Interruptions in community pharmacies: Frequency,sources, and mitigation strategies

BackgroundInterruptions constitute a key part of the communication strategy for healthcare providers, including community pharmacy personnel. Previous research in other healthcare environments has shown that interruptions are very common and may present as patient safety hazards. One 1999 study, conducted in community pharmacy settings, found that interruptions were prevalent and associated with dispensing errors. In the last 20 years, pharmacies have expanded patient services and implemented new technology. Yet, it is unknown how these changes have affected interruption sources and frequency.ObjectiveThe objective was to characterize the frequency and sources of pharmacist task interruptions that occur in community pharmacies.MethodsA cross-sectional qualitative study design was used to evaluate the frequency and sources of pharmacist task interruptions in Wisconsin community pharmacies. The participants included 9 pharmacists and 9 technicians working in 2 independently-owned, 2 mass merchandise, and 2 hospital/clinical-affiliated pharmacies.ResultsInterruption rates ranged from 3 to 7 per hour across the 6 pharmacies. Sources of interruptions included: patients, technicians, self-initiated interruptions, technology used in the pharmacy, and a second pharmacist.ConclusionsInterruptions are common in community pharmacies and the causes are multifactorial. Prudent management of interruptions in these work environments may involve improved technician training and better designs of pharmacy technology.     

Keeping the “continuous” in continuous quality improvement: Exploring perceived outcomes of CQI program use in community pharmacy

BackgroundGiven the significant potential of continuous quality improvement (CQI) programs in enhancing overall levels of patient safety, community pharmacies in North America are under increasing pressure to have a formal and documented CQI program in place. However, while such initiatives may seem great on paper, in practice the outcomes of such programs to community pharmacy practice remain unclear.ObjectiveTo explore the perceived outcomes identified by community pharmacies that adopted and actively used a standardized (i.e., common across pharmacies) CQI program for at least 1 year and to develop a framework for how such outcomes were achieved.MethodsA multi-site study of SafetyNET-Rx, a standardized and technologically sophisticated (e.g., online reporting of medication errors to a national database) CQI program, involving community pharmacies in Nova Scotia, Canada, was performed. During the summer and fall of 2011, 22 interviews were conducted with the CQI facilitators in 12 Nova Scotia community pharmacies; equally split between independent/banners and corporate chains. Of the CQI facilitators, 14 were pharmacists, while the remaining eight were pharmacy technicians. Thematic analysis following the procedures presented by Braun and Clarke was adopted to identify and explore the major outcomes.ResultsResults of the thematic analysis highlighted a number of perceived outcomes from the use of a standardized CQI program in community pharmacies, specifically: (1) perceived reduction in the number of medication errors that were occurring in the pharmacy, (2) increased awareness/confidence of individual actions related to dispensing, (3) increased understanding of the dispensing and related processes/workflow, (4) increased openness to talking about medication errors among pharmacy staff, and (5) quality and safety becoming more entrenched in the workflow (e.g., staff is more aware of their roles and responsibilities in patient safety and confident that the dispensing processes are safe and reliable). In achieving such outcomes, pharmacies had to balance customizing the CQI program to address a number of operational challenges, with ensuring that the core standardized components remained in place.ConclusionsThis research identified the perceived outcomes of CQI program use by CQI facilitators. Additionally, the findings are incorporated into a framework for CQI implementation that can be used by pharmacy managers, corporate head offices, and regulatory authorities to leverage greater CQI adoption and success.     

