Change is fluid. Like the ocean tides, change can have a degree of predictability. Like the storm-driven swells, change can also randomly toss you about and threaten to pull you under the surface.

Change affects various groups of people differently, and balancing the dynamic between members of a team is essential to success. There are many well-worn concepts floating about but one of my favorites is the traffic-light model that designates an individual’s readiness for change. Red is not ready to consider change, yellow is cautiously optimistic of change, and green signifies already in the process of changing with no barriers. This may apply to any behavior, or environmental change, and readiness can vary depending on the topic. For a pharmacy example, you could be a green for administering vaccinations, a yellow for sharing duties with a regulated technician, and a red for minor-ailment prescribing.

Perhaps after a year or two of flu shots, you’ve got it figured out; it’s an enjoyable part of the job to educate folks on the value of vaccinations in general, and the staff keep the appointments on track. At the same time, this new profession has appeared on the horizon. Technician regulation has been in the works for some time, but now candidates are ready to take the reins. It sounds like they will help allow pharmacists to further immerse themselves into clinical duties, but many will hesitate not knowing if they will be ultimately liable for mistakes made by a technician. It will take time to get comfortable. Finally, meeting the demands of patients arriving at the pharmacy with rashes and cold sores is causing some angst; what will the family doctor think? Will I miss a red-flag? What if I make the problem worse? What references should I use?

It’s a good thing change is fluid, as the personal experiences come and others provide positive reinforcement, that red light may assume an orange hue on it’s way to yellow.

Within a team, everyone may be a different color. Anytime change is imminent, psychological reactance rears its head as members of the group digest how it will affect them. Like a newly-diagnosed diabetic told to avoid sugary foods will obsess about ice cream on the drive home, our first reaction is to resist change until we feel in control of it. We’re all different, so the timelines to readiness, and the conditions required to move towards green will vary. The thing is, that diversity is essential for effective group change. I’m sure some of you figure that the red lights are counter-productive. In fact, those in the room that come across as negative and always have reasons to maintain the status quo are just as important as the go-getters that see the limitless sky. The key is the right balance, as mentioned above.

Take a buoy floating on our change ocean:

*Image courtesy of http://www.trekearth.com/gallery/Europe/Malta/South/Malta/Valletta/photo1396766.htm

Let’s say the green, ready-to-inspire, ready-to-act group is the beacon on the top of the buoy. They are visible, shine the light, and can direct people away from the rocks or mark a position. The middle section above the water is heftier. They are the yellow group, watching with hopeful intent that the beacon will indeed take them where they want to go. The red group are the ballast, bobbing just below the surface, providing an anchor and stability to the structure. Their reasons for staying in the water could be entirely reasonable, and there may be barriers they are not yet ready to overcome. This perspective is healthy, and spurs debate. Perhaps those ready to go are overlooking a valid point that may undermine long-term success. In their eagerness, a plan is not well-defined or executed, so a pull from below is necessary to evaluate the next steps.

Too much green, and the structure is top-heavy: chances are good it will topple over and float wherever the ocean decides. Too much yellow, and the beacon will be dim by comparison; although the buoy is a functional structure, initiating change is less aggressive, and will take a lot longer. Too much red, and more of the structure sinks into the depths, rendering it ineffective.

As far as I’m concerned, if we want to reach the sky, let’s make sure we foster a balance that keeps our buoy pointed up straight and tall.

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.

Healthcare is a large community with many moving parts and overlapping worlds. The words ‘community’ and ‘pharmacy’ can be put together to mean either the setting where pharmacy activities take place (community pharmacy) or in reference to the larger pharmacy group (pharmacy community). All pharmacists in all settings are connected by our shared scope of practice, although our day-to-day tasks may differ.

A colleague of mine, Dylana Arsenault, is a hospital pharmacist and director. As a life-long learner, she has always been fascinated with the latest clinical evidence and pharmacy trends in social media. She has been asked many a question from peers as well as other healthcare practitioners on a variety of subjects. Once she stumbles across a great article or reference, there is always some excitement that goes along. A little while back, she sought a way to share that information with others that may be interested. Enter Pharmacy Awesomeness.

