Category Archives: Practice

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The 5 P’s of Team-Building

Every once and awhile, I try to put into words some of the philosophies I’ve adapted and applied in my own workplace. They may seem to have brought me a degree of success, but by no means does this qualify me as an ‘expert’ in the area; if anything there are constant opportunities to refine and better adhere to the points below. A strong team raises the bar for performance. Whether you’re leading a strong team or are a member of one, I find these points help address larger issues, and many of the little problems take care of themselves. Before I start with the main five, there are two themes that happen to start with the letter P that tie each of these together: Please – we always ask for input, behavior changes, or solutions to our shared problems, and Praise – we reward any successes, no matter how small.

1) Presence – By far the most important element in my opinion. In order to follow through on any initiative, a team needs to be cohesive, and complementing of each other. The only way to establish this foundation is a want to be around the team and learn about the individual members. What values are important to them? What constitutes a good vs a bad day? Who are they drawn to for guidance? What contributions make them the most proud? Spending time with the team is the best way to find out.

2) Planning – Having a vision and verbalizing it to the team can’t be understated. In prior posts, I have explored the need to share and engage others as their approaches may be different, but their visions for the team, for the business, for themselves may overlap quite a bit. Together, the strategic plan has input from everyone directly involved with its execution. Potential barriers are identified early on, and individuals are coached to have ownership over their separate pieces of the shared plan. Short-term goals are evaluated, and long-term or stretch targets are adjusted accordingly.

3) Proactivity – This element requires a bit of finesse. Usually borne out of crisis, being proactive serves to not just correct a known problem, but to prevent it from happening in the first place. A definite challenge is proving that the time invested to make a change in behavior, saves the time spent reacting to an undesirable outcome. An example of this would be calling a family member before processing an expensive prescription. This step may offset (or in many cases, save) the time spent correcting the issue after upsetting the customer when they arrive. The key here is the culture change that comes with it. When there are many crises, and therefore, many undesirable outcomes, being proactive is an easier sell. Once the bulk of those are rectified, being proactive becomes the team thought-process and raises the standard of performance. The crises are no longer obvious and staff are much more in control of their work volume, meaning they’re better prepared for the next inevitable wave of change.

4) Practicality – Especially in the beginning, before real bonds are formed between team members, it’s essential to have some ‘easy wins’. These are very realistic, functional process changes that when realized, benefit everyone equally. One pharmacy example was to implement communication stamps and initialing hard copies. The stamps sent consistent messages to assembly staff and the initials identified the person sending the message in case clarification was needed.

5) Patience – This is the toughest element to master. I’ve been blessed to be a part of a number of excellent teams. Some I have had the privilege to lead, others I was made to feel like an important cog in a high-powered machine. The grander the scope or the larger the team, the more energy needs to be invested to keep the train moving. Coaching requirements are unique to the individuals on the team. Some may grab concepts faster than others. Inconsistency with words and actions is expected. Mistakes will be made. Those frustrations are the necessarily evil to grow people. Once they see the value of being around, planning ahead, being proactive and thinking practically, they will make the performance of everyone around them a little bit better.

 

To finish off, team-building is hard. Although that’s admittedly a crude statement to make, there’s no point in mincing words. Sometimes, people associate ‘team-building’ with ice-breakers, or performing tasks with blindfolds and obstacle courses. These exercises may highlight the need to work together and be comfortable with one another, but unless those lessons are translated to the vision and the tasks at hand, they run the risk of being footnotes left behind in the annals of history. Please indulge me as I add a 5a to my list:

per·se·ver·ance
ˌpərsəˈvirəns/
noun
  1. steadfastness in doing something despite difficulty or delay in achieving success.

So is it worth it? Teams are important. People are more important. They’ve made me a better professional, a better person. I hope to help do the same for them.

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Who’s Training Whom?

Before the Rotation

This should be interesting.

A freshly graduated regulated technician student is arriving at my dedicated long-term care dispensary this week to perform her required 4-week clinical rotation.

She will be looking to me for guidance on ethical and procedural issues. She will ask how best to complement the pharmacist on duty and pattern her style accordingly. She will rightly expect that after these four weeks, she will have a defined role with measurable tasks and clear boundaries. Upon licensing, she hopes to offer an immediate impact in whichever pharmacy she is employed.

