Interprofessional Medication Error Disclosure Training Using a Telehealth Consultation Simulation.

Objective. Health professions students must develop collaborative skills to disclose errors effectively and improve patient safety. We proposed that an interprofessional simulation using telehealth technology would provide medical and pharmacy students the opportunity to practice, develop, and grow in their confidence and skills of working collaboratively and disclosing medication errors.Methods. A three-phase interprofessional student simulation was developed. Phase 1 included individual student preparation. An interprofessional telehealth consultation encounter occurred in phase 2 for the error disclosure between the pharmacy and medical students. Phase 3 included faculty-led interprofessional debrief sessions. A pre- and postsimulation survey assessed students' experiences regarding their confidence in error disclosure, use of telehealth technology, and the role of the community pharmacist. Faculty evaluated pharmacy student performance using a 12-point rubric.Results. Presimulation survey responses (n=173) were compared to postsimulation survey responses (n=140). Significant changes were seen for all students' confidence in error disclosure and use of telehealth technology. No significant change was noted in the students' understanding of the community pharmacists' role on the interprofessional team. Pharmacy student performance-based rubric data (n=148) revealed a median score of seven out of 12 for error disclosure and interprofessional communication items.Conclusion. Medical and pharmacy students perceived their confidence improved in interprofessional error disclosure and use of telehealth consultation technology through this interprofessional simulation. Pharmacy students' error disclosure and interprofessional communication skill development were assessed through this simulation.

Evaluation of a simulation-based learning activity for communicating about at-risk opioid behaviors in a community pharmacy setting.

INTRODUCTION: The purpose of our study was to evaluate a learning activity that included an objective structured learning examination (OSLE) focused on identifying and communicating at-risk opioid behaviors in a community pharmacy setting through student perceptions and OSLE performance. METHODS: The activity included a didactic lecture and an OSLE with two opioid use patient cases. Third-year pharmacy students' communication skills were evaluated using faculty-created rubrics. A voluntary, anonymous pre-/post-survey evaluated students' skills confidence and OSLE satisfaction. Responses were analyzed using independent t-tests. An inductive conventional content analysis identified the impact on students' perceptions and future behaviors from post-simulation reflections. RESULTS: One hundred forty-three and 111 students completed the pre- and post-surveys, respectively. Students self-reported confidence in their ability to identify red flags and assess at-risk opioid behaviors, counsel on opioid risk behaviors, refuse opioid prescription fills, and respond to patients' nonverbal responses, all significantly improved pre-to-post. Students reported the OSLE was beneficial to their learning. The mean overall OSLE score was 34.2 out of 45 points (SD ± 6.21). Identified student reflection themes included: importance of patient-centered care, pharmacists' role in patients with at-risk opioid behaviors, recognition of judgement against patients taking opioids, and importance of communication and empathy as strategies to mitigate conflict. CONCLUSIONS: Implementing a new learning activity focused on communication regarding at-risk opioid behaviors allowed students to engage in difficult conversations with standardized patients in a safe simulation environment. Students demonstrated competent skills, increased their self-reported confidence, and were highly satisfied with the learning activity.

Evaluating the impact of a flipped classroom model based on cognitive science of learning strategies in a pharmacotherapy course.

INTRODUCTION: The purpose of this study was to determine the impact of a flipped classroom method based on cognitive science of learning strategies on student performance and experience in a third-year pharmacotherapy course. METHODS: The cognitive science of learning flipped classroom (CSL-FC) strategies in this study included pre-class learning (Preview), in-class application to cases (Retrieval), after-class learning (Spaced Retrieval), and post-module reflection (Deliberate Reflection) in a required pharmacotherapy course. During fall 2017, one instructor piloted the CSL-FC method. During fall 2018, this method expanded to four instructors. All other instructors used traditional lecture-based methods. The same multiple-choice exam questions were used both years. The average exam question scores between teaching methods were compared by independent t-test. Student focus groups were conducted after the 2017 semester. In 2018, students were surveyed using a 5-point Likert rating (1 = strongly agree, 5 = strongly disagree) to evaluate their experience. RESULTS: The 2017 and 2018 classes included 132 and 137 students, respectively. During the two years, exam question scores were significantly better with CSL-FC (n = 136 questions) compared to traditional (n = 110 questions) (88.8% vs 84.9%, respectively; P = .02). The focus group analysis revealed three main themes including a "love-hate relationship," "time," and "it works." Student agreement to the survey question "the cognitive science of learning flipped classroom helped me learn" was 2.18 (SD 1.12). CONCLUSIONS: Implementing a flipped classroom approach based on cognitive science of learning strategies positively impacted student performance and experience in a pharmacotherapy course.

