Medication histories to identify medication-related problems through the pharmacists' patient care process in a simulated ambulatory care laboratory.

BACKGROUND AND PURPOSE: Assessment of the Pharmacists' Patient Care Process (PPCP) in pharmacy curricula has been reported in a variety of contexts, but results have not described individual student performance in a controlled ambulatory care skills laboratory to purposefully identify medication-related problems (MRP) and develop plans for resolution. EDUCATIONAL ACTIVITY AND SETTING: One of five MRPs was embedded within standardized medication profiles to facilitate student completion of three graded ambulatory care medication history encounters in a third-year skills laboratory. Data analysis included student performance in aggregate and according to MRP type from the first to the third medication history encounter. FINDINGS: One hundred thirty-six students completed three medication histories for 408 encounters. Regardless of MRP, the total and subscale scores for adjusted marginal means were significantly higher in Sessions 2 and 3. Performance on MRP scenarios for drug interactions and adverse effects were significantly lower and higher, respectively. Successful collection of patient history significantly influenced marginal mean scores for respective MRPs. SUMMARY: Improvement in student application of PPCP Steps 1 through 3 may be evident using three simulated ambulatory care medication history patient encounters toward the end of the third professional year, with potential influences by MRP type, MRP repetition, and adequate collection of patient history. Repetition with individualized grading and formative feedback are essential for skill development to identify MRPs in this setting. Confirmation of findings and extension into experiential education with higher complexity are needed to develop consistent and effective application of the PPCP to patient care.

Errors in the Administration Technique of Insulin Pen Devices: A Result of Insufficient Education.

Insulin is a high-alert medication in both inpatient and outpatient settings. Insulin can cause significant harm when administered in error. Despite advancements in insulin pen technology, errors in the administration technique remain an issue. Although various factors can contribute to administration errors, lack of education on how to operate these devices is one of the most common reasons they occur. As such, the mechanical technique used by the patient needs to be continually assessed in order to reinforce education where needed. We describe three unique patient cases that depict incorrect administration techniques when using pen devices and the consequences that could have resulted from these errors. These cases involve the use of a syringe instead of a pen needle, injecting without removing the inner cap, and dialing the pen back down instead of pushing the plunger. Although pen devices are relatively simple to use, this article reinforces the need for continual assessment of and education about insulin administration. The teach-back method is an approach that can be used to assess a patient's technique and re-educate them at every available opportunity to reduce the risk of administration errors, which can result in complications and hospitalizations.

Using reflection to evaluate student learning in ambulatory care IPPEs.

PURPOSE: Gather insight from student pharmacists about what they learned and whether objectives of an introductory pharmacy practice experience (IPPE) were achieved in an academic-based ambulatory care site. METHODS: Students wrote post-reflective essays after their first ambulatory care-site visit. They reflected upon their previous assumptions of ambulatory care, and the roles and skills required of pharmacists in this setting. Additionally, students ranked their interest in ambulatory care pre- and post-IPPE. Post-reflection essays were analyzed for recurring themes using a constant comparison method and a respondent validation method was employed to confirm these findings. Wilcoxon signed-rank sum test was used to analyze student interest in ambulatory care and descriptive statistics were used, as appropriate. RESULTS: Overall, 70 reflection articles were analyzed. Assumptions of ambulatory care were either incorrect or proved to be more than what was expected for 60% of students. Based on the themes identified, students learned most about the collaborative practice model, chronic disease state management, and the time commitment necessary for outcomes. Regarding skills required of a pharmacist, students discussed the need for a strong knowledge base, communication, and ability to transfer these skills from one setting to another. Interest in ambulatory care increased after the site visit (p <0.01) and 90% of students who wrote these reflections strongly agreed or agreed with the above findings. CONCLUSIONS: With intentional reflection, ambulatory care IPPEs can serve as a meaningful outlet for learning while also achieving IPPE objectives.

Comparing Direct Oral Anticoagulants and Warfarin for Atrial Fibrillation, Venous Thromboembolism, and Mechanical Heart Valves.