There’s really only one problem: I have never had a regulated technician on staff, nor have I worked with one at another location.

This isn’t necessarily a bad thing. With this trusty preceptor introduction package mailed to me from the community college, I can enter into this experience with an extremely open mind. Although I have a plan for how a regulated technician will contribute in my site, my pharmacists will each need to develop trust in this new professional, and so will I.

The title will be confusing in that when I started in pharmacy, a technician was a technician. A few years ago, the title of ‘Technician’, or RPhT was protected in those provinces where regulation was moving forward. Those who were previously known as technicians were reclassified as ‘assistants’ but in casual conversation, are still often referred to (especially by other healthcare providers) as technicians. After all, their roles were expanded and the label attached to it has come to resemble that of the certified dispensers of yesteryear: able to dispense medications, but not performing the clinical role of the pharmacist.

So, if she’s patient with me, I’ll try to let go of as much as I can: checking of new and refilled prescriptions for completeness and accuracy, screening batched prescriptions through our automation software, accepting and confirming physician and/or nurse practitioner verbal orders. These are all ways to reduce the burden placed on a pharmacist.

 

Aftermath

The first week was full of administrative tasks. We covered workplace health and safety, oriented her to all of our workstations and began reviewing the workbook we had been given. Many tasks requiring evaluation were relatively straightforward; phone etiquette, accuracy with assembling prescriptions, and inventory control required minimal direction as my student had prior dispensary experience.

Then the fun began…

At our site, there are two huge checking-related tasks that swallow up a large part of a pharmacist’s day: witnessing weekly cycle-fills of unit-dose pouches and packaging verification of new and refilled prescriptions. Like a moth to a flame, she grabbed the reins with the cycle-fills. Paired with another regulated technician candidate, they took turns with one verifying and correcting a batch, and the other performing the double-check, manual quality assurance, and sign-off. I then came in behind and repeated the final check. The results were amazing. Not only were all the batches organized and accounted for, they identified procedural gaps in the packaging process for us to correct as a team. Our packaging error rate for the month actually went down. As for the refills/new prescriptions, the learning curve was steeper. I let her grab a bin of packaged prescriptions for a nursing home, and once again followed behind and verified her work. In the three remaining weeks, she checked over 500 prescriptions and found a number of mistakes. The part that I enjoyed was that her questioning and requests for clarification made us all better; we may have just assumed answers in the past in regards to pack sizes, or the wording of directions, or dosing times. In only one case, a quantity was miscalculated by data entry that managed to squeak through, but even this order was misinterpreted by two others.

Now that I’ve seen firsthand the potential impact of such a role on my operation, I can’t wait to get started. Pharmacists have long been responsible for the appropriateness of the therapy as well as the final dispensed product. It’s liberating to be able to focus on the clinical aspects of a prescription: the indication, the dose adjustments, drug or food interactions, and monitoring. Having trusted professional colleagues to ensure accurate dispensing allows more of the pharmacist’s time to be devoted making recommendations, reacting to advisories, and planning staff education.

Many thanks CJ and KLS. Where we go from here will be due to your commitment to quality and professionalism. Pharmacy needs this. You’re teaching me to embrace this change.

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Reporting Incidents – Focus on Long-Term Care

Now that I am back in the realm of long-term care, it’s apparent that some things have changed significantly since I was last here: automation, prescription-processing software and the role of pharmacists as consultant liaisons to nursing home facilities are just a few. Amongst the items that haven’t changed is the responsibility surrounding incident handling and reporting, and it can be argued that it continues to increase in importance. The recent media focus on pharmacy hasn’t been the most positive.

Between the steps of prescribing, dispensing, and the administration of medication, there are countless ways for errors to occur: transcription, misinterpretation, data entry, assembly, dosing time, dosing frequency, length of therapy, interactions, quantity, packaging and labeling, dropped doses, brand changes, discontinuations, etc (you get the idea). Of course we aim to maintain a similar number of safeguards to prevent such errors, but unfortunately some still manage to squeak through.

