Canadian Society of Hospital Pharmacists Annual Supplement

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Canadian Society of Hospital Pharmacists

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JUNE 2018 HOSPITAL NEWS 19

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

20 HOSPITAL NEWS JUNE 2018

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CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Patient-centred Pharmacy Care

Myrella Roy, BScPhm, PharmD, FCCP Executive Director

Patrick Fitch, BSP, ACPR President

Welcome n behalf of the Board of the Canadian Society of Hospital Pharmacists (CSHP), we welcome this opportunity to collaborate with Hospital News in featuring hospital pharmacy practice. CSHP is the national voluntary organization of pharmacists committed to patient care through the advancement of safe, effective medication use in hospitals and other collaborative healthcare settings. Founded in 1947, CSHP is a member-driven organization that operates at several levels: national, provincial branches, local chapters, affiliated boards, committees, and task forces. In 1988, it established the CSHP Research and Education Foundation to raise funds in order to support research projects and targeted education programs undertaken by members of CSHP. It has also forged a strategic alliance with the Association des pharmaciens des établissements de santé du Québec, the hospital pharmacist association in Quebec. CSHP supports over 3100 pharmacist members and student pharmacist and pharmacy technician supporters through the following programs and services: • advocacy and external representation to other organizations and the federal government

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• continuing professional development (conferences, webinars, etc.) and residency accreditation • information sharing in online forums and via a benchmarking report on hospital pharmacy services in Canada, a peer-reviewed journal, and bulletins • promotion of best practices via guidelines and the Excellence in Hospital Pharmacy program • facilitation of research with grants from the CSHP Research and Education Foundation • recognition of excellence with awards and honours In addition to holding a first university degree in pharmacy, a substantial number of pharmacists practising in hospitals and other collaborative healthcare settings have also pursued graduate formal training and studies or have completed a residency program, an additional year or two of experiential education that focuses on the application of therapeutic knowledge to patient care. Residency programs are accredited by the CSHP Canadian Pharmacy Residency Board to ensure quality in terms of both content and learning experience. In closing, we invite you to learn more about CSHP by visiting H www.cshp.pharmacy. ■

The Canadian Society of Hospital Pharmacists describes its vision for patient-centred pharmacy practice in its publication, Pharmacy Practice in Hospitals and Other Collaborative Healthcare Settings: Position Statements: patient-centred pharmacy practice respects and values the patient (and family) as a keypartner in decisions about healthcare. The care model is about getting to know the patient as a person, not a disease that needs to be treated. Listening to, understanding, and respecting the patient’s story about experiences and expectations that will affect the use of medicines are key components of the model. Patients should tell their story about medicines they are currently taking, or have recently taken, and any problems they had taking the medicine. It’s also important for the patient to tell the healthcare team what she realistically expects from the care provided. Pharmacists, and other healthcare professionals, consider this information when choosing which medicine, if any, the patient should take as part of the care plan.

JUNE 2018 HOSPITAL NEWS 21

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

ADVERTORIAL

Automation in Canada’s in-hospital pharmacies

espite the amount of focus on electronic health records today, manual and paper-based processes continue to play a significant role in Canadian hospital pharmacies. According to a recent survey conducted by Ricoh Canada involving over 220 respondents from 179 unique Canadian hospital pharmacies, 2/3rds

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22 HOSPITAL NEWS JUNE 2018

of responding pharmacists stated that their hospital medication order entry processes still rely on paper. Computerized physician order entry (CPOE) projects, which would eliminate most paper based medication workflows, are still many years away for some health care providers, yet automation of medication order management processes is needed to-

day to keep up with demand, ensure patient safety, and meet regulatory requirements. For the great many, for whom budget or resource constraints make it impossible to take on a costly and complex CPOE migration today, the solution may be a hybrid paper-to-digital “bridge” that leverages existing in-hospital technologies and infra-

structure, mirrors existing processes, and can continue to play a role in a future CPOE migration. Ricoh’s Pharmacy order management solution is a relatively low-cost and lightweight workflow and communication tool that Canadian hospitals can deploy today to have a major impact on in-hospital pharmacy efficiency and patient safety.

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Dedicated pharmacists improve patient safety aving a dedicated in-hospital pharmacist who can take the time to listen and educate has made a huge difference for William Knihnicki, a recent patient on 7th Medicine at St. Paul’s Hospital in Saskatoon. “When I came to the hospital, I truly believed I was taking too many drugs. I had no appetite and a lot of pain,” he says. “Having time to really talk to the pharmacist was helpful. She solved my appetite issue and (since then) they’ve even been able to take me off another drug, which is nice. I now understand what the drugs do and why I need to take them.” Experiences such as Knihnicki’s, where in-hospital pharmacists have the time to listen, dig deep into a medical history, answer patient questions, and work closely with their home pharmacy and physician, are becoming more common with the introduction of Connected Care Units (CCUs). CCUs are a system of care where care team members are better connected to one another and are responsible to each other to ensure that patients receive the safest, highest quality care possible. The care of each patient is overseen by a hospital-based physician who manages treatment and tests prescribed by specialists, and by a unit-based registered nurse (RN). The RN collaborates with the physician, specialists and other medical staff, including pharmacists, to assist with patient treatment. An Accountable Care Unit (ACU) follows the same model, but has some enhanced protocols that help ensure consistent care for more intensive medical conditions. The ACU model, now part of a larger Connected Care Strategy, was first implemented in Regina at Pasqua Hospital in 2016. Since that time, a number of ACUs have been established in Regina and Saskatoon. Lloydminster Hospital’s Third Flood Medical Unit launched the Connected Care model in January, while Battlefords Union Hospital in North Battleford designated the Acute Care Medical/Intensive

