, as many reworks caused by other staff members might not even reach the pharmacist’s awareness. The sheer frequency of rework undeniably adds considerable complexity and a significant time burden to the already demanding role of providing pharmaceutical care to patients. As a pharmacist and a fervent advocate for lean principles, I firmly believe that adopting these methodologies offers a robust and transformative solution to these challenges, promising to inject much-needed structure, efficiency, and value into the Irish pharmacy business.

Understanding Rework: A Deeper Dive into the Causes

To effectively combat rework, we must first understand its multifaceted origins. Our study cataloged 325 reworks across 65 study days, revealing distinct patterns and primary culprits.

The three most common categories of rework identified were:

• Labelling Errors (22.8% of all reworks): These were the most frequent category, encompassing a range of inaccuracies that necessitate correction. “Wrong instructions on the label” was the most common individual rework type (8%), highlighting a critical point of failure in communication or data entry. Other significant issues included incorrect quantities (5.2%), wrong strengths (3.4%), and even instances of the wrong patient or brand on the label. These errors often require a complete relabeling process, consuming time and potentially delaying patient access to their medication.

• Prepared Prescriptions Requiring Opening and Repackaging (15.1% of all reworks): This category speaks to inefficiencies in the preparation and dispensing process itself. The most frequent individual rework within this category was “an item omitted from bag” (7.4%), followed by “an additional unwanted item in bag” (4.9%). This means that after a prescription has been seemingly completed and bagged, it needs to be unbagged, corrected, and rebagged, a wasteful duplication of effort. My research further highlights the critical role of communication between pharmacy staff and patients in preventing this type of rework.

• Medication Owings to Patients (13.9% of all reworks): This is a particularly frustrating category for both patients and pharmacy staff. The overwhelming majority of these reworks (71.1%) were directly attributed to “insufficient supply of medication on shelf”. This isn’t just about a missing item; it triggers a cascade of additional work: amending the patient medication record (PMR), placing an order with the wholesaler, and then reassuring the patient about when their medication will be available.

Once the medication arrives, the PMR must be updated again, a new label generated, and the medication checked and provided to the patient. This entire sequence illustrates the deep complexity and time consumption that rework can propagate within a community pharmacy setting. While external factors like wholesaler shortages contribute, a significant portion is undoubtedly due to inadequate inventory management systems within pharmacies themselves.

Beyond these top three, other significant contributors to rework include workflow issues, high telephone call volumes and distractions, prescriptions requiring prescriber clarification, and patients failing to collect automatic prescription refills. Our study also highlighted specific examples such as refrigeration errors, incomplete controlled drug requirements, and typographical errors on labels. These findings collectively underscore the diverse array of challenges that interrupt the smooth flow of prescription processing and the urgent need for systemic improvements.

The Philosophy of Lean: Reducing Waste, Enhancing Value

My personal journey to understanding and advocating for lean principles took a significant step forward with my visit to Toyota in 2024. The insights gained from observing their renowned production system reinforced my conviction that these principles, though originating in manufacturing, are profoundly applicable and indeed vital for healthcare settings, particularly community pharmacies. Lean principles are fundamentally about creating maximum value for the patient by systematically reducing waste and variation, leveling workload, and empowering staff to actively participate in process improvement.

Within the lean philosophy, ‘waste’ is defined as any activity that fails to add value or results in redundancy to the next user, impeding quality and flow, and therefore, should be eliminated. Our study’s definition of rework aligns perfectly with two of the seven forms of waste identified in lean principles: ‘defects’ and ‘inappropriate processing’. When a defect occurs (e.g., a labelling error), or processing is inappropriate (e.g., preparing a prescription that is later uncollected), it inevitably leads to rework – a wasteful activity that consumes time, resources, and often, staff morale.

By embracing lean, pharmacies can move beyond simply reacting to errors to proactively identifying and preventing them. This involves:

• Value Stream Mapping: Visually mapping the entire prescription processing workflow to identify every step, distinguishing between value-adding activities and non-value-adding waste. This allows for a clear understanding of where rework typically occurs.

• Standard Work: Developing clear, consistent, and standardized procedures for all tasks to reduce variation and ensure quality. This is particularly relevant for addressing common labelling errors or ensuring complete prescriptions.

• Just-in-Time Inventory: Optimising stock levels to avoid both overstocking (which can lead to expired medications or storage issues) and understocking (which directly causes “owings” rework). My study highlighted insufficient medication on the shelf as a major cause of rework, making robust inventory management a key area for lean intervention.