As we become more advanced with our packaging systems and software, there has been a steady shift in the quality and quantity of medication errors requiring a response and an action plan. Here are some observations and some points for consideration:

1) Reporting rates have increased – Both at a facility level and the dispensary level, we are seeing more reports flowing through. There has been a conscious change through regulatory bodies to report any and all perception of error, regardless of who may interpret the potential risk (administrator, pharmacist, assistant, RN, LPN, family member, etc).

2) Errors are more easily identifiable – If drug administration moves from a multi-dose to a unit-dose packaging format, it becomes apparent if single doses were given or not. If doses were provided from a vial, the risk of double-dosing or under-dosing is higher, but not necessarily identified until a later date (if at all). The emergence of electronic medication administration records (eMAR) has added a new layer of error potential as well; if stop dates aren’t entered properly by pharmacy staff, it will prompt a dose to be given after a course is complete and no inventory remains.

3) The vast majority are of the ‘near-miss’ variety – This tells me that the quality assurance measures we employ are working. Problems are identified prior to administration of medication, so there is virtually no potential for patient harm, yet we may still craft action plans to prevent recurrence.

4) The severity of actual medication incidents is declining – This is a personal observation in that I don’t have any comparative evidence to recite. We used to see errors within drug classes with similar strengths and directions (i.e. paroxetine vs. fluoxetine, metoprolol vs. atenolol), or look-alike drugs that end up in the same bottles (i.e. Synthroid 50ug/domperidone 10mg, lorazepam 1mg/gliclazide MR 30mg, Tylenol #3/Metformin 500mg, etc). These types of errors are devastating for everyone involved. Our prescription-processing systems and packaging automation go a long way to prevent wrong product or strength dispensing. However, if a broken tablet was found in a vial, it may not be recorded as an incident, but if it’s in a unit-dose package, that specific dose is incorrect and should be recorded as such.

5) Raw numbers alone do not tell the whole story – Nobody likes to have incidents of any kind, but we need to report them to learn about gaps in our training and our service that we genuinely want to address. Without any context, an incident rate may be considered high or low, but we need to dive deeper into the severity of errors being reported and the steps involved in the breakdown. One example I have was from a number of years ago that was recounted by a pharmacy manager friend of mine. A batch of unit-dose packaging was run with an incorrect start date. In this case, the first medication pouch was due to start on Sept 23 when it should have been Sept 24. Upon delivery, nursing staff would have received a duplicate day of medications and this was identified right away. The pharmacy was notified and in response, corrected an administrative error where two staff members failed to properly sign-off on checking the dates. As this particular batch had twelve people, it was reported as twelve separate errors. I concede that from a facility side, the near-miss could have potentially affected twelve people. From a quality assurance perspective, there was one procedural error, and therefore one action plan to execute. The quarterly service report nevertheless looked quite poor, and pharmacy staff were discouraged.

In closing, the last thing anyone wants is a culture of fear. Error reporting in any setting should be about transparency and working together for the benefits of our mutual patients. We learn and adapt our programs to properly address shortcomings in a timely manner, with penalties reserved for a failure to take steps to fix whatever may be flawed, not for the reporting itself.

We are proud to strive for a world where no mistakes are made and therapies result in optimal outcomes. Till then, we will continue to support each other to follow-up errors and use a team-approach to discuss remedies.

After all, there is only one problem with being perfect; you never learn know how to fix anything.

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Sharing a Vision

“Vision is the art of seeing what is invisible to others.” – Jonathan Swift*

The author of such noted works as Gulliver’s Travels and A Modest Proposal offers this piece of wisdom for anyone in a role that requires forward thinking and plan execution. My favorite part of this quote is the word ‘art’ being used as a descriptor. Art is creation; it’s translating ideas and intuition into reality. That’s the power of the human mind: what you see could very well be invisible to those around you, but those around you are also seeing things that may be invisible to you. When I graduated, the idea of paid medication reviews was foreign. We were available to the public for all of their medication needs, whether it be a 3-minute consult or one lasting half an hour. Those off-hand medication reviews were not formalized or necessarily valued as they should have been. It wasn’t until a small group lobbied associations and governments to fund these services that they started to appear.

The best part? Vision as an art, is not defined in black and white. It’s like a rainbow in that every person views through their own prism; the conditions and viewing angle are unique and the person directly next to you will not capture the same arc or brilliance. Whether narrow or broad spectrum, a vision is defined by a person’s individuality, style and skill-set. Those same medication reviews now have a framework, but it’s up to each pharmacist to create value for their patients and for themselves as practitioners.

