Pharmacists’ and Pharmacy Students’ Ability to Identify Drug-related Problems Using TIMER (Tool to Improve Medications in the Elderly via Review)

Objective

Determine the effectiveness of TIMER (Tool to Improve Medications in the Elderly via Review) in helping pharmacists and pharmacy students identify drug-related problems during patient medication reviews.

Methods

In a randomized, controlled study design, geriatric patient cases were sent to 136 pharmacists and 108 third-year pharmacy students who were asked to identify drug related-problems (DRPs) with and without using TIMER.

Results

Pharmacists identified more tool-related DRPs using TIMER (p = 0.027). Pharmacy students identified more tool-related DRPs using TIMER in the first case (p = 0.02), but not in the second.

Conclusion

TIMER increased the number of DRPs identified by practicing pharmacists and pharmacy students during medication reviews of hypothetical patient cases.     

Best possible medication history for hemodialysis patients obtained by a pharmacy technician

Background:

Outpatients undergoing hemodialysis are at high risk for adverse drug events. Limited resources make it challenging for pharmacists to routinely obtain a best possible medication history (BPMH).

Objectives:

The primary objective was to determine whether, for patients undergoing hemodialysis, a pharmacy technician has the skills to obtain a BPMH that would allow a pharmacist to identify drug-related problems. The secondary objectives were to determine the number and types of medication discrepancies and drug-related problems identified and the time required by the technician to complete the BPMH.

Methods:

All patients treated in the hemodialysis unit during the study period were included, except for those who required an interpreter or were unable to participate in an in-person interview. A single technician was taught how to interview patients according to a structured format. For each patient, the technician’s BMPH was verified by a pharmacist. The agreement rate between technician and pharmacists was determined, along with the number and types of discrepancies and drug-related problems identified.

Results:

The technician interviewed 99 patients. Of the 1334 medication orders reviewed, the technician and pharmacists agreed on all but 15 (agreement rate 98.9%). A total of 358 medication discrepancies were noted for 93 patients (3.8 discrepancies per patient). Of these, 210 (59%) were undocumented intentional discrepancies, and 148 (41%) were unintentional discrepancies (most commonly errors of commission). Of the 135 drug-related problems identified, the majority involved dosing problems or nonadherence. The technician required an average of 17 min for each interview.

Conclusion:

An adequately trained technician was capable of interviewing patients to create a BPMH. A variety of medication discrepancies and drug-related problems were identified. Generation of a BPMH by a technician is a useful approach allowing pharmacists to identify drug-related problems.     

Women's health promotion within a community advanced pharmacy practice experience

Objective

To establish low-cost easily conducted health promotion interventions for advanced pharmacy practice experience (APPE) students in community pharmacy settings that would increase women''s awareness about health issues using Food and Drug Administration (FDA) educational materials.

Methods

Students distributed fact sheets on medication use, heart disease, and diabetes to women over 45 years of age at 6 community pharmacy APPE sites. Interventions completed were either personal medication records (PMR) to identify medication-related problems (MRP) or heart health screenings followed by completion of an anonymous patient satisfaction survey instrument.

Results

Over 1500 fact sheets were distributed. Fifty-eight women (age 61 ± 15 years) completed PMRs, which identified 57 MRPs in 42 patients. Twenty-four women indicated the screening was “useful/very useful” for increasing medication understanding. Sixty-three women completed heart health screenings. Thirty-one of the 40 who completed the survey instrument indicated the screening was “useful/very useful” for learning heart disease risk.

Conclusions

Community pharmacy APPE students interventions identified MRPs and patients at risk for heart disease. These health promotion interventions enhanced women''s awareness of these topics while guiding students to achieve the desired curricular outcomes.     

An Advanced Pharmacy Practice Experience in Inpatient Medication Education

Objective

To describe a unique advanced pharmacy practice experience (APPE) in which pharmacy students provided medication education to hospitalized patients.

Design

Students were trained to independently assess patients'' needs for education and identify drug-related problems. Students then provided medication education and performed medication therapy management under the supervision of clinical staff pharmacists. To assess the impact of the APPE, the number of hospitalized patients assessed and educated during the 3-month time period prior to student involvement was compared to the first 3 months of the APPE.

Assessment

Student participation increased the number of patients receiving medication education and medication therapy management from the hospital pharmacy. At the end of the APPE, students reported that the experience positively affected their ability to impact patients'' care and to critique their own learning and skills.

