IPC exam II Flashcards
what is digital health
No universal definition for; the intersection between technology & healthcare
Broad scope: includes mobile health (mHealth), health information technology (HIT), wearable devices, telehealth & telemedicine, & personalized medicine
Uses clinical decision support (CDSS), artificial intelligence (AI), machine learning
Digital health tools: technologies for use as a medical product or as a companion in diagnostics
Benefits of digital health technologies
A holistic view of a patient’s health allows improved outcomes & enhances efficiency
- Clinician’s access to patient data
- Patients gain more control over their health
Disease prevention
- (ex: CDC app, fitness app, etc.)
Early diagnosis of life-threatening diseases
- (ex: EasyDetectDisease app)
Management of chronic conditions outside traditional healthcare settings
- (ex: patient engagement software) (figure 1)
Benefits of digital health technologies
Increases efficiency & quality: providing real-time data work more efficiently
- Example: having access to all patient glucose levels allows you to adjust medications versus patient coming to your clinic & leaving glucose paper log at home
Improve access: Tylenol Smart Check™ Digital Ear Scope
Personalize medicine:
- Online access to electronic health records through online portals: clinic notes, lab results, medication list
- Self-monitoring apps: Migraine Buddy app
Disadvantages/challenges of digital health
Security and privacy concerns
Healthcare industry’s challenge in processing data
Resistance from patients &/or healthcare professionals
Artificial Intelligence (AI) is a core technology in digital transformation
AI is when computers and other machines mimic human cognition & can:
- Learn, think, make decisions, or take actions
- Daily life example: shopping recommendations, predictive text, calculators
Benefits in healthcare:
- helps in the delivery of more accurate diagnoses & treatment plans
- Analyzes large data to develop improved preventive care recommendations
Ex: predict & track the spread of infectious diseases by analyzing data
- Crucial role in public health to combat epidemics & pandemics
new AI listens to toilet sounds to detect diarrhea
diarrhea detector lol
Machine learning is a technique of AI
Uses algorithms to analyze and identify patterns within datasets
- Does not have to be explicitly programmed
- Learns directly from data
Healthcare Chatbots are AI technology that runs on rules of machine learning
Automate repetitive and lower-level tasks of a medical representative
Assist in scheduling appointments
Available around the clock
Aidia™ is a smart adherence system that uses smart bottles
Device lights & chimes to alert that it’s time for medication
Equipped with cellular chip (real-time connection between patient, pharmacy, & care team)
Rechargeable bottle (lasts ≈ 10 months)
Sends personalized reminders by phone or text to alert patients if they are late to take a dose
Pharmacist perspective https://youtu.be/X03e0Gt-WpE
Patient perspective https://youtu.be/wMrdrKWZ6oA
The toothbrush is a smart device that works with any toothbrush
World’s first fitness tracker for your mouth
Tracker fits on any toothbrush
Beeps, when set brushing duration, is over
Patients download the Truthbrush™ app
- View brush duration
- Notification about brushing activity
- Track entire family
- Compare performance to others in the same age group
Truthbrush™ allows patients to share data with a dentist
Provides real-time, actionable information on patient brush habits
Alerts dentist to patients that need assistance
Suggests a pre-set message click delivered as a notification to patient’s Truthbrush app
Digital ear cleaning kits
Gives a view of the inside of the ear canal via a video feed on the phone
Allows patients to see what they are doing & how close the scraping spoon is to the eardrum
???? Easier to avoid injury
May still need ear wax softener (carbamide peroxide, Debrox®) for large ear wax accumulation
According to the American Academy of Otolaryngology—Head and Neck Surgery Foundation, “The physical removal of earwax should only be performed by a healthcare provider.