Now anyone can be artistic but most often the quality is measured by social perception or taste. Do you have a favorite genre of music? How about painters or sculptors? For those that don’t thrill you, does that make the artist any less talented or the art of poorer quality? Does anyone remember the controversy when the National Gallery of Canada spent $1.8 million dollars to buy the Voice of  Fire? Regardless of our own opinions on Abstract Expressionism, this piece was a result of Barnett Newman’s vision and is admired and appreciated by many. If you are interested in viewing more of Mr. Newman’s works, please visit: https://www.artsy.net/artist/barnett-newman

So if everyone has artistic capability and may see things others can’t, why do certain folks stand out in the crowd as being visionaries in their respective fields?

 

‘Great leaders communicate a vision that captures the imagination and fires the hearts and minds of those around them.‘ – Joseph B. Wirthlin*

It’s rather difficult to formulate an opinion or contribute to a vision if you’re not aware it exists. That song on the radio was written, arranged and recorded, but until it was promoted there were few listeners. Van Gogh was certainly eccentric but if he had never dared to show his canvas to anyone, it’s doubtful he’d have much of a place in history. In the Canadian pharmacy world, our leaders have provided the Blueprint For Pharmacy and on an increasing scale, policy decisions are being made in reference to the Blueprint vision.

We are all experiencing enormous change integrating these new clinical services to current practices. Our local leaders are communicating their visions through provincial associations and government relations. Demonstration projects are popping up in Nova Scotia in the form of the Bloom Program and funded minor ailment prescribing. Perhaps there are plenty of items happening that were once invisible to you. By the same token, it’s up to us to communicate our visions as well. Insert yourself into the discourse and create your own art for how your future should look. Have a supportive family doctor in the clinic that performs home-visits? Perhaps there is an opportunity to collaborate on a disease-state management program. Interested in reading lab screening for thyroid disorders? Someday, endocrinology may be needing our help to identify red flags or coordinating dose adjustments. There is no wrong answer or approach so don’t be afraid to apply your style.

After all, you’re seeing things no one else can; only you can make them visible.

 

*Quotes courtesy of Brainy Quotes – http://www.brainyquote.com/

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Temporarily Grounded

I missed my flight home this morning.

It’s a new experience to be sure. As I get acclimated to an unfamiliar airport terminal for the next five hours or so, I couldn’t help but to somehow try to turn it into a positive experience.

The travel itinerary started innocently enough; a quick trip to meet with a colleague over the dinner-hour followed by an aquarium visit with a close friend who lived nearby. It took me a while to plan and commit to this trip. This wasn’t just any colleague, in fact it was the point of the excursion. I was to meet the editor who believed in my writings enough to feature it in a national magazine over a year before and she deserved a personal thank you. I bit the bullet, took a chance to meet her and I’m so glad I did.

During the course of a wonderful brunch filled with Benedicts and omelettes, we chatted about media and content planning, provincial success stories from pharmacy entrepreneurs, and initiatives taking shape below our Canadian border (all of which I found fascinating and hope to highlight in a future post).

As pleasant as yesterday was, today is off to a rocky start. My alarm went off as scheduled with over an hour’s grace to reach the airport. Unfortunately, this was the first time I had used this particular airport, which is an important point to mention for reasons that will become apparent.

Thinking I was a mere 6-7 km jaunt to my destination, the cab picked me up with 20 minutes to spare before the specified arrival time on my boarding pass. Well, that 6-7 km cab ride came along with with what felt like 50 intersections and intermittent traffic snarls. Still, we managed to arrive about 10 minutes late; not the end of the world, but a bit rushed. I hurry inside, print my boarding pass and realize the queue in front of me is waiting to board the ferry across the canal to the actual terminal. My agitation is welling up inside with 18 minutes to departure. The ferry docks…except it doesn’t. Watching the mast outside the window bob and weave, forward and reverse for the next 12 minutes (yes, I was counting) was very disconcerting. The fellow in front of me is now furiously on his cell trying to delay take-off. I can only imagine what it was like for the passengers waiting to disembark.

