How did we get here? Evolution of specifications grading in a required skills-based course series.

BACKGROUND AND PURPOSE: Specifications grading is a mastery-based grading approach to unlock student potential and empower students to focus on learning goals while receiving and acting on meaningful feedback. Within specifications grading, bundles are created to group assignments and assessments. Based on student achievement within each bundle, overall course grade is determined. This article describes the development and implementation of a specifications grading schema in a required skills-based course series, along with lessons learned. EDUCATIONAL ACTIVITY AND SETTING: In a longitudinal course series with both a didactic and lab component, specifications grading was utilized for determination of the overall course grade. Key components of the specifications grading schema were defined by assignment bundles. Assignment bundles aligned with knowledge and skills taught and assessed in each course and also included summative capstone assessments. Each bundle was assigned a numeric grade linked to a letter grade which determined the students' final grade in the course. FINDINGS: Following first course offerings, several changes to the specifications grading schema were made to improve tracking of assignments and activities, to improve consistency across courses, and to aid in final course grade determination. All quizzes were changed to optional, formative quizzes to encourage student accountability. Additional changes were made to the processes of capstone remediation and reassessment, which led to changes in language of the grading schema. SUMMARY: Developing and implementing specifications grading was a crucial first step in building a required skills-based course series, which led to further refinement and improvement for future course offerings.

Incorporation of Innovative Strategies for Patient Education in Pharmacist-Led Transition of Care Initiatives.

As patients transition between health care settings, they are at an increased risk of adverse events and medication errors as a result of medication changes and miscommunication. Pharmacists have traditionally provided transitions of care (TOC) services, including patient education, in a face-to-face manner with the goal of reducing medication errors and enhancing patient safety and understanding. However, changes in care delivery models, a burdened health care workforce, and diminishing resources necessitate innovative approaches for the provision of patient education within TOC. Pharmacists should consider novel approaches to expand scope, reduce barriers, and creatively use existing resources to optimize patient education in TOC.

A Scoping Review of Student Pharmacist-Led Transitions-of-Care Initiatives.

OBJECTIVES: To identify and evaluate the current literature pertaining to student pharmacist-led transitions-of-care (TOC) initiatives and to inform pharmacy educators regarding the current and future roles of pharmacy learners in TOC. FINDINGS: A total of 14 articles were identified describing student-led initiatives in care transitions to the inpatient setting and from the inpatient to the outpatient setting. In most studies, student pharmacists involved in delivering TOC services were completing either an advanced pharmacy practice experience or an introductory pharmacy practice experience and were most commonly performing services such as admission medication history and reconciliation. The studies evaluated the impact of student-led TOC services through the identification or resolution of medication-related problems, interventions, and/or discrepancies and included limited and conflicting results pertaining to patient care-based outcomes. SUMMARY: Student pharmacists are involved in delivering and leading a variety of TOC services in the inpatient setting and postdischarge period. These student-led TOC initiatives not only provide added value to patient care and the health system but also enhance students' preparation and readiness for pharmacy practice. Colleges and schools of pharmacy should incorporate learning experiences into the curriculum that equip students to contribute to TOC efforts and promote continuity of care across the health system.

Teaching pharmacy students a systematic approach to medication order verification.

BACKGROUND AND PURPOSE: Inpatient medication order verification is an important skill for pharmacy students to learn for patient safety. This article describes a systematic approach to order verification that enables students to apply didactic knowledge and determine the presence of drug therapy problems during verification decisions. EDUCATIONAL ACTIVITY AND SETTING: At two different colleges of pharmacy, an order verification module for second-year pharmacy students introduced a checklist for reviewing medication orders in a patient chart and identifying the presence of drug therapy problems. Students had to make a "verify or not" decision for each non-verified order and document their decision in both the chart and on a game-based learning platform. FINDINGS: Over four academic years, 756 students participated in the module. With the checklist approach to order verification, students were able to identify the drug therapy problems of "dose too high" and "no drug therapy problem present" but were challenged by "wrong drug," "dose too low/renal dosing," and "duplication of therapy." SUMMARY: The order verification checklist was a beneficial tool for teaching a systematic approach to inpatient medication order verification.

Evaluation of the protective effects of ß-blockers in the management of acute exacerbations of chronic obstructive pulmonary disease.

WHAT IS KNOWN AND OBJECTIVE: The purpose of this study was to evaluate the association between early ß-blocker continuation and major inpatient events in patients hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS: This single centre, retrospective, investigational review board approved cohort study evaluated patients admitted for a primary diagnosis of AECOPD. Patients were evaluated based on early continuation of a ß-blocker whether a ß-blocker was initiated within 24 hours of admission and continued for at least 72 hours. Patients with AECOPD who did not receive ß-blockers were assigned to the control group. Major inpatient events were a composite outcome composed of arrhythmias, myocardial infarction (MI) and death. Safety data were collected on the incidences of bradycardia, bronchospasms and hypotension. RESULTS AND DISCUSSION: Of the 96 patients admitted for AECOPD, fifty-five patients were included in the early ß-blocker group and forty-one patients in the control group. Early ß-blocker utilization was associated with a significantly lower rate of major inpatient events compared with the control group (40% vs 80.5%; P < 0.001). Arrhythmias were significantly less common in the early ß-blocker group (30.9% vs 65.9%; P = 0.001); however, there were no significant differences in the rates of MI (9.1% vs 14.6%; P = 0.54), death (0 vs 0) or safety outcomes between groups. WHAT IS NEW AND CONCLUSION: ß-blocker therapy could result in a paradigm shift in managing chronic obstructive pulmonary disease patients from a true cardiopulmonary approach. This retrospective cohort study demonstrated early ß-blocker continuation in patients admitted for an AECOPD was associated with less major inpatient events, primarily arrhythmias.

