Jamie A. Stone

E-prescribing errors in community pharmacies: Exploring consequences and contributing factors

OBJECTIVE To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors. METHODS Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10. RESULTS Pharmacy staff detected 75 e-prescription errors during the 45 h observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information. CONCLUSION Study findings suggest that a wide range of e-prescribing errors is encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies.

Facilitating collaboration between pharmacists and physicians using an iterative interview process

OBJECTIVE To elicit and describe mutually agreed upon common problems and subsequent solutions resulting from a facilitated face-to-face meeting between pharmacists and physicians. DESIGN Descriptive, exploratory, nonexperimental study. SETTING Wisconsin from October to December 2011. PARTICIPANTS Physicians and community pharmacists. INTERVENTION Face-to-face semistructured interviews with pharmacists and physicians from the same community, informed by previous individual interviews. MAIN OUTCOME MEASURES Methods to enhance collaboration and barriers to implementing collaboration between pharmacists and physicians. RESULTS Physicians and pharmacists generated ideas in which collaboration could improve patient care, including controlled substance monitoring, medication adherence, collaborative practice agreements for point-of-service issues, and a mechanism for urgent communication. Methods on how to collaborate on these issues also were discussed. CONCLUSION Bringing physicians and pharmacists together for a face-to-face interaction that was informed by information gained in previous individual interviews successfully stimulated conversation on ways in which each profession could help the other provide optimal patient care. This interaction appeared to dispel assumptions and build trust. The results of this project may provide pharmacists with the confidence to reach out to their physician colleagues.

Using a conflict conceptual framework to describe challenges to coordinated patient care from the physicians' and pharmacists' perspective

BACKGROUND In an effort to increase cost-effectiveness of health care and reduce overall costs, patient-centered medical homes have been proposed to spur fundamental changes in the way primary care is delivered. One of the chief principles that describe a patient-centered medical home is that care is organized across all elements of the broader health care system, including community pharmacies. OBJECTIVES To identify and describe challenges derived from a conflict management framework to a physician-pharmacist approach to coordinating patient care. METHODS A descriptive, exploratory, non-experimental study was conducted in Wisconsin (U.S. State) from June to December, 2011. Data were collected through two rounds of face-to-face interviews with physicians and community pharmacists. The first round involved one-on-one interviews with pharmacists and physicians. The second round brought pharmacist-physician dyads together in an open-ended interview exploring issues raised in the first round. Content analysis was guided by a conflict management conceptual framework using NVivo 10 qualitative software. RESULTS A total of four major themes emerged from the conflict analysis of interviews that illustrate challenges to coordinated patient care: Scarce resources, technology design and usability, insurance constraints, and laws and policy governing patient care. The study findings indicate that both groups of health care professionals work within an environment of conflict and have to negotiate the challenges and strains that exist in the current health care system. Their need to work together, or interdependence, is primarily challenged by scarce resources and external interference. CONCLUSIONS Efforts to coordinate patient care through teams of inter-professional health care providers will be more successful if they acknowledge the inherent conflict that exists. Efforts should be made to provide an infrastructure for interdependence and to support interpersonal communication.

Barriers and facilitators to recovering from e-prescribing errors in community pharmacies.

OBJECTIVE To explore barriers and facilitators to recovery from e-prescribing errors in community pharmacies and to explore practical solutions for work system redesign to ensure successful recovery from errors. DESIGN Cross-sectional qualitative design using direct observations, interviews, and focus groups. SETTING Five community pharmacies in Wisconsin. PARTICIPANTS 13 pharmacists and 14 pharmacy technicians. INTERVENTIONS Observational field notes and transcribed interviews and focus groups were subjected to thematic analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) work system and patient safety model. MAIN OUTCOME MEASURES Barriers and facilitators to recovering from e-prescription errors in community pharmacies. RESULTS Organizational factors, such as communication, training, teamwork, and staffing levels, play an important role in recovering from e-prescription errors. Other factors that could positively or negatively affect recovery of e-prescription errors include level of experience, knowledge of the pharmacy personnel, availability or usability of tools and technology, interruptions and time pressure when performing tasks, and noise in the physical environment. CONCLUSION The SEIPS model sheds light on key factors that may influence recovery from e-prescribing errors in pharmacies, including the environment, teamwork, communication, technology, tasks, and other organizational variables. To be successful in recovering from e-prescribing errors, pharmacies must provide the appropriate working conditions that support recovery from errors.