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Care Unit as a Connected Care Unit in February. One of the most significant changes within Connected Care hospital units is to have care team members (attending physician, primary nurse, pharmacist, social worker, Client Patient Access Services, physical and occupational therapy, dietician, etc.) dedicated to and located on the unit. This allows for more meaningful and regular interactions with patients like William and with other health care providers while improving patient medication safety. Jeff Herbert was the first pharmacist in Saskatoon to participate in the ACU model of care, and the first Saskatchewan pharmacist to be Structured Interdisciplinary Bedside Rounds (SIBR®) certified. “Prior to the ACU, a pharmacist was responsible for providing care to 80-100 patients every day. All we could do was solve problems generated from the dispensary and complete as many admission medication reconciliations as possible. Working on the ACU is a dream as I finally get to practice the way I was educated in my undergraduate training and pharmacy residency. Being able to see and talk with all my patients on a daily basis empowers them to understand what’s actually going on with their medications during their hospitalization.” “The pharmacists on this unit now have more time to truly investigate patients’ care needs because the number of patients they are responsible for is significantly lower,” says Barb Evans, pharmacy manager for St. Paul’s and Royal University hospitals. “We have time to do our work like we have always wanted to.” Another major patient safety improvement for pharmacists on 7th Medicine involves discharge medication planning. “We now have time to focus on discharge planning and communication,” explained Evans. “We can make sure the patient, their pharmacy and their family physician are all aware of what drugs need to continue post-discharge and what drugs have

This article was submitted by the Saskatchewan Health Authority. www.hospitalnews.com

Janelle Bortis, one of the pharmacists on 7th Medicine at Saskatchewan Health Authority, meets with her patient, William Knihnicki, at his bedside. been stopped. This improves safety and can reduce readmissions.” Knihnicki credits his good experience to dedicated staff on the unit. “I feel so much better. Thank you.”

The Connected Care Strategy is a provincial initiative designed to improve emergency wait times and patient flow, and strengthen team-based care H in hospitals and in the community. ■

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CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Hospital pharmacies:

Did you know? 1. Hospitals have pharmacies that are responsible for providing the medicines used throughout the hospital • Outpatient pharmacies in hospitals are not the same as hospital pharmacies. Hospital pharmacies take care of the patients in the hospital. • If your hospital has an outpatient pharmacy, that is not the hospital pharmacy. 2. The pharmacy team helps improve medication use • Hospital pharmacies have pharmacists, pharmacy technicians, and others who

work to help ensure that patients receive safe and effective medicines. They do more than dispense drugs! The pharmacy team works in close collaboration with other healthcare professionals to ensure the most appropriate care is being provided to patients. Together, they prevent and solve problems people might have in properly taking their medicines. There are almost 7 000 pharmacists working in hospitals in Canada, and roughly the same number of pharmacy technicians and assistants together. • They looks for trends in how drugs are being used in the hospital and

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what safety problems might be occurring. Their in-depth analysis helps the hospital to make improvements. 3. Pharmacists work with other healthcare professionals like nurses, doctors, and others on the patient care unit • Pharmacists are medication experts who review and assess a patient’s health information and medication history to ensure that any medications prescribed for the patient are needed, effective, and are safe to be administered. They create pharmacy care plans that are specific to what is best for the patient– that can mean switching medicines, starting new ones, or stopping some. And, they follow up to see how the patient is reacting to the drug – is she doing better with the drug or having side effects? • Patient care improves when a pharmacist is directly involved in the care of patients on the unit. There are better patient outcomes, decreased emergency department visits, decreased hospital re-admissions, decreased length of stay, decreased overall health-care costs, and fewer adverse drug reactions. • Pharmacists work in many areas of the hospital directly caring for patients – in emergency departments, inpatient care units, or outpatient clinics. Some pharmacists also provide care in the patient’s home. • Pharmacists teach other healthcare professionals about medicines: how the drugs work, how to prepare the drugs to give to patients, how to check if the patient is benefitting from the drug, and the significance

of drug interactions that might occur with other drugs the patient is taking, or how the patient’s medical condition could affect how the drug works for the patient. 4. Pharmacy technicians do more than count tablets • Pharmacy technicians are largely responsible for ensuring that the drugs prescribed for a patient are supplied correctly – the right medication, in the right formulation, at the right strength, in the right quantities. • They make sure that drugs are available in the patient care areas in case a patient needs immediate, urgent, or emergency care. • They listen to the patient (or her family) share information about the medicines the patient is taking. This information is recorded in the patient’s health record and is used by pharmacists and other prescribers to make decisions about how to best care for the patient. 5. The pharmacy team helps prepare patients to manage their medications at home • The pharmacy team reviews the list of medicines that the patient should be taking at home to make sure that it is correct and complete. They teach people how to use devices to take their medication (for example, by inhaler or by injection). They also help the patient create a plan to properly take their medicines after they are discharged from the hospital. This often involves communicating with the patient’s community pharmacist, home care nurse, or H physician. ■

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Do not use abbreviations:

Are we winning? et’s start with a pop quiz. Check out figure number one for an example of a record extracted from a patient’s progress notes as part of the best possible medication history:

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es Canada’s “Do Not Use: List of Dangerous Abbreviations, Symbols and Dose Designations.” To support this adoption, we developed a stellar armamentarium of tools to help prescribers and front line staff reduce the risk for patient harm.

THE BEST TOOLS TO HELP

c) Type of Do Not Use abbreviation used d) Incidence of Do Not Use abbreviation use This information is available to leaders, managers and staff in user-friendly graphs and tables to monitor progress in a variety of formats. With this information at your fingertips, you can really focus on which “Do Not Use Abbreviations” to target.

Imagine you’re the prescriber using YOU KNOW YOUR ENEMY this information to write admission orWe at AHS have some handy tools ders. What will you prescribe? Choose that help remind us about our “Do Not the best answer: MONTHLY AWARENESS Use Abbreviations” list. A) Humalog 40 units at breakfast, 20 CALENDAR units at lunch, 60 units at dinner Make your campaign Visible. AUDIT TOOL AND AUDIT and Lantus 140 units at bedtime. Monthly Awareness Calendars are RESULTS TRACKING B) Humalog 44 units at breakfast, 24 available that create a strong visual At AHS, a monthly/quarterly comunits at lunch, 64 units at dinner presence in your area highlighting an puterized audit tool is used to capture and Lantus 144 units at bedtime. abbreviation of the month, which is up quantitative and qualitative informaC) Humalog 4 units at breakfast, 2 for eradication. Take a look at Figure tion including: Units at lunch, 6 units at dinner number three to see the kinds of calena) Prescriber Profession and Lantus 14 units at bedtime. dars we distributed around our sites. di b) Type of order We’ll get to the answer nswer of this pop quiz in a second.. But first, what needs to be stressed here is how hazardous a misinterpreted abbreviation n can be. This is a classicc example of what we call ll a “Do not Use Abbreviaation.” “U” can and does cause use serious and fatal medication ion errors. It can be interpreted eted as the letter U or can easilyy be misinterpreted as the number mber four (4) or even the number mber zero (0). Add a dash of illegible egible handwriting and that becomes comes a recipe for a major medication cation catastrophe. So, which order did d you choose? The admitting orders were actually written as Choice B above. Fortunately, a savvy pharmacist noticed the unusual dosing and requested clarification. The Alberta Health Services (AHS) policy adopted the Institute for Safe Medication PracticLeft: Figure 4: Poster; right: figure 3: Calendar

