Assessment of Pharmacy Department Patient Safety Culture with the Use of Validated Work Environment Survey Indices.

CONTEXT: Patient safety culture (PSC) improvement is a strategy that can foster patient well-being. Measuring PSC without using a validated instrument has been proposed. OBJECTIVE: To assess the strengths of correlations between the Agency for Healthcare Research and Quality's validated Community Pharmacy Survey on Patient Safety Culture (CPSPSC) composites and nonvalidated People Pulse (PP) work environment indices. DESIGN: This was a cross-sectional, anonymous, voluntary survey. METHODS: This survey was conducted online in an ambulatory pharmacy department that had approximately 900 staff members within an integrated health care delivery system. All pharmacy department staff were asked to participate. CPSPSC composites and PP indices were calculated as percent-positive scores (PPS). Thirty-six correlations between PP index and CPSPSC composite PPS were assessed with the Pearson product-moment correlation coefficient. Correlation strengths were interpreted as very weak (± 0.00 to 0.19), weak (± 0.20 to 0.39), moderate (± 0.40 to 0.59), strong (± 0.60 to 0.79), and very strong (± 0.80 to 1.0). RESULTS: A total of 429 (47.4%) pharmacy staff participated. Overall, correlations between CPSPSC composites and PP indices' PPS varied widely. Although all correlations were positive and the majority of correlations were statistically significant, no correlations were identified as very strong. Ten correlations were strong, 16 were moderate, 4 were weak, and 3 were very weak. CONCLUSION: Although health care system personnel may prefer to measure PSC with a survey instrument that assesses a variety of workplace environment measures, these findings suggest that use of nonvalidated work environment indices will not provide accurate assessment of PSC in a pharmacy department.

Pharmacy Survey on Patient Safety Culture: Benchmarking Results.

OBJECTIVE: This study's objective was to assess the patient safety culture in a large, integrated health delivery system's pharmacy department to allow for benchmarking with other health systems. METHODS: This was a cross-sectional survey conducted in a pharmacy department consisting of staff members who provide dispensing, clinical, and support services within an integrated health delivery system. The U.S. Agency for Healthcare Research and Quality's 11-composite, validated Pharmacy Survey on Patient Safety Culture questionnaire was transcribed into an online format. All departmental staff members were invited to participate in this anonymous survey. Cronbach α and overall results and contrasts between dispensing and clinical services staff and dispensing pharmacists and technicians/clerks as percentage positive scores (PPSs) are presented. Differences in contrasts were assessed with χ tests of association. RESULTS: Completed questionnaires were received from 598 (69.9%) of 855 employees. Cronbach α ranged from 0.55 to 0.90. Overall, the highest and lowest composite PPSs were for patient counseling (94.5%) and staffing and work pressure (44.7%), respectively. Compared with dispensing service, the clinical service participants had statistically higher PPSs for all composites except patient counseling, communication about mistakes, and staffing and work pressure (all P > 0.05). The technicians/clerks had a statistically higher PPS compared with the pharmacists for communication about mistakes (P = 0.007). All other composites were equivalent between groups. CONCLUSIONS: Patient counseling consistently had the highest PPS among composites measured, but opportunities existed for improvement in all aspects measured. Future research should identify and assess interventions targeted to improving the patient safety culture in pharmacy.

Renal Drug Dosing. Effectiveness of Outpatient Pharmacist-Based vs. Prescriber-Based Clinical Decision Support Systems.

OBJECTIVE: The purpose of this study was to compare the effectiveness of an outpatient renal dose adjustment alert via a computerized provider order entry (CPOE) clinical decision support system (CDSS) versus a CDSS with alerts made to dispensing pharmacists. METHODS: This was a retrospective analysis of patients with renal impairment and 30 medications that are contraindicated or require dose-adjustment in such patients. The primary outcome was the rate of renal dosing errors for study medications that were dispensed between August and December 2013, when a pharmacist-based CDSS was in place, versus August through December 2014, when a prescriber-based CDSS was in place. A dosing error was defined as a prescription for one of the study medications dispensed to a patient where the medication was contraindicated or improperly dosed based on the patient's renal function. The denominator was all prescriptions for the study medications dispensed during each respective study period. RESULTS: During the pharmacist- and prescriber-based CDSS study periods, 49,054 and 50,678 prescriptions, respectively, were dispensed for one of the included medications. Of these, 878 (1.8%) and 758 (1.5%) prescriptions were dispensed to patients with renal impairment in the respective study periods. Patients in each group were similar with respect to age, sex, and renal function stage. Overall, the five-month error rate was 0.38%. Error rates were similar between the two groups: 0.36% and 0.40% in the pharmacist- and prescriber-based CDSS, respectively (p=0.523). The medication with the highest error rate was dofetilide (0.51% overall) while the medications with the lowest error rate were dabigatran, fondaparinux, and spironolactone (0.00% overall). CONCLUSIONS: Prescriber- and pharmacist-based CDSS provided comparable, low rates of potential medication errors. Future studies should be undertaken to examine patient benefits of the prescriber-based CDSS.

Clinical Outcomes of Continuation of Metformin Titration Instructions with Electronic Prescribing.