The boat empties and we climb aboard. It turns out the ferry pilot was having difficulty lining up the ramp and needed numerous attempts. At this time the plane is gone and I’m rehearsing how I will explain myself at the registration desk. I saunter stoically to the lady and present my worthless paper that five minutes before had masqueraded as a plane ticket. Since my cell battery was low, they allowed me one phone call befitting my punishment. Now my drive won’t be waiting for me at the the other end and my kids won’t be stranded at school.

So here I am. Thinking about pharmacy and subsisting on a $11 ham sandwich from the lounge. The whole experience reminds me of when I began offering a new clinical service at my dispensary and you’re probably wondering where that ridiculous segue came from. We had a pilot (see what I did there?) to promote minor ailments and I had someone asking about herpes simplex. Let’s see:

– I started out nervous. I wondered if I was able to commit in the first place without having an idea how it would turn out or how it would impact workflow.

– Once invested, I was able to consult with colleagues who were aware of success stories and had strategies to overcome my misgivings. Through conversation and research, I felt pumped up and ready to go.

–  When the time came, I was met with some barriers: my own planning was flawed due to an unfamiliarity with the process (paperwork, time commitment) and perhaps a little overconfidence. In addition, there were factors out of my control that ultimately led to a setback (staff illness, appointment cancellation that ended up not being re-booked).

The end result? I was forced to reflect and figure out the current situation. I certainly learned a few things that helped for the next time.

The next chance will come along very soon, and likewise, I won’t be missing that next flight.

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Dispensing Pride

The terms ‘pharmacy’ and ‘dispensing’ go hand-in-hand. Prescribers diagnose disease and approve treatment. We fill the treatment orders and dispense the therapy, along with any important educational points, to patients and their families. This has been our role for generations. We are known as some of the most trusted and most accessible health professionals in the world.

I admit to being a proud dispenser, but my priorities are beginning to shift. Medication has always held a fascination for me: the clever brand names (remember Desyrel? I still have ‘DEpressive SYmptom RELief’ bouncing in my skull somewhere), the odd shapes of certain tablets and the splashy marketing campaigns. Sometimes missing however, was the proper transfer of information to others. My counseling skills took time to develop, and early on I felt robotic and scripted when interacting with patients.

As a student, I recall basic functions such as writing up manual credits to Blue Cross or the now defunct Maritime Medical. We made funky compounds with Anthralin powder that stained everything a heinous shade of yellow ochre that would make Bob Ross proud. We were the gatekeepers of all things pharmaceutical and sometimes a cursory counseling session was all that a patient received. Sure, in classes and labs we were coached on communication styles and higher standards but the reality was a bit disheartening; dispensing was the main focus and any clinical intervention seemed like an exciting ‘Eureka’ moment for the team to share instead of the norm.

Doing pharmacy relief immediately after graduation had it’s advantages and disadvantages. Although leaving work at work when a shift was over was nice, ensuring patient follow-up and continuity of care was extremely inconsistent from one site to the next. Every interaction was a point-in-time and documentation was rather erratic from one pharmacist to the next. We were however excellent at monitoring days supply of benzos and narcs. I may not have had the relevant history or familiarity with the tools to best determine your pain control but I could certainly attest that those sixty OxyContin 40mg were triple-counted by three different people.

My, how times have changed…

So, there is less of a focus on pack sizes and pricing (still important, but more of a management focus as opposed to pharmacist); better prescription software has lessened the need to manually update every drug file or pricing strategy. Now it’s more empowering to take a deeper look at interactions and latest research guidelines. The volume of calls to the third-party plan to correct date of birth issues are tasks that now may be delegated. We are becoming more intimately involved with special authorization criteria and therapeutic substitutions. Cognitively, we have more opportunity to apply ourselves; with prescribing rights, we can now identify certain DRPs and be able to solve them for a patient. Things like INR and renal adjustments may now feature a pharmacist’s name on the order as we get other health professionals to recognize our new-found decision-making abilities. In fact, just the other day, I was able to halve a sulfamethoxazole dose for an elderly resident with a compromised creatinine-clearance.