POSTERS ‘Do Not Use Abbreviation’ posters are available to be displayed in high traffic areas such as patient care areas and physician lounges. Figure number four shows the kinds of posters we’ve used at our different sites.

VIDEO MESSAGING AHS uses video message displays on patient care area information monitors. Whenever possible, we’ve displayed different messages about our “Do Not Use Abbreviations” list as quick reminders to physicians and other healthcare professionals as they’re checking in on patients.

GET YOUR TEAMS ON BOARD Spread the word. Rally the troops to your cause with targeted education sesprescribers, nurses and pharsions for prescribers macists. There are superb awareness educational aand resources available tto physicians. See tthis doctor’s video testimonial about te what almost hapw pened to him: pe https://www. youtube.com/ watch?v=npCvQtVmbAo&feaCv ture=youtu.be ture As corny as it A sounds, our grandfasoun thers were right when they said, “people do really support causnot re they support people es; th with ccauses.” We eradicated Polio in Canada in just 21 short years making it everyone’s by mak cause. Imagine what we can do together with “Do Not Use Abbreviations” if pick them up as our we all pic H cause. ■

This article was submitted by Celina Colegrave and Ken Wou, Alberta Health Services. 26 HOSPITAL NEWS JUNE 2018

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Diversion of opioids and other controlled medications in hospitals pioid-related deaths have been on the rise in Canada in recent years, resulting in leaders to call on action to address this crisis. The Joint Statement of Action to Address the Opioid Crisis outlines the many initiatives underway including improving prescribing through new guidelines, ensuring availability of antidotes to treat overdoses and supporting access to resources for practitioners and those affected by opioid use disorder. Recognizing that there has been minimal study of the safeguards surrounding the large supplies of opioids and controlled drugs in hospitals, the HumanEra research team based at North York General Hospital, along with the Institute of Safe Medication Practices Canada (ISMP) recently conducted a scoping review of the literature and an extraction of diversion data from Canadian database repositories. The findings thus far, together with direct observations of hospital practices around the medication use and peripheral processes, aim to identify specific vulnerabilities that may exist within the hospital environment and inform future interventions that may mitigate the identified risks. Publication of these findings is expected in 2018-2019. The Canadian Society of Hospital Pharmacists will make use of HumanEra’s research as they develop guidelines for preventing, identifying, and responding to opioid diversion in hospitals and other healthcare facilities. The guideline will update and build on previous guidance documents from Health Canada and will include input from many collaborators. To date, partners include Health Canada, HealthCareCAN, the Canadian Nurses Association, the Canadian Anesthesiologists’ Society, the Paramedic Association of Canada, the Canadian Association of Emergency Physicians, ISMP Canada, and several health professional regulatory bodies. Publication of the guidelines is expectH ed at the end of 2018. ■

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This article was submitted by Sarah Jennings, Canadian Society of Hospital Pharmacists and Dorothy Tscheng, Pharmacist, Institute for Safe Medication Practices Canada (ISMP Canada). 28 HOSPITAL NEWS JUNE 2018

Members of BC Cancer’s Pharmacy Team in Vancouver.

Optimizing drug therapy for patients with cancer id you know that one in two Canadians are diagnosed with cancer at some point in their lives and that one in four Canadians die from cancer? So unfortunately, either we or someone we know and care about will be faced with the diagnosis of cancer. Medication therapy for cancer, although life-saving in some circumstances, can have significant side effects and drug interactions, to the extent that medication errors can lead to devastating outcomes for patients. Pharmacists, through their medication expertise can identify and resolve drug therapy problems, thus improving the intended outcomes with drug therapy, while minimizing side effects and drug interactions. At BC Cancer in Vancouver, pharmacists identify and resolve more than 20,000 medication-related problems every year. They do this by tapping into their in depth clinical knowledge about drug therapy, while asking such questions as: • Are the right types of medications being used for the diseases that the patient is experiencing or may be at risk for? • Are medications prescribed at the right doses, routes, frequencies, and durations? • Are there any potential or actual drug interactions between the prescribed cancer medications

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AT BC CANCER IN VANCOUVER, PHARMACISTS IDENTIFY AND RESOLVE MORE THAN 20,000 MEDICATION-RELATED PROBLEMS EVERY YEAR and other medications and/or natural health products the patient is taking? • Can the patient’s medication therapy be simplified by discontinuing the medications that are no longer needed? • Is there anything the patient could do to minimize the risk of experiencing medication-related side effects or complications? • When should the patient contact the healthcare team to share potential concerns about cancer treatment? • Are there certain tools and resources to help patients learn more about their cancer and its treatment, and assist them with complying with their prescribed medication therapy? Without question, there are numerous health benefits to patients having their medications reviewed by a pharmacist in the cancer setting and otherwise. Wouldn’t it be great if every patient in the healthcare system could have access to a pharmacist for the purpose of a comprehensive medication review? This would have huge cost-saving impli-

cations, in addition to known health benefits. In addition to clinical interventions, pharmacists at BC Cancer are integral members of the healthcare team, who contribute to the development of cancer treatment protocols, pre-printed order forms, patient information handouts, drug information requests, research initiatives, as well as many other patient-focused activities. An area of research that has created quite a lot of interest at BC Cancer is its Personalized Oncogenomics Program (POG), which is a collaborative clinical research initiative that evaluates the impact of genomic sequencing on treatment planning for BC patients with advanced cancers. By understanding the genomic changes that contribute to cancer and its behaviour, cancer treatment can be more targeted to potentially achieve better results for patients. Through innovative research and multidisciplinary expertise and teamwork, it is hoped that patients with cancer may achieve improved health outcomes and prolonged survival from their H treatments. ■

