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Canadian Society of Hospital Pharmacists

Joint Venture Partnership supports


implementation of Vanessa’s Law with educational material By Ellen Gardner and Valentina Jelincic dverse drug reactions (ADRs) and medical device incidents (MDIs) occur in hospitals, including emergency departments, and in people’s homes – but such events are significantly underreported. The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa’s Law, honours the memory of Vanessa Young, who died at the age of 15 due to a heart problem after being prescribed cisapride. Vanessa’s Law is intended to increase medication and device safety in Canada by strengthening Health Canada’s ability to collect information and take quick and appropriate action when a serious health risk is identified. The Law includes a mandatory requirement for hospitals to report serious ADRs and MDIs. This provision of the law comes into effect later this year.


serious ADR and MDI reporting. “The Joint Venture partnership leverages the strengths of our organizations, in collaboration with Health Canada, to support provinces and territories, hospitals and healthcare providers in preparing for implementation of the Vanessa’s Law mandatory reporting requirements,” says ISMP Canada CEO Carolyn Hoffman. “We are extremely proud to be working with Health Canada in partnership with ISMP and CPSI to address serious gaps in safety reporting in hospitals,” says Leslee Thompson, CEO of HSO.

MAKING THE CONTENT RELEVANT AND USEFUL One of the principles guiding the Joint Venture is that the best people to communicate information about mandatory serious ADR and MDI reporting are those closest to their audience.

Education Modules – A Helpful Approach? Response

# of Pilot Respondents Proportion of Respondents













Figure 1: 94% of respondents to the Pilot questionnaire indicated that the approach to education about Vanessa’s Law mandatory requirements is helpful. Three organizations – the Institute for Safe Medication Practices Canada (ISMP Canada), the Health Standards Organization (HSO), and the Canadian Patient Safety Institute (CPSI) – are working in a joint venture to assist Health Canada with outreach, education, and feedback to encourage 20 HOSPITAL NEWS JUNE 2019

Therefore, hospitals, educational organizations, and accrediting bodies are encouraged to use the educational material in a way that is most useful and relevant to their stakeholders. The educational content is contained in five PowerPoint modules, which include one concise overview module.

“The educational modules are designed to be ’building blocks’ for healthcare providers to integrate into their own learning or to incorporate into orientation, continuing education, and other education activities,” says Sylvia Hyland, Vice President and Chief Operating Officer at ISMP Canada. The Joint Venture partners suggest the materials be used in the following ways to raise awareness of Vanessa’s Law and to support reporting and learning: • Hospitals can include some, or all, of the educational slides in their orientation programs. • Educators can use the content in presentations or as part of a curriculum. • Professional associations, colleges, and societies can use the content to create accredited courses or certification programs for continuing education. • Patient and consumer organizations can use the materials to increase awareness and knowledge among their members.

MODULES CONTRIBUTE TO UNDERSTANDING OF VANESSA’S LAW A pilot test of the educational material was held for three weeks in March and April. Stakeholders were invited to review the modules and provide feedback by responding to a questionnaire. The Vanessa’s Law Questionnaire was completed by 255 unique respondents from across Canada, both individuals and organizations. The largest numbers of respondents were pharmacists and hospitals. From the questionnaire, it was learned that respondents reviewed

one, some, or all of the educational modules. The majority (83.1%) of respondents had reviewed all five modules. Results from the pilot include: • Over 89% of respondents reported they had a good or strong understanding of Vanessa’s Law after reviewing the educational modules. • 94% of respondents indicated that use of the slides/modules in communication about Vanessa’s Law will be a helpful approach. • 91% of respondents indicated that they will be using the slides to communicate about Vanessa’s Law mandatory reporting requirements. • Many respondents provided helpful suggestions for additional information to be included in the final PowerPoint slides. • Respondents also provided suggestions for additional educational formats that could be considered in future for additional knowledge dissemination/translation. “These results are very encouraging in that they reveal a high level of interest in using the educational material in communicating about Vanessa’s Law,” says Sylvia Hyland. The Joint Venture partners will be incorporating the feedback to produce the final education modules, scheduled for release in July 2019. “Vanessa’s Law is essential to Canada’s healthcare system,” says Chris Power, CEO of the Canadian Patient Safety Institute. “We can’t improve what we don’t measure. These new reporting requirements will help contribute to improving the safety of drugs and medical devices. Everyone in Canada deserves safe healthcare.” Learn more about Vanessa’s Law on H the Health Canada website. ■ www.hospitalnews.com


CSHP’s new CEO Jody Ciufo aims to amplify the voice of hospital pharmacists across Canada n December, 2018 the Canadian Society of Hospital Pharmacists (CSHP) announced the appointment of Jody Ciufo as its new Chief Executive Officer. Since then, the Society has been on a path towards elevating the profile of hospital pharmacists. With full support of the CSHP Board of Directors, Ciufo is applying effective leadership strategies honed over her lengthy career in association management. Her mandate is to grow the membership, engage the hospital pharmacy community, and amplify the association’s collective voice. Relying on her experience and successful track record in turning things around for associations, the CSHP Board of Directors is changing the game at CSHP. “The Society has an incredible opportunity to leverage the shifting landscape within the association world,” says CSHP Board President, Douglas Doucette. “Our members want us to build on our past successes – not rest on them. People