The Power of Peer Mentoring to Support Women Pharmacy Faculty Personally and Professionally.

Regardless of a faculty member's career stage, effective mentoring is critical for successful professional development and a thriving academic career. Traditional mentor-mentee relationships can be effective but may present challenges for some faculty depending on their individual needs and institutional resources. The use of peer mentoring circles, where group members serve as both mentor and mentee, may provide additional resources and benefits to faculty at all career stages and appear especially beneficial for women faculty because of their focus on interconnectedness and collaboration. However, literature is scarce regarding effective mentoring strategies for women pharmacy faculty. As members of one women faculty-only peer mentoring circle, we describe our experiences using this mentoring strategy and offer recommendations for other faculty members considering this approach.

Determining the impact of an interprofessional simulation focused on social determinants of health among pharmacy students.

INTRODUCTION: The purpose of this study was to determine the impact on pharmacy students' self-perception of knowledge, skills, collaborative behavior, and satisfaction after participating in an interprofessional (IP) simulation focused on social determinants of health (SDOH) and substance use. METHODS: Pharmacy students completed a voluntary questionnaire after participating in an IP simulation focused on SDOH and substance use where they collaborated with social work (SW) students. Questions assessed the students' understanding and knowledge of SDOH and students' confidence in asking patients about their substance use, willingness to refer patients to SW, and satisfaction with the simulation. The data were analyzed using a Wilcoxon signed-rank test. RESULTS: Results of pharmacy students' (N = 68) self-reported knowledge of SDOH and skills addressing and counseling on SDOH were improved following an IP simulation. No statistically significant change was observed in students' confidence when asking about or advising a patient on their substance use. There was a positive, significant change in how likely pharmacy students would refer patients to SW (P < .001) in their future practice. CONCLUSIONS: This simulation proved to be an effective way to improve pharmacy students' self-reported knowledge of SDOH and skills for assessing and counseling on resources for SDOH. The simulation was effective in exposing pharmacy students to the role of social workers on the team and how they address SDOH and substance use issues.

Trainee Research Related to the Opioid-Related Activities Database Abstracts Presented at the 121st Virtual Annual Meeting of the American Association of Colleges of Pharmacy, July 13-31, 2020: Implementing an Activity to Identify and Communicate about At-Risk Opioid Behaviors in a Community Pharmacy.

Objective. To evaluate the effectiveness of an opioid objective structured learning experience (OSLE) focused on identifying and communicating about at-risk opioid behaviors in a community practice setting. Methods. A literature search included a review of the AACP Opioid-Related Activities Database that identified and evaluated educational activities, such as the RESPOND program (Oregon State University), that focused on communication surrounding opioids. A lack of activities emphasizing how to convey concerns about at-risk behaviors and refuse to fill opioid prescriptions in the AACP database was noted. With permission, aspects of the RESPOND program were utilized to develop a new opioid activity that included a didactic lecture and OSLE. The OSLE included two cases where students refused to fill an opioid prescription and counseled a patient demonstrating at-risk opioid behaviors on an opioid prescription. Student communication was evaluated by rubrics that were created and adapted from other activities included in the AACP database. A voluntary and anonymous survey that utilized a Likert scale (strongly agree to strongly disagree) evaluated student confidence in their skills and satisfaction with the activity before and after the OSLE. Results. One hundred forty-four and one hundred nine students completed the pre- and post- surveys, respectively. After the OSLE, student confidence in their ability to assess at-risk opioid behaviors, counsel a patient demonstrating at-risk behaviors, refuse to fill an opioid prescription, and respond to a patient's nonverbal responses improved by 67%, 37%, 49%, 46%, respectively. A majority of students (81%) felt that practicing these skills in an OSLE was beneficial. Conclusion. Incorporating an opioid OSLE allowed students to practice engaging in difficult conversations with patients demonstrating at-risk opioid behaviors and improved student's self-reported confidence. A majority of students agreed the OSLE was beneficial.