This article was submitted by Shirin Abadi, BC Cancer. www.hospitalnews.com

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ADVERTORIAL

NAPRA Pharmacy Cleanrooms

Practical considerations for design, construction and maintenance ospitals across the country are in the process of determining how they will address the facility requirements contained in the latest model standards released by the National Association of Pharmacy Regulating Authorities (NAPRA). The new requirements apply to both Sterile Compounding and Hazardous Compounding facilities and introduce the requirement to meet cleanroom construction and operation standards for the facility. Specific design challenges for hospitals include: how to upgrade existing facilities while maintaining services, ensuring the existing building services could support the rooms, and optimizing the design for process flow and productivity while keeping staff and patients safe. Cleanrooms require sophisticated wall construction and HVAC which can be a challenge to implement in some areas. Available cooling, power, and floor-to-ceiling

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space can be big factors in determining the location of these pharmacies. Similarly, hazardous compounding suites must be vented directly outdoors and incorporate proper exhaust clearances and dilution. In most cases a modular cleanroom solution offers considerable benefits including cleanroom grade wall/ceiling systems, faster assembly resulting is less down-time and impact to staff and patients. The assembly is often designed to fit within the available space. In addition to meeting NAPRA and CSA design requirements, the new facilities focus on providing a flexible and productive space for staff. Construction of pharmacy cleanrooms requires significant attention to detail. Cleanroom providers have systems which allow for completely flush surfaces for windows, doors, and other components of the room. The ISO standard 14644 requires all room corners to be coved, including at ceilings and floors. Doors, walls, and ser-

vices mounted in rooms must be airtight to ensure pressure control can be achieved. Modular cleanrooms have embedded raceways for electrical, services, and low-level returns which make sealing the environment easier to achieve. Critical to cleanroom construction is selection of wall materials that are suitable for the harsh chemical cleaning agents that are required. Surface treatments such as uPVC and stainless steel are preferred. During installation of the cleanroom there must be careful consideration to how the equipment, services, casework, and wall system interface. Coving on wall interfaces restrict placement of casework and equipment. Similarly, any ledges or flat surfaces must be minimized, often requiring shrouds to ensure the room can be effectively cleaned. Allowance must be made to ensure equipment can be moved into the space once all walls and doors are in place. Every opening into the room, including electrical, IT,

plumbing, and services must be completely sealed to ensure pressure control is maintained. Operation considerations include a pressure monitoring and recording system to ensure spaces meet required performance. Systems integrated to the facilities Building Automation system gives building operators access to monitor the cleanroom continuously, and safely retain data. The HEPA filter units can include LED status indicators letting staff know if any maintenance is required. Use of glazing and half lights on the doors provide good visibility into the space and reduce any claustrophobic effect. Pharmacy compounding rooms constructed to meet the new NAPRA model standards offer a new level of safety for staff and patients. Introducing cleanroom standards to the operation of these facilities can be an opportunity to revisit compounding operations, improve overall process flow, and ultimately protect both staff and patients.

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CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Wait, what?

Pharmacists also work in primary care clinics? harmacists who work in primary care clinics (or family health teams) are becoming more commonplace in Canada; they provide a number of services to improve the healthcare people receive. One of the most important things they do is involve people in decision making surrounding their medications. Due to the complexity of modern medicine, choosing the best treatment for chronic diseases is no easy task. Pharmacists working in primary care settings frequently have thorough discussions with patients and prescribers about the often numerous medication options for treating chronic diseases. Using their expertise in medications, they help patients clearly understand

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the benefits, risks, and costs of medications to allow patients to decide which medication would best suit them. The less acute nature of primary care clinics provides enough time for all parties involved to review this information and agree on the best course of action. After a decision about treatment is made, the pharmacist, patient, and prescribers continue to work together at follow up visits. During these appointments the primary care pharmacist supports dose optimization, and monitors how well the medication is working. The appointments also provide opportunities to work closely with the patient to manage or resolve any adverse effects the patient is having due to medications. Periodically, pharmacists will check in to ensure the

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PHARMACISTS WORKING IN PRIMARY CARE SETTINGS ALSO HAVE A ROLE IN ENSURING THAT WHEN THE PATIENT IS ADMITTED TO A HEALTHCARE INSTITUTION (SUCH AS A HOSPITAL) THAT THE TRANSFER IN CARE IS DONE AS SAFELY AS POSSIBLE medications continue to meet the patient’s and provider’s goals, and consider safely discontinuing (deprescribing) medications if they are not. Pharmacists working in primary care settings also have a role in ensuring that when the patient is admitted to a healthcare institution (such as a hospital) that the transfer in care is done as safely as possible. Making sure appropriate information about the patient’s medication flows from the primary care home to acute care facilities and back again after an acute care stay can reduce medication mis-

adventures and prevent readmissions to hospital. Pharmacists also educate patients on any medication changes that may have resulted from an admission, reinforcing any learning that occurred while the patient is still in the hospital. These are a few of the roles that pharmacists working in primary care perform on a daily basis to improve the health of the people they interact with. Ask if there is a pharmacist on your healthcare team that can work with you to educate you about, and H optimize your medications. â–

This article was submitted by Robert Pammett, Northern Health. 30 HOSPITAL NEWS JUNE 2018

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Pharmacists in the

Emergency Department

can do so much more harmacists are quite often found in emergency departments (ED); working away to gather a best possible medication history from patients; and performing medication reconciliation for admission to hospital. A Best Possible Medication History is when a health care provider compares the list of medications provided by a patient or caregiver, to another reliable source of information – such as the medication profile kept from

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your community pharmacy or a recent hospital visit. Having two sources of information helps to ensure the accuracy. Then, when there is a decision to admit a patient, OR to return home but with a modification of medication, the pharmacist will compare the medication lists from before coming to hospital and after coming to hospital to ensure that there are no differences in the lists and that the patient is receiving the medication they are supposed to and none that they aren’t supposed to. www.hospitalnews.com

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

STUDIES HAVE SHOWN THAT A MAJORITY OF VISITS TO AN EMERGENCY DEPARTMENT CAN BE CLASSIFIED AS MEDICATION RELATED For this reason, it is always important to bring an updated list to the ED from your pharmacy, or bring with you all the medications you take on a regular basis.

