Implications of involving pharmacy technicians in obtaining a best possible medication history from the perspectives of pharmaceutical, medical and nursing staff: a qualitative study

A blueprint for success: Using an implementation framework to create a medication history technician pilot program

BACKGROUND

Medication discrepancies at transitions of care may compromise patient safety. Trained pharmacy technicians can reduce harmful medication discrepancies at transitions of care by collecting medication histories.

OBJECTIVE

We describe how to create a program integrating medication history technicians (MHTs) into the hospital discharge process using implementation science.

PRACTICE DESCRIPTION

We created our MHT program at a Veterans Affairs (VA) hospital.

PRACTICE INNOVATION

We used an evidence-based framework and implementation science to tailor our MHT program to meet local stakeholder needs.

EVALUATION METHODS

We completed a literature review and review of current discharge practices. Then, we completed a workflow pilot, a needs assessment, and semistructured interviews with pharmacy technicians and pharmacists. We integrated these findings to identify barriers of MHT program implementation. Finally, we mapped these barriers to implementation strategies to create an MHT program implementation blueprint.

RESULTS

The literature review and review of current discharge practices revealed opportunities for our program to reduce medication discrepancies. We applied these findings to our proof-of-concept workflow pilot, which reduced medication discrepancy rates at discharge. When we explored barriers in the needs assessment, we learned that 4 of 6 pharmacy technicians had some training conducting medication histories, but 5 of 6 requested additional training for the new MHT role. We explored these and additional barriers in semistructured interviews. Four themes emerged: elements of pharmacy technician training, challenges to implementation, program logistics and workflow, and pharmacy technician self-efficacy. We mapped barriers to implementation strategies to create an MHT program implementation blueprint, including developing pharmacy technician training materials, modifying our workflow, creating program evaluation materials, and strategizing how to overcome anticipated and current implementation barriers.

CONCLUSIONS

We used implementation science to create a tailored MHT program. Others may adapt our implementation blueprint to fit local stakeholder needs.

PRN Medicines Optimization and Nurse Education

Medicines management is a high-risk and error prone process in healthcare settings, where nurses play an important role to preserve patient safety. In order to create a safe healthcare environment, nurses should recognize challenges that they face in this process, understand factors leading to medication errors, identify errors and systematically address them to prevent their future occurrence. ''Pro re nata'' (PRN, as needed) medicine administration is a relatively neglected area of medicines management in nursing practice, yet has a high potential for medication errors. Currently, the international literature indicates a lack of knowledge of both the competencies required for PRN medicines management and the optimum educational strategies to prepare students for PRN medicines management. To address this deficiency in the literature, the authors have presented a discussion on nurses' roles in medication safety and the significance and purpose of PRN medications, and suggest a model for preparing nursing students in safe PRN medicines management. The discussion takes into account patient participation and nurse competencies required to safeguard PRN medication practice, providing a background for further research on how to improve the safety of PRN medicines management in clinical practice.

Improving efficiency through workflow optimization in a pharmacist-run diabetes clinic

PURPOSE

To evaluate the impact of hiring nonclinical support staff on pharmacist productivity and diabetes control outcomes in internal medicine clinics of an integrated healthcare system.

METHODS

A retrospective, longitudinal cohort study was conducted. Patients were included if they were contacted by telephone for a diabetes consultation with a clinical pharmacist from July 1, 2015, through June 30, 2017. Nonclinical support staff were hired in July 2016 to schedule patient appointments with the clinical pharmacists. The primary outcome was the average rate of completed telephone encounters per month before and after hiring of nonclinical support staff. The secondary outcome was the mean change in glycated hemoglobin (HbA1c) level in patients who had a laboratory assay completed within 90 days of clinical pharmacist outreach. The tertiary outcome was the call completion rate for scheduled appointments vs unscheduled calls.

