Integrating Patient Safety Discussions with First-Year Doctor of Pharmacy Students in a Skills Lab Course.

The patient safety problem has been well established for over 20 years in the United States (U.S.), and there is a recognized focus on ensuring that health professions' trainees receive explicit education in various patient safety principles and practices. While the literature provides examples of different approaches towards patient safety education for pharmacy students, there are few that focus on first-year pharmacy students. This educational observational study describes the implementation and evaluation of two 20 min patient safety learning activities integrated into a required pharmacy skills lab course. The first learning activity utilized a mock prescription and patient safety checklist that had students identify patient safety problems on the prescription, followed by a group discussion of implications for the patient. The second learning activity used images of common safety problems with a facilitated group discussion to have students identify systems-based solutions to those problems. Our study's findings revealed that students were able to identify basic patient safety problems and safety solutions, although some additional foundational information may be needed, particularly for students who may not have pharmacy work experience. Additional research is needed to continue building a literature base on patient safety education approaches, particularly for first-year pharmacy students.

Independent community pharmacies' provision of enhanced services: A mixed methods approach.

BACKGROUND: The pharmacy profession continues to broaden toward a patient-centered care practice. Pharmacy members of formal enhanced services networks are embracing this practice. However, descriptions of how pharmacies adopt a patient-centered care practice by providing enhanced services are not widely known. OBJECTIVES: To explore the pharmacy services of Nebraska independent community pharmacists within the context of the pharmacy profession's transition toward patient-centered care and determine if pharmacy participation in a formal enhanced pharmacy services network is associated with the provision of enhanced services. METHODS: A mixed methods approach was used by first conducting a cross-sectional quantitative survey, followed by a small qualitative study to further explain the survey findings. The survey of 193 Nebraska independent community pharmacies included members and nonmembers of the Nebraska Enhanced Services Pharmacies (NESP) network. Data were collected on the enhanced services offered. Survey analyses used descriptive and inferential statistics. Qualitative data on reasons for offering enhanced services and their profitability were subsequently collected using a focus group of 3 independent community pharmacy owners. The interview transcript analysis used coding to generate major themes. RESULTS: The survey response rate was 59%. Across all respondents, the average number of enhanced services offered was 17.3 out of 47 services studied. NESP members provided more enhanced services (x¯ = 20) than non-NESP members (x¯ = 16), P = 0.003. NESP membership was associated with the opinion that offering enhanced services increases profits, P = 0.016. The major themes were "NESP members have always been taking care of people" and "Profitability from enhanced services is key for sustainability of independent community pharmacies." CONCLUSION: Independent community pharmacies provide a range of enhanced services. NESP members provided more enhanced services than non-NESP members and focused on taking care of people by providing enhanced services. NESP membership may provide opportunities for pharmacies to offer more enhanced services to patients with the intent to improve patient-centered care.

A MIXED-METHODS EVALUATION OF STANDALONE PERSONAL HEALTH RECORD USE BY PATIENTS WITH TYPE 2 DIABETES.

Background: Self-management of diabetes is key for achieving positive clinical outcomes, with personal health records (PHRs) proposed as a patient-centered technology for facilitating self-care. However, few studies have described patient engagement with a PHR, including facilitators and barriers to use from the perspective of actual users. Objectives: To compare use of a standalone PHR by patients with Type 2 diabetes to usual care through assessment of self-care behaviors, and short-term impact on social cognitive outcomes and hemoglobin A1c (HbA1c). Methods: A mixed-methods design combining a comparative effectiveness pilot with qualitative interviews was used. Qualitative interviews explored the primary outcome of changes in self-care behaviors, while quantitative data obtained from health records and a survey focused on social cognitive and clinical outcomes. Results: A total of 117 participants completed the study (intervention group = 56, control group = 61). Only 23 individuals used the PHR at least once after baseline. Five themes emerged from the qualitative analysis describing participants' experiences with the PHR and identifying reasons for lack of engagement. Quantitative findings supported qualitative results with no significant changes in HbA1c and only a significant increase in diabetes knowledge in the intervention group. Conclusions: Study findings revealed low PHR uptake and minimal impact on study outcomes, including lack of communication and information-sharing between patients and providers. Future research should explore the fit of PHRs within the context of other self-management tools, integration with provider workflow, and the need for enhanced functionalities beyond an information repository to optimally support patient self-care.