BUT DID YOU KNOW THE PHARMACIST IN THE ED CAN DO SO MUCH MORE?

Pharmacists are the health care provider best suited to provide information about medications. Studies have shown that a majority of visits to an ED can be classified as medication related. Having a pharmacist to review the history of why a patient may be

presenting to the department can help inform either the cause for this visit or prevent any future drug related issues occurring in the future as a result of treatments received or prescribed in the ED. In most provinces in Canada, pharmacists are able to prescribe for minor ailments and prescribe independently in collaborative practice with physicians and when given a diagnosis. Because of this, a pharmacist working in the ED is able to assess the need for medication and prescribe under certain conditions. The pharmacist can review lab results and follow up with patients if

they need treatment with antibiotics. This is one way that pharmacists can also help to ease the burden in busy emergency departments. Another area where the unique skill set of a pharmacist can be used is during traumas or resuscitations. A pharmacist has unique knowledge of medication use during these high stakes situations, and can anticipate the needs of the patient with respect to medications – have the doses prepared and ready to administer when asked for. This helps to save valuable

minutes; and ensures that nurses are at the bedside caring for their critically ill patient. One final area a pharmacist can provide useful assistance is our knowledge of drug toxicities and overdoses. Intentional and accidental overdoses are managed in the emergency department; and a pharmacist is able to gather the history of ingestion, confirm the substance and quantity, as well as recommend on the antidote to be given, dose, and parameters for monitoring H recovery. n

IN MOST PROVINCES IN CANADA, PHARMACISTS ARE ABLE TO PRESCRIBE FOR MINOR AILMENTS AND PRESCRIBE INDEPENDENTLY IN COLLABORATIVE PRACTICE WITH PHYSICIANS AND WHEN GIVEN A DIAGNOSIS

This article was submitted by Melanie MacInnis, IWK Health Centre (located in Halifax).

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CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Medication Safety Exchange ealthcare organizations providing patient care in Canada analyze medication incidents that occur in their organizations. The valuable knowledge gained from these local analyses can benefit other healthcare providers and organizations, and importantly – prevent patient harm from similar incidents. The Med Safety Exchange is a webinar series hosted by the Institute for Safe Medication Practices Canada (ISMP Canada) that offers a dynamic and supportive mechanism for shared knowledge while supporting the dissemination of incident learning. It fosters a learning culture and the development of strategies and safeguards for preventing patient harm. The first six webinars held from September 2017 to February 2018, reflected national interest and participation, with participation from all provinces and most territories. Webinar presenters represented both grassroots facilities as well as national organizations, such as the Canadian Patient Safety Institute (CPSI), Health Canada, ISMP Canada (including the Community Pharmacy Reporting Program – CPhIR), the Canadian Institute for Health Information (CIHI), and the Canadian Society of Hospital Pharmacists (CSHP).

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Participants’ responses to a post-webinar survey demonstrated perceived utility of the medication safety-related learnings, willingness to implement presented recommendations to optimize medication safety, and the value of medication incident reporting (Figure 1).

THE MED SAFETY EXCHANGE IS A WEBINAR SERIES HOSTED BY THE INSTITUTE FOR SAFE MEDICATION PRACTICES CANADA (ISMP CANADA) The success of the pilot demonstrated that the Med Safety Exchange is a valuable, practical, and beneficial program to promote reporting, sharing, and learning for all healthcare practitioners across Canada. Visit the website (https://www.ismp-canada. org/MedSafetyExchange/) to register for the next webinar, and contact medsafetyexchange@ismpcanada.ca to share learning from your medication incident analyses and your medication H safety initiatives! ■

Figure 1: Responses to the post-webinar survey questions related to medication safety culture. This article was submitted by Ambika Sharma, Pharmacist and Michael Hamilton, Physician, ISMP Canada. 34 HOSPITAL NEWS JUNE 2018

Telepharmacy services in Canada By Sammu Dhaliwall ith its large land mass and population density in relatively few pockets, Canada’s hospital pharmacy departments across the country face immense challenges providing pharmacist services. Many remote and rural communities are unable to recruit the services of a pharmacist for daytime work, and don’t have the economies of scale to keep a full time pharmacist busy. As technologies have advanced to improve the safety of medication distribution systems, even urban hospitals in populated areas have yet to embrace the true safety nets that pharmacists bring when medication orders are verified around-the-clock. The vast majority of hospital pharmacies still shut down overnight, despite the fact that healthcare is 24/7 and many of our sickest patients are ordered medications overnight. For such reasons, telepharmacy has been a growing service offer for health institutions over the past 15 years. The Canadian Society of Hospital Pharmacists defines telepharmacy as “The use of telecommunications technology to facilitate or enable the delivery of high-quality pharmacy services in situations where the patient or healthcare team does not have direct (in-person) contact with pharmacy staff.”1 Telepharmacy can be used to in many ways, for example, clinically review new orders 24/7, remotely check sterile IV preparations, or provide counseling to patients at discharge from the hospital. The first recognized telepharmacy services in Canada were within some of the health regions of British Columbia and New Brunswick in 2003, in which larger regional hospitals helped review orders for certain small hospitals that didn’t have regular onsite pharmacists to help support the patients. In 2004, a private telepharmacy company started providing remote clinical order review to a hospital in Moose Factory, Ontario, as the hospital

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was not able to recruit a pharmacist. This telepharmacy company today services over 45 hospitals, providing remote clinical order review around-the-clock and additionally helps pharmacy departments meet medication management standards by experimenting with videoconference technologies (including Ontario Telemedicine Network’s secure links to healthcare institutions). While there are many other current examples of telepharmacy services provided across the country, large gaps remain, leaving many deficiencies in pharmacy services. Technologies utilized to provide Telepharmacy in Canada include:

MEDICATION ORDER MANAGEMENT SOLUTIONS • Allowing nurses to scan physician medication orders securely to the remote pharmacist in hospitals which are still mostly paper-based • Enable one pharmacist to manage multiple hospitals simultaneously with clinical support and specific medication reviews overnight to improve efficiencies and safety

VIDEOCONFERENCE SOLUTIONS • Allowing pharmacists to communicate with patients for education and discharge counselling • Enabling pharmacists to communicate with physicians, nurses and other healthcare providers.

