Community pharmacists' subjective workload and perceived task performance: a human factors approach

Feasibility of a contraceptive-specific electronic health record system to promote the adoption of pharmacist-prescribed contraceptive services in community pharmacies in the United States

Objectives

Pharmacists in over half of the United States can prescribe contraceptives; however, low pharmacist adoption has impeded the full realization of potential public health benefits. Many barriers to adoption may be addressed by leveraging an electronic health records (EHR) system with clinical decision support tools and workflow automation. We conducted a feasibility study to determine if utilizing a contraceptive-specific EHR could improve potential barriers to the implementation of pharmacist-prescribed contraceptive services.

Materials and Methods

20 pharmacists each performed two standardized patient encounter simulations: one on the EHR and one on the current standard of care paper-based workflow. A crossover study design was utilized, with each pharmacist performing encounters on both standardized patients with the modality order randomized. Encounters were timed, contraceptive outputs were recorded, and the pharmacists completed externally validated workload and usability surveys after each encounter, and a Perception, Attitude, and Satisfaction survey created by the research team after the final encounter.

Results

Pharmacists were more likely to identify contraceptive ineligibility using the EHR-based workflow compared to the paper workflow (P = .003). Contraceptive encounter time was not significantly different between the 2 modalities (P = .280). Pharmacists reported lower mental demand (P = .003) and greater perceived usefulness (P = .029) with the EHR-based workflow compared to the paper modality.

Discussion and Conclusion

Pharmacist performance and acceptance of contraceptive services delivery were improved with the EHR workflow. Pharmacist-specific contraceptive EHR workflows show potential to improve pharmacist adoption and provision of appropriate contraceptive care.

Linking Inner Context and Innovation Factors: Examining a pharmacy-based intervention through the eyes of pharmacy staff

INTRODUCTION

Community pharmacies, as unique and accessible healthcare venues, are ideal locations to implement interventions aiming to improve patient care. However, these interventions may increase workload or disrupt workflow for community pharmacists, technicians, and other staff members, threatening long-term sustainment. There are growing calls from the field of implementation science to design for intervention sustainment and maintenance by maximizing innovation fit. Senior Safe™, an intervention to facilitate safer over-the-counter (OTC) product selection by older adults, serves as a case study to examine the congruence between Innovation Factors and community pharmacy Inner Context constructs and their implications for workload and sustainment.

METHODS

Using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, this qualitative study identified factors surrounding Senior Safe implementation. Semi-structured interviews were conducted with staff from pharmacies where Senior Safe was implemented. Two coders independently analyzed interview transcripts using deductive analysis based on EPIS constructs. Thematic analysis was used to generate three themes that encapsulated innovation fit.

RESULTS

Nineteen pharmacy staff members participated, with the majority reporting no significant change in their workload or workflow due to Senior Safe. Interview feedback supported a pre-existing culture of the healthcare system to engage patients, of leadership commitment to patient safety initiatives, and of an amplified role of pharmacy technicians.

DISCUSSION AND CONCLUSION

Pharmacy staff interviews revealed congruence between Innovation Factors and Inner Context that likely yielded intervention workload neutrality. This study highlighted the importance for researchers to consider maintenance and sustainability when designing and implementing an intervention and the critical influence of culture and leadership support during this process.

Handing Off Electronic Prescription Data From Prescribers to Community Pharmacies: A Qualitative Analysis of Pharmacy Staff Perspectives

OBJECTIVES

The aims of the study are to understand the process of how community pharmacies handle electronic prescriptions (e-prescriptions) and learn about different errors or potential errors encountered.

METHODS

Fifteen remote, semistructured interviews were conducted with community pharmacy staff. Interview analysis was done with two adapted Systems Engineering Initiative for Patient Safety methods to understand the workflow and an affinity wall, which led to key words that were tallied to understand the frequency of different issues.

RESULTS

Data entry in community pharmacies is a process that varies based on the different software platforms receiving e-prescriptions. Data entry of a medication product is typically a human-reliant process matching an e-prescription with an equivalent medication product. Current automated safety supports focus on matching the dispensed medication to the medication chosen at data entry. Substitutions may be required for a variety of reasons, however, pharmacists' comfort and permissions in doing so without provider involvement fluctuates.

CONCLUSIONS

Prescription errors remain that could be prevented with additional support at the data entry step of e-prescriptions. Few studies demonstrate where these errors originate and what role current technology plays in contributing to or preventing these errors. Future work must consider how these matches between prescribed medications and pharmacy fulfilled medications occur. There is a need to identify potential tools to support data entry and prevent medication errors.

Quality of work life (QWL) of community pharmacists and its association with subjective evaluations of pharmaceutical services

Background

In Japan, pharmacists' role has drastically changed in recent years. However, previous studies have not performed internal marketing analysis for Japanese community pharmacists so that they improve the quality of work life (QWL) and be satisfied with it. Further, few studies are conducted on Japanese community pharmacists' QWL and its effect on the quality of pharmaceutical services.

Objectives

This study aimed to reveal associations between community pharmacists' QWL and their subjective evaluations of pharmaceutical service.

Methods

A questionnaire survey was conducted among 2027 pharmacists, with the cooperation of 20 corporations that run pharmacies. The collected data were subjected to multiple regression analysis, using SPSS 29.

Results

Standard multiple regression shows that 27.4% of variance in pharmacists' subjective evaluations of their service was explained by QWL and other control variables, such as age, gender, and employee status (p < .001, R2 = 0.274). This analysis showed that factors behind pharmacists' QWL, "meaning of existence in the workplace" and "pride in work," explained pharmacists' subjective evaluations of pharmaceutical service (β = 0.307, p < .001, β = 0.277; p < .001, respectively).