Failure of chemical thromboprophylaxis in critically ill medical and surgical patients with sepsis.

PURPOSE: Critically ill patients who develop sepsis may be at a higher risk of venous thromboembolism (VTE) prophylaxis failure; however, studies in this population are limited. The objective of this study was to identify the incidence of VTE prophylaxis failure in this population. METHODS: This retrospective review of patients admitted to the intensive care unit between February 2013 and September 2015 included patients who were diagnosed with sepsis and received heparin or enoxaparin VTE prophylaxis. RESULTS: Of the 355 patients included, 42 (12.5%) developed a VTE. Acute respiratory distress syndrome (ARDS) (31% vs 16.7%, P = .0272) and higher positive end expiratory pressure (10 vs 8, P = .0066) were associated with increased risk of VTE prophylaxis failure. Logistic regression identified ARDS an event risk factor (odds ratio, 2.58; 95% confidence interval, 1.22-5.42). The VTE was associated with an increased intensive care unit (14 vs 9 days, P = .01) and hospital length of stay (26 vs 15 days, P < .0001). The median time from sepsis diagnosis to VTE event was 9 days (interquartile range, 5-13). CONCLUSION: Critically ill patients with sepsis had a high rate of VTE prophylaxis failure with ARDS being identified as a risk factor for VTE prophylaxis failure.

Impact of an antimicrobial stewardship initiative to evaluate ß-lactam allergy in patients ordered aztreonam.

PURPOSE: An evaluation of the clinical and economic impact of an antimicrobial stewardship quality initiative (ASQI) focusing on allergy assessment in patients with a documented ß-lactam allergy prescribed aztreonam was conducted. METHODS: This retrospective study was executed at a hospital with an interdisciplinary antimicrobial stewardship program (ASP). A total of 186 patients with self-reported ß-lactam allergies who were prescribed aztreonam while admitted during a 36-month time period surrounding the ASQI implementation were included. The primary study outcome was median time in hours to aztreonam discontinuation among nonanaphylactic patients. RESULTS: After implementation of the ASQI, the percentage of patients continued on aztreonam for the duration of therapy was nearly cut in half, and a greater percentage of patients were switched to ß-lactam antibiotics. No adverse effects associated with ß-lactam therapy were observed in any study patient. Antimicrobial cost savings was not associated with any difference in clinical outcomes. Overall, hospitalwide aztreonam prescribing and aztreonam use declined. Institutional aztreonam orders per 1000 patient-days decreased from 1.5 to 1 after implementation of the ASQI. Additionally, hospitalwide aztreonam days of therapy per 1000 patient-days was reduced from 3.6 in the pre-ASQI period to 1.8 in the post-ASQI period. CONCLUSION: An ASQI that included critical evaluation of patient-reported ß-lactam allergies led to decreased aztreonam use, reduced antimicrobial expenditure, and similar clinical outcomes to those observed before implementation.

Use of rivaroxaban in a patient with history of nephrotic syndrome and hypercoagulability.

OBJECTIVE: Hypercoagulability, resulting in thromboembolic events, can be a life-threatening complication of nephrotic syndrome (NS). Conventional anticoagulants, such as warfarin, have been the standard of care for more than 50 years; however, the availability of target-specific oral anticoagulants (TSOACs) have provided additional options for the treatment and prevention of thromboembolic events. Documented use of the TSOACs in patients with NS and hypercoagulability is currently limited. CASE SUMMARY: We present the case of an 18-year-old young woman with NS and renal vein thrombosis who was readmitted with bilateral pulmonary emboli on therapeutic doses of warfarin, with a goal international normalized ratio of 2.0 to 3.0. The decision was made to transition the patient from warfarin to rivaroxaban, an oral factor Xa inhibitor. DISCUSSION: Rivaroxaban was the first of the emerging TSOACs to be FDA approved for both prevention and treatment of venous thromboembolism. With favorable safety and efficacy data compared with warfarin in addition to a predictable pharmacokinetic profile and the lack of requirement of routine monitoring, rivaroxaban provides a useful alternative in this patient population. SUMMARY: While on therapeutic anticoagulation, a patient previously diagnosed with NS and renal vein thrombosis experienced pulmonary emboli on a conventional anticoagulant and was switched to a target-specific oral anticoagulant with documented completion of 6 months of therapy without recurrent thromboembolism.