cap medic
simplifying inhalers for correct and regular use
Guides patients with the right steps at the right time
- Correctly use inhalers
Track lung function
Medication reminders on the app & device
Fits most metered-dose inhalers
Rechargeable; long battery life
CapMedic allows remote patient monitoring
Securely shares data with a clinician about medication use & lung function
Allows data-driven decisions
Reimbursable under the new CMS telehealth policy
Pharmacists are involved in asthma & COPD management through collaborative practice agreements in the ambulatory care setting
FDA approves pill with sensor that digitally tracks if patients have ingested their medication
cool
this is AbilifyMyCite
AbilifyMyCite is a combo of smart pill & wearable Bluetooth patch
1st FDA-approved drug with a digital ingestion tracking system
Captures medication ingestion
Captures objective and physiological data
For patients ≥ 18 years old with bipolar disorder, major depression, or schizophrenia and have a compatible smartphone
Components: pill, patch, app, dashboard, conversation
Components of AbilifyMyCite: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg
A pill: aripiprazole tablets with sensor
- Integrated technology ingestible event marker (IEM); the size of a grain of sand (1 mm)
- Sensor made of natural ingredients; indicates when tablet dissolves by transmitting a signal to patch; leaves body as waste
- The patient does not feel the sensor or signal it sends
Components of AbilifyMyCite: continued
A patch: nonmedicated wearable sensor made of:
- A reusable data pod (the size of a small watch face)
Contains a slim sensor that automatically logs medication ingestion, activity, rest
Data sent via Bluetooth to the MYCITE® app within 3 minutes (may take up to 2 hours); the patient should be within 9 feet of the smartphone
Does not track the location of the patient
Pod paired once, at setup, & used for up to 1 year
Weekly disposable adhesive strip to hold pod in place
- App notifies patient to change adhesive strip
Applied to the right or left side of the stomach
May cause local skin irritation
Components of AbilifyMyCite: continued
An App: receives & displays information from Bluetooth patch
- Patient can record their mood, how well they rested, the reason for skipping the pill
A dashboard: an online portal for the healthcare team to see data
A conversation: remember factors such as bad connection, reception, and not having a smartphone may impact the consistency & reliability of data
Aria is an autoinjector used for ease of tracking administration
it is a reusable device
10-second injection
Delivers a broad range of drug viscosity
Audio-visual user feedback
Reusable electronic drive with rechargeable battery (2-3 years life)
Single-use disposable cassettes
Built-in Bluetooth connects to mobile phones
Automatically records dose administered
Allows sharing data with clinician
The pharmaceutical company has to manufacture drug in that cassette
- Unclear which medications currently available for use with Aria autoinjector
Digital device to autoinject in an emergency!
Auvi-Q
Digital device to autoinject in an emergency!
Auvi-Q® (epinephrine injection) is an automatic device to administer epinephrine IM
Pocket size: size of a credit card, thickness of a cell phone
- Manufactured with a 100% automated robotic production line
- > 100 automated quality checks for each device
- Consistent high-quality
Voice instructions to guide the user through epinephrine injection
Auto-retractable needle that may not be felt
Video Games for Attention Deficit Hyperactivity Disorder (ADHD) - the only doctor-prescribed video game treatment for kids with ADHD
EndeavorRX® is a prescription-only video game FDA-approved for ADHD in kids 8-17 years. Use as an adjunct to medications, clinician-directed therapy, and/or educational programs
Supported by 5 clinical studies with > 600 children with ADHD
- Improvement in sustained and selective attention
- No benefit to hyperactivity
How to use it? ≈ 25 minutes/day x 5 days a week x ≥ 4 consecutive weeks, or as prescribed
May not be appropriate for kids with photo-sensitive epilepsy, color blindness, physical limitations
Side Effects - only 3 events led to device discontinuation
No subject reported irreversible effects after discontinuation
You can download the EndeavorRx® app, but can’t sign in without a prescription
Prescription = The caregiver receives a text message from Phil Pharmacy with instructions on the next steps then once payment is processed, the caregiver receives an activation code by text/email to download the app from App Store® or Google Play™
Cash price $99
If covered by insurance then the price is based on the patient’s copay
Patient assistance programs available through the manufacturer
how to endeavor Rx works
uses sensory stimuli and motor challenges to target areas of the brain that play a role in attention function
kids are challenged to multi-task and ignore distractions by navigating courses, collecting targets, and avoiding obstacles
an algorithm measures performance and customizes each patient’s treatment in real time
Which Apps can you recommend?
Safe to recommend an app developed/adopted by the CDC for patients
Safe to use an app developed/adopted by the CDC to look up information yourself
Safe to recommend an FDA-approved app, if applicable to your patient
Example: Endeavorrx® for ADHD
Safe to recommend an FDA-approved digital device, If applicable to your patient
Example: Auvi-Q
Safe to recommend not using a digital health tool for an intervention that a guideline does not recommend
Example: earwax cleaning tools
Otherwise, further appraisal of the app is required to determine benefits & potential harm
Centers for Disease Control and Prevention (CDC) – Digital & Social Media page
Consumer/General Public Apps: CDC Health IQ
Example questions:
- Do you know the minimum SPF needed to protect yourself from the sun’s harmful rays?
- How many seconds you should wash your hands to kill germs?