The paradigm shift started long before my degree, but the visionaries who foresaw such radical changes had their work cut out for them. The baby-boomers were heading into retirement, and the aging population needed more medications to combat heart disease, diabetes and high cholesterol. In lockstep with that, they were also going to need more clinical care, and more than what general practitioners would be able to handle, especially in rural areas. I look forward to plugging some gaps through medication reconciliation, minor ailment prescribing, and lab requisitions.

To sum up: I am proud of my dispensing hat, I am proud of my expanded clinical duties now, and trust that I will enjoy however the role evolves from here. I guess I’m just proud to be a pharmacist.

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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New Year, New Challenges

As I rang in the New Year with a few close friends, it really started to sink in. Everything had been a blur the previous week and it was finally starting to catch up.

And no, I’m not talking about rum and eggnog.

On December 30, I accepted a new position to manage a dedicated long-term care site. You can never predict when opportunities like this come along, and although hesitant to leave the most stable position I’ve held in a long time, the application was sent. At this stage in my career, my only real fear is stagnation; I’ve felt that sensation before and have no desire to dance with complacency. Thankfully, that stage has not yet arrived but could have appeared on the horizon at any moment. It’s best for me to be thinking ahead.

I have done this kind of work in the past and had always hoped to make it back, but this time it feels different. My first foray was helter-skelter; long hours, rushed chaos, problem-solving emergency calls after closing time, and staff watching me learn as I muddled along. To this day, I thank them for their patience. Amid all of that, it was also my first real exposure to institutional pharmacy. Under the guise of a semi-retail operation, we provided medications solely to nursing homes, with a few supplies and/or convenience items the facilities needed. As primary consultant, I can speak fondly of my interactions with nursing staff, administrators, the medical director and a Nurse Practitioner with whom I have been working to promote polypharmacy.ca.

Nowadays I feel I have grown in a myriad of ways professionally. I’ve worked on some amazing teams and helmed some progressive projects. I have worked with student pharmacists and 30-year veterans. There has been pharmacy-related exposure to academia, government, hospital and most recently, journalism. Although I feel ready for the role ahead, suffice it to say there is still a long way to go. It’s a bigger team in a site with larger growth ambitions but the structure is sound so we can hit the ground running. Everyone is pointed in the right direction and I need to find a way to feed that positive energy.

Oftentimes when I have entered new environments, they have been in need of stability. The desire to be proactive is usurped by the need to be reactive, at least at the beginning. Ensuring policies and procedures are being followed to cut down on incidents, being detail-oriented with communication so everyone knows how to handle situations serve as a good place to start. The key is promoting consistency, which sometimes challenges current habits. The squeaky wheel often gets the grease, but sometimes the reverse is also true: your most patient customers / colleagues / support figures give you more rope when the going gets tough. It’s much appreciated, sure, but must not be taken for granted. It’s a nice change to begin where most of that coaching has already taken place.

I am excited to meet my new team and to see if I can fit in without upsetting the chemistry they’ve developed. My learning curve will be steep, but manageable. Respect is not an entitlement; I must earn it from every person I work with and for. After receiving a debrief from upper management, I can already feel the synapses firing on projects we can undertake and roles we can expand.

So as I bid farewell to my current team over breakfast this weekend, the gratitude will spill over like the Horseshoe Falls. We shall celebrate how far we’ve come and how close we’ve grown, almost as a family. I have friends for life (or as long as they’ll have me) and they deserve the best in the next phase. I’m not an emotional sort, but I couldn’t be more proud of the pharmacy and the grocery store proper. You’ve helped me grow and learn even more about myself. You’ve prepared me for this next challenge and I promise to not let you down. You’re welcome to check in anytime; I will be doing the same.

Onward and upward…

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Broaching Breaches

The expectation of privacy in today’s world is becoming increasingly difficult. Everything is becoming electronic; online banking, online shopping, email lists and profiles built on computer system are common in every business nowadays. Pharmacy is no different. With the advent of the Personal Information Protection and Electronic Documents Act (PIPEDA), ground rules are in place for private sector businesses to collect, maintain and disclose any type of personal information contained in a database. Obtaining consent is essentially the gateway to collection;  if we are not able to collect, maintain and use the information for the purpose of filling prescriptions, it’s very difficult to  provide service, if at all. Having accurate allergies and diagnoses can definitely impact the appropriateness of a new therapy or dose change.