This facebook page began as a fun project to post links, articles, news items to friends and friends of friends, but it’s quickly expanded to include professors, entrepreneurs, retail, hospital, industry pharmacists from many locales. Due to facebook privacy policies, it remains a closed group but those that ask to join will be treated to an amalgam of fun and education from a very diverse group of contributors.

Currently, there are internet memes interspersed with links promoting apps that help switch antidepressants and university academic detailing resources for oral contraceptives. A little scrolling will bring you to guidelines on prescribing hydrocortisone and a skin cancer self-exam book-ending a funny image featuring Star Trek’s Captain Picard. Everyone likes a little levity now and again, and this format really lets you browse through and trip on amusing items and many topics that may not be on the forefront of your practice, but feature pearls that you can use today. I also find that my academic curiosity is stoked to research and rediscover subjects that have been gathering dust in the dark recesses of a mind that graduated 14+ years ago.

So to all members of this great pharmacy community: stay curious, and stay connected. Take an extra minute to check a news feed, or scroll a Twitter trend that resonates with you. Most importantly, if it’s helpful or fascinating for you, chances are there are many others who would feel the same, so find a way to share it. I have a quick suggestion. Perhaps send Dylana a note asking to post your article/link/amusing pic/resource and become one of the three-hundred plus who receive instant notifications.

Whenever the passion for the profession seems to wane, it’s refreshing to feed off of the excitement of others and rekindle that fire. Pharmacy is awesome. A reminder now and then certainly doesn’t hurt.

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.

I was thinking recently about what it meant to people to discuss failure. Wikipedia provides the standard definition:  “Failure is the state or condition of not meeting a desirable or intended objective, and may be viewed as the opposite of success.” Further in the article, it touches on failure as being a matter of perspective or following an individual’s belief system, so I’d like to pick up that baton and run with it for a bit.

In order to fail, one requires a defined expectation or a set of expectations. These may be personal goals (working out three times a week, learning a new language) or work-related (reducing incident rates, increasing inventory turnover), but from the get-go there are usually criteria for success and deadlines to be met. If those conditions are not met, then we would deem it a failure. It feels so final, and somewhat dejecting.

So what if we took control over those conditions?

Think of a complex project. Perhaps there are ten things to accomplish to complete the project, and when the deadline approaches, only eight are met. Would that be a failure? Worst-case scenario, even if the project hinged on all ten being completed, and therefore the eight completed steps were rendered meaningless, there would be positives. The experience gained by pushing through the completed portions would give a sense of confidence and allow for more efficient action the next time. On the other hand, those remaining pieces were either too challenging with the timelines given, or required resources or training that weren’t available. So, on reflection, we are set up to have a greater chance of success for the next project.

Instead of ‘failing’, it’s more like we’re ‘on the path to success’. Let’s look at prescribing services. It’s been a few years since legislation was passed in Nova Scotia to allow pharmacist prescribing. Other provinces have taken up the mantle and are promoting to the public in varying ways. Our version features limited funding for government drug plan beneficiaries for select minor ailments. This is a positive step and the measurement of success is outcome-based; will the service be in-demand, will it save clinic or emergency room visits? Most importantly, will the pharmacist gain the trust of the public to carry out the services start to finish independent of a primary care physician? To place the yardstick to measure service value, we need repetition and a significant volume of interactions. So if we don’t reach a specified number, does that make the project a failure?

I prefer to think of it in terms of positives. What this opportunity has created is a forum for pharmacists to work towards a common goal and discuss what has worked and what hasn’t. Each new patient discussion extends the awareness to another family or community group, each physician notification provides education as to what we are able to remove from a hectic clinic workload. As pharmacists receive support to change their practice styles, this will allow for successful prescribing activities, and every dipping of the toe into the new waters is an encouraging one.

Really, the only failure in any of this is a failure to try something new. It’s like disliking a food you’ve never tried (which I’m sure we’ve all done at some point); you will never know if you’re missing out. So be bold – if you’re willing to learn from mistakes, and aren’t afraid to find success, then you can #Neverfail.

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.

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.

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.