RESULTS

In total, 6,709 patients were included; their average age was 55 years. After the intervention, the mean (SD) rate of completed telephone encounters increased from 61% (3.8%) to 77% (3.5%) (P < 0.001). Small improvements were noted in glycemic control, as measured by the mean (SD) percentage of patients with an HbA1c concentration of <8%, which increased from 31% (5.2%) to 42% (3.0%) (P < 0.001), and the mean (SD) change in average HbA1c concentration, which increased from 8.9% (0.2%) to 8.5% (0.1%) (P < 0.001). Throughout the study, scheduled calls were more likely to be completed than unscheduled calls (mean [SD] completion rate, 66% [9.0%] vs 74% [6.0%]; P < 0.001).

CONCLUSION

Hiring nonclinical support staff led to greater efficiency among the clinical pharmacist team, yielding a higher volume of telephone interactions, a modest overall decrease in HbA1c values, and an increased likelihood of reaching patients by phone.

Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward

OBJECTIVE

Medication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including a best possible medication history (BPMH) compared with a standard medication history in patients admitted to an internal medicine ward.

DESIGN

Prospective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model.

SETTING

Internal medicine ward in a secondary care hospital in Southern Switzerland.

PARTICIPANTS

The first 100 consecutive patients admitted in an internal medicine ward.

PRIMARY AND SECONDARY OUTCOME MEASURES

Medication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified.

RESULTS

The median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model.

CONCLUSION

Even in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to avoid a notable number of clinically relevant discrepancies and potential adverse drug events.

[Involvement of hospital pharmacy technician for expanding medication reconciliation process in France: Actors' willingness and opinions]

OBJECTIVES

Medication reconciliation is widely promoted by international health authorities. Its expansion requires human resources, which are limited and unequally distributed among health care facilities. Recent international studies support the involvement of pharmacy technician in the medication reconciliation process but his role remains unstructured in France. We aimed to assess pharmacy technicians' opinions and willingness to be involved in the medication reconciliation process expansion and to identify the levers and barriers of the project.

METHODS

A field study was conducted among health facilities of our territory hospital group. Semi-structured interviews were carried out with different pharmacy technicians. Data were analyzed using a qualitative thematic analysis approach.

RESULTS

Overall, 12 pharmacy technicians from 5 hospitals were interviewed and almost all assumed their rightful place in the medication reconciliation process (n=11), with a view to revaluating tasks. For all pharmacy technicians, the main barriers to participate in medication reconciliation were the lack of time and training. The spread of a "patient culture", the supervision by pharmacists, the desire to be part of the care team in the ward and additional training requests were major levers of change.

CONCLUSIONS

Pharmacy technicians' role in expanding medication reconciliation process is legitimate and must be standardized in France. The deployment of the project requires to be formalized within a territory and should consider and develop local organisations.

[Medication safety in Switzerland: Where are we today?]

Empirical research shows that medication safety is an urgent area of concern in the Swiss healthcare system. Adverse drug events and medication errors are common and risks such as polypharmacy are widespread. No comprehensive national strategy explicitly dedicated to medication safety exists in Switzerland. The federalist system of government with relative autonomy of the cantons relating to healthcare laws influences the implementation of national healthcare reforms, also to the disadvantage of medication safety. Direct dispensing of drugs by the prescribing physician is permitted in almost all German-speaking cantons. This special feature of the Swiss system implies specific challenges for medication safety. Nonetheless, there is an increasing number of national activities dealing with various aspects of medication safety, such as the "progress!" programmes within the National Quality Strategy. Within the National Research Programme "Smarter Health Care" (NRP 74) of the Swiss National Science Foundation, several research projects are currently focusing on medication safety. Clinical pharmacy activities in hospitals are relatively widespread. In the primary care sector, pharmaceutical care practice and the corresponding competencies for pharmacists are being further developed. However, a comprehensive strategy, priority-setting and effectiveness studies involving all stakeholders are required in order for the Swiss healthcare system, to meet the challenges facing medication safety in a forward-looking manner.