OBJECTIVES: To summarize available data for use of direct oral anticoagulants in nonvalvular atrial fibrillation, venous thromboembolism, and mechanical heart valves including dose-response consistency to offer considerations for pharmacotherapeutic decision-making for oral anticoagulants. DATA SOURCES: A Medline search of English-language studies published between 2000 and March 2015 was conducted to identify pertinent papers using combinations of the following words: apixaban, atrial fibrillation, dabigatran, direct oral anticoagulant, edoxaban, factor IIa inhibitors, factor Xa inhibitors, mechanical heart valves, novel oral anticoagulant, rivaroxaban, venous thromboembolism, and warfarin. STUDY SELECTION AND EXTRACTION: Original studies, guidelines, and approved prescribing information were evaluated and included if contributing new or complementary data toward the objective. References for all identified studies were reviewed and entries included if contributory. DATA SYNTHESIS: Randomized controlled trials have established the safety and efficacy of direct oral anticoagulants in atrial fibrillation and venous thromboembolism for most patient groups. Direct oral anticoagulants should not be used in patients with mechanical heart valves until proven safe and effective. There are groups for which questions remain regarding inter-patient dose-response consistency for direct oral anticoagulants. There are postmarketing data suggesting poorer real-world performance of dabigatran relative to clinical trial data. CONCLUSION: Direct oral anticoagulants offer several advantages over warfarin, and large clinical trial data establish the appropriateness of their use in broad populations. There remain groups for whom the relative benefit and risk of these agents relative to warfarin are uncertain. A patient-specific approach in pharmacotherapeutic decision-making is appropriate.

Interprofessional pharmacy observation activity for third-year dental students.

Interprofessional learning is a key component of today's health sciences education. Within a two-course series in dental pharmacology and therapeutics, a dental curriculum was revised to provide an interprofessional activity to expose dental students to a community pharmacy setting. The objectives of this activity were to augment students' learning about drug laws and prescription writing, as well as to foster interprofessional relationships and collaboration between pharmacists and dentists. Dental students were scheduled for one-hour observations at community pharmacies on campus. Learning objectives to guide this activity focused on demonstrating community pharmacy operating procedures, identifying ways to minimize prescribing and dosing errors, and understanding how pharmacists can assist dentists in prescribing. Following the observation, students were required to submit a written assignment, which accounted for 14 percent of their course grade. All 119 dental students (100 percent) enrolled in the course for the summers of 2012 and 2013 completed the activity. The average grade on the written assignment was 96.2 out of 100. At the end of the course, students were asked to participate in an online course evaluation survey, for which response rates were 37 percent and 43 percent for 2012 and 2013, respectively. The students rated the pharmacy observation activity favorably on this course evaluation. The pharmacy observation activity provided a successful interprofessional component to the didactic pharmacy course and was well received by the dental students as well as the community pharmacists.

Assessing student pharmacists' ability to identify drug-related problems in patients within a patient-centered medical home.

OBJECTIVE: To quantify, describe, and categorize patient drug-related problems (DRPs) and recommendations identified by fourth-year (P4) student pharmacists during a live medication reconciliation activity within a patient-centered medical home (PCMH). METHODS: Fourth-year student pharmacists conducted chart reviews, identified and documented DRPs, obtained live medication histories, and immediately provided findings and recommendations to the attending physicians. Documentation of DRPs and recommendations were analyzed retrospectively. RESULTS: Thirty-eight students completed 99 medication reconciliation sessions from June 2011 to October 2012 during their advanced pharmacy practice experience (APPE). The students obtained 676 patient medication histories and identified or intervened on 1308 DRPs. The most common DRPs reported were incomplete medication list and diagnostic/laboratory testing needed. Physicians accepted 1,018 (approximately 78%) recommendations. CONCLUSION: Student pharmacists successfully identified and reduced DRPs through a live medication reconciliation process within an academic-based PCMH model. Their medication history-taking skills improved and medication use was optimized.

Glycemic index of American-grown jasmine rice classified as high.

The primary objective was to determine the glycemic index (GI) of jasmine rice grown in the United States (US). Secondary objective was to compare the GI of US grown jasmine rice to those grown in Thailand. Twelve healthy subjects were served all four brands of jasmine rice and a reference food (glucose), each containing 50 g of available carbohydrate. Fingerstick blood glucose was measured at 0, 15, 30, 45, 60, 90, and 120 min after consumption following a fasting state. The GI was calculated using the standard equation. The GI values for test foods ranged from 96 to 116 and were all classified as high GI foods. No difference in GI was found between American-grown and Thailand-grown jasmine rice. Although not statistically significant, observations show glycemic response among Asian American participants may be different. GI should be considered when planning meals with jasmine rice as the main source carbohydrate.