Conclusion

The inpatient medication education APPE provided students the opportunity to be responsible and accountable for the provision of direct patient care. In addition, the APPE benefitted the hospital, the school of pharmacy, and, most importantly, the patients.     

Potentially inappropriate medications in geriatric outpatients with polypharmacy: application of six sets of published explicit criteria

AIM

Our aim was to compare the practicability of six different potentially inappropriate medication (PIM) criteria in geriatric outpatients with polypharmacy.

METHODS

We analysed baseline data from the Medication Safety Review Clinic in Taiwanese Elders (MSRC-Taiwan) study. The prevalence and correlates of PIMs were determined on the basis of criteria developed in the USA, Canada, France, Norway, Ireland and Thailand. The percentage of PIMs considered as drug-related problems and the problem-solving rate are reported.

RESULTS

In the 193 participants, the prevalence of PIM varied from 24 to 73%. Application of the criteria revealed that a high number of chronic medications was a common risk factor for having at least one PIM. Of the 1713 medications reviewed, 5.6–14.8% were considered PIMs. Only 30–40% of the identified PIMs were reported as drug-related problems by the MSRC team experts. Criteria with a higher number of statements and a higher percentage of local market/institution drug availability tended to detect more PIMs.

CONCLUSIONS

The prevalence of PIM varied significantly when different criteria were applied. Caution should be exercised in applying PIM criteria developed in other regions when medication availability in the local market is limited.     

Pharmacy-Based Medication Reconciliation Program Utilizing Pharmacists and Technicians: A Process Improvement Initiative

Background:

Pharmacists and pharmacy technicians have an opportunity to impact the quality of the medication histories and improve patient safety by ensuring accurate medication lists are obtained and complete reconciliation has occurred with the admission medication orders by owning the admission medication reconciliation process.

Objective:

To compare the quality of a pharmacy-based medication reconciliation program on admission utilizing pharmacists and technicians to the usual multidisciplinary process.

Methods:

This was a retrospective chart review process improvement study at a 186-bed tertiary care inpatient facility. Primary outcomes included both the accuracy of pre-admission medications listed and the reconciliation of those medications with admission inpatient orders. Technicians obtained patient medication histories. Pharmacists checked the technician-obtained medication histories and ensured reconciliation of those medications with admission orders.

Results:

Medication accuracy increased from 45.8% to 95% per patient (P < .001) and medication reconciliation increased from 44.2% to 92.8% (P < .001) and remained above benchmark.

Conclusion:

A pharmacy-based medication reconciliation program utilizing both pharmacists and technicians significantly increased the accuracy and reconciliation of medications on admission. These gains were maintained for the duration of the 6-month period studied and beyond per continued process improvement data collection.     

Impact of Patient Empathy Modeling on pharmacy students caring for the underserved

Objective

To determine the impact of the Patient Empathy Modeling pedagogy on students'' empathy towards caring for the underserved during an advanced pharmacy practice experience (APPE).

Design

Pharmacy students completing an APPE at 2 primary care clinics participated in a Patient Empathy Modeling assignment for 10 days. Each student “became the patient,” simulating the life of an actual patient with multiple chronic diseases who was coping with an economic, cultural, or communication barrier to optimal healthcare. Students completed the Jefferson Scale of Physician Empathy (JSPE) before and after completing the assignment, and wrote daily journal entries and a reflection paper.

Assessment

Twenty-six students completed the PEM exercises from 2005-2006. Scores on the JSPE improved. Students'' comments in journals and reflection papers revealed 3 major themes: greater appreciation of the difficulty patients have with adherence to medication and treatment regimens, increased empathy for patients from different backgrounds and patients with medical and psychosocial challenges, and improved ability to apply the lessons learned in the course to their patient care roles.

Conclusion

A Patient Empathy Modeling assignment improved pharmacy students'' empathy toward underserved populations. Integrating the assignment within an APPE allowed students to immediately begin applying the knowledge and insight gained from the exercise.     

Teaching heart failure treatment guidelines and assessing heart failure therapy

Objectives

To determine the effectiveness of the heart failure screening form in teaching heart failure treatment guidelines and prompting students to evaluate patients'' medications to initiate patient education and provider intervention.

Design

Between 2002 and 2009, 123 students used the heart failure screeing form during an elective cardiology advanced pharmacy practice experience (APPE). A subset of 41 students were also assessed for change in heart failure knowledge and confidence pre- and post-APPE.

