Medication prescribing errors: data from seven Lebanese hospitals.

INTRODUCTION: Medication prescribing errors are made all over the world. However, exact data about them are lacking in Lebanon. Our objective was to describe medication errors, including drug-drug interactions in medication orders given to patients admitted to Lebanese hospitals. METHODS: A prospective study was carried out on 313 patients taken from seven Lebanese hospitals; 1826 medication orders were assessed for errors and 456 drug-drug interactions were found. Data was entered and analyzed on SPSS. RESULTS: Around 40% of medication orders were judged to comprise at least one prescribing error, mainly no ordering of parameters monitoring (20%), unnecessary medication (9%), and no indication (7%). Errors occurred mainly in the pediatrics (50%) and internal medicine wards (40%). Having an infectious or gastrointestinal problem almost doubled the risk of medication prescribing error. Antiulcer agents, NSAIDs, antibiotics and steroidal agents were the medications mainly involved. Meanwhile, 12 adverse medication events were reported, with an odds ratio of association to a medication error of 7.4 (p = 0.004). As for drug-drug interaction (DDI), prescriptions comprised zero to 29 interactions, involving medications with low margin of safety such as acenocoumarol, amiodarone and valproate. Pharmacodynamic interactions were mainly found (60%). The majority of DDI were of high clinical significance and well documented (80%), with moderate (59%) to major (17%) severity. CONCLUSION: These results highlight the urgency of an intervention to improve patients' outcomes and avoid deleterious impact of inadequate medication use in Lebanon. The presence of a clinical pharmacist, the inclusion of computerized systems and the application of drug management policies are suggested to decrease medication prescribing errors and enhance the physician attention to DDI.

Prescription and dispensing guidelines in Lebanon: initiative of the Order of Pharmacists of Lebanon.

BACKGROUND: In Lebanon, difficulties in accessing medications are due to two main barriers, mainly: high cost and the lack of medication safety, related to poor-quality (irrational) prescription and use. The objective of this work is to suggest guidelines to implement a unified medical prescription in Lebanon. These guidelines are expected to promote medication safety and decrease pharmaceutical expenditures in the Lebanese context. METHODS: The Order of Pharmacists of Lebanon (OPL) developed a comprehensive set of guidelines for physicians and pharmacists, including a detailed workflow process to improve the use of the unified medical prescription. The guidelines were presented to the Lebanese Ministry of Public Health (MOPH). RESULTS: The project covered prescription guidelines to physicians (handwritten and electronic-prescriptions), and medication dispensing and generic substitution guidelines to pharmacists. Prescription guidelines included all required information about both the prescribing physician and the patient with the maximum of details, comprehensibility, and caution regarding specific populations/co-morbidities/co-prescriptions. Dispensing guidelines included details for safe and appropriate treatment dispensing, pearls for medications' counseling and generic substitution, as well as specific consideration for at-risk populations or those with concomitant medications and co-morbidities. Finally, a suggested workflow clarified the process for improving the unified medical prescription. CONCLUSIONS: The implementation of the guidelines should now be formally evaluated, to assess if they achieve the aims to reduce prescribing and dispensing errors, to improve the quality of medicines' prescription and use, the patient care, and the interaction between all stakeholders.

Clinical preceptor competencies for a better pharmacy education: a suggested framework for Lebanon.

BACKGROUND: Experiential education is a core element in developing the ability of pharmacy students to apply theory to practice, solve problems, and acquire standard pharmacist competencies. To achieve this goal, preceptors play a crucial role as teachers, mentors, and evaluators. The study objective was to identify and describe the core competencies and skills considered essential to the success of clinical preceptor pharmacists in the training of future care providers, in a steadily changing environment. METHODS: A task force was formed within the Scientific Committee of the Lebanese Order of Pharmacists to map, sort, select, and adapt international competencies to the current Lebanese context. RESULTS: Seven roles were identified: Role model/Practitioner/Mentor, Supervisor/Facilitator/Coach/Teacher, Manager, Collaborator/Communicator, Leader, Clinical expert, and Researcher. Related competencies were also defined. CONCLUSION: all aforementioned competencies are expected to improve the acquisition of learning by pharmacy trainees in Lebanon. This framework can be used by pharmacy program directors and preceptors for developmental purposes through self- or peer-evaluation processes, identifying gaps, and helping to fill the needs for a better workforce in academic and experiential pharmacy education.