Health Care Provider/Clinician Apps
- Example: Contraception App, Vaccine Schedule App
https://www.cdc.gov/digital-social-media-tools/mobile/applications/healthiq/index.html
Apps for You (P1, P2, APPE, and Pharmacist)
Medscape: one-stop-shop resource (free after you create an account)
Drugs@FDA Express (free mobile version of FDA’s online database information)
Merck Manual Professional: regularly updated articles, drug information, illustrations (free)
Pharmacist’s Letter: great charts, drug comparisons, monthly newsletters (free for MCPHS students; create an account through the MCPHS library website)
Lexicomp, Micromedex (with paid subscription)
How can digital health help pharmacists?
Growing pharmacist role/services
- Essential: prescription dispensing; ex: CVS app, Walgreens app, etc.
- Advanced: medication use reviews (MURs) (structured review of prescribing, dispensing, and patient use of medications)
- Frees up pharmacist’s time spent on administrative work
Availability of apps on portable devices
↓ time to carry out a service or task: easier to type/search than flipping through papers, updated information
- Ex: rapidly access relevant literature
Inform the decision-making process through clinical decision support
Facilitate pharmacist/staff/patient education through educational apps
Why Medication Safety?
To Err Is Human – 1999 Institute of Medicine (IOM) report
- Up to 98,000 patients harmed annually by healthcare
- Preventable medical errors
- Permanent injury
- Hospital admissions
- ↑ length of stay
- Death
- “First, do no harm”
Medical errors usually do not result from:
- Recklessness
- One individual
- Actions of a particular group
Medical errors usually result from:
- Faulty systems
- Faulty processes
- Faulty conditions
Medication safety & patient safety are activities to promote the safe use of medications & medical care
Medication Safety: “Freedom from accidental or preventable injuries during the course of medication use”
Patient Safety: “Freedom from accidental or preventable injuries produced by medical care”
Medication safety key concepts
Evaluating the medication use process
Identify areas of weakness
Where can the process fail?
Re-design processes
Make it harder to do the wrong thing
Make it easier to do the right thing
Assess each medication error
Identify contributing factors
Learn from each event
Adverse drug event (ADE): An injury resulting from the use of a drug or lack (omission) of an intended drug. Includes all of the following:
can lead to:
Side effects (SEs) or adverse events/reactions (AEs)
Adverse drug reactions (ADRs)
Medication errors (MEs)
ADR Definition:
Any unexpected, unintended, undesired, or excessive response to a drug that:
- Requires drug discontinuation
- Requires changing the drug
- Requires a dose change
- Requires hospital admission
- Increases length of stay
- Requires supportive therapy
- Complicates diagnosis
- Results in temporary or permanent
Harm
- Disability
- Death
- Involves routine doses
Epidemiology
Incidence and severity of adverse drug reactions (ADRs)
- Unpredictable
- Varies depending upon
Hospital size
Hospital type
Patient population
Drugs used
ADR definition used
Can be extremely costly; > $2,000 per patient per event
- Increase length of stay by 2-3 days
2-fold increased risk of death
An estimated 5 – 20% of hospitalized patients experience an ADR
4th to 6th leading cause of death in US
What is not an ADR?
Side effects
- These are expected, predictable, well-known reactions, resulting in little or no change in management
Drug withdrawal
Drug abuse
Accidental poisoning/overdose
Examples of ADRs
Cefazolin (antibiotic) 1G IV Q8H ordered for cellulitis. The patient develops severe hives-like reactions. Cefazolin was discontinued and vancomycin (an antibiotic of a different class) started.
Examples of ADRs
A patient is started on a usual dose of the beta blocker, metoprolol. A few hours later, the patient faints and is rushed to the hospital. The patient’s heart rate was found to be 42 and the physicians administer atropine to increase the heart rate.
Why Report ADRs?