The role of network ties to support implementation of a community pharmacy enhanced services network

BackgroundLimited evidence exists on how to integrate community pharmacists into team-based care models, as the inclusion of community pharmacy services into alternative payment models is relatively new. To be successful in team-based care models, community pharmacies need to successfully build relationship with diverse stakeholders including providers, care managers, and patients.ObjectivesThe aims of this study are to: (1) identify the role of network ties to support implementation of a community pharmacy enhanced services network, (2) describe how these network ties are formed and maintained, and (3) compare the role of network ties among high- and low-performing community pharmacies participating in an enhanced services network.MethodsUsing a semi-structured interview guide, we interviewed 40 community pharmacy representatives responsible for implementation of a community pharmacy enhanced services program. We analyzed for themes using social network theory to compare network ties among 24 high- and 16 low-performing community pharmacies.ResultsThe study found that high-performing pharmacies had a greater diversity of network ties (e.g., relationships with healthcare providers, care managers, and public health agencies). High-performing pharmacies were able to use those ties to support implementation of NC-CPESN. High- and low-performing pharmacies used similar strategies for establishing ties with patients, such as motivational interviewing and assigning staff members to be responsible for engaging high-risk patients. High-performing pharmacies used additional strategies such as assessing patient preferences to support patient engagement, increasing patient receptivity towards enhanced services.ConclusionsCommunity pharmacies may vary in their ability to develop relationships with other healthcare providers, care management and public agencies, and patients. As enhanced services interventions that require care coordination are scaled up and spread, additional research is needed to test implementation strategies that support community pharmacies with developing and maintaining relationships across a diverse group of stakeholders (e.g., healthcare providers, care managers, public health agencies, patients).     

Social distancing and the use of PPE by community pharmacy personnel: Does evidence support these measures?

Community pharmacists are one of the most accessible healthcare professionals and are often served as the first point of contact when it comes to minor ailments and health advice. As such, community pharmacists can play a vital role in a country's response to various preventative and public health measures amid the COVID-19 pandemic. Given the essential nature of community pharmacy as a health service, community pharmacies are unlikely to shut down in any foreseeable lockdown scenario. It is therefore important to assess the preventative measure directives for community pharmacies that are in place to safeguard community pharmacy personnel from SARS-CoV-2 in the various parts of the world. Upon reviewing the recommendations of 15 selected countries across five continents (Asia, Europe, Oceania, North America, and Africa) on social distancing and the use of personal protective equipment (PPE) in community pharmacies, we found inconsistencies in the recommended social distance to be practiced within the community pharmacies. There were also varying recommendations on the use of PPE by the pharmacy personnel. Despite the differences in the recommendations, maintaining recommended social distance and the wearing of appropriate PPE is of utmost importance for healthcare workers, including community pharmacy personnel dealing with day-to-day patient care activities, though full PPE should be worn when dealing with suspected COVID-19 patients.     

Evaluation of community pharmacy service mix: evidence from the 2004 National Pharmacist Workforce Study.

OBJECTIVES: To describe the mix of pharmacy services being offered in different types of community pharmacy practices and to identify factors associated with a community pharmacy offering pharmacy services. DESIGN: Cross-sectional study. SETTING: Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies). PARTICIPANTS: Pharmacists practicing full-time or part-time who worked in community pharmacies and responded to the 2004 National Pharmacist Workforce Survey. INTERVENTION: Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists. MAIN OUTCOME MEASURES: Type and frequency of pharmacy services being offered in a community pharmacy, including dispensing and product-related services (e.g., specialty compounding), and pharmacist care services (e.g., immunizations, smoking cessation, health screening, medication therapy management, wellness screening, nutritional support, and disease management services). RESULTS: Four pharmacist care services were reported as being offered at more than 10% of community pharmacy practices: immunizations, smoking cessation, health screening, and diabetes management. The number of pharmacist care services offered at a community pharmacy was positively associated with having at least three pharmacists on duty, innovativeness of the pharmacy, status as an independent pharmacy, and status as a supermarket pharmacy. More than one half of the community pharmacy practices did not offer any of the eight pharmacist care services included in a pharmacy service index. CONCLUSION: Pharmacy services were reported at relatively few community pharmacies, and were associated with pharmacy innovativeness, pharmacist staffing levels, and pharmacy setting. Some community pharmacies are offering pharmacy services as part of their business strategy, while others are dedicated to dispensing services. Continued study of pharmacy service availability in community pharmacies is needed to improve our understanding of our capacity to deliver such services, including medication therapy management services.     