Are antibiotics substandard in Lebanon? Quantification of active pharmaceutical ingredients between brand and generics of selected antibiotics.

BACKGROUND: In developing countries, brand-generic substitution is not based on validated scientific evidence that confirm the therapeutic equivalence of the generic to the originator. Rather, decisions are made based on the availability of generic medications. Substitution by inappropriate preparations applies to antibiotics, which may increase the risk of resistance in case of underdosing. This analytical study aims to dose and assess for the accuracy of labeling three oral antibiotic preparations, namely ciprofloxacin hydrochloride, amoxicillin trihydrate and amoxicillin trihydrate-clavulanate potassium, the active pharmaceutical ingredients (APIs) found in brand and generic tablets available on the Lebanese market. METHODS: One brand and 4 generics of ciprofloxacin tablets, 3 generic amoxicillin tablets, and 1 brand and 4 generics of amoxicillin-clavulanic acid medications, were quantified, taking 2 batches of each. According to the United States Pharmacopeia (USP) guidelines, ultra-high pressure liquid chromatography was used to measure the APIs content within tablets. The USP required assay limit of the API was taken as the main comparison criteria. RESULTS: Out of the 5 ciprofloxacin medications tested, all 5 were out of the 2% required range, thus being substandard. For amoxicillin, all 3 medications were within the 20% range. As for amoxicillin-clavulanic acid medications, 4 out of 5 medications met the 30% required range of clavulanic acid and one exceeded the claimed amount of clavulanic acid, while all 5 met the assay limit for amoxicillin. CONCLUSION: These findings raise safety and efficacy concerns, providing solid grounds for potential correlations of antibiotic resistance/substandard antibiotics.

Mandatory continuing education for pharmacists in a developing country: assessment of a three-year cycle.

BACKGROUND: In Lebanon, mandatory continuing education (CE) for pharmacists was implemented in January 2014. OBJECTIVE: The objectives of this study are to assess 1) the overall adherence to the mandatory CE program, 2) pharmacists' preferences related to CE, and 3) barriers to adherence to CE. METHODS: By the end of October 2017, an evaluation of pharmacists' participation in the mandatory CE program was conducted using electronic reports available in the Learning Management System (LMS). Descriptive results were presented as frequencies and percentages. In addition, a cross-sectional survey was conducted among pharmacists to better understand their preferences and barriers to their participation to the CE program. Finally, a focus group was organized with pharmacists who did not start their CE. RESULTS: Out of all registered pharmacists in Lebanon, 68.30% started their CE and 25.6% already achieved their required credits. Among pharmacists enrolled in the CE system, the majority (69%) used the online courses at least once. Moreover, CE enrolment was similar among old and young pharmacists except for those newly registered. The majority of pharmacists preferred clinical and pharmacological topics, followed by preventive medicine and transferable skills. Barriers to engaging in CE were mainly work and family obligations, lack of interest, lack of time, and difficulties in commuting and technology use. CONCLUSION: Although results of the present study are similar to those in developing countries, the resistance to change is higher. The Lebanese Pharmacists Association [Ordre des Pharmaciens du Liban] should develop strategies to motivate and enroll more pharmacists in the CE system, based on the barriers and preferences cited in the results, while continuing to offer high quality and cost-favorable CE programs to Lebanese pharmacists.

The Pharmacy Profession in a Developing Country: Challenges and Suggested Governance Solutions in Lebanon.

Throughout the years, changes occurred in pharmacists' roles on international levels. These changes are not being followed in Lebanon where community pharmacy is still practiced in a traditional way. Laws need to be updated to align with international standards to drive a change at the practice level. The Lebanese Order of Pharmacists' (OPL) mission is to raise the level of the profession. It also enforces the laws, defends the rights of pharmacists, and improves the level of practice and development of scientific competence. It is also aiming at providing the conditions for enhancing the patient's access to the appropriate medications and its safe use. Meanwhile, the OPL is facing several challenges, most importantly, the deteriorating financial situation of community pharmacists and the decrease in the retirement fund input. To find proper answers to all these issues, the OPL started working, since 2016, on solutions from a proper governance perspective, jointly with all the stakeholders such as the Ministry of Public Health, the Ministry of Education and Higher Education, the universities, and other professional associations. The suggested solutions include the application of the principles of good governance, provision of paid services, developing pharmacists' core and advanced competencies, accreditation standards generation, and new laws and decrees suggestions concerning clinical pharmacy application in hospitals and community settings, continuing education consolidation and professional development, and research- and assessment-based decisions. The suggested solutions are expected to overcome challenges and barriers while leveraging the profession and advancing it to reach international standards.