National survey of diabetes self-management program coordinators views about pharmacists' roles in diabetes education.

OBJECTIVES: To examine the viewpoints of diabetes self-management training (DSMT) program coordinators about the roles and engagement of pharmacists who participate in DSMT programs, and the engagement between community pharmacies and DSMT programs by developing and administering a nationwide survey. DESIGN: A mixed-methods exploratory sequential design; initial qualitative phase followed by a quantitative phase. Six in-depth interviews of DSMT program coordinators and intensive literature review informed the development of a 20-item survey instrument. Survey responses were descriptively analyzed, and themes were generated from context analysis of open-ended questions to generate the overall findings. SETTING AND PARTICIPANTS: The survey was distributed in 2017 to 742 active American Association of Diabetes Educators DSMT program coordinators in the United States. OUTCOME MEASURES: Proportion of DSMT programs engaging pharmacists and description of pharmacist's roles. Content areas pharmacists teach in DSMT programs. Challenges faced by pharmacists in completing 1000 direct patient hours as a prerequisite for attaining Certified Diabetes Educator certification and strategies used to overcome them. Perceived benefits of pharmacist involvement by coordinators and patients. RESULTS: One-third of DSMT programs have pharmacists involved with most using pharmacists as educators. Coordinators believe that pharmacist care is highly beneficial to patients and recognize that community pharmacist's care is an added benefit to patients. However, collaborative practices are not well established between community pharmacists and DSMT programs. Program coordinators identified challenges they face when trying to involve community pharmacists in program delivery. CONCLUSION: Coordinators of DSMT programs and their patients see pharmacists' care as highly beneficial within DSMT programs. Increasing participation and scope of community pharmacists' involvement is desired by both DSMT coordinators and the patients they serve. There is substantial growth potential for both greater involvement of pharmacists in DSMT programs and enhancing links to community pharmacists' care.

The lock-in loophole: Using mixed methods to explain patient circumvention of a Medicaid opioid restriction program.

BACKGROUND: Lock-in programs are proliferating among private and public payers to restrict access to controlled substance prescriptions and enhance care coordination for patients exhibiting high-risk use of, primarily, opioids. Patients enrolled in lock-in programs are required to seek opioids from a designated provider and pharmacy for insurance coverage of their opioid and benzodiazepine prescriptions. Lock-in program restrictions are often circumvented by patients through out-of-pocket cash purchases of opioid prescriptions, undermining the program's intended function. This study sought to construct and explain trajectories of Medicaid-covered and cash pay opioid prescription fills among adults enrolled in an opioid lock-in program. Methods: We used sequential explanatory mixed methods, which involved a quantitative retrospective cohort analysis of opioid fill trajectories using North Carolina Medicaid administrative claims data linked with state prescription drug monitoring program data, followed by qualitative semi-structured interviews with North Carolina pharmacists. The quantitative component included adults enrolled in the North Carolina Medicaid lock-in program between 10/1/2010-3/31/2012. The qualitative component included a maximum variation sample of community pharmacists in North Carolina delivering care to lock-in patients. Quantitative outcomes included group-based trajectories of monthly Medicaid-covered and cash pay opioid prescription fills six months before and after LIP enrollment, and qualitative analyses generated themes explaining observed trajectories. Results: Two-thirds of subjects exhibited reduced Medicaid-covered opioid prescription fills and no increase in cash pay fills after lock-in enrollment, with one-third exhibiting increased cash pay fills after lock-in. Pharmacists attributed increases in cash pay fills primarily to illicit behaviors, while some cash pay behavior likely reflected new unintended barriers to care. Conclusions: Lock-in programs appear to reduce prescription opioid use for most enrolled patients. However, lock-in programs may have limited capacity to deter illicit behaviors among patients intent on abusing, misusing, or diverting these medications and may introduce new access barriers to necessary care for some.

Health Information Technology Use and Patient Safety: Study of Pharmacists in Nebraska.