The issue of consent can be a minefield. For instance, the Personal Health Information Act (PHIA) in Nova Scotia doesn’t specify an age of consent. The individual must have the capacity to provide informed consent, that is to say that when given all of the pros and cons of allowing personal information to be used in a given situation, they  have a choice to provide that authority, limit the scope, or revoke their previous permissions. In 2008, the criminal code of Canada raised the age of consent in sexual matters to 16, with exemptions down to 14 and in some cases if two minors are involved, even as low as 12. This is important because pharmacists need to determine whether a protective parent should be included within a young patient’s circle of care. As an example, a new birth control prescription is presented by a teen, but her mom picks it up. It’s not always straightforward. The same thing goes for those suffering from mental illness or cognitive decline. A spouse or other family member may be a more reliable source of information when making clinical decisions, but the patient has every right to keep information from being shared with them.

Even with safeguards in place, breaches have happened and will happen from time to time. Faxes sometimes end up at the wrong office or two people with similar names pick up each other’s prescriptions. Nobody intends for these incidents to happen, but the reality is that systems can fail. Perhaps an address wasn’t confirmed or was misheard at pickup. Maybe a large order accidentally included someone else’s bottle during the bagging process. As mentioned above, a counsel session could be initiated with someone who is not within the patient’s circle of care. With expanded scope of services, pharmacists have a heavier burden to communicate any injections or prescribing activities to the primary care-provider. We may not necessarily have longstanding relationships with everyone that receives a flu shot, so while faxing is more convenient than calling an office, we are relying on the patient to specify their family doctor and the potential for error is real. It happens in the other direction as well. Our site has received patient profile requisitions from hospital units intended for other locations, or transfers intended for other pharmacies.

I believe we do an admirable job at upholding these responsibilities. Use of personal information is appropriate to properly advise and advocate for patient care and we’re about to receive more of it in the form of the Nova Scotia Drug Information System (DIS). Other provinces are in various stages of integration; examples include H-Link in Alberta, the Pharmacy Network in Newfoundland and Labrador, PharmaNet in British Columbia and Health PEI. They all currently feed data from institutional and community settings into a central database. While this endeavour is aiming to provide a comprehensive patient profile of all provided health services, it also poses challenges to maintaining privacy. More information will be available to more people in real-time. Applications for this information will be new to many users and perhaps mistakes will be made with security permissions and protocols. Perhaps a look-up with a misspelled name results in accessing the incorrect profile, and adding a care note that doesn’t pertain to that individual. Lab values may be routed to the wrong ‘Dr. Smith’ and communications end up at the wrong office as a result.

At the end of the day, we will continue to apply due diligence in all cases to protect and maintain the integrity and security of the database. The additional information will be available so we can make better, well-rounded clinical decisions for our shared patients. Connecting healthcare providers in community and institutional settings is a huge positive. We can speak the same language based on the same complete profiles. Frankly, many patients seem to assume we already have this access when caring for them, so when we finally do, let’s make the most of it shall we?

 

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Law & Ethics

One of the hats I wear is that of a pharmacy skills-lab demonstrator at Dalhousie University. The fourth-year graduating class is lucky enough (or unlucky, depending on who you ask) to have me stand in as a patient, physician or family member with whom to interact as part of given case scenarios. They are assessed on clinical knowledge but also delivery and style; body language and empathy make up a good portion of the final scoring rubric.

Sometimes I forget just how awkward it is to be a student.

Every year the course evolves, and the content of lab scenarios is tweaked to account for the expanding scope of practice. Prescription adaptations are new within the past two fall semesters, as are injection training modules. A couple of weeks ago, the lab focused on law and ethics, which has always been part of the curriculum, but not always represented in lab scenarios. The written cases were excellent, and would be challenging for seasoned practitioners, let alone mature students.

I have been practicing for over a decade. Although I have first-hand knowledge of some difficult moral and ethical dilemmas that occur in the pharmacy world, most times they have been second or third-hand. Staff members stealing narcotics from the safe, substance abuse in the workplace, and sexual harassment are just a few examples of uncomfortable situations that can arise in a dispensary. None are straight-forward and all require discipline to separate responsibilities under the law and the empathy for the person or persons involved. The law doesn’t care if it was a one-time occurrence or a habitual behaviour, the situation needs to be dealt with as dictated. However the follow-up may have a few more layers. Does the individual have mental health issues that have not been treated? Are they a danger to themselves or others? Is this terrible error in judgement easily corrected?