Encourages ADR surveillance
Monitors drug safety in our patient population
Promotes education about potential ADRs
Identifies problems leading to ADRs
ADR Reporting Systems
External
- FDA MedWatch
- Voluntary form FDA 3500
- Can be completed online at www.fda.gov/medwatch/
- Used for severe or unusual adverse events
- Vaccines excluded
FDA Adverse Event Reporting System (FAERS)
Vaccines adverse event reporting system (VAERS)
https://vaers.hhs.gov/reportevent.html
Internal
- Institutional ADR reporting system
FDA MedWatch
Reporting/ Analysis/ Dissemination
Reporting may prompt:
- Modification in how the drug is used
- Change in labeling
- Modification in product design
- Communication of the issue
- Leads to increased patient safety
Example medication where change in labeling occurred due to ADRs reported with original dosing
immediate release
previous dosing: 10mg immediately before bedtime
new dosing rec:
- women: 5mg immediately before bedtime
- men: 10mg consider starting at 5mg
extended release
previously dosing: 12.5mg immediately before bedtime
new dosing:
- women: 6.25mg immediately before bedtime
- men: 12.5mg consider starting at 6.25mg
Low-dose sublingual tablet
previous dosing:
- women: 1.75mg taken once per night
- men: 3.5mg taken once per night
A medication error is any preventable event that
may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.
Epidemiology of Medication Errors
$5,857: Cost per preventable error in hospitals
7,000: Number of US deaths from medication errors each year
$17 billion: Estimated US annual cost of preventable errors
High Alert Medications (HAMs) is a way of classifying medications based on safety‐ related characteristics - Raise awareness!
Medications have ↑’d risk of causing significant patient harm when used in error
Errors not more common
The impact (patient harm) of error is greater
Examples: anticoagulants, insulin, IV sedation, opiates
Medication Error Reporting provides information that leads to new knowledge and improved patient safety (learning)
losec changed to Prilosec
celebra changed to Celebrex
Categorizing Errors
A: Circumstances or events that can cause error
Example: Look-alike, sound-alike medications stored near each other
B: An error occurred that did not reach the patient; “Near miss”
Example: Medication labeled incorrectly but caught in the pharmacy
C: An error occurred that reached the patient but did not cause patient harm
Example: Docusate sodium 100 mg PO was given to the incorrect patient x1 dose
Categorizing Errors
D: An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm
Example: Oxycodone 20 mg was given to a patient who was prescribed oxycodone 5 mg; the patient was monitored for sedation but did not experience any adverse effects or excess sedation
E: An error occurred that may have contributed to or resulted in temporary patient harm and required intervention
Example: Patient was not prescribed his home antihypertensive medications when admitted to the hospital and later needed urgent treatment for elevated BP
Categorizing Errors
F: An error occurred that may have contributed to or resulted in temporary patient harm and required initial or prolonged hospitalization
Example: A patient with heart failure missed 2 doses of furosemide and became fluid-overloaded, requiring prolonged hospitalization
G: An error occurred that may have contributed to or resulted in permanent patient harm
Example: A patient missed 3 doses of levetiracetam and had a seizure that led to a disability
Categorizing Errors
H: An error occurred that required intervention necessary to sustain life
Example: Patient receives oral phenytoin suspension intravenously and goes into cardiac arrest but is subsequently resuscitated
I: An error occurred that may have contributed to or resulted in the patient’s death
Example: A patient is given 800 mg of clozapine intended for another patient, has a seizure, and passes away
Time to Practice!
Nurse instilled drops of Afrin nasal spray into the patient’s eye instead of Tobrex® eye drops and immediately recognizes the error. The nurse informs the physician about the error and is instructed to monitor the patient.
Type D
- moniDoring
Time to Practice!
Discharge note states patient will be discharged home on nitrofurantoin for UTI prophylaxis. Due to age and kidney function, nitrofurantoin use is contraindicated in this patient. Pharmacy student contacted the covering team and the medical intern removed the med from the list of discharge medications. Another antibiotic was prescribed.
Type B
- But I caught it
Time to Practice!
Inpatient was prescribed Prozac 40 mg PO BID (was noted as a home med). On day 2, pharmacist discovered (through patient) that his home med is actually 40 mg once daily. One additional 9 pm dose was given to patient before discrepancy found. Patient had no complaints after 2nd dose last night.
Type C
- patient got it but Caused no harm
Medication Safety is a Specialty Area of Pharmacy Practice
yes
human nature and contributory system factors lead to
error
Errors are mostly……
Random in nature?
or
Recurrent patterns?
Recurrent patterns so we can predict them
Accident Causation Model was developed by James Reason, a professor of psychology; explains:
How errors happen
Many layers of defense
Opportunities for failure
Person Approach vs. System ApproachWhat type of culture is promoted?