REMOTE CAMERA VERIFICATION SOLUTIONS (which bring telepharmacy support to one of the highest risk areas of hospital pharmacy – compounding of sterile products, chemotherapy, and non-sterile medications): • Allowing for remote check of compounded products by pharmacist or pharmacy technician and future traceability of products if errors are suspected or recalls occur. www.hospitalnews.com

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

TELEPHARMACY AS “THE USE OF TELECOMMUNICATIONS TECHNOLOGY TO FACILITATE OR ENABLE THE DELIVERY OF HIGHQUALITY PHARMACY SERVICES IN SITUATIONS WHERE THE PATIENT OR HEALTHCARE TEAM DOES NOT HAVE DIRECT (IN-PERSON) CONTACT WITH PHARMACY STAFF • Successfully implemented in Newfoundland & Labrador enabling chemotherapy products to be prepared in remote hospitals, allowing patients to receive life-saving therapy closer to home Although telepharmacy has been used by Canadian hospitals for over

15 years, there is a need for expansion of its use in the future, to allow for advancement in how pharmacy services are delivered to and received by patients and to provide all patients, regardless of geographical location in Canada, the same H standard of care. ■

This article was submitted by Sammu Dhaliwall, Telepharmacy Services Solutions.

Pharmacy Services 24/7 Improves Patient Safety All 3 cases occurred in the late evening/overnight period, when the hospital pharmacy department was closed, and the telepharmacy service was in place, ensuring the safety of all prescribed medications. Case 1: An order for dalteparin (an anticoagulant) was prescribed with a dose of 2,500 units (prevention of deep vein thrombosis (DVT) dosing). After review and investigation, the telepharmacist determined that the patient actually had (DVT), and required a full treatment dose instead. The telepharmacist determined that the physician’s intended dose was 25,000 units (a zero was left off by mistake) As the patient was obese, the telepharmacist determined 12,500 units twice daily was a safer and more effective option and got the order changed to this. Prompt pharmacist review right after prescribing, resulted in the patient receiving the correct dose immediately, for a serious, potentially life-threatening condition. Case 2: Patient X was admitted to hospital with an order for long-acting Isosorbide Monohydrate (ISMN) once daily. As ISMN was not on hospital formulary and not stocked by the hospital, the nurse decided to substitute with an equivalent dose of Isosorbide Dinitrate (ISDN) once daily. Upon reviewing the order, the telepharmacist advised the nurse that the two are not equivalent and determined that the patient had her own supply of ISMN which the pharmacist instructed the nurse to use instead, thus preventing the wrong medication from being administered. Case 3: An order was received for warfarin 4.5 mg to be given now. The telepharmacist noted that the patient’s INR (a measure of how long it takes the blood to clot) was too high and noted that the admitting diagnosis was a nose bleed. The telepharmacist immediately intervened to get the warfarin order held and ensured that the INR would be checked and warfarin reassessed the next day. The immediate action of the telepharmacist in this case, ensured the best chance of a positive outcome, by preventing a potentially serious bleed. Contact Northwest Telepharmacy Solutions to prevent medication errors from occurring while the inpatient pharmacy is closed after-hours and on weekends. No patient deserves a medication error.

www.northwesttelepharmacy.ca www.hospitalnews.com

JUNE 2018 HOSPITAL NEWS 35

Pharmacy

residency training in canada

any pharmacists working in hospitals have completed a pharmacy residency program. What are pharmacy residencies? They are structured, post-graduate education programs designed to enhance pharmacist skills, knowledge and abilities. These programs build upon the foundational skills learned in pharmacy programs. Through structured rotations in pharmacy practice, education, research, and administration, residency programs aim to prepare pharmacists for challenging and innovative pharmacy practice. Graduate of

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pharmacy residency programs are an important source of highly qualified pharmacists trained in institutional practice. In Canada, pharmacy residency programs deliver their educational content in alignment with published residency standards that are established by the Canadian Pharmacy Residency Board (an affiliated board of the Canadian Society of Hospital Pharmacists). The 2018 Accreditation Standards for Pharmacy (Year 1) Residencies are designed to develop pharmacists who are proficient in providing direct patient care in a variety of clinical settings.

BD is one of the largest global medical technology companies in the world and is advancing the world of health by improving medical discovery, diagnostics and the delivery of care. The company develops innovative technology, services and solutions that help advance both clinical therapy for patients and clinical process for health care providers. BD has 65,000 employees and a presence in virtually every country around the world to address some of the most challenging global health issues. BD helps customers enhance outcomes, lower costs, increase efficiencies, improve safety and expand access to health care.

bd.com 36 HOSPITAL NEWS JUNE 2018

PHARMACY RESIDENCIES ARE STRUCTURED, POST-GRADUATE EDUCATION PROGRAMS DESIGNED TO ENHANCE PHARMACIST SKILLS, KNOWLEDGE AND ABILITIES As well, graduates gain competency in pharmacy operations, project management, education, practice management, and leadership. The 2016 Accreditation Standards for Advanced (Year 2) Pharmacy Residencies build upon the competencies developed in a Year 1 Pharmacy Residency, and further refine these skills in a defined area of practice (specific therapeutic area, patient population or type of practice). Residents of these programs are expected to demonstrate expertise in direct patient care. These programs also focus on teaching and research. There are 34 accredited Pharmacy (Year 1) Residency Programs and three accreditation-pending Pharmacy (Year 1) Residency Programs. There is currently one accreditation-pending Advanced (Year 2) Pharmacy Residency Program, with several other programs currently under development. These programs operate in 9 of the 10 Canadian provinces and range

in size from a single resident to over 45 residents. While all of these programs are designed to comply with the corresponding residency standards, differences between programs exist in requirements and experiences. Some programs are offered in specialty areas, including pediatrics, mental health, cancer care and primary care, while others are offered in general practice settings. In spite of these differences in practice experiences and requirements, all residency graduates will meet the required competencies upon graduation and will be granted use of the ACPR or ACPR2 designation for the Year 1 or Year 2 program, respectively. Graduates from these programs go on to work in a variety of roles such as clinical pharmacists, clinical pharmacy specialists, pharmacy leaders, educators and researchers. More information on Residency Programs in Canada can be found on the Canadian Pharmacy Residency Board website H (https://cshp.ca/cprb). â–