This study aimed to describe the impact of 13 different health information technologies (HITs) on patient safety across pharmacy practice settings from the viewpoint of the working pharmacist. A cross-sectional mixed methods survey of all licensed practicing pharmacists in 2008 in Nebraska (n = 2195) was developed, pilot-tested and IRB approved. One-fourth responded (24.4%). A database of pharmacists' responses to closed-ended quantitative questions and in vivo qualitative responses to open-ended questions was built. Qualitative data was coded and thematically analyzed, transformed to quantitative data and descriptive and relational statistics performed. One-third were involved in an error of any kind in the six months preceding the survey, and half observed an error or "near miss". Most errors or near misses were attributed to workload. When asked specifically about the 13 HITs, these participants reported 3252 observations about the types of errors that were associated with each. These were reports about either error types reduced or eliminated by integration of HIT (n = 1908) or occurring in association with a specific technology's use (n = 1344). Integration of HIT into pharmacy practice also introduced new error types such as excessive alert programming in the pharmacy computer systems clinical information support causing pharmacists to experience alert fatigue and ignore warnings or bar code scanners mismatching NDC codes of products resulting in wrong drug product identification. Continued vigilance is essential to identifying patient safety issues and implementing safety strategies specific to each HIT.

Error types with use of medication-related technology: A mixed methods research study.

BACKGROUND: Health information technology has been integrated throughout the medication use process to enhance safety, quality, and care efficiency. However, technologies have the potential to eliminate or reduce, but also create some new types of errors. OBJECTIVE: Assess specific error types before and after the incorporation of two different health information technologies (HITs), e-prescribing and automated dispensing cabinets (ADCs), into pharmacists' daily work. METHODS: A mixed methods design guided use of a pre-existing database of pharmacist survey responses describing patient safety HIT-related issues in the form of errors prevented and errors observed. In vivo descriptive text responses were converted into error types. Descriptive analysis was performed to characterize the error types associated with each HIT. RESULTS: Four error types were eliminated with the use of e-prescribing, three new error types emerged, and three error types persisted. With ADC use, four error types were eliminated, three new error types emerged, and three error types persisted. CONCLUSION: Each technology has its own error types, and some persist regardless of HIT use. There is a need to determine optimal risk reduction approaches for each unique HIT introduced, and design safety practice improvement for error types unaffected by the introduction of HIT use.

An online health informatics elective course for doctor of pharmacy students.

OBJECTIVE: To describe the development and assessment of an online elective health informatics course and determine its potential for universal integration into doctor of pharmacy (PharmD) curricula. DESIGN: A 2-credit hour online elective course was developed and offered to all PharmD students; voiced-over Powerpoint lectures were used to deliver content. ASSESSMENT: Assessment of student performance was measured using quantitative metrics via discussion questions, quizzes, written papers, and examinations. Qualitative findings were measured through discussion questions, a goal-setting classroom assessment technique, and an end-of-course reflection. Students report finding value in the course and recognizing how the knowledge gained could impact their future practice as pharmacists. CONCLUSION: An online course in health informatics can be an effective way to deliver content and provide a blueprint for continued integration of the content into curricula.

Implementing Collaborative Learning in Prelicensure Nursing Curricula: Student Perceptions and Learning Outcomes.

This study evaluated learning outcomes and student perceptions of collaborative learning in an undergraduate nursing program. Participants in this 3-phase action research study included students enrolled in a traditional and an accelerated nursing program. The number of students who passed the unit examination was not significantly different between the 3 phases. Students had positive and negative perceptions about the use of collaborative learning.

A Qualitative Case Study Exploring Nurse Engagement With Electronic Health Records and E-Prescribing.

There is a national focus on the adoption and use of electronic health records (EHRs) with electronic prescribing (e-Rx) for the goal of providing safe and quality care. Although there is a large body of literature on the benefits of adoption, there is also increasing evidence of the unintentional consequences resulting from use. As little is known about how use of EHR with e-Rx systems affects the roles and responsibilities of nurses, the purpose of this qualitative case study was to describe how nurses adapt to using an EHR with e-Rx system in a rural ambulatory care practice. Six themes emerged from the data. Findings revealed that nurses adjust their routine in response to providers' preferential behavior about EHR with e-Rx systems yet retained focus on the patient and care coordination. Although perceived as more efficient, EHR with e-Rx adoption increased workload and introduced safety risks.

