OBJECTIVES: Understand the cognitive, behavioral, and environmental factors motivating deception in community pharmacies.

METHODS: Texas pharmacists were randomly selected from a state registry and recruited to participate in a 60-minute, virtual semi-structured interview about dispensing controlled substances. The participant was asked to describe a time when they were unsure whether to dispense a controlled substance prescription and ultimately did not fill the prescription. After the first six interviews, transcripts were analyzed using an inductive grounded theory approach. These interviews were applied an open coding approach to develop a preliminary coding matrix. The remaining six interviews were coded using a constant comparative approach.

RESULTS: The sample consisted of twelve pharmacists (2 independent, 2 hospital, and 8 retail). 76 distinct codes were identified and grouped into 19 themes that conceptually explained three forms of prescription denial: with constructive counseling, without explanation, and with deception. Participants also discussed that pharmacy curricula did not prepare them to deny prescriptions and that their approach was learned on the job through peer mentorship.

CONCLUSIONS: Environmental and employer pressure to efficiently process prescriptions and minimize exposure to liability have created an adverse practice environment for community pharmacists. Prevailing professional vulnerability, fear of confrontation, and a lack of rigorous practical training perpetuate a practice model aimed at moving customers through a store rather than promoting health. Without guidance from regulators to pharmacy chains and enforceable policy, pharmacists are likely to continue to be pressured to protect employer over patient interests. The current paradigm of making a dispensing decision prior to a patient encounter is aligned with the structure of many pharmacy practice curricula which rely on paper cases rather than mock encounters and patient care simulations to educate pharmacists on clinical decision making.