Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy.

A possible association between interruptions and distractions and the occurrence of dispensing errors was investigated. Fourteen pharmacists and 10 technicians in an ambulatory care pharmacy at a general medical-surgical hospital were tested for distractibility by using the group embedded figures test (GEFT) as well as for visual acuity and hearing. They were videotaped as they filled prescriptions during a 23-day period in 1992. A study investigator compared each filled prescription with the physician's written order, noted details of deviations, verified with the pharmacist any errors that occurred, and asked the pharmacist to correct the error if necessary. Interruptions and distractions were detected and characterized by reviewing the videotapes. None of the study participants had significant hearing or visual impairment. There was a significant association between GEFT scores and error rates. A total of 5072 prescriptions were analyzed, and 164 errors were detected, for an overall error rate of 3.23%. Wrong label information was the most common type of error (80% of errors detected). A total of 2022 interruptions (mean +/- S.D. per half hour per subject, 2.99 +/- 2.70) and 2457 distractions (mean +/- S.D. per half hour per subject, 3.80 +/-3.17) were detected. The error rate for sets of prescriptions with one or more interruptions was 6.65% and for sets during which there were one or more distractions, 6.55%. Interruptions and distractions per half hour were both significantly associated with errors. In an ambulatory care pharmacy, interruptions and distractions over a half-hour period were associated with dispensing errors, a majority of which involved incorrect label information.

Readiness for change: implications for patient care.

The strategic position of pharmacists within the community allows frequent interactions with many patients, thus making pharmacists potentially valuable resources for assisting patients in making behavioral changes regarding adherence to treatment. The Transtheoretical Model is a behavior-change model that provides a functional approach through which pharmacists can help patients to reach specific behavioral goals. The model is described and stage-specific examples of patient-pharmacist dialogue are provided to show how the model may be used to promote progression through the stages.

Pharmacists' readiness for rendering pharmaceutical care.

OBJECTIVE: During the 1970s and 1980s, Prochaska and DiClemente developed the Transtheoretical Model (TTM) of Change to explain, predict, and change multiple human behaviors. This study applied the TTM to measure pharmacists' readiness for rendering pharmaceutical care. It also identified and measured factors that facilitate rendering pharmaceutical care and factors that are barriers, as well as the strength of these factors for each stage of readiness. DESIGN: Data were collected using an instrument developed following the work of Prochaska. Pharmacists completed this survey at the 1996 APhA Annual Meeting & Exposition. RESULTS: The results support the theory behind the TTM; that is, with any behavior change, individuals will fall into several stages of readiness for change, and the vast majority will not be ready to take action within the next six months. Also consistent with the theory, the cons of engaging in a behavior tended to be more salient for individuals in the precontemplation/contemplation stages than for those in the action/maintenance stages. Individuals in administrative positions are more likely to engage in behavior that leads to submitting documentation for compensation. CONCLUSION: Continuing education efforts must address the needs identified in each stage of readiness.

Relationships between ambient sounds and the accuracy of pharmacists' prescription-filling performance.

Associations between ambient sounds and accuracy of pharmacists' prescription-filling performance in a pharmacy was studied. Pharmacists were videotaped as they filled prescriptions each workday for 23 days. Each filled prescription was inspected by the investigator. Deviations from the physician's written order were considered errors. Videotape analysis was used to detect unpredictable, predictable, uncontrollable, and controllable sounds. A within-subjects case control study design was employed to determine whether the frequency of ambient sounds was significantly different when prescriptions with errors, compared with those without errors, were filled. Loudness, in terms of equivalent sound levels (Leq) for each half hour, was analyzed for a relationship to dispensing error rate. A mean dispensing error rate of 3.23% was found. Unpredictable sounds, controllable sounds, and noise had a significant effect on pharmacists which resulted in a decreased dispensing error rate. These results suggest that the quality of pharmacists' performance is not adversely affected by ambient sound. As equivalent sound levels increased, the error rate increased to a point, then decreased.

Pharmacy applications of the transtheoretical model in smoking cessation.

The transtheoretical model for intentional behavior change is described, and pharmacists' use of the model in smoking-cessation interventions is discussed. This model combines elements of theories used in psychotherapy and behavior modification. In the model are five stages (precontemplation, contemplation, preparation, action, and maintenance) that describe when behavior change occurs. To be most effective, a health care provider's interventions should match the patient's stage of change. The model also includes 10 cognitive and behavioral processes that describe how change occurs while a person is moving among the stages. The processes (social liberation, dramatic relief, helping relationships, consciousness-raising, environmental reevaluation, reinforcement management, self-reevaluation, stimulus control, counterconditioning, and self-liberation) define change in terms of the coping strategies used. Before intervening, the pharmacist needs to ask questions about the patient's behavior that will identify the stage. If smokers in the precontemplation stage are receiving medications for chronic diseases, pharmacists can make them aware of the negative effects of smoking on their specific conditions. People in the contemplation stage are open to education about smoking and health, and those in the preparation stage are ready to set goals and choose methods for cessation. Smokers in the action stage are attempting to quit. Pharmacists can offer support, reinforcement, and guidance to people in the action and maintenance stages. Pharmacists can use the transtheoretical model to categorize patients by their stage of change and then devise and deliver appropriate and individualized interventions.