Assessment

A total of 1,114 heart failure patients were screened and assessed using the tool with a mean age of 71.9 ± 12.9 years. Of those, 535 (48%) patients met screening criteria and participated in heart failure education. From 2008 through 2009, there were 45 heart failure interventions with a 60% provider acceptance rate. Significant improvements were made in heart failure knowledge and in all areas of confidence at the end of the APPE for the 41 students assessed.

Discussion

The heart failure screening form is an effective tool to teach evidence-based medicine and to prompt students to initiate provider intervention and patient education. Its use is associated with significant increases in knowledge and confidence in heart failure medication therapy management in fourth-year pharmacy students.     

A virtual clean room to teach USP 797 regulations for intravenous medications

Objective

To provide a virtual environment for pharmacy students to learn United States Pharmacopeia Chapter 797 (USP 797) requirements, while recognizing the role of pharmacists in the safe use of intravenous (IV) medications.

Design

A virtual laboratory was created that included stations for IV medications, product verification, medication safety, and patient cases pertaining to high-alert medications. Pharmacy students used 3-D glasses and a wireless controller to navigate through the session and identify violations of USP 797 regulations.

Assessment

Preassessments and postassessments were administered to students who completed the session in each of the 2 years it was offered. In the first year, 88% of students strongly agreed or agreed that the sessions met their expectation. Following their APPE clerkship, 92% of these students felt the virtual IV room prepared them for the IV clean room experience. In the second year, 88% of students felt the experience enhanced their understanding of clean room procedures. After session completion, 75% of participants perceived medication errors to be more significant. Written examinations also were administered and students'' mean scores improved significantly compared to those of students'' prior to implementation of the session (89.6% in year 0; 91.2% in year 1; and 96.1% in year 2).

Conclusion

The immersive virtual environment is a contemporary and effective way to teach USP 797 requirements and enhance the awareness of medication errors.     

High-fidelity patient simulation series to supplement introductory pharmacy practice experiences

Objective

To introduce a high-fidelity simulation series into a 5-year doctor of pharmacy (PharmD) curriculum to demonstrate a hybrid model for introductory pharmacy practice experience (IPPE) delivery.

Design

Fourth-year pharmacy students at a satellite campus participated in a 6-week high-fidelity patient simulation series in which small groups of students worked with members of a patient care team to care for patients in the following scenarios: asthma exacerbation, acute decompensated heart failure, and infective endocarditis with a subsequent anaphylactic reaction to the antibiotic. Fourth-year pharmacy students at the main campus who did not participate in the simulation served as a comparator group.

Assessment

Students'' scores on a knowledge-based post-simulation quiz were significantly higher than scores on the presimulation quiz (p < 0.05). Knowledge retention was significantly higher among the simulation participants than students in the comparator group (p = 0.004). The majority (76%) of students felt more confident “making clinical recommendations to a healthcare provider” after completing the simulation series (p = 0.01).

Conclusion

High-fidelity patient simulation is an effective active-learning strategy to augment IPPEs that allows students to apply clinical skills in a realistic but low-risk patient care setting.     

Pharmacy Student Knowledge and Communication of Medication Errors

Objectives

To describe and evaluate pharmacy students'' knowledge of and comfort in communicating, managing, and preventing medication errors.

Methods

Using a cross-sectional design, a survey instrument was administered to fifth-year pharmacy students. The survey instrument included both open- and close-ended questions to describe and examine factors associated with knowledge and comfort in communication of medication errors.

Results

Survey instruments were completed by 93 students (90% response rate). Nearly 80% reported not having received training in communicating medication errors. The perception of having more adequate training was related to greater knowledge in the communication of medication errors (p ≤ 0.001). Knowledge was also associated with students having greater comfort in communicating medication errors (p ≤ 0.05).

Conclusions

The need and value of additional training for pharmacy students in communicating medication errors was demonstrated. Educational interventions should be developed to provide consistent instruction on these communication issues.     

Pharmacy students' preferences for various types of simulated patients

Objective

To evaluate pharmacy students'' preferences for various types of simulated patients.

Methods

Second-professional year (P2) pharmacy students participated in 7 learning activities that used simulated patients including community volunteers, College administrative staff, course instructors, and student peers. Students ranked each simulated patient type according to believability, skill development, and preference using a 5-point Likert scale.