Conclusion

This study shows that improving QWL, especially "mental and physical effects on work" and "pride in work," might contribute to improving community pharmacists' services.

Adapting a community pharmacy intervention to improve medication safety

BACKGROUND

Community pharmacies are an ideal location to address challenges of over-the-counter medication safety, yet many successful interventions are only tested in a few pharmacies without expansion, creating unrealized opportunities to improve patient care on a larger scale. Scaling up to numerous pharmacies can be challenging because each community pharmacy has unique needs and layouts and requires individualized adaptation.

OBJECTIVES

This paper reports techniques for (a) adapting a community pharmacy intervention to fit the unique physical layout and patient needs of health system pharmacy sites without increasing staff workload, (b) identifying strategies to gather feedback on adaptations from stakeholders, and (c) developing materials to share with pharmacy champions for them to independently implement and sustain the intervention in their organization.

PRACTICE DESCRIPTION

The study team collaborated with Aurora Pharmacy, Inc to develop an intervention designed to increase awareness of safe over-the-counter medication use for older adults.

PRACTICE INNOVATION

Senior Safe, a community pharmacy-based intervention, was designed, implemented, and tested using the Exploration, Preparation, Implementation, and Sustainment implementation framework.

EVALUATION METHODS

Senior Safe was adapted through pilot testing and a randomized control trial. Feedback was collected from key stakeholders, including pharmacy staff, older adults, and a research advisory group.

RESULTS

A finalized version of Senior Safe, as well as an implementation package, was provided to Aurora Pharmacy to integrate into all 63 sites.

CONCLUSION

This multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but it requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.

Clinical decision support systems in community pharmacies: a scoping review

OBJECTIVE

Clinical decision support systems (CDSS) were implemented in community pharmacies over 40 years ago. However, unlike CDSS studies in other health settings, few studies have been undertaken to evaluate and improve their use in community pharmacies, where billions of prescriptions are filled every year. The aim of this scoping review is to summarize what research has been done surrounding CDSS in community pharmacies and call for rigorous research in this area.

MATERIALS AND METHODS

Six databases were searched using a combination of controlled vocabulary and keywords relating to community pharmacy and CDSS. After deduplicating the initial search results, 2 independent reviewers conducted title/abstract screening and full-text review. Then, the selected studies were synthesized in terms of investigational/clinical focuses.

RESULTS

The selected 21 studies investigated the perception of and response to CDSS alerts (n = 7), the impact of CDSS alerts (n = 7), and drug-drug interaction (DDI) alerts (n = 8). Three causes of the failures to prevent DDIs of clinical importance have been noted: the perception of and response to a high volume of DDI alerts, a suboptimal performance of CDSS, and a dearth of sociotechnical considerations for managing workload and workflow. Additionally, 7 studies emphasized the importance of utilizing CDSS for a specific clinical focus, ie, antibiotics, diabetes, opioids, and vaccinations.

CONCLUSION

Despite the range of topics dealt in the last 30 years, this scoping review confirms that research on CDSS in community pharmacies is limited and disjointed, lacking a comprehensive approach to highlight areas for improvement and ways to optimize CDSS utilization.

Evaluation of patient safety culture in community pharmacies

Background

The majority of medical mistakes risking patient safety have been related to medication. Numerous international health organizations support assessing safety culture in healthcare organizations as a successful tactic for long-term safety development.

Objective

This study aimed to assess patient safety culture, investigate determinants of patient safety in community pharmacies and identify strengths and possible improvements concerning patient safety in the Lebanese community.

Method

An observational descriptive cross-sectional study was conducted using the Pharmacy Survey on Patient Safety Culture (PSOPSC). It was distributed among Lebanese community pharmacists.

Results

One hundred forty-five community pharmacists completed the survey. High percent positive response (PPR) was seen in the domains of patient counseling (86.4%) and teamwork (83.9%). "Staffing, Work Pressure, and Pace" composite scored 41.2%. Female pharmacists were shown to be more dedicated to patient safety culture, namely in patient counseling skills (P < 0.05). Working for 32 to 40 h per week (β = 19.305), and for >40 h per week (β = 18.315) were significantly associated with increased patient safety score.

Conclusion

An overall positive perception towards patient safety culture was seen among Lebanese community pharmacists.

Australian community pharmacy service provision factors, stresses and strains: A qualitative study

Introduction

Despite the desire of pharmacists to provide new and more clinically focused services, strain on the community pharmacist workforce is a known barrier to their service provision. Causes are unclear, although the impact of increased workload, as well as broader role-related and systemic causes have been suggested.

Aims

To (1) explore the role strain, stress and systemic factors affecting Australian community pharmacists' provision of cognitive pharmacy services (CPS), using the Community Pharmacist Role Stress Factor Framework (CPRSFF), and (2) adapt the CPRSFF to the local setting.

Methods

Semi-structured interviews were conducted with Australian community pharmacists. Transcripts were analysed with the framework method to verify and adapt the CPRSFF. Thematic analysis of particular codes identified personal outcomes and causative patterns in perceived workforce strain.

Results

Twenty-three registered pharmacists across Australia were interviewed. CPS role benefits included: helping people, and increased competency, performance, pharmacy financial return, recognition from the public and other health professionals, and satisfaction. However, strain was worsened by organisational expectations, unsupportive management and insufficient resources. This could result in pharmacist dissatisfaction and turnover in jobs, sector or careers. Two additional factors, workflow and service quality, were added to the framework. One factor, "View of career importance versus partner's career", was not apparent.