• Continuous Improvement (Kaizen): Fostering a culture where all staff members are encouraged to identify problems, suggest improvements, and participate in small, incremental changes to optimize processes. This empowers the front-line staff who are most familiar with daily operations.

• Visual Management: Using visual cues and displays to make the status of work clear and immediately apparent, helping to flag potential issues before they become reworks.

Practical Implications for Irish Pharmacy Practice

The findings of our study provide tangible areas where Irish community pharmacies can begin to implement lean principles and address rework.

Firstly, the high prevalence of labelling errors (22.8%) points to the need for rigorous doublechecking mechanisms and potentially automated systems to minimize human error. Currently, comprehensive staff training on accurate data entry and label verification, could significantly reduce this rework category. Secondly, the frequent rework on prepared prescriptions (15.1%), particularly due to omitted or unwanted items, underscores the importance of final checks before bagging, as well as clear communication with patients regarding their order. Implementing a standardized patient ordering protocol, could be a simple yet effective lean intervention.

Thirdly, the substantial rework caused by medication owings (13.9%) due to insufficient stock highlights a critical area for inventory management improvement. Pharmacies should evaluate their current inventory systems for effectiveness. This could involve implementing robust stock rotation practices, leveraging technology for demand forecasting, and establishing clear communication channels with wholesalers to anticipate and mitigate shortages. While some shortages are external, internal inventory control remains a powerful lever for reducing rework.

Our study also revealed interesting trends related to staffing and workload. We observed that pharmacies with higher levels of dispensary staff (two pharmacists and four or more total dispensary staff) recorded less rework than those with fewer staff. While our small sample size limits generalizability, this finding aligns with previous research indicating that inadequate pharmacist cover can lead to medication errors. Rework and errors, while distinct, both represent failures in planned actions. This suggests that appropriate staffing levels are not just about managing volume but are integral to preventing inefficiencies and maintaining quality.

Furthermore, the observation that rework occurred more frequently during peak hours (9 am-12 pm and 3 pm-6 pm) and significantly increased after 6 pm in the sole pharmacy open until 9 pm, hints at the role of fatigue as a contributory factor. Lean principles emphasize leveling the workload to prevent peaks and troughs that contribute to stress and errors. This could involve optimizing scheduling to ensure adequate coverage during busy periods and considering strategies to mitigate fatigue during extended shifts.

Finally, the development of our comprehensive rework list, which successfully captured over 91.7% of all rework instances, is a significant strength of this study. This list can serve as an invaluable tool for other pharmacy staff to conduct their own internal audits, identify specific training needs, and foster a stronger safety culture. It provides a concrete framework for initiating lean improvement cycles within individual pharmacies.

Conclusion: A Call to Action for a More Efficient Future

This study unequivocally demonstrates that prescription rework is not an anomaly but a frequent occurrence in Irish community pharmacies, imposing a substantial burden on both staff and operations. The primary culprits—labelling errors, medication owings (largely due to stock insufficiency), and prepared prescriptions requiring subsequent repackaging—highlight specific areas where targeted interventions can yield significant improvements. While our study’s limited sample size prevents definitive conclusions on the impact of pharmacy and pharmacist characteristics on rework frequency, it strongly suggests a correlation that warrants further investigation with larger cohorts.

My journey to Toyota cemented my belief that lean principles are not just theoretical constructs but practical, powerful tools that can fundamentally reshape how we operate. The estimated four hours of pharmacist time spent on rework per week, translating to an astonishing 208 hours per pharmacy per year, represents a colossal amount of wasted potential. By strategically minimizing rework through the application of lean methodologies, we can unlock significant time and cost benefits, enabling us to reallocate precious resources. This means more time for pharmacists to engage in essential clinical pharmacy services, enhance patient safety during prescription processing, and ultimately, better meet the diverse healthcare needs of our communities.

The future of community pharmacy in Ireland hinges on our collective commitment to efficiency and continuous improvement. By embracing lean principles, we can transform challenges into opportunities, reduce unnecessary workload, and cultivate a more structured, resilient, and patientcentric pharmacy business. This research serves as a starting point, generating awareness and providing a framework for action. It is now imperative for pharmacy staff, researchers, and policymakers to collaborate in developing and implementing robust strategies to minimize rework, ensuring that our pharmacists can dedicate their expertise to where it matters most: enhancing patient care.