Person approach (Culture of Blame)
- Human failings
- “bad things happen to bad people”
- Punitive (does not promote reporting errors)
- Result is recurrent errors
System Approach (Culture of Safety or Just Culture)
- Errors are expected
- Understand how errors happen
- Learn from error events
- Non-punitive (encourages reporting errors)
- Result is a safer environment
Swiss Cheese Model
some holes due to active failures
hazards go right through it
other holes due to latent conditions
successive layers of defenses, barriers & safeguards
Active versus Latent Failures
People-Based
- Mistakes
- Memory lapses
- Procedure violations
active
System-based
- Understaffing
- Inexperience
- Inadequate equipment
latent
Medication Use Process
prescribing
dispensing
administration
monitoring
More Examples: Latent Failures
Similar medication names
Medications with multiple brand names
Stocking medications with multiple
concentrations
Environment
Technology
Similar Medication Names:Look-alike, Sound-alike (LASA) Names
FDA reviews drug names before marketing
About 100 healthcare professionals volunteer to assist with reviews
1/3 of all proposed drug names get rejected
Some names even get changed post-marketing:
- Losec changed to Prilosec
- Losec confused with Lasix
Brtintellix changed to Trintellix (vortioxetine)
- Brintellix confused with Brillinta
LASA Names
Examples
Clonidine 0.5 mg and Klonopin 0.5 mg
Celexa and Celebrex
Risperidone and Ropinirole
Dexamethasone and Dexmedetomidine
Medications with Multiple Brand Names
Bupropion:
Wellbutrin SR
Wellbutrin XL
Budeprion SR and XL
Aplenzin
Lamivudine:
Epivir
Epivir HBV
Finasteride:
Propecia
Proscar
Sildenafil:
Viagra
Revatio
Environment
Workload
Interruptions
Light
Noise
Heat/ humidity
Phones
Cluttered areas
Technology
Different types of IV pumps
Too many lines
Technology that is too slow or too difficult
More Examples: Active Failures
Illegible handwriting
Using error-prone (dangerous) abbreviations
Omitting important information on prescription
Erroneous calculations
Selecting the wrong drug (electronically or physically)
E-Prescribing does not solve everything!
haha
Swiss Cheese Model example:
MD orders heparin drip
one RPh short today
heparin and hespan are stocked on the same shelf
Tech pulls a bag of Hespan off the shelf and labels it as Heparin
Minimal training for new technicians
Heparin requires a 2nd pharmacist check; is only checked by one
Pharmacist does not catch error when checking
Medication Error
Errors in Health Care
Preventing errors by:
Being more careful
Trying harder
Providing education
Has not worked!
Must use safe design principles to reduce likelihood of error
Safe Design Principles
Simplify
Standardize
Reduce variation
Use forcing functions and constraints
Use redundancies
Avoid reliance on memory
Automate carefully
Simplify
Taking steps out of a process
If too complicated…
Too much time to learn it correctly
Too many opportunities for confusion
Users will find another way: “Workarounds”
Forcing Functions
Easy to do the right thing
Impossible to do the wrong thing
Creates a “hard stop”:
Must change your action
Avoid Reliance on Memory; Brain has limitations
Checklists
Standardized order forms
Safe medication practices for written information
Medication lists
- Physician order forms (paper or electronic)
Telephone/verbal orders or prescriptions
- Transferring information
- Refer to the handout!
Avoid Dangerous Abbreviations
Frequently used & misinterpreted
Have caused patient harm
Prohibited for use in ANY part of the medical record in the hospital setting
- Includes written and electronic records
Also part of The Joint Commission “Do Not Use” List
Avoid Dangerous Abbreviations & Prescribing Practices
do not used
U
IU
QD, Q.D, QOD, Q.O.D.
lack of leading zeros
drug abbreviations: MS, MSO4, MgSO4
use
Unit
international unit
daily or every other day
no trailing zero
morphine sulfate
magnesium sulfate
Preventing Errors with Dangerous Abbreviations
QD
- Can be mistaken for QID or QOD
Write out “daily”
Preventing Errors with Dangerous Abbreviations
QOD
- Can be mistaken for QD or QID
Write out “every other day”
Preventing Errors with Dangerous Abbreviations
U for unit
- Can be mistaken for a number (4 or 0) or for cc
Write out “unit” or “units”
IU for international units
- Can be mistaken as IV or 10
Write out “international units”
Preventing Errors with Dangerous Prescribing Practices
Trailing zero after decimal point (1.0 mg)
Decimal point can be missed resulting in overdoses (1.0 mg read as 10 mg)
Never write a zero by itself after a decimal point
Exception: when trailing zero is required to demonstrate the level of precision of the value being reported, such as for lab results,imaging studies, or catheter/tube sizes
Preventing Errors with Dangerous Prescribing Practices
No leading zero before a decimal dose (.5 mg)
- Decimal point can be missed resulting in overdoses (.5 mg read as 5 mg)
Always use a zero before the decimal point (0.5 mg)
Preventing Errors with Dangerous Abbreviations
MSO4 MS MgSO4
- Can be mistaken for each other
Write out the complete drug name
Morphine sulfate
Magnesium sulfate
Example 1- Improving clarity of medication lists
BEFORE
Zolpidem 5mg PO QHS prn
Colchicine .6 mg PO BID
Metoprolol tartrate 25 mg 1/2 tablet PO BID
Atorvastain 40 mg PO daily
PCN 500 mg PO Q6H
APAP prn
More Error Prevention: Correct system failures
Separate easily mistaken drugs
Example: Cortisporin Otic vs. Cortisporin Ophthalmic, Heparin vs. Hespan
Shelves
Automated dispensing machines
Identify drugs that are more likely to be misfilled
Identify “red flag” (high alert medications)
- Use extra caution
Don’t GUESS or become a mind reader!