Assessing Self-Perceived Interprofessional Collaborative Competency on Advanced Pharmacy Practice Experiences Through Interprofessional Simulations.

Objective. To implement and assess the impact of Doctor of Pharmacy (PharmD) students participating in a required interprofessional (IP) simulation during an advanced pharmacy practice experience (APPE). Methods. Fourth-year PharmD students completing APPEs were required to participate in one of three IP simulations during the 2016-2017 academic year to improve their interprofessional teamwork and collaboration skills. Pharmacy student self-perception of IP competence was measured by the Interprofessional Collaborative Competency Attainment Survey (ICCAS), administered in a retrospective pre-/post-test design. Responses were analyzed using descriptive statistics to obtain an overview of the data. Paired t tests were used to compare the pre- and post-test results. Results. During the 2016-2017 academic year, 157 PharmD students were assigned to complete an IP simulation. Student scores on the six subscales of the ICCAS (communication, collaboration, roles and responsibility, collaborative patient-centered approach, conflict management, and team functioning) were compared. Scores in all categories significantly increased after completion of the simulation. Conclusion. Following participation in an IP simulation, PharmD students felt competent to engage in IP collaboration, and this, along with their performance on APPEs, determined their practice-readiness for IP teamwork upon graduation.

Potential best practices for assessment of interprofessional team-ready behaviors on APPEs.

INTRODUCTION: To determine potential best practices for assessment of team-ready behaviors of pharmacy students participating in interprofessional advanced pharmacy practice experiences (APPEs). METHODS: Preceptors received training on two interprofessional behavioral assessment tools, the modified interprofessional collaborator assessment rubric (mICAR) and individual teamwork observation and feedback tool (iTOFT). Preceptors evaluated students at midpoint and end of APPE using each tool. Preceptors completed a utility survey on each tool to determine a preference. Focus groups were conducted with a subset of preceptors to elicit further perspectives. Experts in interprofessional education (IPE) and accrediting board members were interviewed to determine a national perspective of best practices. RESULTS: Nineteen preceptors participated in the study. Of these, 12 completed all components of the study. No significant difference was found comparing utility of mICAR to iTOFT, although mICAR trended toward being easier to use/understand (p = 0.29). Focus group participants (n = 8) felt using a tool led to enhanced feedback and interprofessional experiences and all preferred mICAR. IPE experts and accrediting board members perceived best practices to include using a tool that aligns with IPE collaborative competencies, embedding the tool into existing APPE evaluation processes, and that is applicable to all health professional learners/evaluators. CONCLUSIONS: Preceptors preferred mICAR to iTOFT, though no significant difference was observed. Additional research is needed to confirm these results and for best practices to emerge. Future steps include evaluating interprofessional teamwork using a tool in a 360-evaluation of the individual learner by preceptors outside of the learner's own profession.

A Reflective Assignment Assessing Pharmacy Students' Interprofessional Collaborative Practice Exposure During Introductory Pharmacy Practice Experiences.

Objective. To assess the effectiveness of a required reflective writing assignment to document students' exposure to and experience with interprofessional collaborative practice (IPCP) during introductory pharmacy practice experiences (IPPEs). Methods. Pharmacy students completed the assignment during their community or institutional pharmacy IPPE and electronically submitted their written reflections. Twelve codes were created to indicate opportunities, barriers, and patient-centered care identified in the community pharmacy reflections. Fourteen codes were created to indicate interprofessional communication, roles, patient-centered care, and teamwork identified in the institutional pharmacy reflections. The reflections were then qualitatively analyzed to identify and code themes related to IPCP. Results. Two hundred twenty-eight reflections were submitted. Exposure to an observed IPCP was described in 51% of the community pharmacy reflections and in 100% of the institutional pharmacy reflections. Identified opportunities to improve IPCP in community pharmacy were extended pharmacy services, expanded networking and relationships, making more phone calls to other health professionals, and greater use of technology. The identified barriers to IPCP in community pharmacy were difficulty accessing patient health data, lack of direct access to prescribers, hierarchy, pharmacy workload, and lack of timely communication. The identified themes that impacted IPCP in institutional settings included dysfunctional communication, technology use, mutual respect, role overlap, teamwork, nonphysician leadership, and personal relationships. Conclusion. Implementing a reflective assignment during IPPEs was an effective way to document student exposure to and experience in IPCP in two types of pharmacy practice settings and helped to meet pharmacy accreditation standards of having IPE included in early experiential education settings.