Attitudes of Lebanese pharmacists towards online and live continuing education sessions.

BACKGROUND: Continuing education (CE) is an internationally recommended approach as a lifelong learning model for pharmacists, enabling them to maintain the necessary knowledge, skills and ethical attitudes so as to remain current and competent in their practice. OBJECTIVES: The objective of this study is to 1) describe factors associated with taking different types of CE courses among pharmacists in Lebanon, and 2) assess the correlation between types of CE activity and the attitude of Lebanese pharmacists (motivation and value) and their computer literacy. METHODS: This is a cross-sectional observational study conducted between February and May 2017, using a random sample of Lebanese pharmacists from all districts of Lebanon. All pharmacists were eligible to participate; the sample consisted of those who agreed to complete the questionnaire. The questionnaire includes questions about computer literacy, motivation and value about CE, in addition to sociodemographic characteristics of pharmacists. RESULTS: Out of the 750 questionnaires distributed, 628 (83.73%) were filled out and returned to be analyzed. The mean age of the participants was 39.04 (SD 10.57) years, 66.9% of them were females, and 41.1% of them had a bachelor degree in pharmacy and worked in Mount Lebanon. Among the 628 respondents, 567 (90.3%) have earned at least one CE credit. Of those, 5.4% took mainly online courses, 15.4% took mainly live courses and the remaining took both types of CE. Higher motivation (aOR=1.05; CI 0.994-1.109) and higher value (aOR=1.076; CI 0.968-1.197) were associated with higher odds of taking live CE courses. Higher motivation (aOR=1.07; 95%CI 0.994-1.152) was associated with higher odds of taking online CE courses. Higher motivation (aOR=1.059; 95%CI 1.006-1.114) and higher general confidence with computer use (aOR=1.058; 95%CI 1.012-1.106) were significantly associated with higher odds of taking both types of CE courses. CONCLUSIONS: A high percentage of Lebanese pharmacists enrolled in the CE system, mainly driven by motivation and value of CE, in addition to a higher general confidence in computer use. Further efforts should be exerted by the Lebanese Order of Pharmacists to motivate pharmacists and help them improve their computer literacy, which is expected to improve not only enrollment in CE activities, but also the completion of their CE requirements.

Projecting the future size of the Lebanese pharmacy workforce: forecasts until the year 2050.

BACKGROUND: Despite the rigorous regulations governing the pharmacy profession in Lebanon, the increasing numbers of pharmacy graduates seem to be the greatest threat of demise. No forecast is available to assess the long-term projections of pharmacists supply. OBJECTIVE: The objective of this manuscript is to project the future size of the Lebanese pharmacy workforce till 2050 and discuss their potential consequences on the labour market. METHODS: This study was carried out in collaboration with the Lebanese Order of Pharmacists (OPL), where official numbers were retrieved from the registered pharmacists' database from 2006 to 2017. The data were analyzed as time series using the Auto-Regressive Integrated Moving Average (ARIMA) method. Projected numbers were plotted using Microsoft Excel office. RESULTS: The ratio of pharmacists to 10 000 inhabitants up till the end of 2017 was estimated at 17.52, compared with a worldwide mean of 5.09, with a continuous increase seen with the coming years, possibly reaching an estimated 41.17 pharmacists per 10 000 inhabitants by the year 2050. The total number of pharmacies increased from 1546 in 2006 up to 3174 at the end of 2017 nationwide, with a major increase seen in Bekaa (206.35%) and South Lebanon (171.08%) governorates, respectively. CONCLUSION: Our study shows that the dramatic increase in pharmacy graduates will worsen with time. To curb it, it is important to vote and apply new laws, and initiate a collaborative work between academia, professional associations, and employers from all sectors to find innovative solutions.

