Pharmacy 302W SPE Manual 2013 – 2014
Pharmacy 302W SPE Manual 2013 – 2014 If you have questions regarding the SPE Program, please contact: Ms. Wanda Spurrell Room 3442, School of Pharmacy Memorial University of Newfoundland St. John’s, NL A1B 3V6 Phone: 709-777-6498 Fax: 709-777-7044 e-mail: [email protected] Table of Contents Acknowledgments Introduction ............................................................................................................................. i - xii Educational Outcomes ........................................................................................................ i Pharmacy 302W Learning Objectives .......................................................................... ii - iii General Performance Guidelines for the Student ......................................................... iv - v Addressing Student/Preceptor Concerns............................................................................ vi SPE Checklist............................................................................................................ vii - viii Activities & Questions and Evaluation ............................................................................. ix Activity and Question Checklist ................................................................................ x - xii Section 1: Provide Patient Care .............................................................................................. 1 - 4 Objectives ............................................................................................................................1 Readings and References ....................................................................................................1 Tools and Forms ..................................................................................................................1 Activities & Questions ................................................................................................... 2 - 4 Section 2: Accept Professional Responsibilities ..................................................................... 5 - 8 Objectives ............................................................................................................................5 Readings and References ....................................................................................................5 Activities ........................................................................................................................ 5 - 8 Section 3: Provide Drug and Drug Use Information and Recommendations ..................... 9 - 10 Objectives ............................................................................................................................9 Readings and References ....................................................................................................9 Tools and Forms .................................................................................................................9 Activities & Questions ................................................................................................. 9 - 10 Section 4: Use Management Skills in Practice ................................................................... 11 - 16 Objectives ..........................................................................................................................11 Readings and References .......................................................................................... 11 - 12 Activities & Questions ............................................................................................... 12 - 16 Evaluation Forms - Separate Enclosure, Preceptor’s Manual Tools and Forms – Separate Enclosure, Student’s Manual Acknowledgments The Structured Practice Experience (SPE) program is an integral component of the course of study leading to the Bachelor of Science in Pharmacy degree at Memorial University of Newfoundland. The program is coordinated and administered by the School of Pharmacy. Since time spent in the SPE is eligible and contributes towards meeting the practice experience requirements for licensing with the Newfoundland & Labrador Pharmacy Board (NLPB), the program has been planned and developed with input from the NLPB through the Joint Committee on Structured Practice Experience. We appreciate the support of all the dedicated pharmacists who volunteer their time and share their knowledge and experiences by serving as preceptors in the program. The policies, procedures, evaluation tools and other materials in this manual continue to develop and evolve. We thank both the preceptors and students for their constructive feedback and invite you to continue to offer your comments and suggestions for improvement. We hope that participation in the practice experience program is rewarding and enjoyable for all. Introduction Educational Outcomes The Association of Faculties of Pharmacy of Canada (AFPC) has developed educational outcomes for pharmacy graduates in Canada. These outcomes have been adopted by the School of Pharmacy and guide the curriculum and experiential learning program. Students are expected to demonstrate specific knowledge, skills and behaviours from the following key areas with the goal of becoming Medication Therapy experts: 1. Care Provider: Graduates use their knowledge, skills and professional judgement to provide pharmaceutical care and to facilitate management of patient’s medication and overall health needs. 2. Communicator: Graduates communicate with diverse audiences, using strategies that take into account the situation, intended outcomes of the communication and the target audience. 3. Collaborator: Graduates work collaboratively with teams to provide effective, quality health care and to fulfill their professional obligations to the community and society. 4. Manager: Graduates use management skills in their daily practice to optimize the care of patients, to ensure the safe and effective distribution of medications, and to make efficient use of health resources. 5. Advocate: Graduates use their expertise and influence to advance the health and well-being of individual patients, communities, and populations, and to support pharmacist’s professional roles. 6. Scholar: Graduates have and can apply the core knowledge and skills required to be a medication therapy expert, and are able to master, generate, interpret and disseminate pharmaceutical and pharmacy practice knowledge. 