Conclusion

The CPRSFF was found to be valuable in exploring the pharmacist role system and analysing workforce strain. Pharmacists weighed up positive and negative outcomes of work tasks, jobs and roles to decide task priority and personal job significance. Supportive pharmacy environments enabled pharmacists to provide CPS, which increased workplace and career embeddedness. However, workplace culture at odds with professional pharmacist values resulted in job dissatisfaction and staff turnover.

Effectiveness and sustainment of a tailored over-the-counter medication safety intervention in community pharmacies: A randomized controlled trial

INTRODUCTION

The Senior Section is a continuation of a previous intervention that aims to address a gap in medication safety, specifically related to older adult selection and use of over-the-counter medications. The purpose of this paper is to describe the protocol of this study.

METHODS

This study will occur in three phases: an adaptation phase, an effectiveness phase using a randomized controlled trial, and a sustainment phase. This study will take place in conjunction with administrative leadership and pharmacy sites of a regional Midwest integrated health system. Eye tracking technology will inform the adaptation of the intervention and demonstrate effectiveness in the randomized controlled trial. Following the randomized controlled trial, the health system will implement the intervention without research team support. Fidelity and long-term effectiveness outcomes will be collected to demonstrate sustainment.

DISCUSSION

The potential implications of this study are a complete and sustained redesign of the pharmacy setting to include educational and directional materials on medication safety, leading to a decrease in over-the-counter medication misuse in older adults. This project could provide a road map for pharmacy organizations to tailor and adopt the Senior Section, to ultimately reduce inappropriate over-the-counter medication use in older adults.

Implementation outcomes of the Structured and Codified SIG format in electronic prescription directions

OBJECTIVE

To determine the extent of implementation, completeness, and accuracy of Structured and Codified SIG (S&C SIG) directions on electronic prescriptions (e-prescriptions).

MATERIALS AND METHODS

A retrospective analysis of a random sample of 3.8 million e-prescriptions sent from electronic prescribing (e-prescribing) software to outpatient pharmacies in the United States between 2019 and 2021. Natural language processing was used to identify direction components, including action verb, dose, frequency, route, duration, and indication from free-text directions and were compared to the S&C SIG format. Inductive qualitative analysis of S&C direction identified error types and frequencies for each component.

RESULTS

Implementation of the S&C SIG format in e-prescribing software resulted in 32.4% of e-prescriptions transmitted with these standardized directions. Directions using the S&C SIG format contained a greater percentage of each direction component compared to free-text directions, except for the indication component. Structured and codified directions contained quality issues in 10.3% of cases.

DISCUSSION

Expanding adoption of more diverse direction terminology for the S&C SIG formats can improve the coverage of directions using the S&C SIG format. Building out e-prescribing software interfaces to include more direction components can improve patient medication use and safety. Quality improvement efforts, such as improving the design of e-prescribing software and auditing for discrepancies, are needed to identify and eliminate implementation-related issues with direction information from the S&C SIG format so that e-prescription directions are always accurately represented.

CONCLUSION

Although directions using the S&C SIG format may result in more complete directions, greater adoption of the format and best practices for preventing its incorrect use are necessary.

Prevalence and risk factors of burnout among Lebanese community pharmacists in the era of COVID-19 pandemic: results from the first national cross-sectional survey

BACKGROUND

Community pharmacists (CPs) are increasingly facing occupational challenges as a result of the COVID-19 pandemic, putting them at high risk of burnout. This study aimed to assess the prevalence of burnout among Lebanese CPs during the COVID-19 pandemic and to identify its associated factors.

METHODS

An online survey was conducted among Lebanese CPs between February 1st and March 30, 2021. Collected data included information on sociodemographic characteristics, exposure and work-related variables, the Copenhagen burnout inventory (CBI), and the COVID-19 threat perception scale. Prevalence of burnout was calculated. Multiple logistic regressions were performed to identify the factors associated with the three burnout domains.

RESULTS

A total of 387 CPs participated in the survey. Of the total, 53.7% were females; and 43.2% were aged less than 40 years old. The prevalence of moderate-to-high personal, work-related and client-related burnout was 77.8%, 76.8, and 89.7%, respectively. Younger age, staff pharmacist, working more than 40 h per week, high perceived COVID-19 threat were associated with a moderate-to-high likelihood of burnout in all three domains. However, altruistically accepting the risks of caring for COVID-19 patients was the only variable that was associated with a lower likelihood of burnout in all three domains.

CONCLUSION

An alarming prevalence of personal, work-related and client-related burnout was revealed among Lebanese CPs. This study has many implications for practice and provides a framework for establishing policy interventions to reduce burnout levels among Lebanese CPs. Preventive strategies and interventions on individual and organizational basis are recommended.

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

Considerations of Australian community pharmacists in the provision and implementation of cognitive pharmacy services: a qualitative study

Background

Australian federally-funded cognitive pharmacy services (CPS) (e.g. medication management and reconciliation services) have not been translated into practice consistently. These health services are purportedly accessible across all Australian community pharmacies, yet are not delivered as often as pharmacists would like. There are international indicators that pharmacists lack the complete behavioural control required to prioritise CPS, despite their desire to deliver them. This requires local investigation.

Objective

To explore Australian pharmacists’ perspectives [1] as CPS providers on the micro level, and [2] on associated meso and macro level CPS implementation issues.

Methods

Registered Australian community pharmacists were recruited via professional organisations and snowball sampling. Data were collected via an online demographic survey and semi-structured interviews until data saturation was reached. Interview transcripts were de-identified then verified by participants. Content analysis was performed to identify provider perspectives on the micro level. Framework analysis using RE-AIM was used to explore meso and macro implementation issues.