This article was submitted by Jennifer Bolt, Canadian Pharmacy Residency Board, Chair. www.hospitalnews.com

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

TO ADDRESS YOUR CONCERNS REGARDING DRUG WASTAGE. At BD, we understand the importance of readiness, especially with the new beyond-use dating requirements as part of the NAPRA Model Standards just around the corner. A key imperative for Canadian pharmacies will be managing the costs associated with these new standards. The BD PhaSeal ™ closed-system drug transfer device (CSTD) is a system that can both alleviate safety concerns and potentially drive savings to your bottom line as part of a drug vial optimization (DVO) program.1 With decades of conversion management expertise here in Canada, you can rely on BD to guide you through a custom conversion program suited precisely to your unique needs. Discover the difference of the right partner. Discover the new BD.

Speak today with your BD representative about BD HDS solutions, including the BD PhaSeal™ and Texium™ systems, or email PhaSeal.Canada@bd.com 1 Carey ET, Forrey RA, Haughs RD, et al. Second look at utilization of a closed-system transfer device (PhaSeal). Am J Pharm Benefts. 2011;3(6):311–318. © 2018 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company. MC9062

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JUNE 2018 HOSPITAL NEWS 37

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Opioids for pain after surgery: Your questions answered – resource for patients urgical patients are four times more likely to receive opioids at discharge from hospital than their non-surgical counterparts. A recent study of post-surgical patients by Brat et al (2018), showed each additional week of opioid prescription is associated with a significant increase in opioid misuse among opioid-naïve patients. A patient resource, “Opioids for pain after surgery: Your questions answered” was developed collaboratively with, and endorsed by, Patients for Patient Safety Canada, the Canadian Patient Safety Institute (CPSI), the Canadian Society of Hospital Pharmacists (CSHP), the Canadian Deprescribing Network, Choos-

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ing Wisely Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), the Canadian Nurses Association (CNA), the Canadian Medical Association (CMA), the Canadian Association of General Surgeons, and the Institute for Safe Medication Practices Canada (ISMP Canada). This resource was developed in accordance with recent guidelines and preferred practices. The handout, which builds on the movement ‘5 Questions to Ask about Your Medications’, was launched by Choosing Wisely Canada through the Opioid Wisely Campaign. The aim is to equip patients with important messages in plain language about opioid use after surgery. Some

Pharmacy Capital Contract to Meet New NAPRA Standards HealthPRO is now accepting commitments from members for its Biosafety Cabinets and Hoods Contract. Ranging from Biosafety Cabinets, Laminar Flow Hoods and Compounding Isolators, including Class I, II and III protection levels for use in a variety of controlled environments, pharmacies and cleanrooms. For more information, please contact: Rafael Perez Director, Capital Equipment rperez@healthprocanada.com

38 HOSPITAL NEWS JUNE 2018

THIS RESOURCE WAS DEVELOPED IN ACCORDANCE WITH RECENT GUIDELINES AND PREFERRED PRACTICES key messages include: use the lowest possible dose for the shortest possible time; opioids are usually required for less than one week after surgery; and ask about the use of other methods to reduce pain including non-opioid pain medications. The resource also advises patients to securely store medications and to return any unused medications to a community pharmacy. Improper storage or disposal of opioids has resulted in accidental poisonings, medication errors, and inappropriate use. The Health Product

Stewardship Association (www.healthsteward.ca) can be contacted for more information about locations that accept unused medication returns. Opioids for pain after surgery: Your Questions Answered is available: In English: https://www.ismp-canada.org/download/OpioidStewardship/ OpioidsAfterSurgery-EN.pdf In French: https://www.ismp-canada.org/download/OpioidStewardship/ OpioidsAfterSurgery-FR.pdf For more information about use of opiH oids, visit www.opioidstewardship.ca ■

This article was submitted by Alice Watt and Sylvia Hyland, Pharmacists, Institute for Safe Medication Practices Canada (ISMP Canada). www.hospitalnews.com

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CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

It’s just culture, so what? onder for a moment any of the times that you or your colleagues were involved in a medical or medication incident – an incorrectly processed prescription, a miscalculated dose, or ordering a treatment intervention for the wrong patient perhaps? In the wake of such an incident, how did you or your colleagues react? Perhaps you experienced the tensing up upon realizing the error, followed by the desperation of looking for a solution. What are the underlying causes of your reaction? Is it fair that healthcare professionals should be exclusively blamed for or be held accountable for the failings of a healthcare system that they do not control? What are the problems with such a culture? Are there alternatives?

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MINDFUL ORGANIZATIONS CONTINUALLY LEARN, ADJUST, AND REDESIGN SYSTEMS FOR SAFETY AND MANAGE BEHAVIOURAL CHOICES MATURELY BLAME CULTURE It is characterized by blame being attributed to outcomes rather than the actions leading to or the systematic factors that contributed to the outcomes. Disciplinary action is usually carried out against the healthcare professional(s) closest to the incident and the punishment is dispensed in order to deter future undesirable behaviour. Reprimands range from public condemnation and shame, documentation of disciplinary action in employee

Revolutionizing the Patient Medication Experience Keeping patients at the center of care means ensuring medication availability, affordability, safety, and adherence. At Omnicell, we’re inspired to create safer and more efficient ways to manage medications and supplies across all settings of care. We empower our healthcare partners to reach their unique goals through an industry-leading medication management platform that drives operational, financial, and clinical success, including: Workflow Automation – By leveraging innovative hardware and software solutions, health systems can shift staff focus from operational demands to meaningful clinical contributions. Predictive Intelligence – Real-time, cloud-based reporting, analytics, and benchmarking drive more strategic decision making. Performance-Driven Partnerships – Solutions that are customizable, scalable, and easily integrated into hospital IT systems, including EHRs, are designed to meet any organization’s unique needs.

personnel files, and in extreme cases, termination. The typical response to a culture of blame is characterized by an unwillingness to take risks or accept responsibility for mistakes for fear of criticism or punishment. This causes people to blame each other in order to avoid the punishment. Healthcare practitioners will likely remain silent in response to performance problems, near misses, or professional errors. Such mistrustful silence will make incident analysis harder and more difficult to identify existing vulnerabilities in organizational processes that may inevitably result in recurring errors, regardless of the professional performing the task.