7. Professional: Graduates honour their roles as self-regulated professionals through both individual patient care and fulfillment of their professional obligations to the profession, the community and society at large. These outcomes have been used to develop the various activities in the SPE program and the evaluation tools used to assess students’ performance. http://www.afpc.info/downloads/1/AFPC_Education_Outcomes_AGM_June_2010.pdf i Pharmacy 302W Pharmacy 302W is a structured practice experience after the second year of the pharmacy program, consisting of a 4-week placement in a hospital pharmacy. It is intended to introduce the student to the role and function of hospital pharmacists in the healthcare system by having the student participate in drug distribution and patient care activities in a hospital setting under the supervision of a pharmacist preceptor. The 302W manual is organized into sections, each containing specific assignments to assist the preceptor in helping the student develop knowledge and skills in key competency areas; and to enable the preceptor to assess the student’s level of proficiency and competency in each area. The table on the following page defines the competency categories by providing a brief description of the components that make up each one, based on the expected learning outcomes for a second year student. Some activities in the manual are linked to just one learning outcome, while other activities may be associated with several outcomes. For example, a student responding to a drug information question from a physician or nurse may demonstrate elements of the communicator, collaborator, scholar and professional educational outcomes. ii Pharmacy 302W Learning Goals Competency Area Competency Elements Care Provider A. Assesses patients • Develops professional, caring relationships with patients and/or caregivers • Efficiently and accurately gathers and assesses relevant history from the patient, his/her profile, caregivers and other health professionals • Assesses if a patient’s medication-related needs are being met B. Plans Care • Develops & implements care plans that address patients’ drug-related problems and priority health needs Communicator • Effectively communicates non-verbally and verbally with others • Communicates effectively in writing Collaborator • Functions as a member of a team • Works collaboratively with the patient and/or health professionals to provide care Manager • Manages his/her time and recognizes the importance of efficiency in the workplace • Participates in the safe and efficient distribution of medications • Incorporates the use of technology, where applicable • Familiarizes him/herself with quality assurance and improvement initiatives Advocate • Supports patient access to required health services • Supports the role of pharmacists in the health care system Scholar • Demonstrates understanding of the core knowledge covered thus far and is able to apply this knowledge in daily practice • Provides drug information and recommendations • Educates regarding medications and appropriate medication use Professional • Demonstrates professionalism throughout patient encounters • Practices in an ethical manner and assures primary accountability to the patient • Seeks/accepts feedback to identify limitations or strengths in own performance • Demonstrates professional accountability e.g., complies with legal and regulatory requirements of practice; respects and fulfills professional standards of practice; accepts responsibility for decisions; maintains a professional image iii General Performance Guidelines for the Student The primary objective of the practice experience program is to learn from experience. Students are expected to actively participate in pharmacy practice during the rotation. The student, not the preceptor, is responsible for his/her own learning. Pharmacy preceptors volunteer their time to teach students. The preceptor’s first duty is to his/her patients and work site. Students should not expect the preceptor to be there to teach all of the time. The student is expected to take the initiative and: • • • • • establish with the preceptor, a schedule and time line for completing activities. complete the required activities in the manual. seek ways to apply his/her knowledge to practice situations. seek regular consultation with the preceptor to obtain feedback on performance and advice concerning areas in need of development. accept and act upon constructive criticism. In order to maximize the learning experience, the student should indicate to the preceptor any areas in which s/he has had previous experience and also areas in which s/he may need particular help. While each student has a primary preceptor, s/he may learn valuable information and skills from others and, therefore, should be open to learning from other pharmacists and professionals (e.g., physicians, nurses) and staff (particularly technicians) at the site. Throughout the manual, the statement, “Discuss with your preceptor...” may be interpreted as, “Discuss with your preceptor or a designated alternative person...” (i.e. another pharmacist, technician, nurse, etc.) A minimum time requirement of 35 hours per calendar week is mandatory during the SPE. Students are expected to be punctual and present at the site according to the schedule arranged with the preceptor. Students may not leave the practice site during scheduled hours without permission from the preceptor. Absences are permitted only in the case of legitimate illness, bereavement or family emergency. Any student who must be absent during the SPE is required to notify both the preceptor and the SPE Coordinator as soon as it is determined that (s)he is not able to attend. A note from a health professional (as per Memorial University Regulations 2013/14, Sections 5.14.4 and 5.14.6; http://www.mun.ca/regoff/calendar/sectionNo=REGS-0859) or other appropriate written documentation must be supplied to the SPE Program Coordinator for all absences. Preceptors are requested to note any absences on the student evaluation forms. Missed time is expected to be made up. Students must exhibit a professional appearance, both in manner and dress, and must follow the standards of the pharmacy to which they are assigned. Each student must wear a name tag indicating his/her full name and the title “Pharmacy Student.” A laboratory/dispensing jacket is also required, unless otherwise directed by the preceptor. iv Students are expected to adhere to the following guidelines for conduct: • • • • • Students are expected to behave with mutual respect and courtesy toward all pharmacy staff, patients and their families, and other health professionals. When interacting with patients, students must clearly identify themselves as Pharmacy Students. Professional decisions or judgments should not be made by the student without the advice or approval of a pharmacist. Students must respect any and all confidences revealed during the SPE including patient data/health conditions, pharmacy records, professional policies, financial information or anything else of a confidential nature. The advice, direction or criticism of the preceptor, or other pharmacists should not be questioned in public (especially in the presence of patients or other health professionals) but is best discussed in private. Students are expected to be attentive to the laws and regulations which govern pharmacy practice and seek clarification from their preceptor when necessary. Students and preceptors are referred to the SPE Program Policy Handbook http://www.mun.ca/pharmacy/practice/SPE_Policy_Handbook_2013.pdf for complete information about the SPE Program structure, administration and policies. v Addressing Student/ Preceptor Concerns It is important for students to discuss any concerns they have about their SPE with the preceptor or the SPE Program Coordinator at the time of the concern. Little or nothing can be done if the student waits until the end of a rotation to bring up a problem. The following approach is suggested as the best way to handle