Results

Twenty-three participants across Australia gave perspectives on CPS provision. At the micro level, pharmacists did not agree on a single definition of CPS. However, they reported complexity in interactional work and patient considerations, and individual pharmacist factors that affected them when deciding whether to provide CPS. There was an overall deficiency in pharmacy workplace resources reported to be available for implementation and innovation. Use of an implementation evaluation framework suggested CPS implementation is lacking sufficient structural support, whilst reach into target population, service consistency and maintenance for CPS were not specifically considered by pharmacists.

Conclusions

This analysis of pharmacist CPS perspectives suggests slow uptake may be due to a lack of evidence-based, focused, multi-level implementation strategies that take ongoing pharmacist role transition into account. Sustained change may require external change management and implementation support, engagement of frontline clinicians in research, and the development of appropriate pharmacist practice models to support community pharmacists in their CPS roles.

Trial registration

This study was not a clinical intervention trial. It was approved by the University of Technology Sydney Human Research Ethics Committee (UTS HREC 19–3417) on the 26th of April 2019.

Medication Counseling Practices in Medicine Retail Outlets Found in Bench Sheko Zone, Southern Nations, Nationalities, and Peoples' Region, South West Ethiopia

Objective

The objectives of this research were to investigate pharmacy professionals’ counseling practices as well as to evaluate pharmacy professionals’ counseling skills and the content of counseling services provided to patients visiting medicine retail outlets.

Methods

A facility-based observational cross-sectional study was used to assess medication counseling practice by pharmacy professionals. Data were gathered through an observation and a semi-structured questionnaire. Epi data version 4.0.2 was used to enter data, which was subsequently exported to SPSS version 21.0 for analysis. ANOVA and post hoc statistical analyses were used to investigate the association between independent and dependent variables; and a 0.05 p-value was considered.

Results

This study has a total of 105 pharmacy professionals that were included in the analysis. The majority of those who responded were between the ages of 25 and 29. The most common drug information offered by pharmacy staff to patients was frequency of administration (90%), length of therapy (90%), and unit dose dispensed, according to the current study (86%). Pharmacy professionals’ age was significant on components of counseling practice as on mentioning the name of drugs during dispensing the medication (p=0.000), the route of administration (p=0.000), a drug dose (p=0.003), frequency of drug administration (p=0.016), proper medicine storage (p=0.024), type of dosage form (p=0.025), and duration of treatment (p=0.012). In comparison with the other age groups, an age greater than 40 years was significant on components of counseling practice (p=0.001) as a factor associated with penurious counseling practice than the other groups.

Conclusion

This study shows that counseling practice is still quite low in comparison to what is expected. Some of the issues that affect counseling include a high patient load, the lack of a private counseling room, a lack of updated drug knowledge, and a lack of experience were factors that influence counseling.

Performance evaluation of a prescription medication image classification model: an observational cohort

Technology assistance of pharmacist verification tasks through the use of machine intelligence has the potential to detect dangerous and costly pharmacy dispensing errors. National Drug Codes (NDC) are unique numeric identifiers of prescription drug products for the United States Food and Drug Administration. The physical form of the medication, often tablets and capsules, captures the unique features of the NDC product to help ensure patients receive the same medication product inside their prescription bottle as is found on the label from a pharmacy. We report and evaluate using an automated check to predict the shape, color, and NDC for images showing a pile of pills inside a prescription bottle. In a test set containing 65,274 images of 345 NDC classes, overall macro-average precision was 98.5%. Patterns of incorrect NDC predictions based on similar colors, shapes, and imprints of pills were identified and recommendations to improve the model are provided.

A participatory research approach in community pharmacy research: The case for video-reflexive ethnography

Video-reflexive ethnography (VRE) is a qualitative methodology that explores the complex nature of healthcare 'as it really is'. Its collaborative and reflexive process invites stakeholders (e.g. pharmacists and pharmacy support staff) to participate in analysing their everyday work practices as captured on video footage. Through close collaboration with practitioners and attention to their work contexts, VRE may be a useful methodology to engage a time-poor pharmacy workforce in research about themselves, encouraging more practitioner involvement in practice-based research. Aside from research, VRE has also been used effectively as an intervention to facilitate learning and change in healthcare settings, and could be effective in provoking change in otherwise resistant pharmacy environments. Much like traditional ethnographic approaches, VRE researchers have relied on being present 'in the field' to observe, record and make sense of practices with participants. The COVID-19 pandemic however, has introduced restrictions around travel and physical distancing, which has required researchers to contemplate the conduct of VRE 'at a distance', and to imagine new ways in which the methodological 'closeness' to stakeholders and their workplace contexts can be maintained when researchers cannot be on site. In this commentary, we outline the rationale for participatory methods, in the form of VRE, in pharmacy research. We describe the underlying principles of this innovative methodology, and offer examples of how VRE can be used in pharmacy research. Finally, we offer a reflexive account of how we have adapted the method for use in community pharmacy research, to adapt to physical distancing, without sacrificing its methodological principles. This paper offers not only a new methodology to examine the complexity of pharmacy work, but demonstrates also the responsiveness of VRE itself to complexity, and the potential breadth of future research applications in pharmacy both during and beyond the current pandemic.

Community pharmacist perceptions of increased technician responsibility

BACKGROUND

Pharmacists have struggled to find time to spend on clinical tasks. As such, regulatory steps have been taken by some states to expand the scope of practice for community pharmacy technicians.

OBJECTIVE

The objective of this study was to determine what settings and characteristics predict pharmacists' comfort levels with technicians giving or receiving verbal prescriptions, performing nonclinical medication therapy management tasks, administering vaccinations, and verifying prescriptions.

