INDEPENDENT DOUBLE CHECKS FOR SINGLE PRACTITIONERS

Rationale

As pharmacy practice has evolved to include more direct patient care services, oversight of these services has not kept pace. This trend was exacerbated by the COVID-19 pandemic, which ushered in new test-to-treat models for pharmacy teams and introduced new flexibilities into telehealth. As care has shifted, pharmacists may be placed in situations in which they are overseeing many aspects of medication use, from independent prescribing to dispensing, without any additional verification checks. Other clinicians, including physicians and nurse practitioners, may also be in similar positions. Regardless of setting, without adequate patient safety safeguards (e.g., high-reliability process, technology and/or human review), placing one clinician in charge of the elements of the medication-use process related to ordering, dispensing and administration, as well as any patient evaluation and monitoring, increases the risk for errors and adverse outcomes. While human checks are preferable for high-risk drugs, nothing in this policy should be considered to oppose appropriate autoverification of orders.