troublesome situations that may arise during the SPE program: • • • • Bring the concern to the attention of the other person directly and attempt to resolve the issue together. Be as specific as possible when identifying a problem; always listen carefully and thoughtfully to the other person. Focus on the situation, not the person. Serious or unresolved difficulties should be brought to the attention of the SPE Coordinator. Students with concerns should only share these with the individual involved, the preceptor, or the SPE Program Coordinator, not with any other students, pharmacy staff, other preceptors, etc. vi SPE Checklist This checklist should be referred to at the beginning and throughout the SPE program by the student and preceptor in order to ensure that the necessary items are covered. Check (√) as the task is completed. ( √) Before Starting the SPE Student is registered as a Pharmacy Student with the appropriate provincial licensing body Student has provided preceptor with letter of introduction ( √) First Day Student is introduced to pharmacy staff members Student is given a tour of the pharmacy which includes location of important areas, including the following: • Arrangement of pharmaceuticals in dispensary • Work space/Computer to use • Pharmacy library/Reference materials • Washroom/Lunch room/Coat storage Preceptor discusses with student policies and procedures for: • Dress code • Daily schedule, including breaks, lunch, etc. • Telephone procedures (e.g., how to answer the phone, pharmacy phone #, fax #, preceptor’s pager #) • Security within the pharmacy • Confidentiality • Internet access • Special hospital policies or procedures (There may be orientation to the hospital at some sites.) • Any other pertinent topics Student and preceptor review goals for the SPE program & establish a schedule for completing activities ( √) During SPE Preceptor provides immediate and specific feedback to student, as required Student completes/discusses with the preceptor activities & questions in the manual Student and preceptor complete documentation for activities & questions Preceptor completes Preceptor’s Evaluation of Student (Midpoint) by end of Week 2 Student and preceptor discuss student’s performance at midpoint vii ( √) End of SPE Student completes required documentation and returns to SPE Coordinator • Activity & Question Checklist (completed and signed by both student and preceptor) • Audit Materials • Student’s Evaluation of the Preceptor & Site • Student’s Evaluation of the SPE Program (online, via ‘Survey Monkey’) Preceptor completes required documentation and returns to SPE Coordinator • Preceptor’s Evaluation of the Student (Final), including Certification of Supervised SPE • Preceptor’s Evaluation of the SPE Program Student and preceptor discuss student’s performance viii Activities and Questions and Evaluation The following sections contain a number of activities and questions which must be completed successfully by the end of the SPE. The ‘Activities’ are provided to give the student an opportunity to learn about and gain experience relating to the educational outcomes. They are intended to stimulate discussion between the student and preceptor. The preceptor and student may also have additional ideas for useful activities to maximize the student’s practice experience. The ‘Questions’ must be completed by the student, the answers reviewed by the preceptor and discussed with the student. Some questions and activities require a written answer and are identified in the manual by the use of “document” in bold font. These items are required to be submitted to the SPE Coordinator within one week of completing the rotation for auditing purposes. All materials for audit should be submitted in a neat, orderly manner* and must not violate patient confidentiality (i.e. avoid use of patient names, address, MCP #, phone #, etc.). An Activity and Question Checklist follows on the next page. It is to be used as a guide and monitor to ensure that all required activities and questions are completed. It should be consulted regularly and items checked off as they are done. The filled-out Activity and Question Checklist is required to be returned to the School at the end of the 4-week SPE. SPE rotations are academic courses and must be successfully completed in order to enter the next year of pharmacy study and to graduate from the School of Pharmacy. Overall evaluation of the SPE will result in the assignment of one of the following letter grades: PWD (pass with distinction), PAS (Pass) or FAL (Fail). A passing grade is contingent upon: • the student’s ability, as determined by the preceptor, to meet/achieve the required competencies as per the Preceptor’s Evaluation of Student form • satisfactory attendance • proper completion of activities and questions, as determined by preceptor’s evaluation and workbook audit Note: Expectations for student submissions in a neat, orderly manner* - Responses should be typed using a computerized word-processing program. - Questions and sections should be clearly numbered and labeled. - Audit material should not be submitted as loose sheets but organized in a duotang folder or binder. - The following forms should be submitted separately from the audit material: Student’s Evaluation of Preceptor & Site, Preceptor’s Evaluation of Student/Certification of Supervised SPE and Preceptor’s Evaluation of SPE. ix Activity and Question Checklist Activity or Question Description Timeline for Completion (e.g., Week 1, 2, 3 or 4) Completed Reviewed with Preceptor Student’s Initials & Date Preceptor’s Initials Section 1: Provide Patient Care A1.1 Assess patient medical/medication history A1.2 Review and assess new medication orders A1.3 Discuss/participate in medication reconciliation A1.4 Identify drug-related problems A1.5 Determine desired therapeutic goals A1.6 Compare therapeutic alternatives A1.7 Create an individualized recommendation A1.8 Create a monitoring plan A1.9 Provide patient education Q1.1 - 2 Evaluate drug interactions scenarios Section 2: Accept Professional Responsibilities A2.1 Discuss access to medications in hospitals A2.2 Discuss safe medication practices A2.3 Discuss adverse drug reaction reporting A2.4 Discuss medication incident reporting A2.5 Discuss liability and risk management x Activity or Question Description Timeline for Completion (e.g., Week 1, 2, 3 or 4) A2.6 Discuss ethical issues A2.7 Complete learning activity and discuss privacy and confidentiality A2.8 Discuss relationship with industry Completed Reviewed with Preceptor Student’s Initials & Date Preceptor’s Initials Section 3: Provide Drug & Drug Use Information and Recommendations A3.1 Review DI resources and answer DI questions assigned by preceptor Q3.1 - 2 Answer DI questions in manual Section 4: Use Management Skills in Practice A4.1 Discuss delegation of duties A4.2 Discuss/participate in repackaging of meds A4.3 Discuss/participate in bulk compounding and sterile product preparation A4.4 Discuss/participate in the medication order process A4.5 Discuss drug use control and the hospital formulary A4.6 Discuss/participate in medication distribution; discuss medication administration A4.7 Discuss/participate in the drug procurement process A4.8 Discuss department