METHODS

This study employed a national Internet-based survey of community pharmacists using a health care marketing research panel. The Consolidated Framework for Implementation Research (CFIR) was used as a theoretical basis for inquiry, particularly the CFIR domains of "outer setting," "inner setting," and "individual characteristics." As the outcome variable of this study, the respondents were asked to report their comfort levels with technicians performing the 4 advanced tasks. Four multivariable linear regression models identified statistically significant predictors of pharmacists' comfort with each task. Repeated measures analysis of variance (ANOVA) was used to compare the pharmacists' comfort levels among tasks.

RESULTS

For all 4 tasks, pharmacists who believed that technicians had the ability to complete each task were more comfortable with technicians completing those tasks. In addition, pharmacists with perceptions of stronger technician interest in advanced tasks were found to be more comfortable with technicians taking on more responsibility for all tasks except vaccine administration. Repeated measures ANOVA found that pharmacists' comfort levels differed on all 4 tasks.

CONCLUSION

This study found that the CFIR domains of inner setting (pharmacy location) and individual characteristics (perceptions of technicians and pharmacist education) affect pharmacists' level of comfort with technicians taking on additional responsibilities, but outer setting variables such as regulations do not. This suggests that pharmacist characteristics may affect the expansion of technician task responsibilities, no matter what state regulations allow.

Role of pharmacists in optimising opioid therapy for chronic non-malignant pain; A systematic review

BACKGROUND

Opioid optimisation is a global issue in Chronic Non-malignant Pain (CNMP) management.

OBJECTIVE

This systematic review aims to assess the effectiveness of interventions delivered by pharmacists in outpatient clinical settings, community pharmacies and primary care services in optimising opioid therapy for people with CNMP and to explore stakeholders' opinions about role of pharmacists in optimising opioid therapy.

METHODS

We conducted searches in PubMed, CINAHL, Psych Info, EMBASE, ISI Web of Science and Conference Proceedings and International Pharmaceutical Abstracts. All studies where pharmacists in outpatient clinical settings, community pharmacies and patient care services helped in optimisation of opioids in the treatment of CNMP as individuals or part of a team were included. Authors followed the 27-item PRISMA guidelines and the review was registered in PROSPERO. All authors were involved in screening and selection of studies and included studies between January 1990-June 2020. Studies not published in English language and participants with cancer pain were excluded. All the included studies were descriptively synthesized.

RESULTS

Fourteen studies were included in the final data synthesis of this review and the total number of participants in all studies was 1175. Interventions by pharmacists were successful in decreasing opioid dose in 4 studies and improved patient opioid safety in 5 studies. Stakeholders considered that the role of pharmacists in optimisation of opioid therapy for people with CNMP can be promising and should be further developed.

CONCLUSION

This systematic review gives an overview of pharmacist intervention feasibility, stakeholders' opinions and possible benefits on opioid optimisation in people with CNMP in outpatient clinical settings, community pharmacies and primary care settings. However, further research is warranted, which can guide the development of new policies and guidelines for the utilisation of pharmacists to promote opioid safety in people using prescription opioids for CNMP management.

Evaluation of Patient Safety Culture in Community Pharmacies

OBJECTIVE

Medication errors are common in community pharmacies. Safety culture is considered a factor for medication safety but has not been measured in this setting. The objectives of this study were to describe safety culture measured using the Agency for Healthcare Research and Quality (AHRQ) Community Pharmacy Survey on Patient Safety Culture and to assess predictors of overall patient safety.

METHODS

This is a cross-sectional survey of community pharmacists practicing in Wisconsin measuring safety culture. Demographic variables collected included pharmacist and pharmacy characteristics. Data were analyzed using descriptive statistics, χ, and multivariate logistic regression analyses.

RESULTS

A total of 445 surveys were completed (response rate, 82%). Safety culture was positively associated with the following: an independent pharmacy (adjusted odds ratio [AOR], 1.69; 95% confidence interval [CI], 1.11-2.57), a health maintenance organization or clinic (AOR, 2.25; 95% CI, 1.34-3.78), being somewhat familiar with patients (AOR, 3.35; 95% CI, 1.82-6.19), or very/extremely familiar with patients (AOR, 8.8; 95% CI, 4.68-16.59). Five of the composite scores differed significantly from the results of the AHRQ pilot study (response to mistakes, communication openness, organizational learning-continuous improvement, communication about prescriptions across shifts, and overall patient safety). Consistent with the AHRQ pilot study, the composite describing staffing, work pressure, and pace had the lowest score (37.6%).

CONCLUSIONS

Understanding the safety culture of community pharmacies can help identify areas of strength and those that require improvement. Improvement efforts that focus on staffing, work pressure, and pace in community pharmacies may lead to better safety culture.

Workload of pharmacists and the performance of pharmacy services

Objective

To evaluate the influence of pharmacists’ dispensing workload (PDW) on pharmacy services as measured by prescription suggestion rate (PSR) and dispensing error rate (DER).

Method

This was an observational study in northern and southern Taiwan’s two largest medical centers, from 2012 to 2018. We calculated monthly PDW as number of prescriptions divided by number of pharmacist working days. We used monthly PSR and DER as outcome indicators for pharmacists’ review and dispensing services, respectively. We used Poisson regression model with generalized estimation equation methods to evaluate the influence of PDW on PSR and DER.

