Relationship between publication of a postgraduate year 1 residency research project and subsequent career type at a large academic medical center.

PURPOSE: The study objectives were to (1) quantify the overall incidence of residency publications of postgraduate year 1 (PGY1) residency alumni; (2) evaluate annual fluctuations in publications over time; and (3) compare the career types of residency alumni who published their PGY1 residency research projects to those for alumni who did not. METHODS: A retrospective cohort study was performed among individuals who completed a PGY1 acute/ambulatory care residency between 2010 and 2021. A list of residency alumni was obtained along with the corresponding titles of their research projects. Each resident's name was entered into PubMed and Google Scholar to find the corresponding publication. LinkedIn and other publicly available resources were used to determine the career types of residents immediately after residency as well as their current career types. RESULTS: In total, 178 residency alumni completed an acute/ambulatory care PGY1 residency, of whom 16.7% (30/178) published their residency research project. Publication was associated with career type among those who pursued a postgraduate year 2 residency but was not associated with career type immediately after the PGY1 residency or current career type. The presence of an academic preceptor was associated with a higher probability of publishing compared to residents who did not have an academic preceptor (31.5% vs 10.5%; P < 0.01). CONCLUSION: The frequency of publications was within the range reported elsewhere, with fluctuations over time. Presence of an academic preceptor improved the probability of publication.

Impact of a contactless prescription pickup kiosk on prescription abandonment, patient experience, and pharmacist consultations.

OBJECTIVE: Investigate the impact of increased access to new and refilled prescriptions by means of an automated pickup kiosk (Asteres ScriptCenter) on prescription abandonment rates, patient experience, and pharmacist consultations. DESIGN: Nonrandomized, observational study using retrospective, deidentified data from the filling pharmacy, the kiosk, and a pharmacist-completed counseling documentation log over a 35-month study period. SETTING AND PARTICIPANTS: Hospital employees opting to use a kiosk located in the lobby with 24 hours a day, 7 days a week access for pickups and a telephone pharmacist consultation service compared with employees using the regular counter at the filling pharmacy. OUTCOME MEASURES: Return to stock (RTS) rate to assess prescription abandonment, time to prescription pickup, consultation duration, kiosk user assessment, and pharmacist assessment of counseling ability. RESULTS: Approximately 9% of employees (440) enrolled to use the kiosk, with 5062 kiosk pickups recorded for new prescriptions (29%), refill prescriptions (33%), and over-the-counters (38%). The mean kiosk RTS (4.3% ± 3.2) was lower than that at the regular counter (5.6% ± 0.8), P = 0.04, whereas the mean time to pickup was approximately 1 day greater at the kiosk than the regular counter (2.8 ± 0.4 vs. 1.8 ± 0.2, P < 0.001). The average kiosk consultation was approximately 1 minute shorter (2.0 ± 1.4) than that of the regular counter (3.4 ± 1.9, P < 0.001), and fewer patients using the kiosk (15.7%) had additional questions at the end of a consultation session than patients at the regular counter (38.8%, P < 0.001). Most of the kiosk users agreed that their prescription questions were answered and that kiosk convenience was an important reason for using the filling pharmacy. Almost all (>90%) pharmacists indicated that they were able to effectively counsel patients at the kiosk and the regular counter. CONCLUSION: The kiosk, used by self-selected health care workers located in a hospital workplace setting with 24 hours a day, 7 days a week access, was a convenient, contactless pickup extension of the filling pharmacy with a lower prescription abandonment rate and similar pickup and consultation characteristics as at the regular pharmacy counter.

A Correlation of a Medication-Focused Risk Score to Medication Errors at Discharge.

Pharmacy transitions-of-care services at the time of hospital discharge are helpful in reducing medication errors. Validated risk tools are commonly used by pharmacists to identify patients at greatest benefit of these services. However, current tools lack assessment of medication-related risk factors and predict hospital readmissions rather than medication errors. To address this, a novel medication-focused risk tool (UCSD-Rx risk score) was created to help classify patients at a higher risk for medication errors. This study was split into 2 phases aimed to internally validate the risk score. Phase I of the study compared the predictability of 30-day unplanned readmissions between the UCSD-Rx risk score and a well-validated risk tool, the LACE+ index. To further specify our risk score for pharmacist use, phase II of the study analyzed the predictability of the risk score to medication errors at discharge. Phase I demonstrated similar classification performance of 30-day unplanned readmissions between the UCSD-Rx risk score (C-statistic, 0.66; 95% confidence interval [CI], 0.64-0.68; P < .0001) and the LACE+ index (C-statistic, 0.69; 95%CI, 0.67-0.71; P < .0001). In phase II, logistic regression showed an increasing UCSD-Rx risk score was predictive of individuals who would experience a medication error at discharge (odds ratio, 1.068; 95%CI, 1.005-1.136; P = .035). Results of this study demonstrate that the UCSD-Rx risk score is a promising tool targeted for pharmacist use to identify patients that may benefit most from transitions-of-care services prior to discharge.