Successful management of anticoagulation therapy during international travel.

Warfarin is considered a high-risk drug because of its narrow therapeutic window, variability in dose response, and multitude of drug and food interactions. Although travel advice is available for patients who are taking warfarin, it is geared toward patients who are traveling to developed countries and tends to be lacking in detail. We describe a 53-year-old woman with two mechanical heart valves and chronic atrial fibrillation who was taking warfarin for thromboembolism prophylaxis and had plans to travel to Vietnam for 10 weeks. Three days before her departure, she was prescribed amiodarone for long-term use. As a result of the extended duration of her travel and the complexities of warfarin use, the pharmacists who managed the patient's anticoagulation reviewed several aspects of a comprehensive management approach with the patient for a safe international trip. They assessed the patient's thromboembolic and hemorrhagic risks, and determined which other drugs (e.g., enoxaparin, phytonadione), dosages, and adequate supplies would be required along with warfarin, as well as how to safely transport these drugs during travel. In addition, the logistics of effectively monitoring international normalized ratio (INR) levels were evaluated, and methods of managing multiple potential scenarios were carefully planned out. Contact with the patient was made through pharmacist-directed telephone visits throughout the travel period. A total of 12 telephone visits were conducted with the patient during the 10 weeks of travel. Her INR was supratherapeutic on three occasions and was subtherapeutic once; however, neither enoxaparin nor phytonadione were needed during the travel period, and the patient returned safely to the United States. Effective and safe use of high-risk drugs for patients leaving the United States requires extensive pretravel planning, and pharmacists can play a central role in optimizing therapeutic outcomes for these patients during international travel.

Probable warfarin and dapsone interaction.

We describe a case of a 41-year-old woman who was stable for over a year on 22.5 mg/week of warfarin. At a follow-up visit, her international normalized ratio (INR) was found to be supratherapeutic at 3.9. Her only significant change was acyclovir initiation for shingles, and clindamycin and dapsone for infection on her right foot. An interaction report was run using Micromedex with no interactions reported. Sixteen percent of the weekly dose was held and maintenance dose was continued. Two weeks later, the INR remained supratherapeutic at 4.3, with discontinuation of clindamycin and dapsone, 5 days earlier, as the only change. This time an interaction report was run using Lexi-Comp, which identified an interaction between warfarin and dapsone. The INR has been therapeutic and stable since discontinuation of transient factors. It is hypothesized that warfarin and dapsone compete for binding on the CYP2C9 and CYP3A4 isoenzymes and therefore serum concentration of warfarin was elevated.

Assessing the need for diabetes self-management education in the Oklahoma city vietnamese community.

INTRODUCTION: To assess the diabetes self-management educational (DSME) needs of the Vietnamese diabetic population in the Oklahoma City metropolitan area. METHODS: Participants in this explorative study included 50 Vietnamese adults with type 1 or type 2 diabetes recruited from the offices of four primary care physicians in the Oklahoma City metropolitan area. Participants completed a culturally sensitive survey focused on their diabetes history, knowledge and need of DSME, and health beliefs. Responses were evaluated using means and frequency analysis. RESULTS: The mean age of participants was 62.7±9.1 years. Over 80% of participants were most comfortable speaking and reading Vietnamese, and 62% had never received a high school diploma. Less than 50% of participants reported ever receiving education regarding diabetic complications, nutrition, desirable glycated hemoglobin values, diabetic medications, daily self-care, risk of smoking, or cardiovascular risk associated with diabetes. More than 80% of participants requested more education in all areas of DSME except smoking risk in diabetes, with all participants requesting delivery of this education in Vietnamese. CONCLUSION: DSME is needed and desired in the Vietnamese community of the Oklahoma City metropolitan area. Education should be provided in the Vietnamese language with most targeted to lower literacy levels. Vietnamese diabetes educators should facilitate increased access to DSME knowledge and skills in efforts to improve glycemic control and overall health status for this community.