administration and organizational structure xi Activity or Question Description Timeline for Completion (e.g., Week 1, 2, 3 or 4) A4.9 Discuss accreditation and quality improvement A4.10 Discuss management concepts (e.g., resource allocation, policy development) Q4.1 - 6 Answer calculations questions Completed Reviewed with Preceptor Student’s Initials & Date Preceptor’s Initials The preceding activities have been completed by the student and discussed with the preceptor as indicated. We certify that the information provided is complete and is in no way false or misleading. Student’s Signature: Date: ______________________ Preceptor’s Signature: Date: ______________________ xii Section 1: Provide Patient Care Objectives After completing this section, the student is expected to be able to: Demonstrate caring, professional behaviour toward the patient and/or the patient’s care provider. Gather and document current and past medical and medication information through hospital chart review and, potentially, patient or caregiver interview. Recognize information required for hospital patient profiles. Review new medication orders using standard criteria. Synthesize information from a patient’s profile, a medication order, and other information to identify and prioritize the patient’s drug-related needs. Assess patient and disease information to determine desired therapeutic goals (for an assigned patient case). Compare therapeutic alternatives; create and rationalize optimal therapeutic recommendations (assigned case). Formulate a plan to monitor for safety and efficacy of the care plan (assigned case). Provide patient education and prepare a medication schedule. Identify the main steps of the medication reconciliation process and discuss the role of the pharmacist in medication reconciliation. Reading and References CSHP Official Publications Guidelines for Drug-Use Control, 2008 Medication Reconciliation: Statement on the Role of the Pharmacist, 2009 Pharmaceutical Care lectures and labs, Pharmacy 3650/3651 Drug Interactions resource, e.g., Drug Interactions Analysis and Management (Hansten and Horn), Drug Interaction Facts-Facts and Comparisons (DS Tatro), Interactions in Micromedex database, Lexi-Interact in e-Therapeutics Therapeutics resource, e.g., Therapeutic Choices, in e-Therapeutics (including Minor Ailments, Products for Minor Ailments) Abbreviations, see website www.medilexicon.com Tools and Forms Pharmaceutical Care Work-Up Tool Pharmaceutical Care Work-Up: Patient Assessment Form Sample Medication Profile and Medication Schedule 1 Activities Pharmacists provide patient care by collaborating with patients and other health care providers to help prevent, identify, and resolve drug-related problems . This is achieved by checking that the patient is taking the right drug; is receiving the right dose; is receiving treatment for all medical problems; is not receiving unnecessary drug therapy; is adherent with treatment; and is not experiencing an adverse drug reaction or negative effect due to a drug interaction. A1.1 Patient Assessment Refer to Pharmaceutical Care lectures/labs, Patient Assessment. a. Review a minimum of one patient chart. Confidentially document, using the Pharmaceutical Care Work-Up: Patient Assessment Form, the patient’s current and past medical and medication information. b. If possible, interview patient(s) to obtain their current and past medical and medication information. Confidentially document using the Patient Assessment Form. A1.2 Medication Order Review Refer to Section 3.1, Medication Order Review in Guidelines for Drug-Use Control, CSHP Official Publications. a. Discuss with your preceptor the process for reviewing a new medication order, the patient’s profile, and resolving any questions/problems. b. Using list 3.1.3, review new medication orders for a minimum of two different patients. c. Review the medication profiles for the above patients, identifying the information listed in 3.1.4 and 3.1.5. d. Utilizing the patients’ medication profiles, assess the new medication orders to identify problems such as those listed in 3.1.6. A1.3 Medication Reconciliation Refer to Medication Reconciliation: Statement on the Role of the Pharmacist, CSHP Official Publications. a. Identify the three main steps of the medication reconciliation process. b. Discuss with your preceptor the role of the pharmacist, other pharmacy staff and healthcare providers in medication reconciliation at your practice site. How is information technology being used to facilitate the process? c. If possible, participate in medication reconciliation activities. 2 Complete Activities 1.4 – 1.8, for the case of ‘SG.’ (separate enclosure): Refer to Pharmaceutical Care lectures/labs A1.4 Identifying Drug-Related Problems a. Create a patient-specific drug-related problem list. b. Document the DRP(s) and discuss with your preceptor. Select the DRP of highest priority and work it up as follows, including references: A1.5 Determining Desired Therapeutic Goals a. Determine desired therapeutic goals for the patient. Ensure the goals are measurable, achievable, specific and have a definite time frame. b. Document these therapeutic goals and discuss with your preceptor. Include references, as appropriate. A1.6 Comparing Therapeutic Alternatives a. Compile a list of therapeutic alternatives, using a therapeutic alternatives chart. Ensure the chart is individualized for the patient. b. Document the chart and review with your preceptor. Include references, as appropriate. A1.7 Creating an Individualized Recommendation a. Decide on an individualized recommendation for the patient. b. Document these recommendations and discuss with your preceptor. Include references, as appropriate. A1.8 Creating a Monitoring Plan a. Design a plan to monitor for efficacy and safety of the therapeutic decision which includes delegation of responsibility for monitoring to the patient, pharmacist or other health professional. The parameters should be specific and have a definite time. b. Document (in chart form) the monitoring plan and review with your preceptor. Include references, as appropriate. A1.9 Patient Education In order for patients to use their medications properly, they must be provided with sufficient information about the medication. Hospital pharmacists play an essential role in teaching patients about their medications. Refer to Sample Medication Profile and Sample Medication Schedule (Tools and Forms). a. Confidentially document a medication profile and create a medication schedule for one patient. Ask your preceptor to evaluate. b. If possible, observe or participate in verbal counseling of patients. Alternatively, counsel your preceptor on the medications from part (a). 