Building an effective therapeutic alliance: competence, trustworthiness, and caring.

Patient counseling and pharmaceutical care require much more than the provision of information. They require a commitment on the part of the pharmacist to the well-being of the patient. They also require the formation of a therapeutic alliance. Patients are not likely to tell pharmacists about problems they have in managing their drug therapy if they believe they will be judged or scolded for nonadherence. Patients must feel safe enough to present problems or ask questions. In responding to how patients manage their illnesses and interpret the pharmacists' instructions, pharmacists must treat each patient as unique. Pharmacists must develop a flexible system of response. What is comforting to one patient might be frightening to another. By developing a flexible system of response, pharmacists will be able to treat patients more effectively. There are no right or wrong answers, only those that work. A pharmacist's basic understanding and true desire to care for the patient will increase the number of successful responses.

Patient treatment adherence. Facility design and counseling skills.

OBJECTIVE: To describe the essential facility characteristics for a model patient counseling area: (1) activities that should be accommodated by the facility; (2) special environmental and interior design features, with a discussion of their impact on the healthcare provider-patient interaction; (3) storage and equipment requirements; and (4) determination of space requirements for the counseling area. A second objective is to suggest a strategy to follow when justifying an adherence clinic. DATA SOURCE: Primary and secondary sources of literature were reviewed in the areas of pharmacy, psychology, and architecture to identify design specifications for the patient counseling area. CONCLUSIONS: The design of a counseling area can indirectly affect the quality of the interaction between the patient and healthcare provider, primarily in terms of its effect on communication. The key features that should be included in the design of the area are different levels of privacy (visual and auditory), "soft" interior decoration, and accommodation of people with disabilities. There are several design-related barriers to communication that should be avoided in the facility. The space required for a counseling area is dependent upon the scope of services provided--approximately 100-130 square feet may be necessary.

Stresses and satisfactions of the two-pharmacist relationship.

Potential advantages and disadvantages of dual-career relationships are identified, and strategies for addressing common issues encountered by dual-career couples are presented. With regard to career issues, clarification of expectations and discussion between partners regarding career commitment, job selection and mobility, and maintenance of professional identity is emphasized. Benefits of dual-career relationships include shared occupational interests, financial rewards, and respect for each partner's professional expertise. Strategies for managing domestic responsibilities include modifying standards, setting priorities, and distributing tasks evenly among family members. Pharmacist couples who are parents have chosen several routes in managing child-care issues, including postponing childbearing until each adult's career is established, decreasing one partner's career involvement, and hiring community or in-home caretakers. Sharing equally in child care can help prevent an excessive workload for one parent. Progressive family-oriented employment practices may also aid dual-career couples with children. Striking a balance between career and family is identified as perhaps the most challenging task facing the dual-career couple; time distribution must be adjusted according to the couple's priorities. Identifying realistic priorities, negotiating honestly regarding attainment of mutual and individual goals, and maintaining flexibility are key in achieving success in the professional and private lives of two-pharmacist couples.

Pharmacy financial management.

This study was undertaken to aid Blue Cross & Blue Shield of Alabama in determining an equitable dispensing fee and to examine profitability in the study pharmacies. A 25 percent random sample of community pharmacies (independent, chain, professional, and independent discount) in Alabama was studied, indicating an average breakeven cost to fill a prescription of $3.04. Pharmacy profitability was derived from the prescription department, with the front-end merchandise (all non-prescription items) contributing negatively to profitability in the average community pharmacy.

Ohio hospital formularies: an analysis of structure, process, and outcome.

A cross-sectional survey of Ohio hospital formulary systems conducted in the fall of 1982 is presented. The study describes the current status of formulary systems and formularies and analyzes the relationships between structure, process and outcome variables related to formularies and 21 randomly selected Ohio Department of Public Welfare (ODPW) Drug Efficiency Study and Implementation (DESI)-listed drugs. Fifty-five per cent of the state's hospitals reported having a formulary. Hospitals with formularies appeared to have a lower ratio and number of ODPW-DESI agents in stock. However, two variables maximally discriminated the avoidance of ODPW-DESI drugs: 1) the number of drugs in inventory or on formulary, and 2) the existence of a formulary. The results suggest that having a formulary assists in the avoidance of ineffective drug products, but the study's process variables could not predict formulary existence or positive outcomes.