A qualitative study of how patients with type 2 diabetes use an electronic stand-alone personal health record.

BACKGROUND: Patient use of personal health records (PHRs) to manage their health information has been proposed to enhance patient knowledge and empower patients to make changes in their self-care behaviors. However, there remains a gap in understanding about patients' actual PHR use behaviors. The purpose of this qualitative study was to explore how patients with type 2 diabetes used a PHR to manage their diabetes-related health information for self-care. MATERIALS AND METHODS: Fifty-nine patients with type 2 diabetes were interviewed 3-6 months after receiving initial training on a free-of-charge, Web-based PHR. Interviews were audio-recorded, transcribed, and analyzed using an iterative process of in vivo coding, categorization, and theme development. RESULTS: Nine themes emerged, three of which expressed positive experiences: complete and accessible record; increased awareness; and behavioral changes. The remaining six themes expressed negative experiences: out of sight, out of mind; I would have used it if I were sicker; economic, infrastructure, and computer literacy barriers; lack of patient-provider engagement; double tracking; and privacy and security concerns. CONCLUSIONS: Despite some potential positive benefits resulting from PHR use, several barriers inhibited sustained and effective use over time. Provider and patient education about the benefits of PHR use and about the potential for filling in information gaps in the provider-based record is key to engage patients and stimulate PHR adoption and use.

Patient safety problem identification and solution sharing among rural community pharmacists.

OBJECTIVES: To implement a communication network for safety problem identification and solution sharing among rural community pharmacists and to report participating pharmacists' perceived value and impact of the network on patient safety after 1 year of implementation. DESIGN: Action research study. SETTING: Rural community pharmacies in Nebraska from January 2010 to April 2011. PARTICIPANTS: Rural community pharmacists who voluntarily agreed to join the Pharmacists for Patient Safety Network in Nebraska. INTERVENTION: Pharmacists reported errors, near misses, and safety concerns through Web-based event reporting. A rapid feedback process was used to provide patient safety solutions to consider implementing across the network. MAIN OUTCOME MEASURES: Qualitative interviews were conducted 1 year after program implementation with participating pharmacists to assess use of the reporting system, value of the disseminated safety solutions, and perceived impact on patient safety in pharmacies. RESULTS: 30 of 38 pharmacists participating in the project completed the interviews. The communication network improved pharmacist awareness, promoted open discussion and knowledge sharing, contributed to practice vigilance, and led to incorporation of proactive safety prevention practices. CONCLUSION: Despite low participation in error and near-miss reporting, a dynamic communication network designed to rapidly disseminate evidence-based patient safety strategies to reduce risk was valued and effective at improving patient safety practices in rural community pharmacies.

How baccalaureate nursing students value an interprofessional patient safety course for professional development.

Nursing students need foundation knowledge and skills to keep patients safe in continuously changing health care environments. A gap exists in our knowledge of the value students place on interprofessional patient safety education. The purpose of this exploratory, mixed methods study was to understand nursing students' attitudes about the value of an interprofessional patient safety course to their professional development and its role in health professions curricula. Qualitative and quantitative data were collected from formative course performance measures, course evaluations, and interviews with six nursing students. The qualitative themes of awareness, ownership, and action emerged and triangulated with the descriptive quantitative results from student performance and course evaluations. Students placed high value on the course and essential nature of interprofessional patient safety content. These findings provide a first step toward integration of interprofessional patient safety education into nursing curricula and in meeting the Institute of Medicine's goals for the nursing profession.

Research skills training for the doctor of pharmacy in U.S. schools of pharmacy: a descriptive study.