Results

The monthly mean of 463,587 (SD 32,898) prescriptions yielded mean PDW, PSR and DER of 52 (SD 3) prescriptions per pharmacist working days, 30 (SD 7) and 8 (SD 2) per 10,000 prescriptions monthly, respectively. There was significant negative impact of PDW on PSR (adjusted rate ratio, aRR: 0.9786; 95%CI: 0.9744–0.9829) and DER (aRR: 0.9567; 95%CI: 0.9477–0.9658). Stratified analyses by time periods (2012–2015 and 2016–2018) revealed the impact of PDW on PSR to be similar in both periods; but with positive association between PDW and DER in the more recent one (aRR: 1.0086, 95%CI: 1.0003–1.0169).

Conclusions

Reduced pharmacist workload was associated with re-allocation of pharmacy time to provide prescription suggestions and, more recently, decrease dispensing errors. Continuous efforts to maintain appropriate workload for pharmacists are recommended to ensure prescription quality.

Detecting Potential Medication Selection Errors During Outpatient Pharmacy Processing of Electronic Prescriptions With the RxNorm Application Programming Interface: Retrospective Observational Cohort Study

BACKGROUND

Medication errors are pervasive. Electronic prescriptions (e-prescriptions) convey secure and computer-readable prescriptions from clinics to outpatient pharmacies for dispensing. Once received, pharmacy staff perform a transcription task to select the medications needed to process e-prescriptions within their dispensing software. Later, pharmacists manually double-check medications selected to fulfill e-prescriptions before dispensing to the patient. Although pharmacist double-checks are mostly effective for catching medication selection mistakes, the cognitive process of medication selection in the computer is still prone to error because of heavy workload, inattention, and fatigue. Leveraging health information technology to identify and recover from medication selection errors can improve patient safety.

OBJECTIVE

This study aimed to determine the performance of an automated double-check of pharmacy prescription records to identify potential medication selection errors made in outpatient pharmacies with the RxNorm application programming interface (API).

METHODS

We conducted a retrospective observational analysis of 537,710 pairs of e-prescription and dispensing records from a mail-order pharmacy for the period January 2017 to October 2018. National Drug Codes (NDCs) for each pair were obtained from the National Library of Medicine's (NLM's) RxNorm API. The API returned RxNorm concept unique identifier (RxCUI) semantic clinical drug (SCD) identifiers associated with every NDC. The SCD identifiers returned for the e-prescription NDC were matched against the corresponding SCD identifiers from the pharmacy dispensing record NDC. An error matrix was created based on the hand-labeling of mismatched SCD pairs. Performance metrics were calculated for the e-prescription-to-dispensing record matching algorithm for both total pairs and unique pairs of NDCs in these data.

RESULTS

We analyzed 527,881 e-prescription and pharmacy dispensing record pairs. Four clinically significant cases of mismatched RxCUI identifiers were detected (ie, three different ingredient selections and one different strength selection). A total of 546 less significant cases of mismatched RxCUIs were found. Nearly all of the NDC pairs had matching RxCUIs (28,787/28,817, 99.90%-525,270/527,009, 99.67%). The RxNorm API had a sensitivity of 1, a false-positive rate of 0.00104 to 0.00312, specificity of 0.99896 to 0.99688, precision of 0.00727 to 0.04255, and F1 score of 0.01444 to 0.08163. We found 872 pairs of records without an RxCUI.

CONCLUSIONS

The NLM's RxNorm API can perform an independent and automatic double-check of correct medication selection to verify e-prescription processing at outpatient pharmacies. RxNorm has near-comprehensive coverage of prescribed medications and can be used to recover from medication selection errors. In the future, tools such as this may be able to perform automated verification of medication selection accurately enough to free pharmacists from having to perform manual double-checks of the medications selected within pharmacy dispensing software to fulfill e-prescriptions.

A Cross-Sectional Study on Prevalence and Predictors of Burnout among a Sample of Pharmacists Employed in Pharmacies in Central Italy

Burnout is defined as an occupational phenomenon linked to chronic workplace stress that has not been successfully managed and included among the factors influencing health status or contact with health services. Although several studies were performed for assessing this phenomenon, there is a lack of data on the prevalence of burnout and associated predictors, due to different definitions of the syndrome and heterogeneity of assessment methods. One of the well-known evidences on burnout is related to the highest risk professions, which include policemen, firemen, teachers, psychologists, medical students, nurses, physicians, and other health professionals, such as pharmacists. Objective. The aims of the present study were to (1) assess the occurrence of burnout syndrome among a sample of pharmacists employed in public and private pharmacies located in Rome province (Latium Region; central Italy); (2) evaluate the role of some potential predictors for the development of the syndrome. Materials and Methods. A questionnaire elaborated ad hoc was administered online to 2,000 members of the Association of Professional Pharmacists of Rome and its province and employed in public or private pharmacies. The questionnaire included the 14-item Shirom-Melamed Burnout Measure (SMBM) tool and questions on demographic characteristics and working conditions. Results. Physical exhaustion was the burnout dimension with the highest score; besides, approximately 11% of the studied pharmacists were categorized as having clinically relevant burnout levels (≥4.40). Several of the investigated variables significantly influenced the single burnout dimensions at the univariate analyses; multivariate analyses demonstrated that alcohol consumption and workplace location have a significant independent role on the overall SMBM index, while working time significantly influences clinically relevant burnout level. Conclusions. The results revealed that pharmacists are at risk of burnout, and thus, it is necessary to perform specific preventive intervention for managing this occupational threat.

Assessment of perceived workload in academic health center community pharmacies before and after implementation of a central call center

PURPOSE

Results of a study to determine whether reducing pharmacy phone call workload through implementation of a pharmacy services call center (PSCC) led to decreased employee workload, improved efficiency, and increased pharmacist availability for patient care are reported.