3 Questions Drug Interactions The role of the pharmacist in providing pharmaceutical care is to prevent, identify and resolve patients’ drug-related problems, including drug interactions. Drug interaction resources and databases greatly increase the pharmacist’s ability to identify potential interactions. However, in order to provide the best possible care, pharmacists should also be able to identify patient risk factors (for example, renal or hepatic disease) that might lead to potential problems; assess the clinical significance of interactions; and recommend appropriate management strategies. Evaluate the following scenarios for drug interactions. Written documentation is required, including the reference(s) used. For the noted drug interactions, the student should: State the significance of the drug interaction (e.g., minor, moderate, or major) Explain the mechanism of action of the drug interaction Suggest how to manage the interaction Q1.1 AB is a 49 year-old male with chronic myeloid leukemia (CML). The CML is being treated with dasatanib 100 mg po once daily (in the morning). He was hospitalized eight days ago for febrile neutropenia, which is resolving with IV ceftazidime and SC Neupogen®. Since being admitted, AB has been experiencing mild GERD symptoms (“heartburn” occurring 3 times during the past week). The hematology resident has ordered ranitidine 150 mg po BID. Are there any significant drug interactions with any of AB’s current medications? If so, what are they and how should they be managed? Q1.2 RP is a 45 year-old female who has just been diagnosed with bipolar disorder. Given her current blood pressure therapy with hydrochlorothiazide, as well as her history of substance abuse, the psychiatrist decided to treat with valproic acid (instead of lithium). You have already reviewed the potential drug interactions between her current medications with the team, but she now asks you if there are any potential drug interactions with the valproic acid. RP’s regular medications are amitriptyline 50 mg po HS (post-herpetic neuralgia), hydrochlorothiazide 25 mg po daily (hypertension), and pantoprazole 40 mg po daily (GERD). 4 Section 2: Accept Professional Responsibilities Objectives At the end of this section, the student is expected to be able to: Comply with the legal and regulatory requirements of practice. Practice in an ethical manner and assure primary accountability to the patient; maintain patient confidentiality. Discuss the Canada Health Act with respect to medication provision in hospitals. Discuss the pharmacist’s role as an advocate for patients to ensure access to medications. Discuss the role of the pharmacist in ensuring safe medication practices and creating a culture of patient safety (i.e. describe detection, reporting and prevention of adverse drug reactions; discuss disclosure, management and reporting of errors, incidents; discuss risk management). Maintain a professional image (appearance, language, demeanour). Reading and References Canada Health Act, http://www.hc-sc.gc.ca/hcs-sss/medi-assur/cha-lcs/index-eng.php CSHP Official Publications Information Paper on Enhancing Quality and Safety in Medication Use, 2010 Medication Incidents: Guidelines on Reporting and Prevention, 2012 Guidelines for Liability and Risk Management, 2001 Guidelines for Relationship Between Health Care Facility Pharmacists and the Pharmaceutical Industry, 2001 Institute for Safe Medication Practices Canada website, http://www.ismpcanada.org/index.htm Informatics for Pharmacy Students e-Resource, http://afpc-education.info Activities A2.1 Access to Medications in Hospitals Canada Health Act The Canada Health Act is Canada's federal legislation for publicly funded health care insurance. According to the Act, the primary objective of Canadian health care policy is "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers." ‘Medicare’ is a national health insurance program designed to ensure that Canadians have access to medically necessary hospital and physician services, on a prepaid basis. http://www.hc-sc.gc.ca/hcs-sss/medi-assur/index-eng.php Insured hospital services are also defined under the Canada Health Act, http://www.hc-sc.gc.ca/hcs-sss/hospital/index-eng.php. Under the Act, all necessary drug therapy administered within a Canadian hospital setting is insured and publicly funded. 5 a. In discussion with your preceptor, compare and contrast who pays for medications in the community vs. the inpatient hospital setting. Are third party payers (Blue Cross, for example) billed for medications prescribed to hospital inpatients? b. Find out who pays for non-formulary medications that are authorized for use within the hospital. Under what circumstances does the patient (or his/her third party insurance plan) pay for the medication? Under what circumstances does the hospital pay for the medication? c. Discuss with your preceptor what occurs when a patient is discharged from the hospital on a medication s/he cannot afford. What are the potential implications of such a situation? Compare the cost effectiveness of keeping a patient in hospital to ensure access to medications vs. discharging patients when they do not have access to recommended medications. d. Discuss with your preceptor what the pharmacist’s role is as an advocate for patients to ensure appropriate access to medications. A2.2 Safe Medication Practices Hospital pharmacists play an essential role in ensuring that patients receive safe, quality care. Pharmacists oversee medication distribution within healthcare facilities and work to ensure that systems and processes are sound, reliable and designed to minimize the occurrence of errors. Working with physicians and other healthcare professionals, pharmacists also ensure that appropriate prescribing decisions are made, patient outcomes are monitored, and adverse drug events are prevented and/or appropriately managed. Pharmacists further help improve the quality and safety of medication use by providing patient education and services such as medication reconciliation. Additionally, pharmacy departments play an important role in creating a culture of patient safety by recognizing and managing high-‐risk situations and by investigating and reporting medication incidents and adverse events. (Adapted from: Canadian Society of Hospital Pharmacists. Hospital Pharmacists: Information Paper on Enhancing Quality and Safety in Medication Use. Ottawa (ON): Canadian Society of Hospital Pharmacists; 2010.) a. Discuss with the preceptor instances in his/her practice which demonstrate the effect of the provision of patient care services by pharmacists in reducing the incidence of preventable adverse drug reactions, generating positive patient outcomes (e.g., in terms of mortality or readmission to hospital), and improving the quality of medication use. b. Discuss with the preceptor any particular safe medication initiatives or projects that may be ongoing at the site. Refer to The Institute for Safe Medication Practices (ISMP) Canada website c. In the “About Us” section, review the vision, purpose, goals and values of ISMP. d. Look at ISMP “Current Projects”, particularly, Dangerous Abbreviations, Advancing Medication Safety in Pediatrics and Medication Reconciliation. i. Discuss the use of dangerous abbreviations and symbols with the preceptor. Are there others that (s)he is aware of besides those in the list published by ISMP? ii. Note the top five medications reported to ISMP Canada as causing harm through medication error in pediatrics. A2.3 Adverse Drug Reaction Reporting Program Discuss with your preceptor how adverse drug reactions are detected, reported and prevented at your site. 6 A2.4 Medication Incident and Discrepancy Reporting Program Refer to Guidelines for Medication Incident Reporting and Medication