Be Proactive
Use a structured/standardized process when checking EVERY time
Triple-check your work
When in doubt, ask!
In Summary….
Don’t think of medication safety only as a specialty area
Make it part of your practice
Acute and chronic care
Don’t take anything for granted
Check, check, and check again!
Many factors contribute to an error
Learn from each event
Prevent similar events
Use safe design principles
How can you promote safety?
Initially, Who do the PATIENTS see?
registration
provider - MD, NP, PA
Nursing - RN, LPN
Provider Orders:Electronic Medical Record (EMR) or Electronic Health Record (EHR)
orders
Review from IPC I: Common LabsComplete Blood Count (CBC) provides values for:
Hemoglobin
hematocrit
White blood cells (WBCs)
Red blood cells (RBCs)
- Mean corpuscular volume (MCV)
- Mean corpuscular hemoglobin (MCH)
- Mean corpuscular hemoglobin concentration (MCHC)
Platelets (Plt)
Review from IPC I: Common LabsComprehensive metabolic panel (CMP) includes:
BMP or Chem-7:
Sodium (Na+)
Potassium (K+)
Chloride (Cl-)
Bicarbonate (HCO3-)
Blood urea nitrogen (BUN)
Creatinine (SCr)
Glucose (Glu)
Plus:
Albumin
Alkaline phosphatase (ALP)
Alanine aminotransferase (ALT)
Aspartate aminotransferase (AST)
Total bilirubin
Calcium
Where do they go next?
stay in ED room
cath lab
x-ray
MRI
CT scan
OR
yellow pod
inpatient hospital bed
Hospital Testing Examples
Magnetic Resonance Imaging (MRI)
Computerized Tomography
Hospital Location Examples
Catheterization Laboratory (Cath Lab)
Med/Surg Hospital Room
Additional Interprofessional Collaboration
PT
OT
RT
Dietary
social work
microbiologist
pharmacy
Institutional VS Community Pharmacy
Customers
- Patient, families, caregivers, IPE team members
Medical Record Access
- Detailed history, lab, and test results
Interprofessional Collaboration Expected
- Healthcare team is readily accessible and all team players are expected to work together
Tasks and Disease States
- Acute illnesses – rapid changes in patient status, medications used, dosage forms, packaging, labeling, cart fill, automated dispensing cabinets
Where do the pharmacist work in the hospital?
Two main models. There has been a shift from centralized model to decentralized model over the last few decades.
Centralized
- Pharmacist work in the pharmacy
Decentralized
- Pharmacist work throughout on patient care floors and in the pharmacy space
Common Tasks Hospital Pharmacy
Staff/Clinical Pharmacist Tasks:
- Medication order review and verification
- Patient care rounds*
- Evaluate patient medical record for medication related problems
- Medication Information Service
- Compounding – sterile and nonsterile
- Policy and protocol development
- Consult service for complex medication regimens
Ex. Warfarin, vancomycin, or Total Parental Nutrition (TPN) dosing and monitoring
Medication Reconciliation*
Trauma/Code Response Team*
Pharmacy Technicians Tasks
- Compounding – sterile and nonsterile
- Stocking medications
Automated Dispensing Cabinets (ADC)
- Kits or trays for codes or surgery
- Answering phones and triaging requests
- Packaging medications – unit dose packaging
- Medication Reconciliation
Pharmacy organizational chart (an example)
pharmacy director
Hospital Pharmacy Example – Centralized Pharmacy Space
Examples of workstations:
Fill area
IV admixture area
Sterile non-hazardous
Sterile hazardous
Nonsterile Compounding
Pharmacist workstations
Packing area
Controlled Substance storage
Provider Orders - Example
electronic order
Summary
Institutional pharmacy is similar and yet very different than other types of pharmacy settings.