Hepatitis C: A New Era.

More than 2 million Americans are infected with hepatitis C virus (HCV), and only about half are aware that they are infected. Primarily blood-borne, risk factors for the virus include injection or intranasal drug use, unregulated tattoos, incarceration, and blood transfusion before 1992. In addition, 75% of those with the virus were born between 1945 and 1965, thus making the baby-boomer cohort a population of screening interest. Because acute and early chronic HCV are often asymptomatic, screening of at-risk individuals is of utmost importance. Left untreated, HCV can go on to produce significant hepatic and extrahepatic manifestations.

Atrial fibrillation: Effective strategies using the latest tools.

Direct oral anticoagulants or warfarin? Rate or rhythm control? Here's how to determine which strategies to pursue and when.

Accelerating quality improvement within your organization: Applying the Model for Improvement.

OBJECTIVE: To discuss the fundamentals of the Model for Improvement and how the model can be applied to quality improvement activities associated with medication use, including understanding the three essential questions that guide quality improvement, applying a process for actively testing change within an organization, and measuring the success of these changes on care delivery. DATA SOURCES: PubMed from 1990 through April 2014 using the search terms quality improvement, process improvement, hospitals, and primary care. STUDY SELECTION: At the authors' discretion, studies were selected based on their relevance in demonstrating the quality improvement process and tests of change within an organization. SUMMARY: Organizations are continuously seeking to enhance quality in patient care services, and much of this work focuses on improving care delivery processes. Yet change in these systems is often slow, which can lead to frustration or apathy among frontline practitioners. Adopting and applying the Model for Improvement as a core strategy for quality improvement efforts can accelerate the process. While the model is frequently well known in hospitals and primary care settings, it is not always familiar to pharmacists. In addition, while some organizations may be familiar with the "plan, do, study, act" (PDSA) cycles-one element of the Model for Improvement-many do not apply it effectively. The goal of the model is to combine a continuous process of small tests of change (PDSA cycles) within an overarching aim with a longitudinal measurement process. This process differs from other forms of improvement work that plan and implement large-scale change over an extended period, followed by months of data collection. In this scenario it may take months or years to determine whether an intervention will have a positive impact. CONCLUSION: By following the Model for Improvement, frontline practitioners and their organizational leaders quickly identify strategies that make a positive difference and result in a greater degree of success.

Warfarin monitoring in antiphospholipid syndrome and lupus anticoagulant.

OBJECTIVE: To review the available literature on international normalized ratio (INR) and chromogenic factor X (CFX) monitoring in patients with antiphospholipid syndrome (APS), specifically lupus anticoagulant (LA), and furthermore, to identify benefits of one monitoring test compared with the other in the presence of LA. DATA SOURCES: A literature search was conducted through MEDLINE (1946-May 2014) utilizing the following MeSH terms chromogenic compounds, anticoagulants, and factor X. Further articles were identified from original literature citations. STUDY SELECTION: All English-language studies were included that involved INR and/or CFX monitoring in APS patients that focused on a therapeutic anticoagulation level with warfarin therapy. DATA SYNTHESIS: A total of 55 articles were identified, of which nine are referenced because of their relevance for this review: three articles focus on the efficacy of utilizing INR monitoring in patients with APS, five focus on CFX compared with INR for therapeutic warfarin dosing, and one compares different thromboplastins utilizing both INR and CFX monitoring. INR monitoring in patients with APS, specifically LA, was not found to be reliable because thromboplastin reagents are sensitive to LA. Furthermore, when INR was compared to CFX, patients with LA had supratherapeutic INRs despite having CFX within goal range. CONCLUSIONS: In a subgroup of APS patients, INR monitoring may not be safe for determining the dose of warfarin because their INR values can be falsely elevated. Although CFX monitoring is more accurate, it too comes with its own downsides. Managing warfarin therapy in the APS population needs to be individualized.