The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial.

BACKGROUND: Patients with kidney disease are at risk for adverse events due to improper medication prescribing. Few randomized controlled trials of clinical decision support (CDS) utilizing dynamic assessment of patients' kidney function to improve prescribing for patients with kidney disease have been published. METHODS: We developed a CDS tool for 20 medications within a commercial electronic health record. Our system detected scenarios in which drug discontinuation or dosage adjustment was recommended for adult patients with impaired renal function in the ambulatory and acute settings - both at the time of the initial prescription ("prospective" alerts) and by monitoring changes in renal function for patients already receiving one of the study medications ("look-back" alerts). We performed a prospective, cluster randomized controlled trial of physicians receiving clinical decision support for renal dosage adjustments versus those performing their usual workflow. The primary endpoint was the proportion of study prescriptions that were appropriately adjusted for patients' kidney function at the time that patients' conditions warranted a change according to the alert logic. We employed multivariable logistic regression modeling to adjust for glomerular filtration rate, gender, age, hospitalized status, length of stay, type of alert, time from start of study, and clustering within the prescribing physician on the primary endpoint. RESULTS: A total of 4068 triggering conditions occurred in 1278 unique patients; 1579 of these triggering conditions generated alerts seen by physicians in the intervention arm and 2489 of these triggering conditions were captured but suppressed, so as not to generate alerts for physicians in the control arm. Prescribing orders were appropriate adjusted in 17% of the time vs 5.7% of the time in the intervention and control arms, respectively (odds ratio: 1.89, 95% confidence interval, 1.45-2.47, P < .0001). Prospective alerts had a greater impact than look-back alerts (55.6% vs 10.3%, in the intervention arm). CONCLUSIONS: The rate of appropriate drug prescribing in kidney impairment is low and remains a patient safety concern. Our results suggest that CDS improves drug prescribing, particularly when providing guidance on new prescriptions.

Decision support at the point of prescribing to increase formulary adherence.

PURPOSE: Study results demonstrating the effectiveness of order-entry clinical decision support (CDS) alerts as a tool for enforcing therapeutic interchange are presented. METHODS: A retrospective observational study was conducted at an academic medical center to evaluate formulary nonadherence before and after implementation of a fully electronic medical record with computerized prescriber order-entry (CPOE) technology configured to display therapeutic interchange alerts immediately on entry of orders for nonformulary agents. Formulary nonadherence (defined as the proportion of pharmacist-verified nonformulary orders to total verified orders) within eight medication classes was assessed during a six-month baseline period and two consecutive six-month periods after implementation. RESULTS: In the 12 months after implementation of the therapeutic interchange alerts, the overall rate of formulary nonadherence decreased by 65%, from 3.5% at baseline to 1.2% during the second 6-month postintervention period (p < 0.001). The total number of verified nonformulary orders decreased from 300 at baseline to 102 during the second postintervention period. The largest decreases in formulary nonadherence were observed in the intranasal steroid drug class (the rate of nonadherent orders declined by a total of 12 percentage points) and the nonbarbiturate sedatives and hypnotics class (a 5-point decline), with significant 6- and 12-month declines also documented in four of the remaining six drug classes. CONCLUSION: The incorporation of hard-stop CDS alerts into the CPOE system improved the overall rate of prescriber adherence to institutional therapeutic interchange protocols.

Formulary compliance and pharmacy labor costs associated with systematic formulary management strategy.

PURPOSE: The impact of a comprehensive hospital formulary management system on formulary compliance and pharmacy labor costs was evaluated. METHODS: The formulary management system consisted of monitoring nonformulary medication use, reviewing formulary medication use annually, and providing periodic feedback. Workflow scenarios for nonformulary medication requests were identified. Pharmacy personnel were interviewed to obtain the probability of occurrence of each scenario and the time involved. Labor costs were determined by multiplying the average total minutes spent on each activity by the corresponding average salaries per minute. Formulary compliance was compared before the implementation of the formulary management system (January to June 2008) with six consecutive six-month periods after implementation. RESULTS: Nonformulary medication use decreased from 17.8 to 5.9 nonformulary medication initiations per 100 admissions over a three-year period (p < 0.001). Time and labor costs associated with managing nonformulary medication requests varied from 4 to 69 minutes and from $3.68 to $27.28, respectively, depending on the scenario used. Automatically converting to a formulary alternative was the least labor-intensive option ($4.40 per request), followed by changing to a formulary alternative after consulting the prescriber ($9.92). CONCLUSION: A comprehensive formulary management system resulted in increased compliance to a formulary that matched the needs of the institution and minimized the number of nonformulary medication requests. Expanding pharmacists' therapeutic interchange authorities was the least labor-intensive way of managing nonformulary medication requests, and adding the most frequently used nonformulary medications to the formulary was the second least costly option.