Understanding what the patient experiences and how each team member in the care process contributes better helps you understand your role as a pharmacist.
Through the next several lectures we are going to take a deeper dive into medication use processing and skill sets used in an institutional pharmacy setting.
Importance of Good Processes
Increases efficiency
Decreases errors
Saves money
Improves patient outcomes
good outcome
Road Map
Procurement
Storage and Stocking
Distribution
- Ordering, Review, Preparation, Delivery
Administration
Education
Medication Procurement
Procurement a.k.a. Acquisition – the act of obtaining goods or services
Drug storage, Stocking, & Distribution
Automated Dispensing Cabinet (ADC)
- pyxis medstation
Automated Storage
- medication carousel
ADC in Patient care units
Med/Surge Nursing Unit
Cath Lab
Medication Orders:Electronic Medical Record (EMR) or Electronic Health Record (EHR)
electronic med record
Pharmacist Medication Order Review and Verification
Perform Drug Utilization Review (DUR):
Patient Allergies
Medication Duplication
Drug-Disease Interaction
Drug-Drug Interaction
Drug-Food Interaction
Correct Dosing:
Appropriate for age, weight, renal, and hepatic function
Frequency
Route of administration
Correct dosage form for route of administration
Correct rate of infusion and access type (IV medications)
Appropriate labs have been drawn prior to starting medication
Appropriate monitoring parameters have been ordered
Drug preparation - Compounding
IV Room - Sterile Preparation
Non Sterile Preparation
Compound Final Product Verification
For sterile and nonsterile compounding:
- Review all ingredients – before compounding.
- Review the steps of the compounding process.
- Verification of the final products after compounding.
Intravenous Medication Example:
- Order: Magnesium Sulfate 2 g in NS IV Once
After Medications are Verified What Happens?
Medication can be dispensed to nurses from ADC
- Distribution - pharmacy responsible for stocking ADC
Medication can be dispensed from the central pharmacy
- distribution - tube system, robot or human delivery
Medication needs to be compounded
- distribution - tube system, robot, or Human delivery
Distribution/Delivery
Pneumatic Tube System
https://www.youtube.com/watch?v=8AyqGwALd0g
Pros
- Fast delivery
- Less people needed in the delivery process - automated
Cons
- Not everything can be delivered this way – proteins will denature, glass can break
- Subject to human error in terms of delivery – select the wrong location – delivery is delayed
medication administration - nurse or provider
acquire the medication from the pharmacy
preparation of medication for administration
double-check med and patient
educate the patient - drug name, purpose, common side effects
administer the medication
Summary
There are many steps in the medication use process.
Pharmacists are involved in every step of the institutional setting.
A good medication use process increases efficiency, decreases medication errors, saves money, and improves patient outcomes.
Patient Chart Banner
Patient Name, location of care, DOB, broad overview of alerts, MRN (medical record number)
Dark side menu – used to navigate through the patient chart
Major Section of the dark side menu: health, pharmacy, account
health overview
alert
prevention
problems
vital signs
Temp
Pulse
Respiratory Rate (RR)
BP
Pulse oximetry (a.k.a. pulse ox)
Pain – number of different scales that can be used
Growth – height and weight – be careful of the units!
Glucose
Intake and output (a.k.a. Ins and outs)
Quick survey – this is a brief assessment of all of the body systems of the patient – (a.k.a. Review of Systems – ROS)
Orders
Category examples: Medications, Labs, Diet, Consultation, Procedures
Order Item
Frequency
Status
-
-
-
When
Meds
Notes
Care plan
Labs
ABG (Air Blood Gas)
BMP
Complete Metabolic Panel
CBC with differential
CMP (Comprehensive Metabolic Profile)
Creatine Kinase (ck) Isoenzymes
Electrolytes
Lipid Profile
Liver Panel (Liver Function Panel)
Urinalysis
Coagulation Screen
Cerebrospinal Fluid (CSF)
Many more
Pharmacy
Account
Patient address
Language
Occupation
Emergency Contact
PCP (primary care provider)
Rendering Provider
Definition – Transition of care
Movement of patient care from one place to another.