Medication errors in community pharmacy: an investigation into the types and potential causes

Objectives To establish the nature of medication errors occurring within community pharmacy and analyse common error patterns. To identify factors which influence the occurrence of medication errors and near misses, with the intention of designing systems or strategies to reduce the occurrence of these events. Setting Fifteen community pharmacies situated within Brighton and Hove City Primary Care Trust, East Sussex, between January and March 2004. Method A self‐reporting form was designed, piloted and administered to pharmacists, which gathered information on the detection of an error or near miss in the dispensing process. Key findings One‐hundred and thirteen near misses and thirty‐two medication errors were reported. The majority of near misses were detected by the pharmacist at the final check, and the majority of medication errors were detected by the patient or patient's representative. Selection errors were most common, with similar drug names and packaging cited as the main contributory factors. ‘Business’ was frequently cited as the circumstance surrounding the error. Conclusion This study demonstrates that pharmacists do have an important part to play and the positive impact of community pharmacists in preventing, detecting and correcting errors and thus preventing harm to patients in the primary care setting. However, medication errors do occur, and therefore a multifactorial approach by manufacturers, marketing and packaging personnel, in addition to input from pharmacists, may be an effective permanent solution in reducing the errors made.     

Simulated patients in the community pharmacy setting – Using simulated patients to measure practice in the community pharmacy setting

BACKGROUND: Performance measurement and quality of care in community pharmacy settings is problematic because of the lack of formal patient registration and the resultant risk of selection bias. Although simulated patients have been used for teaching and education purposes, particularly in medical settings, their use as a research tool requires exploration in other health settings. The purpose of this paper is to describe how we used simulated patients to measure professional performance of community pharmacy staff. METHOD: Sixty pharmacies participated in a randomised controlled trial (RCT) to evaluate the effectiveness and efficiency of two guideline implementation strategies in the community pharmacy setting. The primary outcome measure for the study was derived from assessment forms completed by simulated patients following covert visits to participating pharmacies. RESULTS: Of the 420 simulated patient visits scheduled, 384 (91%) were completed. Nine visits were reported by pharmacy staff using reply-paid postcards, four of which concurred with known SP visits. Each detected visit was made by a different SP. In a post-intervention survey, 26 (52%) pharmacists stated they had been apprehensive about the use of simulated patients as part of the study, however, 41 (82%) pharmacists agreed that SP visits were an acceptable research method to use in a community pharmacy setting. DISCUSSION: Simulated patients are a feasible method of assessing professional performance in community pharmacy settings and overcome the methodological problems of other measurement methods. Further research is needed to assess the reliability and validity of simulated patients.     

Project Octo-Pills - A practice model engaging community pharmacists in the care of patients from a tertiary hospital

Even while pharmacy practice evolves to a more patient-centric mode of practice, local hospitals, due to high patient load as well as space and resource constraints, find it challenging to conduct thorough medication review and physical medication reconciliation for all patients. In light of this, optimizing the local current healthcare system to involve community pharmacists in the care of patients from public hospitals could potentially better cater to the healthcare needs of the older population. Due to easy accessibility, community pharmacies are often the first point of contact in the healthcare system. Project Octo-Pills aims to engage community pharmacists in the collaborative care of patients from a tertiary hospital, providing patients with quality medication reconciliation and review services from a more convenient location within their neighborhood. This paper describes the model for this pilot initiative.     