OBJECTIVES: As the practice of pharmacy grows increasingly complex, graduates are expected to possess a comprehensive set of skills enabling them to provide optimal patient care. Thus, research skills are becoming increasingly valuable and a necessary part of pharmacist training globally. However, training opportunities for improving research skills have not been well explored in the literature. This study examines how research skills are currently being offered in various Doctor of Pharmacy curricula in US Schools of Pharmacy. METHODS: A five-question survey was e-mailed to key individuals at 95 Colleges of Pharmacy in the USA and Puerto Rico. Responses were aggregated and then stratified by research project requirements, as well as by school type (public or private; Carnegie Foundation classification). KEY FINDINGS: Seventy-nine respondents provided usable surveys for an 83% response rate. Respondents encompassed a representative population of school types. Although most schools do not require completion of a research project (75%), the majority of research skills listed were taught in various forms in over half of the responding institutions. There did not appear to be a significant distinction in research skills training provided based upon school type. However, schools requiring students to complete a research project in order to graduate provided the most comprehensive research skills training. CONCLUSIONS: Research skills training has greatly increased over the past 10 years. However, more study needs to be done in a number of areas, including determining the most effective way to offer research skills training, determining its post-graduate impact and determining its overall effect on the profession of pharmacy.

Personal health record use by patients as perceived by ambulatory care physicians in Nebraska and South Dakota: a cross-sectional study.

The purpose of this cross-sectional study is to examine the awareness and engagement that ambulatory care physicians have with patients who use a personal health record (PHR). This is part of a larger study examining health information technology (HIT) and electronic health record (EHR) adoption by ambulatory care physicians in Nebraska and South Dakota. Descriptive results and inferential findings about physician awareness and engagement are presented in relationship to the physician's stage of EHR adoption, practice type and size, gender, specialty, and age. Overall, physicians' awareness of PHRs and their engagement with the technology remains low. Physicians using EHRs were more likely to be aware and engaged with PHRs than physicians who either plan to adopt EHRs or have no intention to adopt EHRs. Practice type, gender, and specialty have an association as well. The implications of the findings are discussed, and a recommendation is made that education of physicians is needed in this area as the nation progresses toward the creation of a national health information network for health information exchange.

Evaluation of an instructional model to teach clinically relevant medicinal chemistry in a campus and a distance pathway.

OBJECTIVES: To evaluate an instructional model for teaching clinically relevant medicinal chemistry. METHODS: An instructional model that uses Bloom's cognitive and Krathwohl's affective taxonomy, published and tested concepts in teaching medicinal chemistry, and active learning strategies, was introduced in the medicinal chemistry courses for second-professional year (P2) doctor of pharmacy (PharmD) students (campus and distance) in the 2005-2006 academic year. Student learning and the overall effectiveness of the instructional model were assessed. Student performance after introducing the instructional model was compared to that in prior years. RESULTS: Student performance on course examinations improved compared to previous years. Students expressed overall enthusiasm about the course and better understood the value of medicinal chemistry to clinical practice. CONCLUSION: The explicit integration of the cognitive and affective learning objectives improved student performance, student ability to apply medicinal chemistry to clinical practice, and student attitude towards the discipline. Testing this instructional model provided validation to this theoretical framework. The model is effective for both our campus and distance-students. This instructional model may also have broad-based applications to other science courses.

New technology, new errors: how to prime an upgrade of an insulin infusion pump.

BACKGROUND: A series of use errors occurred when switching an ambulatory care clinic patient from an older model to a newer model of an ambulatory continuous subcutaneous insulin infusion pump. CASE REPORT: The nurse practitioner (N.P.) reviewed the new pump's mechanics with the patient, who had a 26-year history of Type 1 diabetes mellitus, and supervised the patient's programming of the pump. At bedtime, a blood sugar of > 250 mg/dL prompted the patient to give herself insulin via the pump. The next morning, she was treated at the emergency department for diabetic ketoacidosis. CASE ANALYSIS: The pump had been improperly primed, resulting in no insulin delivery. The incident also reflected the absence of a fail-safe mechanism(s) on the pump to alert the user to the improper priming and inappropriate handoff of the patient's care. Unlike the old pump, the new pump did not require manual priming. The lack of delivery of insulin resulted in DKA, a potentially life-threatening complication of diabetes. A root cause analysis suggested several important safety issues, including skipping of steps on the patient training checklist and other shortcuts in patient training. DISCUSSION: The clinic developed policies and procedures, including mandatory formal training for each pump model by the certified pump trainer and for initiation of insulin pump therapy. This case illustrates the importance of a structured device selection process, provider education, patient education, and monitoring for safety and effectiveness of technological devices in care.