Examples:
Department to Department – Surgery to the patient floor, emergency room to the patient floor
Change of Shift – day to night
Inpatient to Outpatient – hospital discharge to primary care physician
Outpatient to Inpatient – primary care physician to hospital inpatient
Specialist (cardiology, infectious disease, etc.) to Primary Care
Primary Care to Specialist (cardiology, infection disease, etc.)
Why are we talking about transitions of care?
Preventable medication errors impact 7 million patients in the US annually.
400,000 preventable deaths
1.5 million patients with serious harm
Prolonged hospitalizations and/or hospital readmission increased healthcare costs
The annual cost of these medication errors is about $21 billion dollars a year.
About 30% of hospitalized patients have a discrepancy on their discharge medication list when they leave the hospital.
This leads to adverse drug reactions, drug-drug interactions, and health risks to the patients.
This is a preventable medication error
Points of Concern for Pharmacists
Readmissions
Adverse drug reactions
Medication errors
Omission, duplication, drug-drug interactions
Communication between healthcare providers
Follow-up and coordination of care
Multiple providers prescribing medication
Definition – Medication reconciliation
Formal process
Obtaining the most complete and accurate list of a patient’s medication
Comparing medication orders to all of the medication the patient is currently taking and resolving any discrepancies
Goal
To avoid medication errors including omissions, duplications, incorrect dosing or timing, and drug interactions
Steps in the med Rec Process
Obtain a baseline medication history
Interview the patient/caregiver
Confirm the accuracy of interview information
update the patient’s medical record
communication info. to the healthcare team
Interview: Medication Information to obtain
Specific Medication Questions:
Name
Strength
Dosage form and route of administration
Directions
When was your last dose? What time of day do you take this medication?
Additional questions to ask your patient:
Are you taking any over-the-counter medications?
Are you taking any herbal products?
Are you taking any vitamins?
Allergies and Intolerances Interview Questions
Medication name
Reaction
Age of Reaction
Starting the Patient Interview
How to start – introduce yourself:
Hi, my name is Jen. I am a pharmacist here at MCPHS hospital. I have a few questions for you about the medications you take at home and your medication allergies.
Is now an OK time to talk with you about these?
- This question asks the patient for permission and their time.
Can you please confirm your name and date of birth?
- This question provides a confirmation you are talking to the correct patient.
Confirmation of the information
How can you confirm what the patient is telling us? Or what if the patient doesn’t know the answer to our questions?
Confirmation of Patient Information
How can you confirm what the patient is telling me?
You contact the pharmacy and make the following request:
Hi, my name is Jen Towle. I work for MCPHS Hospital and we have a mutual patient. I would like to get a copy of Jerry Jackson’s medication profile. The patient’s date of birth is 11/16/1955. Thank you.
You can then compare the list you got from the patient against the list you received from the pharmacy to be sure they match.
If there is a discrepancy you will sometimes need to go back to the patient to ask for further clarification.
Conclusion
Pharmacists can play a unique and important role in helping to improve the current system.
Improvements in transitions of care will lead to improved patient care and outcomes.
Your goal is to attempt to get the most accurate list of medications the patient is currently taking and how they are taking them. Along with any other medication history that helps treat your patient.
A good quality medication reconciliation prevents medication errors.
What vaccines might be appropriate for a pregnant woman?
- Tdap for every pregnancy, ideally during gestational weeks 27 to 36 weeks gestation
- Inactivated Influenza vaccine
- COVID‐19 vaccine – ensure patient is fully vaccinated
- RSVPreF (Abrysvo) during gestational weeks 32 to 36 in RSV season
Bivalent
Which vaccines are live? Recombinant?
MMR, varicella, influenza, rotavirus, typhoid are live
Recombinant modified vaccinia anakara, canaryox (alvac), shingles, HPV, meningitis, hep B
What are some special considerations for live vaccines?
Immunocompromised, elderly, pregnant women, ppl with anaphylactic allergies
What are the roles of adjuvants in vaccines?
Adjuvants help the body to produce an immune response strong enough to protect the person from the disease he or she is being vaccinated against.
an ingredient used in some vaccines that helps create a stronger immune response in people receiving the vaccine. In other words, adjuvants help vaccines work better.
Be familiar with the administration of multiple vaccines in one day.
Data show this does not cause any adverse effects
- Consider how many pathogens are on the surfaces you touch every day
- The immune system is designed to handle it!
- Delaying vaccines increases:
- Risks of infection and outbreaks
- Number of appointments/health care system burden
- Likelihood that the vaccine schedule will not be completed