Cost of pain medication to treat adult patients with nonmalignant chronic pain in the United States.

BACKGROUND: Nonmalignant chronic pain (NMCP) is a public health concern. Among primary care appointments, 22% focus on pain management. The American Academy of Pain Medicine guidelines for NMCP recommend combination medication therapy (including analgesics, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, antidepressants, and anticonvulsants) as a key component to effective treatment for many chronic pain diagnoses. However, there has been little evidence outlining the costs of pain medications in adult patients with NMCP in the United States, an area that necessitates further consideration as the nation moves toward value-based benefit design. OBJECTIVES: To estimate the cost of pain medication attributable to treating adult patients with NMCP in the United States and to analyze the trend of outpatient pain visits. METHODS: This cross-sectional study used the National Ambulatory Medical Care Survey (NAMCS) data from 2000-2007. The Division of Health Care Statistics, National Center for Health Statistics, and the Centers for Disease Control and Prevention conducted the survey. The study included patients aged ≥18 years with chronic pain diagnoses (identified by the ICD-9-CM codes: primary, secondary, and tertiary). Patients prescribed at least 1 pain medication were included in the cost analysis. Pain-related prescription medications prescribed during ambulatory care visits were retrieved by using NAMCS drug codes/National Drug Code numbers. National pain prescription frequencies (weighted) were obtained from NAMCS data, using the statistical software STATA. We created pain therapy categories (drug classes) for cost analysis based on national pain guidelines. Drug classes used in this analysis were opioids/opioid-like agents, analgesics/NSAIDs, tricyclic antidepressants, selective serotonin reuptake inhibitors, antirheumatics/immunologics, muscle relaxants, topical products, and corticosteroids. We calculated average prices based on the 3 lowest average wholesale prices reported in the Red Book 2009 for maximum recommended daily dose. Total pain medication costs were calculated in 2009 and 2013 dollar values. The study analyzed NMCP-related outpatient visit trends and used time series analysis to forecast visits using U.S. population data and statistics. RESULTS: The total costs of prescription medications prescribed for pain were $17.8 billion annually in the United States. Cost estimates were captured based on a total of 690,205,290 (~690 million) weighted outpatient visits made for chronic pain from 2000 to 2007 in the United States. Of those patients, 99% received a medication that could be used for NMCP. Among the patients, 29% reported taking ≥5 medications. A linear trend of pain visits is visible, reporting change (from 11% to 14%) from 2000 to 2007 in the United States. All agents except opioids/opioid-like agents and analgesics/NSAIDs were further categorized as adjuvant therapy to create 3 major drug class categories. The largest 3 categories of pain therapy for the United States (annually) were analgesics/NSAIDs ($1.9 billion), opioids ($3.6 billion), and adjuvants ($12.3 billion). Despite having the highest prescription frequency nationally, analgesics/NSAIDS accounted for about 11% of the overall pain medication costs. This study found that adjuvant therapy accounted for 69% of the total pain medication costs. Among adjuvants, 33.5% of the cost was contributed by antirheumatics/immunologics. Other adjuvants included muscle relaxants (4.4%), topical products (8.6%), and corticosteroids (9.4%). CONCLUSIONS: This study demonstrated national prescribing costs and use within various drug categories of pain medications in a large outpatient population over an 8-year period in the United States. Policymakers, stakeholders, and health plan decision makers may consider this cost analysis, since they need to know how drug costs are being allocated. Moreover, information about costs and use of pain medications is valuable for the practitioner making individual patient care decisions, as well as for those who make population based decisions. This study reported an increasing trend of outpatient pain visits in the United States. Therefore, policymakers and health plan decision makers may expect a growing number of pain-related outpatient visits in coming years and allocate resources accordingly to meet the need.