METHODS

A pre-post study was conducted using the NASA Task Load Index (NASA-TLX) instrument. Pharmacists, pharmacy technicians at 7 academic health center community pharmacies, and PSCC staff provided NASA-TLX data over 5 days during 3 data collection periods before and after PSCC implementation. Perceived workload was measured as an overall workload score (OWS) and mean scores for 6 NASA-TLX workload dimensions (mental demand, physical demand, temporal demand, performance, effort, and frustration).

RESULTS

Relative to pre-PSCC values, mean postimplementation OWS scores significantly decreased in all 7 pharmacies (from 33.3 to 29.1 overall, p < 0.001) but especially in small pharmacies (from 31.7 to 27.6, p < 0.001). Scores for the physical demand and frustration dimensions were low in both the PSCC and in the 7 pharmacies, while scores for the performance dimension remained high (range, 6.8-8.3). In general, scores for all other measured NASA-TLX dimensions decreased after PSCC implementation, more so at smaller pharmacies. The PSCC staff mean OWS score increased over time (from 26.8 to 28.6, p < 0.0001) but remained near the overall pharmacy average of 29.1.

CONCLUSION

Use of the NASA TLX allowed for a direct subjective measurement of workload as perceived by pharmacy and PSCC employees before and after PSCC implementation. Long-term effects of the PSCC on workload should be assessed.

Drug-drug interactions and pharmacists' interventions among psychiatric patients in outpatient clinics of a teaching hospital in Saudi Arabia

Background

Lack of recognition of labeled drug-drug interactions (DDIs) is a type of medication error of particular relevance to the treatment of psychiatric patients. Pharmacists are in a position to detect and address potential DDIs.

Objective

This study aimed to explore pharmacists' role in the identification and management of DDIs among psychiatric patients in psychiatric outpatient clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia.

Method

This study was a retrospective, cross-sectional medical chart review of patients visiting outpatient psychiatric clinics. It utilized medical records of patients who were taking any psychotropic medications and were prescribed at least one additional drug. The hospital Computerized Physician Order Entry system was used to identify DDIs and determine the pharmacists' interventions. The Beers criteria were applied to detect inappropriate prescribing among older patients.

Results

On average, the pharmacists intervened in 12 out of 213 (5.6%) cases of major or moderate DDIs. Older age, higher number of prescription medications, the severity of DDIs, and the utilization of lithium and anticoagulants were positively associated with the pharmacist undertaking an action.

Conclusion

Future studies should explore the prevalence rate of harmful DDIs among psychiatric patients on a large scale and examine the effectiveness of different pharmacy policies in the detection and management of DDIs.

The Effectiveness of Nonprescription Drug Labels in the United States: Insights from Recent Research and Opportunities for the Future

Despite providing a consistent and comprehensible format for over-the-counter (OTC) drug communication, research suggests important limitations in the communication effectiveness of the Drug Facts Label required on OTC drugs in the United States. This literature is reviewed and some of these critical limitations of the Drug Facts Label (DFL) highlighted. These include difficulty communicating complex information that requires integration of multiple pieces of label information and limited adaptability to serve the unique needs of individual populations (e.g., low literacy or older consumers). Potential ways to improve the DFL's communication effectiveness are identified along with complementary opportunities to improve OTC drug communication by leveraging the role of pharmacists and use of adjunctive technologies.

A text mining analysis of medication quality related event reports from community pharmacies

BACKGROUND

Medication errors are estimated to cost $42 billion in annual global treatment costs. Pharmacy-based Patient Safety Organizations (PSO) are tasked with collecting and analyzing incidents, near misses, and unsafe condition reports as one way of engaging pharmacies in quality improvement efforts. Collectively, these reports are referred to as quality related events (QREs). Large-scale analysis of typed narratives from QRE reports across organizations has been a missing component of quality improvement programs.

OBJECTIVE

To identify topics within the components of a proposed medication safety event framework contained in the free-text narrative of QRE reports.

METHODS

A retrospective, observational analysis of data from a PSOs voluntary reporting system, from January 1, 2011 to December 31, 2014. The dataset contained structured and unstructured data elements. A structural topic model extracted themes from the free-text narrative component of the report. These topics were assigned a human label and mapped onto constructs of the medication safety event framework.

RESULTS

A total of 531,555 QREs were analyzed from 1660 pharmacies. 90.6% were near miss and unsafe condition reports. There were 40 topics generated. There were 29 topics identified as QRE types, 3 were identified as contributing factors, and 5 were related to signals/alerts that an incident or near miss had occurred. One topic each was identified as a recovery step and a quality improvement strategy. One topic was not assigned a human label. Examples of topics labeled included incorrect tapering directions, needing to double-check work, and attention-related contributing factor.

CONCLUSIONS

The free-text narrative provided novel information compared to the structured fields of the reports. Topics were mapped onto a proposed medication safety event framework to advance knowledge of medication QREs and identify ways to improve medication safety in community pharmacy. Future work may focus on communicating these topics to the pharmacies to improve medication safety efforts.

Minimizing the impact of interruptions in a pediatric retail pharmacy

Researchers identified two needs of the in-hospital pediatric retail pharmacy. First was the reduction of the risk and frequency of errors. Second was the need to improve the efficiency of primary pharmacy tasks. Interruptions were identified as the primary issue. The team performed an extensive literature review and conducted interviews and observations to assess the pharmacy work system, work flow, and the impact of interruptions. A human factors analysis was done to accurately represent the pharmacy work system from data collection, and derive recommendations to improve efficiency and accuracy. Some of the recommendations were rapidly implemented into the pharmacy work system, including increased staffing during periods of high work demand, changes to counter spacing, and design changes to bags intended to contain refrigerated components. The research team conducted follow-up observations and collected survey data from pharmacy staff to determine the impact of the implemented interventions and identify key improvements.

