William E Fassett

Patient Safety and Quality Improvement Act of 2005

Objective: To review Public Law (PL) 109-41—the Patient Safety and Quality Improvement Act of 2005 (PSQIA)—and summarize key medication error research that contributed to congressional recognition of the need for this legislation. Data Sources: Relevant publications related to medication error research, patient safety programs, and the legislative history of and commentary on PL 109-41, published in English, were identified by MEDLINE, PREMEDLINE, Thomas (Library of Congress), and Internet search engine–assisted searches using the terms healthcare quality, medication error, patient safety, PL 109-41, and quality improvement. Additional citations were identified from references cited in related publications. Study Selection and Data Extraction: All relevant publications were reviewed. Summarization of the PSQIA was carried out by legal textual analysis. Data Synthesis: PL 109-41 provides privilege and confidentiality for patient safety work product (PSWP) developed for reporting to patient safety organizations (PSOs). It does not establish federal mandatory reporting of significant errors; rather, it relies on existing state reporting systems. The Act does not preempt stronger state protections for PSWP. The Agency for Healthcare Research and Quality is directed to certify PSOs and promote the establishment of a national network of patient safety databases. Whistleblower protection and penalties for unauthorized disclosure of PSWP are among its enforcement mechanisms. Conclusions: The Act protects clinicians who report minor errors to PSOs and protects the information from disclosure, but providers must increasingly embrace a culture of interdisciplinary concern for patient safety if this protection is to have real impact on patient care.

Frequency and characteristics of cognitive services provided in response to a financial incentive.

OBJECTIVE To determine the effects of a financial incentive on the number and types of cognitive services (CS) provided by community pharmacies to Medicaid recipients in the State of Washington. DESIGN Prospective randomized trial. CS were reported using a problem-intervention-result coding system over a 20-month period. SETTING AND SUBJECTS Pharmacists practicing in 110 study (financial incentive) and 90 control community pharmacies. RESULTS Study pharmacists documented an average of 1.59 CS interventions per 100 prescriptions over a 20-month period, significantly more than controls, who documented an average of 0.67 interventions (P < .05) per 100 prescriptions. One-half (48.4%) of all CS were for patient-related problems, 32.6% were for drug-related problems, 17.6% were for prescription-related problems, and 1.4% were for other problems that did not involve drug therapy. A change in drug therapy occurred as a result of 28% of all CS documented in this demonstration. Changes were rarely (2.4%) due to generic or therapeutic substitution and almost always (90%) followed communication with the prescriber. The average self-reported time to perform CS was 7.5 minutes; 75% of interventions were < or = 6 minutes. Considerable differences existed between study and control groups in the types of problems identified, intervention activities performed, and results of interventions. CONCLUSION A financial incentive was associated with significantly more, and different types of, CS performed by pharmacists.

Key Performance Outcomes of Patient Safety Curricula: Root Cause Analysis, Failure Mode and Effects Analysis, and Structured Communications Skills

As colleges and schools of pharmacy develop core courses related to patient safety, course-level outcomes will need to include both knowledge and performance measures. Three key performance outcomes for patient safety coursework, measured at the course level, are the ability to perform root cause analyses and healthcare failure mode effects analyses, and the ability to generate effective safety communications using structured formats such as the Situation-Background-Assessment-Recommendation (SBAR) situational briefing model. Each of these skills is widely used in patient safety work and competence in their use is essential for a pharmacists ability to contribute as a member of a patient safety team.

Over-the-Counter Availability of Plan B Emergency Contraception: Further Discussion and Commentary

The controversy surrounding the potential switch of the Plan B emergency contraceptive therapy from prescription to over-thecounter status has been unprecedented. Regulatory, professional, and societal aspects of this issue have been discussed recently and will no doubt continue to be debated. In this editorial, members of the Medicine, Law, and Ethics panel of The Annals of Pharmacotherapys Editorial Board offer a sampling of viewpoints touching on varying aspects of the controversy. Readers may wish to consider the ramifications of their professional decisions in this and similar situations in advance of having to make such decisions.

Report of the Academy Presidents: Leading key initiatives as part of APhA's strategic plan

APhA–APPM As I reflect upon my first year as President of APhA–APPM, I am impressed with the level of engagement of our members and the significant growth of the Academy throughout the year. With the launch of several new Special Interest Groups (SIGs) for Academy members this year, the Academy has in just 2 short years successfully implemented a structure by which more of our members can interact and engage in the work of the Association and the pharmacy profession. As we face the ever-changing needs of our health care system, I can assure you through the leadership and planning process that the Academy consistently focused work and efforts in 2013–14 on the charges handed down by APhA President Steven Simenson—assisting in transforming the role of the pharmacist, employing ways of empowering members, participating in advocating for the profession, and working to develop leaders. The result is significant progress in advancing the profession, based upon the hard work and tireless efforts of you, our members, working hand in glove with the elected leaders of APhA–APPM and the staff of our Association. We have accomplished a lot, but we still have a tremendous amount of work to do. Practice and the future of the profession As our health care system continues to evolve in the wake of health care reform and implementation of the Affordable Care Act, pharmacy is changing. With APhA playing a major role, the profession has undertaken the ambitious effort of achieving provider status for pharmacists, with the members of APhA–APPM at the forefront of these efforts. As health care professionals, we will share their patient care stories, advocate to elected leaders at the federal and state level, and explore new models at the federal, state, and private-payer level for access and coverage of pharmacists’ patient care services. It is our role as APhA–APPM to provide you—our practitioner Hilliard

Book Review: On Being a Doctor 2: Voices of Physicians and Patients:

Current information on the causes, etiology, and initial management of dyspepsia are provided in this book. Additionally, alternative management strategies and quality-of-life issues are addressed. Tables and graphs visually support the information presented. Because there are different authors for each chapter, some information (on Helicobacter pylori, for example) is repeatedly mentioned in several chapters, although there is a separate chapter on H. pylori and nonulcer dyspepsia. Perhaps this chapter could have also included H. pylori in view of ulceration as well. Useful features are the clinical vignettes consisting of case studies followed by questions about the cases and concluding statements. However, only three cases are offered; more examples would have been useful. The most interesting chapter discusses alternative medical therapies for dyspepsia, accompanied by tables of herbal and other natural treatments. At a price of

Washington State CARE Project: downstream cost changes associated with the provision of cognitive services by pharmacists.

35.00, this book should be useful to the target audience of primary care physicians. Pharmacists would also find this book useful due to its discussion of nontraditional therapies and its summaries of economic issues and nonsteroidal antiinflammatory drugs. In conclusions, Dyspepsia provides a valuable concentration of information that bridges the gap between medical literature and clinical practice and focuses on cost-effective strategies.