JUST CULTURE: AN ANTIDOTE In this type of culture, the goal is not blame but rather process improvement, ultimately to advance patient safety. Process improvement is a disciplinary approach in which an organization learns and improves by openly identifying and examining its own weaknesses. Members can openly question existing practices, express concerns, and admit mistakes without suffering ridicule or punishment. The complexity of the situation, determining factors that “allowed” or even “encouraged” the error, are considered. The individuals involved receive constructive feedback and fair-minded treatment. This kind of culture fosters mindfulness through-

out an organization. Mindful organizations continually learn, adjust, and redesign systems for safety and manage behavioural choices maturely. However, the main issue with this type of culture is that, if poorly implemented, it can result in worse outcomes than a blame culture. Therefore, a just culture requires careful consideration and well thought-out implementation. This is not an easy task, because the impact of quality improvement techniques and isolated training programs on cultural change has been shown to be limited.

CHANGING CULTURE: WHAT CAN WE DO ABOUT IT? Organizational culture cannot evolve sequentially, but requires a holistic approach. Without a fundamental change to the core values, norms, and expectations of the organization, change remains superficial and shortlived. Failed attempts to change may lead to cynicism, frustration, loss of trust, and deterioration in morale among members. It is only with the support of leadership and a human resources (HR) department that has the necessary institutional authority to implement consistent HR and professional practices that help shift general healthcare culture towards shared learning from incident analysis and just culture. In a practice environment with a just culture, all members of the healthcare team understand their ethical responsibility to call out defects, including their own, in the system of care without fear of retribution. In such a culture, healthcare professionals can feel at ease, safe in the knowledge that their mistakes will not necessarily lead to punishment but will always lead to systematic corrections and institutionH al improvements. ■

To learn more, visit www.omnicell.com Aleksa Stankic is a PharmD Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; Certina Ho is a Project Lead at the Institute for Safe Medication Practices Canada (ISMP Canada). 40 HOSPITAL NEWS JUNE 2018

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CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

excellence

What is in hospital pharmacy practice? atient-centred care. Best practice. Communication and collaboration. It’s no coincidence that these are the three themes of CSHP’s program, Excellence in Hospital Pharmacy. CSHP’s Excellence in Hospital Pharmacy program is a multi-year initiative that aligns with CSHP’s Strategic Plan (to 2020). Patients are our focus. Excellence will assist pharmacy teams to strive to provide exceptional care to patients and help improve patient health outcomes. It is specifically designed to assist members in focusing their efforts towards fostering excellence

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PATIENT-CENTRED CARE. BEST PRACTICE. COMMUNICATION AND COLLABORATION.

and innovation in patient care. The overarching goal for the program is “Improving Patient Health Outcomes”. Excellence draws on many of the expectations laid out in CSHP’s Phar-

macy Practice in Hospitals and Other Collaborative Healthcare Settings: Position Statements. The collection of statements in this publication “describes a desired and achievable level of performance that is applicable to

the practice of pharmacy in a healthcare organization, regardless of geographical location, experience, or area of practice.” As such, it describes the high quality of patient-centred care that patients should receive from its hospital pharmacy staff. The statements also recognise that pharmacy personnel do not work alone, but rather are partners in care, working closely with the patient and with other healthcare workers. And, that this care cannot be provided without being good stewards of the resources given to manage how medications are used throughout the healthcare H organization. ■

JUNE 2018 HOSPITAL NEWS 41

Making a difference around these key themes: Patient Engagement/Patient-Centredness Best Practice, including Patient Safety Effective Communication and Collaborative Practice Listens Values

iples, 3 th princ em 6 s,

Improving patient health outcomes.

Collaborates The pharmacist develops and assesses the pharmacy care plan in collaboration with other members of the healthcare team. • Proportion of patients who receive comprehensive direct patient care from a pharmacist working in collaboration with the health care team. (cpKPI1) • Proportion of patients for whom a pharmacist participates in interprofessional patient care rounds to improve medication management. (cpKPI1) • Proportion of pharmacists whose practice includes advanced practice roles. 1

Cares The pharmacist provides proactive patient-centred care to develop a pharmacy care plan that reflects the patient’s goals. • Proportion of patients for whom a pharmacist has developed and initiated a pharmacy care plan. (cpKPI1) • Proportion of patients who receive education from a pharmacist about their disease(s) and medication(s) during their hospital stay. (cpKPI1) • Proportion of patients who receive medication education from a pharmacist at discharge. (cpKPI1) • Extent of patient-reported involvement in care decisions.

Implements The pharmacy department implements risk-reduction strategies to improve the safety of the medication-use system. • Implementation of medication system risk-reduction strategies. • Evaluation of the impact of medication system risk-reduction strategies.

Fernandes O, Toombs K, Pereira T, Lyder C, Bjelajac Mejia A, Shalansky S, et al. Canadian consensus on clinical pharmacy key performance indicators: knowledge mobilization guide. Ottawa, ON: Canadian Society of Hospital Pharmacists; 2015.

cshp.ca/excellence 42 HOSPITAL NEWS JUNE 2018

ason 1 re es,

Communicates The pharmacist communicates the plan of care to the professionals who will assume responsibility for care of the patient at care transitions. • Proportion of patients whose plan at transition of care is communicated to the appropriate health care provider. • Proportion of patients who receive documented medication reconciliation at discharge (as well as resolution of identified discrepancies), performed by a pharmacist. (cpKPI1)

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The pharmacy team views patients as valuable, effective partners in shared decision-making. • Presence of patient experience advisors participating on at least one pharmacy committee or working group. • Implementation of tools for staff and leadership that include expectations regarding patient-centred care.

The pharmacy team listens to, understands, and respects the patient’s story about experiences and expectations that will affect the use of medications. • Extent of patient-reported communication with the pharmacy team. • Extent of patient-reported satisfaction with their interactions with the pharmacy team.

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