The prescription pickup lag, an automatic prescription refill program, and community pharmacy operations

OBJECTIVES

To determine the effect of an automatic prescription refill program on the prescription pickup lag in community pharmacy.

DESIGN

A post-only quasi-experimental design comparing automatic and manual refill prescription cohorts for each of the 3 Centers for Medicare and Medicaid medication adherence metrics.

SETTING

A 29-store community pharmacy chain in the Midwest.

PARTICIPANTS

Community-dwelling patients over the age of 65 years receiving prescription medications included in the statin, renin-angiotensin-aldosterone system antagonist, or non-insulin diabetes adherence metrics.

INTERVENTION

An automatic prescription refill program that initiated prescription refills on a standardized, recurrent basis, eliminating the need for patients to phone in or drop off prescription refills.

MAIN OUTCOME MEASURES

The prescription pickup lag, defined as the number of days between a prescription being adjudicated in the pharmacy and the prescription being picked up by the patient.

RESULTS

A total of 37,207 prescription fills were examined. There were 20.5%, 22.4%, and 23.3% of patients enrolled in the automatic prescription refill program for the statin, renin-angiotensin-aldosterone system antagonist, and diabetes adherence metrics, respectively. Prescriptions in the automatic prescription refill cohorts experienced a median pickup lag of 7 days compared with 1 day for the manual refill prescriptions. 35.2% of all manual refill prescriptions had a pickup lag of 0 days compared with 13% for automatic refills. However, 15.4% of automatic prescription refills had a pickup lag of greater than 14 days, compared with 4.8% of manual refills.

CONCLUSION

Prescriptions in the automatic prescription refill programs were associated with a significantly longer amount of time in the pharmacy before being picked up by the patient. This increased pickup lag may contribute positively by smoothing out workload demands of pharmacy staff, but may contribute negatively owing to an increased amount of rework and greater inventory requirements.

Assessing the validity of using serious game technology to analyze physician decision making

Background

Physician non-compliance with clinical practice guidelines remains a critical barrier to high quality care. Serious games (using gaming technology for serious purposes) have emerged as a method of studying physician decision making. However, little is known about their validity.

Methods

We created a serious game and evaluated its construct validity. We used the decision context of trauma triage in the Emergency Department of non-trauma centers, given widely accepted guidelines that recommend the transfer of severely injured patients to trauma centers. We designed cases with the premise that the representativeness heuristic influences triage (i.e. physicians make transfer decisions based on archetypes of severely injured patients rather than guidelines). We randomized a convenience sample of emergency medicine physicians to a control or cognitive load arm, and compared performance (disposition decisions, number of orders entered, time spent per case). We hypothesized that cognitive load would increase the use of heuristics, increasing the transfer of representative cases and decreasing the transfer of non-representative cases.

Findings

We recruited 209 physicians, of whom 168 (79%) began and 142 (68%) completed the task. Physicians transferred 31% of severely injured patients during the game, consistent with rates of transfer for severely injured patients in practice. They entered the same average number of orders in both arms (control (C): 10.9 [SD 4.8] vs. cognitive load (CL):10.7 [SD 5.6], p = 0.74), despite spending less time per case in the control arm (C: 9.7 [SD 7.1] vs. CL: 11.7 [SD 6.7] minutes, p<0.01). Physicians were equally likely to transfer representative cases in the two arms (C: 45% vs. CL: 34%, p = 0.20), but were more likely to transfer non-representative cases in the control arm (C: 38% vs. CL: 26%, p = 0.03).

Conclusions

We found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory.

The association of subjective workload dimensions on quality of care and pharmacist quality of work life

BACKGROUND

Workload has been described both objectively (e.g., number of prescriptions dispensed per pharmacist) as well as subjectively (e.g., pharmacist's perception of busyness). These approaches might be missing important characteristics of pharmacist workload that have not been previously identified and measured.

OBJECTIVES

To measure the association of community pharmacists' workload perceptions at three levels (organization, job, and task) with job satisfaction, burnout, and perceived performance of two tasks in the medication dispensing process.

METHODS

A secondary data analysis was performed using cross-sectional survey data collected from Wisconsin (US) community pharmacists. Organization-related workload was measured as staffing adequacy; job-related workload was measured as general and specific job demands; task-related workload was measured as internal and external mental demands. Pharmacists' perceived task performance was assessed for patient profile review and patient consultation. The survey was administered to a random sample of 500 pharmacists who were asked to opt in if they were a community pharmacist. Descriptive statistics and correlations of study variables were determined. Two structural equation models were estimated to examine relationships between the study variables and perceived task performance.

RESULTS

From the 224 eligible community pharmacists that agreed to participate, 165 (73.7%) usable surveys were completed and returned. Job satisfaction and job-related monitoring demands had direct positive associations with both dispensing tasks. External task demands were negatively related to perceived patient consultation performance. Indirect effects on both tasks were primarily mediated through job satisfaction, which was positively related to staffing adequacy and cognitive job demands and negatively related to volume job demands. External task demands had an additional indirect effect on perceived patient consultation performance, as it was associated with lower levels of job satisfaction and higher levels of burnout.

IMPLICATIONS/CONCLUSIONS

Allowing community pharmacists to concentrate on tasks and limiting interruptions while performing these tasks are important factors in improving quality of patient care and pharmacist work life. The results have implications for strategies to improve patient safety and pharmacist performance.