Incident/Discrepancy Prevention, CSHP Official Publications. Refer to the ISMP Medication Incident and Near Miss Reporting Program, http://www.ismpcanada.org/err_index.htm a. Discuss with your preceptor a minimum of five medication incidents or discrepancies that occur during your rotation (or that may have occurred in the past). Talk about the factors which might have contributd to the incident and the follow-up that was required (e.g., recommendations, implementation of system improvements). b. Discuss the strategies your site has in place to prevent medication incidents. c. View the ISMP Report a Medication Incident Form. Click on each field, including drop down menus, noting the specific information requested. d. Discuss with the preceptor the merits of a non-punitive, voluntary approach to medication error reporting. A2.5 Liability and Risk Management Refer to Guidelines for Liability and Risk Management, CSHP Official Publications. a. Discuss the legal concept of negligence with your preceptor. Distinguish between “oops” and “silent” scenarios. Consider examples, real or hypothetical, of each type of incident. b. If possible, fill out the Risk Assessment Tool and discuss suggestions your preceptor has for decreasing risk for liability at your site. A2.6 Ethical Issues in Hospital Pharmacy Discuss with your preceptor any ethical issues that arise during your rotation. Discuss the role of health care professionals when patients jeopardize their own safety &/or lives by contradicting medical advice. For example, an alcoholic with multiple past admissions for liver cirrhosis who continues to drink, an IV drug user with infective endocarditis who discharges herself against medical advice, or a diabetic with admissions for DKA (diabetic ketoacidosis) who is non-adherent with medication and diet? A2.7 Privacy and Confidentaility Refer to Informatics for Pharmacy Students – e-Resource which can be accessed at http://afpceducation.info a. Complete, as self-directed study, Student e-Resource, Domain 4 on privacy, security and confidentiality in the care of patients. As each activity is completed, a check mark will appear in the box next to it (for box with solid border, you can click it to tick the box when you have completed the activity). Upon completion of all activities, print the screen as documentation and submit with your audit material. b. Discuss with your preceptor policies and procedures regarding patient confidentiality. Talk about the types of actions that may constitute a privacy breach (e.g., accessing your own or a relative’s health record when the information is not required to do your job; discussing patient information in public areas; taking documents containing patient information out of the hospital). What precautions should be taken to protect 7 patient confidentiality when discussing patient cases and completing required activities (reviewing medication profiles and medication orders) during the SPE? A2.8 Relationship with Pharmaceutical Industry Refer to Guidelines for Relationship Between Health Care Facility Pharmacists and the Pharmaceutical Industry, CSHP Official Publications. Find out if pharmaceutical companies fund research, education, or make donations at your site. What are the ethical implications of such donations? 8 Section 3: Provide Drug & Drug Use Information and Recommendations Objectives After completing this section, the student is expected to be able to: Recognize, access and describe common drug information resources in a hospital pharmacy. Respond to drug information needs by: receiving and interpreting the drug information request formulating an appropriate search strategy retrieving appropriate information synthesizing information to create an appropriate recommendation that is communicated verbally and in writing (to preceptor). Document a drug information request and response using the form provided. Reading and References Available drug information resources at your site Tools and Forms Student Drug Information Request Documentation Form Activities The student is required to complete the following activities: A3.1 Drug Information Resources a. Locate the drug information texts. Discuss with your preceptor any additional drug information resources (paper files, electronic resources, etc.) that your site has. Review the contents of any references with which you are not familiar. b. Answer a minimum of two drug information questions as assigned by your preceptor. One of these should be regarding a drug interaction. Please choose requests with enough complexity to require more than one resource in order to formulate sufficient responses. Be sure to cite at least THREE different drug information resources in each response. Document using the form in the Tools and Forms section. 9 Questions Answer the following questions. Document your answers. Q3.1 a. You are a clinical pharmacist working on a surgery unit at a large tertiary care facility. Mrs. Ynez is a 60 year-old female who has recently been transferred to your floor from the ICU. Upon transfer your patient is ordered potassium chloride 40 mEq in 1 L D5W run at 10 ml/hr (the pharmacy manufactures this product in their CIVA center using potassium chloride solution containing 2 mEq/mL potassium); she is to continue this for 24 hours. Mrs. Ynez is also ordered meropenem 500 mg IV Q8H. Each 500 mg dose meropenem is diluted in a 500 ml bag of D5W, giving a final concentration of 1 mg/mL. The nurses on your floor are wondering if this medication can be given via Y-site with the potassium chloride solution, as Mrs. Ynez currently only has one peripheral IV access site. Your pharmacy carries Zeneca brand of meropenem and B. Braun brand of potassium chloride. Can Mrs. Ynez’s meropenem be run via Y-site with her potassium chloride? b. 24 hours later, Mrs. Ynez’s potassium chloride order is discontinued. However, she is now experiencing some anxiety for which she has been prescribed lorazepam 1 mg IV Q8H PRN. Your hospital carries Wyeth brand of lorazepam. Your pharmacy carries 2 mg/mL lorazepam vials which are diluted with an additional 1 mL of NS prior to administration. The nurses now want to give the patient’s meropenem and lorazepam via Y-site. Is meropenem compatible or incompatible with lorazepam solution when given via Y-site? Q3.2 Mr. Pickles is a 64 year-old man admitted to your hospital for surgical repair of an abdominal herniation. Post-operatively, he is experiencing nausea and some gastrointestinal reflux for which the physician has written an order for metoclopramide 10 mg IV Q6H, and dimenhydrinate 50 mg IV Q6H. The nurse taking care of Mr. Pickles wants to know if she can administer these two medications in the same syringe. Your hospital carries Horner brand dimenhydrinate 50 mg/ml vials and Nordic brand metoclopramide 10 mg/2 ml vials. What do you tell the nurse regarding the compatibility of these medications in the same syringe? 