As preceptors, it’s natural to shield students on rotation from these difficult situations because they have so much on their plates already. So the students in lab were in a bit of a quandary. The scenarios were new and surreal. They had to think fast, interact with a possible offender and gather the information they needed to make a sound decision. The weird thing was that when I had received the case to review, the scenario almost exactly matched an incident I experienced during my first management role. The emotions I felt at that time came flooding back, mostly about how afraid I was to confirm my suspicions that someone was dispensing to themselves. As a new manager at the time, I made the situation about me, and how much trouble I would be in had I been wrong. That said, it was dealt with properly but I completely understand the thought process my students utilized. My answers to their questions were the same as I had received when I went through the situation myself, as was the doubt I tried to create that it was more than a harmless misunderstanding.

The feedback I provided to the students along with their responses identified the two adjoining conclusions: you can uphold the law by reporting and documenting a potential crime or professional misconduct, while at the same time ethically supporting individuals by referring them to a mental health specialist or social worker as needed. For the most part, it is not one over the other.

It amazes me each year the empathy and comfort the students display in their interactions, even awkward ones. There is no doubt that they will all encounter a situation or two that test their knowledge of pharmacy law and blur the lines of the ‘right’ and ‘wrong’ ways toward a resolution. Introducing these new professionals to a few of these possible scenarios should aid their thought processes for when they’re out practicing on their own.

I would say the lab was a resounding success.

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Flu Shot Redux

Oct 19,2014.

The date has been bandied about for the commencement of this year’s flu vaccination season. Although the date may change slightly from this posting, Nova Scotia is ramping up for a robust campaign to exceed last year’s success. Pharmacies in the province provided upwards of 80,000 doses of the seasonal vaccine while physicians provided only about 18,000 doses less than the prior year. Interestingly enough many pharmacies, including my own, were late receiving supply or had only one injection-certified pharmacist on staff for a good portion of the fall/winter months.

Last year, performing injections was new for pharmacists here, but we got pretty good at it. In the time since, I’ve been keeping in practice with travel vaccines and have recently been in demand for the shingles shot as patients become more comfortable dropping in to ask about them. For a service so straightforward and quick (the act, not necessarily the pre- and post-documentation), people genuinely appreciate the convenience and most will happily pay any associated fees to avoid sitting in a clinic waiting room.

I’ll be the first to confess that I’m not that excited about needles; whether I’m giving or receiving a shot, my feeling is quite neutral. I know there are plenty of practitioners who can give and not receive, or have a mental block when it comes to touching a patient. The sight of blood in any amount may not be on your daily agenda but the reality is that pharmacists have proven we can fill a large care gap…a care chasm as it were. An at-risk individual may be stopping in for a blood-pressure medication refill and perhaps receive a shot at the same time. A family of four with two kids under the age of ten come to pick up a few things on the way back from a matinee and now they’re no longer influenza carriers for Christmas dinner with Nan. A pregnant woman’s fears about harming her baby will be allayed.

The point here is that I see the value in providing the service to those that want it. Many members of the public are against flu vaccination. That is their right, and I have no interest in putting anyone on the defensive. I DO however want to be available to anyone who is eager to protect themselves and will pass the word that we’re ready and willing to provide for their family and friends if they are so inclined. Waiting on our first lot of vaccine is making for suspenseful week with the multitude of phone calls we’ve been fielding, so the demand is there. Signs are up and clinics are being planned. It appears we’re going to be receiving Agriflu, which is pre-filled 0.5mL of convenient, time-saving goodness. To be sustainable, our approach will be to treat any request for a vaccination no different than an acute medication for a patient; wait times may vary depending on the time of day and the volume we’re processing. These are duties we will carry out as best we can with the flow of the day.

You can bet that as long as the flu vaccine supply lasts, pharmacies will be instrumental in finding deltoids to receive it. When the season passes, we’ll be ready for the travel rush of winter.

Emergency kits inspected? Supplies ordered? Forms printed? Staff primed on intake? This year, it looks like we’re all ready to rock.

Just remember to save a shot for yourself.

 

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.