Medication management activities performed by informal caregivers of older adults

Background: Medication management is commonly performed by informal caregivers, yet they are often unprepared and ill‐equipped to manage complex medication regimens for their older adult care recipients. In order to develop interventions that will enhance the caregivers ability to safely and confidently manage medications, it is critical to first understand caregiver challenges and unmet needs related to medication management. Objectives: To explore how informal caregivers manage medications for their older adult care recipients by identifying the activities involved in medication management and the tools or strategies used to facilitate these activities. Methods: Four focus groups with caregivers of older adults were conducted with 5–9 caregivers per group. Participants were asked to describe the medication management activities performed and the tools or strategies used to facilitate these activities. Focus groups were recorded, transcribed verbatim, and analyzed for themes using an inductive approach. Results: Caregivers were commonly involved in 2 types of activities: direct activities requiring physical handling of medications such as obtaining medications, preparing pill boxes, and assisting with medication administration; and indirect activities that were more complex and required more of a cognitive effort by the caregiver, such as organizing and tracking medications, gathering information, and making treatment decisions. They utilized a variety of tools and strategies to support these medication management activities; however, these approaches often needed to be modified or personalized to meet the specific needs of their caregiving situation. Conclusions: Informal caregivers play a vital role in ensuring safe and appropriate medication use by older adults. Medication management is complex and involves many activities that are supported through the use of a variety of tools and strategies that have been adapted and individualized to each specific caregiving scenario. Caregivers should be an important component of interventions that aim to improve medication use among older adults. HIGHLIGHTSCare recipient health status determined caregiver involvement with medications.Monitoring activities were more complex and required more cognitive effort.Some caregiver take on provider‐like roles to adjust medication regimens.Tools and strategies often need to be modified to meet caregiver needs.Caregivers experienced difficulties even in relatively basic caregiving situations.

The prescription handoff in community pharmacy: a study of its form and function.

OBJECTIVE To describe and explore handoffs in community pharmacy. DESIGN Descriptive, exploratory, nonexperimental study. SETTING Wisconsin, August to October 2008. PARTICIPANTS Community pharmacists. INTERVENTION Brief, face-to-face, semistructured interviews. MAIN OUTCOME MEASURE Information on characteristics of handoffs, including the reasons for handoffs, what kind of information is shared during handoffs, and how information is shared. RESULTS The overarching reasons handoffs are done in community pharmacy are because some of the necessary information is confusing, contradictory, or absent, and/or the drug product is not in stock. Handoff information typically consists of a description of the problem, the current status of the problem, what information is still needed, and future steps to resolve the problem. Handoffs can occur synchronously during a shift change or asynchronously when one pharmacist signs out at the end of the day and another pharmacist opens the pharmacy the next morning. While synchronous handoffs are generally verbal in nature, asynchronous handoff information is primarily conveyed via paper or electronic notes on the dispensing computer system. CONCLUSION Our results suggest that handoffs do take place in community pharmacies and that the process is unstructured and variable. Future studies should fully characterize this process and explore possible strategies for improvement.

A preliminary examination of over-the-counter medication misuse rates in older adults

Background: Older adults are the largest consumers of over the counter (OTC) medications. Of the older adults who are at risk of a major adverse drug event, more than 50% of these events involve an OTC medication. Objective: To explore how older adults select and hypothetically use OTC medications and if the selected medications would be considered safe for use. Methods: Walking interviews were conducted with 20 community‐dwelling older adults in a community pharmacy. Each participant selected an OTC medication for a hypothetical pain and sleep scenario. Data were analyzed for four types of misuse: drug–drug interaction, drug–disease interaction, drug–age interaction, and excess usage. Results: At least one instance of potential misuse was found in 95% of participants. For sleep medications, drug–drug interactions and drug–age interactions were more common, affecting 50% and 65% of participants respectively. The most common type of misuse noted in the pain products selected was that of drug–drug interaction, with a total of 39 occurrences, affecting 60% of the participants. Conclusions: OTC misuse is common among older adults, and it is important for older adults to seek out resources, such as a pharmacist, to help them make safe OTC decisions.

Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis

Background The U.S. Agency for Healthcare Research and Quality (AHRQ) developed a hospital patient safety culture survey in 2004 and has adapted this survey to other healthcare settings, such as nursing homes and medical offices, and most recently, community pharmacies. However, it is unknown whether safety culture dimensions developed for hospitals can be transferred to community pharmacies. The aim of this study was to assess the psychometric properties of the Community Pharmacy Survey on Patient Safety Culture. Method The survey was administered to 543 community pharmacists in Wisconsin, USA. Confirmatory factor analysis was used to assess the fit of our data with the proposed AHRQ model. Exploratory factor analysis was used to determine the underlying factor structure. Internal consistency reliabilities were calculated. Results A total of 433 usable surveys were returned (response rate 80%). Results from the confirmatory factor analysis showed inadequate model fit for the original 36 item, 11-factor structure. Exploratory factor analysis showed that a modified 27-item, four-factor structure better reflected the underlying safety culture dimensions in community pharmacies. The communication openness factor, with three items, dropped in its entirety while six items dropped from multiple factors. The remaining 27 items redistributed to form the four-factor structure: safety-related communication, staff training and work environment, organisational response to safety events, and staffing, work pressure and pace. Cronbachs α of 0.95 suggested good internal consistency. Conclusions Our findings suggest that validation studies need to be conducted before applying safety dimensions from other healthcare settings into community pharmacies.

Improving Quality and Safety through Human Factors Collaborations with Healthcare The System Engineering Initiative for Patient Safety

Multiple reports from the Institute of Medicine and the National Academy of Engineering, (IOM 2001; Reid et al., 2005; Kaplan et al., 2013) have called for the use of human factors engineering (HFE) and systems engineering principles and methods/tools to improve health care delivery. Yet, the integration of engineers into health care settings and the education of clinicians and other health care professionals on human factors and systems engineering principles and methods/tools remain in its infancy. A recent editorial by Xiao and Fairbanks (2011), discusses a small, but growing presence of professionals who are “bilingual” in both human factors and medicine. Indeed, Carayon (2011) identified human factors as an innovation that will require diffusion into healthcare through the use of HFE methods and tools, increasing the health care professional knowledge of HFE, and the hiring HFEs in healthcare organizations. To achieve the goal of integration, there will be many “models” of healthcare – human factors collaborations, from experts working together from their different ‘silos’ to true bilingualism. SEIPS, the Systems Engineering Initiative for Patient Safety (Carayon et al., 2006), aims to integrate human factors and systems engineering with healthcare disciplines. Our panel of SEIPS-affiliated engineers and healthcare professionals represents many different types of collaborations across this spectrum and their work spans multiple healthcare settings and disciplines, including: ambulatory primary care, inpatient pediatrics, community pharmacy, and oncology.

Work System Barriers to Providing Safe Over-the-Counter (OTC) Medication Recommendations for Older Adults

Background: Unsafe medication use represents a major public health concern, especially for older adults. OTC medications, those that can be purchased without a formal prescription or advice from a health care professional, are one contributor to unsafe use because of their perceived safety and accessibility. Despite the recognition of pharmacists’ ability to help patients make safe OTC medication choices, the prevalence of older adult misuse of OTC medications is well documented. Objective: To identify barriers to pharmacists providing safe OTC medication recommendations to older adults. Methods: Twenty-one retail pharmacists in three focus groups with questions developed using the critical incident technique. Analysis was guided by the Input-Performance-Output Model for Health Care Professional Performance. Results: Thematic analysis revealed barriers within all of the input categories of the work system model, including provider, patient, work system, organizational factors, and external environment. The results provide support that any intervention to improve safe OTC medication use in older adults should take into consideration the role of individual and interacting components of the work system.