Survey of institutions with multiple pharmacy residency programs.

PURPOSE: The processes used by institutions to manage and coordinate multiple pharmacy residency programs were evaluated. METHODS: An 18-question survey was developed. The survey was distributed via e-mail to all University HealthSystem Consortium (UHC) member institutions. The survey request was e-mailed to the pharmacy director of each hospital. Respondents submitted their information in an unblinded process. The survey was completed between May 31, 2011, and June 29, 2011. Respondents who indicated that their institution did not have four or more residency programs did not complete the remaining survey questions. Descriptive statistics were used to analyze survey responses. RESULTS: Of the 236 surveys distributed, 43 (18%) were completed. Of these, 28 had at least four unique residency programs. The majority of specific duties related to residencies (i.e., budgeting, project development, compliance with residency standards, scheduling of rotations and operations, and residency showcase preparation) were primarily the responsibility of the residency program director (RPD), residency activities coordinator, chief resident, or department chair or director. All of the programs surveyed had a residency program advisory committee (RAC). A majority of the programs (96%) had only one advisory committee overseeing both their postgraduate year 1 and postgraduate year 2 programs. The majority of respondents (60%) reported utilizing part-time administrative support for the residency programs; the remaining 40% reported no administrative support. CONCLUSION: UHC organizations with multiple pharmacy residency programs placed the majority of the responsibility for programs on the RPD, residency activities coordinator (where that model was used), and the pharmacy department chair. All programs utilized an RAC to govern the residency programs at their sites.

Development of a pharmacist-psychiatrist collaborative medication therapy management clinic.

OBJECTIVE: To describe a needs assessment, practice description, practice innovation and reimbursement of a psychiatric pharmacist medication therapy management (MTM) clinic with related challenges and opportunities. SETTING: An MTM clinic established in collaboration with the Outpatient Psychiatric Services (OPS) at the University of California San Diego (UCSD), under contract with the San Diego County Health and Human Services Agency Adult and Older Adult Mental Health Services (A/OAMHS). PRACTICE DESCRIPTION: Two board-certified psychiatric pharmacists provided direct patient care using a collaborative practice protocol 3 days per week. Clinical services included pharmacotherapy management, laboratory monitoring, medication counseling, and psychosocial referrals to other providers. PRACTICE INNOVATION: Payment to UCSD OPS for clinical services was based on a contract between the San Diego County A/OAMHS and the clinic. Two pharmacists co-managed mental health patients and billed for medication management based on face-to-face contact time (medication minutes) and documentation time with each patient. MAIN OUTCOME MEASURES: Number of patients comanaged, dropout rates, visit duration, and billed minutes. RESULTS: From May 2009 to December 2010, two pharmacists comanaged 68 patients, mean (± SD) age 48.6 ± 11.6 years, diagnosed with major depressive, schizophrenic, schizoaffective, and/or bipolar disorder. A total of 56 (82.3%) patients were clinically stable and remained on the pharmacist caseload, but 12 (17.6%) patients were lost to follow-up (10 lost contact, 1 moved, 1 expired). On average, patients had 7.7 patient visits , for 491 total visits (with an average of 26 minutes per visit) that were billed at a rate of $4.82 per minute for medication minutes, translating to $84,542.80. CONCLUSION: With provider education and appropriate physician champions, pharmacists are able to work collaboratively with psychiatrists in a mental health clinic.

Effects of a direct refill program for automated dispensing cabinets on medication-refill errors.