BACKGROUND: Anecdotal evidence suggests that metformin titration instructions are not being updated and refill requests are approved without modification of the titration instructions such that the titration instructions is continued for patients newly initiated on metformin. METHODS: This was a retrospective cohort analysis of adult patients who received newly initiated metformin pharmacotherapy. Patients were followed from their initial metformin purchase through two subsequent metformin refill purchases. Outcomes, including the 3-year incidence rate of patients with at least one set of continued titration instructions and proportions of patients with at least one gastrointestinal adverse effect (AE) and those with an elevated glucose measurement at follow-up, were assessed during the time period between patients' second and third metformin purchases. Analyses were performed comparing the exposure (i.e., patients with continued instructions) group to the control (i.e., patients without continued instructions) group. RESULTS: The exposure group had a higher mean age and chronic disease score but lower metformin starting dose than the control group (all p < 0.05). The 3-year incidence rate of patients with at least one continuation of titration instructions was 60.3 % (95 % CI 58.3-62.3). Gastrointestinal AEs were rare with equivalent proportions of patients in each group experiencing an event (p > 0.05). Control patients (48.7 % of patients with a measurement) were more likely to have had poorly controlled glucose than exposure patients (35.7 % of patients with a measurement) (p < 0.001). CONCLUSIONS: A high rate of continuation of titration instructions for patients newly initiated on metformin was observed; however, such continuation did not negatively affect clinical outcomes.

Evaluation of venous thromboembolism risk following hospitalization.

UNLABELLED: A better understanding of the relationship between outpatient venous thromboembolism (VTE) and prior hospitalization is needed including data regarding the utilization of inpatient pharmacologic VTE prophylaxis and its effect on outpatient venous thromboembolic risk. The primary objective was to assess the association between development of outpatient VTE and inpatient hospitalization within the previous 90 days. Additional outcome measures included describing patients who received pharmacologic anticoagulation during hospitalization and identification of factors independently associated with VTE. Case patients in this matched case-control study were diagnosed with an outpatient deep vein thrombosis or pulmonary embolus between January 2005 and December 2007 and were matched on age with up to five to patients who were seen for an outpatient health maintenance visit but had no VTE during the same time frame as their matched case. Information collected from electronic administrative databases and patient medical records included health services utilization, medication use, medical diagnoses, and patient demographic information. Of 2190 cases, 560 patients (25.6%) compared to 151 (1.4%) of 10,942 control patients were hospitalized in the previous 90 days (P < 0.001). Among hospitalized patients, 53.5% of cases and 47.0% of controls received an anticoagulant during hospitalization (P = 0.186). Factors associated with a VTE diagnosis included hospitalization for a surgical, medical, or orthopedic indication in the previous 90 days, younger age, longer hospitalization, cancer and an elevated Chronic Disease Score. CONCLUSIONS: A strong association exists between outpatient VTE diagnosis and hospitalization and gaps in pharmacologic prophylaxis utilization during hospitalization are evident.

Quality experiential education.

The 2007 Accreditation Council for Pharmacy Education (ACPE) Accreditation Standards and Guidelines for the Professional Program in Pharmacy delineate new expectations for experiential education within curricula and include guidance on the development and conduct of Pharmacy Practice Experiences. The American College of Clinical Pharmacy (ACCP) Educational Affairs Subcommittee C developed a position statement to further delineate the views of ACCP on factors necessary to meet contemporary standards for doctoral education in pharmacy and to provide guidance to our membership on how to implement the new standards. This White Paper provides explanation and supporting documentation for positions on quantitative and qualitative aspects of experiential education, as well as requirements for practice sites, preceptor roles, qualification, credentialing, and development and assessment of student performance.

Collaborative drug therapy management by pharmacists--2003.

Since publication of the initial ACCP position statement on CDTM by pharmacists in 1997, the public, government, and much of the health care community at large have come to better appreciate the growing complexity of providing effective and safe drug therapy in today's health care environment. Increased interest in the issues of cost and quality of drug use is evident in the increasing coverage of the issue in the lay press and professional literature. This represents real progress, as well as real opportunity, for pharmacists. It also heightens the potential for a better understanding of the vital role that pharmacists can play in addressing these concerns. The percentage of patients who take several drugs for chronic diseases will continue to increase. Based on current trends, the number of patients who lack adequate access to care, or who receive either suboptimal, inappropriate, or unnecessarily expensive drug therapy for their acute and chronic diseases, will increase. Even as financial and human resources are increasingly strained within the current health care system, costs will continue to rise unless changes are made. Fortunately, qualified pharmacists are prepared, capable, and willing to help address a significant portion of these challenges. The public, many health care providers, some legislators, and a few insurers now recognize that pharmacists, because of their education and training in drug therapy, are well positioned both to accept additional responsibility for patient care and to provide services that make a real difference in health care quality and outcomes. The health care programs administered by the U.S. Public Health Service, the armed forces, and the Veterans Health Administration, as well as 38 states, now support pharmacist participation in CDTM. Pharmacists, working in an interdisciplinary structure with physicians and other health care providers, have demonstrated that they can improve the effectiveness, efficiency, and safety of drug therapy by providing CDTM. It is time to incorporate this valuable professional skill of the contemporary pharmacist as a core component of the delivery of health care services.