10 Section 4: Use Management Skills in Daily Practice Objectives At the end of this section, the student is expected to be able to: Contribute to safe and efficient distribution of medications, by participating in drug distribution services. This includes: interpreting medication orders; medication repackaging; preparation of bulk compounds and sterile products, including performing pharmaceutical calculations, selecting ingredients, identification of storage and handing conditions, documentation in appropriate records, labeling. Understand and demonstrate acquired skill in the use of basic technologies used in drug distribution (e.g., equipment, computer systems, drug information databases, etc.). Describe the contents, purpose and maintenance of the hospital formulary. Compare and contrast various types of medication distribution. Describe steps in medication administration, including medication administration record (MAR) documentation. Demonstrate a knowledge of, and adherence to, policies and standards related to delegation of duties in pharmacy practice; and how legislative, liability or resource issues influence delegation of responsibilities. Set priorities and manage his/her time to maintain efficiency in the workplace. Demonstrate effective interpersonal behaviours in the practice setting, and skills required to maintain good working relationships with personnel. Demonstrate an understanding of inventory management, including drug procurement; accountability and record keeping procedures (e.g., for narcotics); and procedures for returning medications to stock. Outline the type of information that can be found in the pharmacy’s policies and procedures manual. Describe the pharmacy department’s organizational structure (e.g., define the relationships and lines of communication within the service, to other hospital departments, and throughout the organization). List hospital committees that have pharmacy representation. Describe accreditation and continuous quality improvement. Describe resource allocation and policy development within the department of pharmacy. Reading and References CSHP Official Publications – Guidelines for Drug-Use Control, 2008 – Nonsterile Compounding: Guidelines, 1992 – Sterile Preparation of Medicines: Guidelines, 1996 – Repackaging: Guidelines for Health Care Facilities, 1998 – Statement on Unit Dose & IV Admixture Drug Distribution, 2008 Guidelines for Practice Management, 2007 Information Paper on the Role of the Pharmacy Technician, 2001 Guidelines for the Delegation of Functions to Pharmacy Technicians, 2006 Continuous Quality Improvement, 1995 11 • Federal Legislation, http://www.nlpb.ca/pharmacy-practice/ Food & Drugs Act and Regulations (particularly Parts G, Controlled Drugs) Narcotic Control Regulations Benzodiazepines and Other Targeted Substances Regulations Activities The student is required to complete the following activities: A4.1 Pharmacy Technicians Refer to Information Paper on the Role of the Pharmacy Technician; and Guidelines for the Delegation of Functions to Pharmacy Technicians, CSHP Official Publications. a. What are the responsibilities of pharmacy technicians at your site? b. Identify barriers to delegating tasks to technicians at your site (e.g., legislative, liability, or resource issues). A4.2 Repackaging of Medications Refer to Guidelines for Repackaging Products in Health Care Facilities, CSHP Official Publications. a. Observe the repackaging of various dosage forms (oral tablets, oral capsules, oral powders, oral liquids, topical ointments/creams/gels, suppositories/inserts, and narcotics). Which steps are the responsibilities of the technician and of the pharmacist? b. Review a repackaging record and note the information included. c. Review a repackaged product label, noting the information it must contain (according to guideline 6.5.2). d. If possible, participate in repackaging of medications. A4.3 Medication Preparation Refer to Nonsterile Compounding: Guidelines for Pharmacists, CSHP Official Publications. a. Discuss with your preceptor the process for bulk compounding. Which steps are the responsibilities of the technician and of the pharmacist? List five products that are bulk compounded at your site. b. Review a master formula for the information it contains. c. Review a production record and note the information included. d. Compound at least one bulk product from a master formula. Document the batch in a production record and label the product in accordance with the guidelines. Refer to Guidelines for Preparation of Sterile Products in Pharmacies, CSHP Official Publications. e. Review sections 7 and 8 of the guidelines. Discuss with your preceptor the facilities, equipment, sanitation, and garb available for sterile product preparation. f. Discuss the process for preparing sterile products at your site including determination of expiry dates, labeling, record keeping, validation process, documentation, and end product testing. Which steps are the responsibilities of the technician and of the pharmacist? g. Compound at least one sterile product. Document the process and label the product in accordance with the guidelines. 12 A4.4 Medication Orders a. Who has prescriptive authority within the hospital (physicians, interns, residents, nurse practitioners, pharmacists, etc.)? b. Who may write a medication order (pharmacist, nurse, clinical clerk, etc.) and what is the policy regarding verbal orders and cosigning of orders? For example, can verbal orders be taken for narcotics? c. Where and how are medication orders written? Are medication orders separate or combined with other orders (i.e. for lab work, etc.)? Are brand or generic drug names used? What abbreviations are acceptable? Are refills written? Interpret a minimum of five medication orders. d. How do medication orders reach the pharmacy? If possible, participate in this process. A4.5 Drug-Use Control Refer to Section 4.1.1-4.1.7.5, Formulary System, in Guidelines for Drug-Use Control, CSHP Official Publications. Refer to Section 2.7, Pharmacy and Therapeutics Committee in Guidelines for Practice Management, CSHP Official Publications. a. Discuss with your preceptor the use of formularies in hospitals. b. If possible, review the hospital’s formulary, noting the components listed in 4.1.4. c. Discuss with your preceptor how medications are added to the formulary and the role of the Pharmacy and Therapeutics committee. Refer to Federal Legislation, NLPB Pharmacy Manual. d. Review federal regulations regarding narcotics, controlled substances, benzodiazepines and other targeted substances. e. What is the procedure for receiving, dispensing and distributing narcotic drugs to nursing units? Discuss if and how narcotic audits are conducted in the pharmacy and on nursing units. What is the process for resolving discrepancies in narcotic counts? f. Examine records at your site. Compare and contrast how narcotic records are kept in hospital and community pharmacies. A4.6 Medication Distribution and Administration Refer to Section 4.4, Medication Distribution Service; and Definitions in Guidelines for DrugUse Control, CSHP Official Publications. Refer to Statement on Unit Dose & IV Admixture Drug Distribution, CSHP Official Publications. a. Become familiar with the different types of medication distribution (unit dose, controlled dosage, individual patient prescription, ward stock, and selfadministration) b. Using the list in section 4.4.1.2, consider the advantages and disadvantages of each type of medication distribution. Why does CSHP state in 4.4.1.3 that unit dose distribution is the system of choice? Why does CSHP endorse IV admixture? What medications (if any) are dispensed from the pharmacy in unit dose packaging (consider oral tablets, oral capsules, oral powders, oral liquids, IV injections, IV bags, other injections, inhalers, transdermal patches, topical ointments/creams/gels, suppositories/inserts, and narcotics)? 