Continuous quality improvement regulations for community pharmacy practice in the United States

ObjectivesIn the United States, medication errors are considered to be the cause of 7000 deaths annually. Continuous quality improvement (CQI) is a management process that focuses on continually and systematically evaluating the organization’s work process. In community pharmacy, CQI leads to enhanced patient safety through a reduction in medication errors and quality-related events (QREs). There is limited information about the variations in CQI regulations required by State Boards of Pharmacy (SBPs) for community pharmacy across the country. The objective of this study is to comprehensively describe CQI regulations required by SBPs for community pharmacy practice in the United States.MethodsThis was a cross-sectional study. Information regarding SBPs community pharmacy CQI regulations was collected electronically by surveying a representative of each SBP. In addition, a review of State Pharmacy Laws published online complemented the survey data. The percentage of states with CQI regulations for community pharmacy was estimated.ResultsOf the 50 Boards, 16 require pharmacies to maintain CQI programs to monitor and prevent QREs in community pharmacy. The most common elements of CQI programs include the management of known, alleged, and suspected medication errors that reach the patient (73%) and regular reviews of the pharmacy’s aggregate data of medication errors or incidents (73%). The North Dakota SBP regulation is the most comprehensive, followed by that of Iowa, Maryland, Massachusetts, and Montana.ConclusionThere is wide variation among SBP CQI regulations for community pharmacy practice. Standardization of CQI programs across Boards, including a national database for reporting medication errors and QREs would enhance patient safety.     

Patient preferences for objective quality metrics during community pharmacy selection: A discrete choice experiment

BackgroundPatients select healthcare providers and facilities based on a complex array of factors. Pharmacy-level quality metrics have been discussed as a way to help direct patients towards high-quality pharmacies. Limited research has been conducted on the potential impact of quality metrics on the pharmacy selection process.ObjectivesThis study aimed to measure the relative strength of patient preferences for community pharmacy attributes and to describe associations between patient sociodemographic and health characteristics and pharmacy preferences.MethodsThis study elicited preferences for pharmacy attributes using a discrete choice experiment presenting a scenario in which participants had moved to a new location and needed to select a pharmacy. Six attributes were selected based on published literature, expert opinion, and pilot testing feedback. Attributes were relationship-based (hours of operation, staff friendliness/courtesy, pharmacist communication, pharmacist willingness to establish a personal relationship) or competence-based (overall quality and a drug-drug interaction (DDI) specific quality metric). Participants responded to blocks of 10 random and 2 fixed choice tasks assigned by Sawtooth v9.2. Data were analyzed using conditional logit, and Hierarchical Bayes estimates of individual-level utilities were used to compare preferences across demographic subgroups.ResultsStudy participants expressed the strongest preferences for competence-based pharmacy attributes, including DDI-specific and overall quality measures (Attribute Importance Values: 40.3% and 31.3%, respectively). Women ascribed higher utility to 5-star DDI and overall quality ratings than men. Rural respondents and those with inadequate health literacy expressed stronger preferences for patient-pharmacist relationships than those in suburban areas and with adequate health literacy, respectively.ConclusionsRespondents exhibited strong preferences for pharmacies with higher competence-based quality ratings, suggesting that they may perceive medication safety to be a key role of community pharmacists. Future research on patient expectations of and preferences for community pharmacies can inform ways to effectively encourage patient engagement with pharmacists to improve health outcomes.     

Certified pharmacy technicians' views on their medication preparation errors and educational needs.

PURPOSE: The perceptions of certified pharmacy technicians about their medication preparation errors and educational needs were studied. METHODS: A nationwide random sample of 3200 certified pharmacy technicians was mailed a survey with open-ended questions soliciting information about how pharmacists have handled and should handle technicians' medication preparation errors. The participants were also asked about their training needs and continuing-education preferences. RESULTS: A total of 1004 responses (31.4%) were obtained, of which 835 were analyzed. Of the respondents, 44% reported working in chain community pharmacies and 27% in hospital pharmacies. The factors perceived to contribute most to technicians' medication preparation errors were interruptions and inadequate staffing. Pharmacists' most frequent response to an error was to make the technician aware of it and require him or her to correct it. Only about 17% of the respondents indicated that the pharmacist used the error as an opportunity to provide instruction on how to avoid future errors. CONCLUSION: A nationwide sample of certified pharmacy technicians ranked interruptions and inadequate staffing as the factors contributing most to their medication preparation errors.