PURPOSE: The effects of a direct refill program for automated dispensing cabinets (ADCs) on medication-refill errors were studied. METHODS: This study was conducted in designated acute care areas of a 386-bed academic medical center. A wholesaler-to-ADC direct refill program, consisting of prepackaged delivery of medications and bar-code-assisted ADC refilling, was implemented in the inpatient pharmacy of the medical center in September 2009. Medication-refill errors in 26 ADCs from the general medicine units, the infant special care unit, the surgical and burn intensive care units, and intermediate units were assessed before and after the implementation of this program. Medication-refill errors were defined as an ADC pocket containing the wrong drug, wrong strength, or wrong dosage form. RESULTS: ADC refill errors decreased by 77%, from 62 errors per 6829 refilled pockets (0.91%) to 8 errors per 3855 refilled pockets (0.21%) (p < 0.0001). The predominant error type detected before the intervention was the incorrect medication (wrong drug, wrong strength, or wrong dosage form) in the ADC pocket. Of the 54 incorrect medications found before the intervention, 38 (70%) were loaded in a multiple-drug drawer. After the implementation of the new refill process, 3 of the 5 incorrect medications were loaded in a multiple-drug drawer. There were 3 instances of expired medications before and only 1 expired medication after implementation of the program. CONCLUSION: A redesign of the ADC refill process using a wholesaler-to-ADC direct refill program that included delivery of prepackaged medication and bar-code-assisted refill significantly decreased the occurrence of ADC refill errors.

Analysis of the medication-use process in North American hospital systems: underlining key points for adoption to improve patient safety in French hospitals.

This project was designed to underline any actions relative to medication error prevention and patient safety improvement setting up in North American hospitals which could be implemented in French Parisian hospitals. A literature research and analysis of medication-use process in the North American hospitals and a validation survey of hospital pharmacist managers in the San Diego area was performed to assess main points of hospital medication-use process. Literature analysis, survey analysis of respondents highlighted main differences between the two countries at three levels: nationwide, hospital level and pharmaceutical service level. According to this, proposal development to optimize medication-use process in the French system includes the following topics: implementation of an expanded use of information technology and robotics; increase pharmaceutical human resources allowing expansion of clinical pharmacy activities; focus on high-risk medications and high-risk patient populations; develop a collective sense of responsibility for medication error prevention in hospital settings, involving medical, pharmaceutical and administrative teams. Along with a strong emphasis that should be put on the identified topics to improve the quality and safety of hospital care in France, consideration of patient safety as a priority at a nationwide level needs to be reinforced.

Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas.

PURPOSE: The effect of a commercially available bar-code-assisted medication administration (BCMA) technology on six indicators of medication administration accuracy and nine types of medication administration errors in distinct patient care areas were studied. METHODS: This prospective, before-and-after, observational study was conducted in two medical-surgical units, one medical intensive care unit (ICU), and one surgical ICU of a 386-bed academic teaching hospital. Nursing staff were observed administering medications one month before and three months after implementation of BCMA technology. Observations were conducted by two pharmacists and four pharmacy students on weekdays and weekends. Medication administration accuracy was measured using the accuracy indicator of the California Nursing Outcomes Coalition. RESULTS: The majority of medication administrations occurred during the 9 a.m. medication round. After BCMA implementation in the medical-surgical units, improved adherence to patient identification policies was observed, but more distractions of the nursing staff occurred and the medications administered were less frequently explained to the patient. Although an increase in wrong-time errors was observed in the medical-surgical units, the total number of medication errors did not change. When wrong-time errors were excluded, the rate of medication errors decreased by 58%. In the ICUs, the charting of medication administration improved after BCMA implementation, but total medication errors and wrong-time errors did not change. CONCLUSION: Implementing BCMA technology decreased medication administration errors in medical-surgical units but not in ICUs when time errors were excluded. BCMA technology affected different types of medication administration errors in different patient care areas.

Development of an ambulatory palliative care pharmacist practice.

PURPOSE: The roles of a pharmacist in hospice and inpatient palliative care settings have been described. However, no reports of a palliative care pharmacist in an ambulatory care setting have been published. Our objective was to establish a model for incorporating an outpatient clinical pharmacist as part of a multidisciplinary palliative care team. METHODS: A palliative care pharmacist based out of a retail pharmacy was incorporated as part of a consultative ambulatory palliative care service (known as the Doris A. Howell Service) at the University of California, San Diego Moores Cancer Center. The pharmacist completed all legal requirements to prescribe under a collaborative practice agreement in California (including National Provider Identifier [NPI] and US Drug Enforcement Agency [DEA] US Drug Enforcement Agency (DEA) registration). RESULTS: From November 2006 through August 2007, the palliative care pharmacist consulted 29 new patients (the average age of patients was 49; range, 20-78 years) who had 114 clinic visits. The most common reason for referral to the palliative care pharmacist was for pain management (27/29; 93%). During the 114 patient clinic visits, 98% (112/114) of the palliative care pharmacist medication recommendations were accepted by the primary care oncologist. Physicians completed a satisfaction survey and reported that the top three useful activities of the Howell Service were: additional time spent with patients without physician present (90.9%), pain and symptom management (81.8%), and psychosocial support (72.7%). CONCLUSION: This is the first report of a palliative care pharmacist in a retail-based ambulatory care setting. Initial results demonstrate the success of this pilot program.