Good Pharmacy Practice Standardized for Community Pharmacists: The Lebanese Order of Pharmacists Initiative.

OBJECTIVE: The community pharmacist's role is in constant evolution. It shifted from compounding and dispensing to patient-centered services. To guarantee that all pharmacists are providing a service of appropriate quality to every patient, the Lebanese Order of Pharmacists (OPL) took the initiative of developing good pharmacy practice (GPP) guidelines to be applied by community pharmacists for services' quality improvement. METHODS: Within the OPL, a Scientific Committee, the executive authority to organize scientific and educational activities, is appointed. It decided, in January 2018, to elaborate GPP guidelines for community pharmacists and created the Community Pharmacy Practice Subcommittee, which was in charge of this project. The GPP standards suggested by the OPL were inspired by the ones published by international organizations, namely the International Pharmaceutical Federation and WHO, American, European, and regional countries. FINDINGS: The GPP standards comprised 15 sections that tackled the following topics: settings of a pharmacy, handling of stock, extemporaneous compounding, provision of medicines, supply of nonprescription medicines, interaction and communication, documentation systems, equipment, resources, health promotion, diagnostics, pharmacotherapy monitoring, research and professional development, trainees, and para-pharmaceuticals. CONCLUSION: The OPL was able to implement a first draft of the GPP standards for community pharmacists in Lebanon, a developing country with many constraints. The starting project will need to be consolidated by raising awareness and changing misconception among community pharmacists as a first step. Amendments to these guidelines will follow based on the pharmacists' feedback and results of an ongoing national survey conducted by the OPL and academia.

Knowledge of and readiness for medication therapy management among community pharmacists in Lebanon.

Background To follow international standards, the Lebanese Order of Pharmacists would like to start to implement the medication therapy management in community pharmacies. Objective The objective of this study is to evaluate community pharmacists' knowledge of and readiness for medication therapy management. Setting Community pharmacists from all Lebanese regions. Method A cross-sectional observational descriptive study was conducted. Pharmacists at their workplace completed self-administered anonymous standardized questionnaires between June and December 2016, with no compensation in return. Statistical analysis was conducted using bi-variate and multi-variable methods. Main outcome measure The major dependent variable of interest was the willingness to engage in medication therapy management activities. Results While only 376 (46%) of the interviewed pharmacists declared to be familiar with this concept, the majority of interviewed pharmacists 646 (78.8%) agreed on the importance of patient-centered care. Although this service will not be remunerated at this stage, 529 (64.5%) were willing to attend advanced training sessions to become actively engaged in medication therapy management, particularly those who had adequate workflow, staff and time at their workplace (aOR = 1.51; p = 0.045) and those agreeing to review a patient's medication profile and provide interventions as part of their role (aOR = 6.10; p < 0.001). Conclusion Lebanese pharmacists have adequate knowledge and a positive attitude towards medication therapy management services implementation; however, barriers could arise such as inadequate time, workflow and physical space. Efforts should be exerted by the Lebanese Order of Pharmacist to extend the role of the pharmacist and its positive effect on patient outcome.

Situation analysis of community pharmacy owners in Lebanon.

OBJECTIVE: To evaluate the current community pharmacists' interventions and job satisfaction, secondary to the alteration in the financial rewards. METHODS: A cross-sectional study was carried out, using a proportionate random sample of Lebanese community pharmacy owners from all districts of Lebanon. RESULTS: Out of 1618 distributed questionnaires, 1465 (90.5%) were collected back from pharmacy owners. Our study results showed that the monthly sales and profit decreased significantly in the last decade as well as the number of loyal customers (p<0.001 for all). The rent, the total assistant pharmacists' and employees' salaries, income taxes, municipality fees, the total bills (electricity, water, cleaning, security) and the disposal of expired products per year significantly increased during the last 10 years (p<0.001). 95% of the owners said they cannot afford to hire any more pharmacists while 45% said they cannot afford buying software for their pharmacies. Finally, 89% of these owners admitted that their situation was better 10 years ago compared to nowadays. CONCLUSION: Most Lebanese community pharmacists are not financially satisfied; their financial situation deteriorated in the last decade. The ministry of Health along with the Order of Pharmacists in Lebanon should cooperate together to resolve this problem since they are two entities responsible for the patient's health.