Results

One-hundred seven of 155 students (69%) completed the survey instrument. Students preferred community volunteers as simulated patients (mean rank 1.39), followed by peers (2.22), instructors (2.63), and staff members (2.81) (p < 0.001). Greater than 89% agreed or strongly agreed that their work with simulated patients prepared them for actual patients, with community volunteers receiving the highest ratings (p < 0.03).

Conclusions

Although pharmacy students found value in interactions will all types of simulated patients, they preferred community volunteers over staff members and their peers. Future scholarship should explore the relationship among simulated patient types and student learning outcomes.Key words: simulated patient, survey, practice laboratory     

Descriptive Analysis of Patient Readmissions Within 60 Days Due to Medication-Related Events

Background:

Hospital readmissions have become a marker for quality health care. Readmissions secondary to failures of the medication use process are poorly documented and underrecognized.

Objective:

To identify the incidence of readmissions related to the medication use process and identify associated patient- and therapy-related risk factors.

Methods:

A prospective observational cohort study including patients discharged from an acute care medicine unit and readmitted within 60 days. The primary outcome was percentage of readmissions related to drug-related problems (DRPs) as defined by Pharmaceutical Care Network Europe (PCNE). Secondary outcomes included classification of problems using PCNE criteria, type and extent of pharmacist involvement in patient care, and identification of variables associated with a readmission related to a DRP.

Results:

One hundred patients provided informed consent and were included for analysis. A DRP associated with readmission was identified in 64 patients. Sixty-one percent were classified as a potential problem with effect or lack of effect of pharmacotherapy. Patients who had a pharmacy consult were less likely to have a DRP (27% vs 47%; P = .04), and patients who missed follow-up appointments were more than 3 times as likely to have a DRP (20% vs 4%; P = .03). Presence of a pharmacy consult (odds ratio [OR], 0.38; 95% CI, 0.15-0.99; P = .05) and missed follow-up appointments (OR, 5.63; 95% CI, 1.52-20.86; P = .01) remained significant in a multivariate regression model.

Conclusion:

DRPs were frequent in patients who were readmitted within 60 days. Clinical pharmacist involvement in care and support for appropriate patient follow-up may reduce unnecessary admissions.     

Nursing,Pharmacy, and Prescriber Knowledge and Perceptions of High-Alert Medications in a Large,Academic Medical Hospital

Background:

High-alert medications pose a greater risk of causing significant harm to patients if used in error. The Joint Commission requires that hospitals define institution-specific high-alert medications and implement processes to ensure safe medication use.

Method:

Nursing, pharmacy, and prescribers were asked to voluntarily complete a 34-question survey to assess their knowledge, experience, and perceptions regarding high-alert medications in an academic hospital.

Results:

The majority of respondents identified the organization’s high-alert medications, the consequences of an error involving a high-alert medication, and the reversal agent. Most of the risk-reduction strategies within the institution were viewed as being effective by respondents. Forty-five percent of the respondents utilized a high-alert medication in the previous 24 hours. Only 14.2% had experienced an error with a high-alert medication in the previous 12 months, with 46% being near misses. The survey found the 5 rights for medication administration were not being utilized consistently. Respondents indicated that work experience or hospital orientation is the preferred learning experience for high-alert medications.

Conclusions:

This study assessed all disciplines involved in the medication use process. Perceptions about high-alert medications differ between disciplines. Ongoing discipline-specific education is required to ensure that individuals accept accountability in the medication use process and to close knowledge gaps on high-alert medications and risk-reduction strategies.     

Clinical pharmacy consultations provided by American and Kenyan pharmacy students during an acute care advanced pharmacy practice experience

Objective

To compare the clinical consultations provided by American and Kenyan pharmacy students in an acute care setting in a developing country.

Methods

The documented pharmacy consultation recommendations made by American and Kenyan pharmacy students during patient care rounds on an advanced pharmacy practice experience at a referral hospital in Kenya were reviewed and classified according to type of intervention and therapeutic area.

Results

The Kenyan students documented more interventions than American students (16.7 vs. 12.0 interventions/day) and provided significantly more consultations regarding human immunodeficiency virus (HIV) and antibiotics. The top area of consultations provided by American students was cardiovascular diseases.

Conclusions

American and Kenyan pharmacy students successfully providing clinical pharmacy consultations in a resource-constrained, acute-care practice setting suggests an important role for pharmacy students in the reconciliation of prescriber orders with medication administration records and in providing drug information.