13 c. What types of distribution does your site use? Participate in different types of medication distribution. d. After a new medication order for a formulary drug has been entered into a patient’s profile, outline the steps involved in dispensing the order. Consider orders for wardstock, oral unit dose, multi-dose, injectable (IV bag and vial), TPN, and narcotic medications. Which steps are the responsibility of the technician and of the pharmacist? e. What is the process for filling orders for non-formulary, sample, investigation, emergency release and patient-owned medications? f. What is the process for filling stat drug orders? Refer to Section 3.1.9, Medication Orders in Guidelines for Drug-Use Control, CSHP Official Publications. g. What is the importance of stop orders? Which medications are given stop orders at your site? Refer to Section 4.4.3, Labelling in Guidelines for Drug-Use Control, CSHP Official Publications. h. Review one medication label in reference to the guideline. Refer to Section 4.4.9, Delivery of Medications in Guidelines for Drug-Use Control, CSHP Official Publications. i. How are medications delivered within your site? Are all medications delivered the same way (narcotics, chemotherapy, TPN, etc.)? If possible, participate in medication delivery. Refer to Section 4.5, Return of Medications in Guidelines for Drug-Use Control, CSHP Official Publications. j. How are medications returned to the pharmacy? Discuss with your preceptor the policies and procedures for restocking or disposing of returned medications. If possible, participate in this process. Refer to Section 4.8, Administration of Medications in Guidelines for Drug-Use Control, CSHP Official Publications. k. Discuss with your preceptor how medication administration records (MARs) are produced at your site. Discuss policies regarding timing of medication administration. What time are medications scheduled as follows administered: q.d., b.i.d., q. 12 h., t.i.d., q. 8 h., t.i.d. with food, q. h.s., warfarin? l. Schedule a time to observe a nurse administering and charting medications. A4.7 Inventory Refer to Section 4.2, Drug Procurement; and Section 4.3, Drug Inventory Management in Guidelines for Drug-Use Control, CSHP Official Publications. a. Discuss with your preceptor the process for ordering and receiving medications. b. Which steps are the responsibilities of the technician and of the pharmacist? If possible, participate in this process. A4.8 Department Administration and Provision of Pharmacy Services Refer to Sections 2.1 to 2.6, Department Administration in Guidelines for Practice Management, CSHP Official Publications. a. Describe the pharmacy department’s organizational structure (defining the relationships and lines of communication within the service, to other hospital 14 departments, and throughout the organization); find out which hospital committees have pharmacy representatives. b. Discuss the type of information that can be found in the pharmacy’s policy and procedure manual. c. What are the hours of pharmacy services; what provision(s) are made to access medications outside of these hours? A4.9 Quality Improvement Refer to Section 2.9, Quality Management and Medication Use Safety in Guidelines for Practice Management; and Continuous Quality Improvement, CSHP Official Publications. Accreditation Accreditation is a process whereby health organizations assess the quality of their services based on standards of excellence. Evaluation criteria may include standards for leadership and management, patient safety initiatives, medication management, infection prevention and control, staff training and service excellence, among others. Accreditation Canada is an organization that works with health institutions to identify strengths and areas for improvement by providing an external peer review to evaluate the extent to which their services meet national standards. http://www.accreditation.ca/about-us/ a. Discuss with your preceptor what accreditation is and why hospitals seek accreditation. b. Discuss with your preceptor if the pharmacy department at your site participates in an accreditation program. If applicable, view your site’s accreditation certificate. c. Discuss with your preceptor the CQI (continuous quality improvement) initiatives within the department and any barriers to CQI initiatives. A4.10 Management Concepts If possible, arrange to meet with the Director of Pharmacy (or a manager or supervisor) to discuss the following issues: a. Discuss how resources are allocated within the pharmacy department. If possible, view the pharmacy’s budget to understand how resources are allocated for inventory, staffing, supplies, etc. b. Discuss how policies are developed and maintained. 15 Questions Pharmaceutical Calculations Answer the following questions. Show all workings. Document. Q4.1 Cyclosporine is administered before and after organ transplantation at a single daily dose of 15 mg/kg. How many milliliters of a 50 mL bottle containing 100 mg /mL of cyclosporine would be administered to a 140-lb kidney transplant patient? Q4.2 A prescription calls for triamcinolone acetonide suspension to be diluted with normal saline solution to provide 3 mg/mL of triamcinolone acetonide for injection into a lesion. If 5 mL of the suspension contains 125 mg of triamcinolone acetonide, how many milliliters should be used to prepare 10 mL of the prescribed dilution? Q4.3 How many millilitres of a 2% (w/v) solution of lidocaine HCl should be used in preparing 500 mL of a solution containing 4 mg/mL of lidocaine HCl? Q4.4 A child weighing 15 kg is to receive potassium chloride at a dose of 1 mEq/kg over 6 hours. The final concentration of the infusion should be 20 mEq/L. (a) How many milliliters of an injection containing 2 mEq/mL should be used? (b) To what total volume should this dose be diluted with D5W? (c) What should be the infusion rate in mL/min? Q4.5 A patient needs to receive 10 mg of hydromorphone in 250 mL of 5% dextrose solution as a continuous intravenous infusion over 24 hours. (a) How much dextrose will the patient receive from this infusion? (b) How much hydromorphone 4 mg/mL injection is needed to prepare this infusion solution? (c) What is the flow rate in drops/minute to infuse the solution over 24 hours using an administration set with a drop factor of 60 drops/mL? (d) What is the hydromorphone infusion rate in mg/hour? (e) The patient needs to be switched to Hydromorph Contin® in order to leave the hospital. What dose should this patient receive? Q4.6 Rx Chlorobutanol 0.5% 1% q.s. ad 60 mL Phenacaine HCl Boric acid Purified Water Make isotonic sol. Sig. One drop in each eye How many grams of boric acid should be used in preparing the prescription? Sodium Chloride Equivalents Substance Molecular Wt Chlorobutanol 177 Phenacaine HCl 353 Boric acid 61.8 Ions 1 2 1 i 1 1.8 1 16 Sodium Chloride Equivalent 0.24 0.20 0.52
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