today have more membership options to choose from than ever-before. We want to ensure they rely on CSHP for a better member experience, enhanced programs, more educational opportunities and generally new initiatives for diverse needs.” “As a member-driven organization, we approach our mandate as a community working together to ensure our practice is always evolving into something better,” adds Ciufo. Applying this philosophy, Ciufo is underscoring the value of a national voice. “Our collective expression can be felt in things such as our advocacy work,” she says. CSHP recently responded to Health Canada’s intent to amend the Narcotic Control Regulations, the Benzodiazepines and Other Targeted Substances Regulations, and the Food and Drug Regulations - Part G, as they pertain to pharmacists. “On behalf of CSHP members, we requested the regulations reflect contemporary pharmacy practices, close regulatory gaps, remove barriers to practice, and

remove inconsistencies between the regulations,” says Ciufo. Another planned evolution for CSHP is to expand its community of members to include pharmacy technicians. “Pharmacy technicians are such an integral component of the hospital pharmacy world,” says Doucette. “We can’t call ourselves leaders in hospital pharmacy practice without recognizing the value pharmacy technicians add to our community,” he says. “That’s why we offer programs and content for pharmacy technicians such as access to professional liability insurance, pharmacy specialty networks (PSNs) and other resources,” he says. “The next natural step is to strengthen our bond by including pharmacy technicians as full members,” says Doucette, “The (CSHP) Board chose Jody Ciufo based on her experience steering big ships to lead this exciting initiative.” Indeed, bold changes are not new to Ciufo. During the last federal election, as the Executive Director of the Canadian Housing and Renewal Associa-

tion, Ciufo initiated the award-winning Housing For All advocacy campaign that was a key factor in the federal government’s $40 billion commitment to affordable housing in 2016. “I work with a vision of serving the public good, and applying strategies that drive necessary systemic changes,” she says. “The Canadian Society of Hospital Pharmacists is a perfect next-step for that as our work is integral to the best possible patient care through the advancement of safe, effective medication use in hospitals and beyond. I’m inspired by what the Society has achieved and honoured to be chosen to lead this respected organization.” To learn more about Jody Ciufo and H the CSHP please visit www.cshp.ca ■



Taking a deep breath – there’s a pharmacist to help By Negar Golbar hronic Obstructive Pulmonary Disease (COPD) is a respiratory disorder affecting the lungs. Symptoms include shortness of breath, a cough with mucus, lung infections, feeling tired, and wheezing. A common misconception is that these symptoms are a natural part of the aging process. COPD is a slowly progressive disease which means that it will not go away with time and there is no cure. Approximately 500,000 Canadians over the age of 35 have been diagnosed with COPD, and it is estimated that an almost equal number of middle-aged individuals may be suffering from undiagnosed COPD. COPD is the fourth leading cause of death in Canada. It significantly impacts a patient’s quality of life and leads to multiple hospitalizations. In addition to the already harrowing consequences to the patients and their families, annual COPD related health care costs are estimated to be almost $2000 per patient. The annual indirect costs associated with time off work can amount to approximately $1000 per patient. In 2010, the total costs related to COPD in Canada were $4 billion annually and this is expected to increase. Appropriate and prompt medical treatment is nec-



essary to improve quality of life and decrease both personal and health care related costs. COPD does not have a cure, but there are medications that can help. Medical management of COPD is generally done with inhalers that can improve shortness of breath, improve lung function, and help patients stay out of the hospital. Inhaled therapies can help patients return to their normal, active lifestyles and overall, feel better. In recent years, several new inhalers have emerged on the market to help manage COPD. The inhalers come with a variety of medicinal ingredients, combination of ingredients, and devices. Several considerations need to be made when deciding what medication would fit best for the patient. Pharmacists can be helpful in this regard when it comes to tailoring and personalizing therapy. Pharmacists can help select the best, most effective medications for patients while considering factors such as cost, drug coverage, ease of inhaler use, and use of combination therapy so patients have fewer devices to navigate. Pharmacists can also teach patients how to use their inhalers and provide education to help patients understand what their inhalers do. The community pharmacist is often the easiest health

care provider to access for patients; usually there is no appointment needed and short wait times relative to walk-in clinics or emergency rooms. Patients can therefore engage with their community pharmacist regularly and conveniently to discuss their therapy, receive education, refine inhaler technique, and receive coaching on medication adherence. Pharmacists are helpful in COPD management not only in traditional community pharmacies, but within the hospital as well. Many patient care areas of the hospital will have a pharmacist who can help with managing therapy and providing education. Improving outcomes for patients admitted with COPD related illnesses is a major initiative that Alberta Health Services (AHS) Calgary Zone has undertaken. AHS Calgary Zone has implemented the COPD/Heart Failure (HF) Outcomes Improvement Initiative which serves to offer the best care by using the most recent treatment guidelines and providing education to patients. Front line staff such as nurses and pharmacists have taken on the role of educating each patient who is hospitalized because of their COPD in an effort to reduce the rate of readmission. Like in community, the ward pharmacist brings value to the team

by helping select appropriate therapy, being considerate of the cost to the patient, providing education and assessing inhaler technique, discussing COPD action plans, and liaising with the community pharmacy so there are no gaps in therapy. Additionally, if the patient shows any interest in quitting smoking, the ward pharmacist can create a smoking cessation plan that can start in the hospital and continue once the patient is discharged. Although there is no cure for COPD, it can be successfully managed and even prevented with the right education. Approximately 80-90 per cent of all COPD cases are caused by smoking; therefore, quitting smoking is the most effective way to prevent COPD from happening and to slow disease progression if already diagnosed. Early cessation of smoking is optimal; however, it is never too late to quit. Pharmacists both in community and in hospital can play an important role in helping patients quit smoking. Pharmacists can help create quit plans, monitor and encourage, provide options to help combat cravings, and help patients navigate all the nicotine replacement options. Depending on the province, the pharmacist may even be able to prescribe medications H to help patients quit. ■ www.hospitalnews.com

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A day in the life of a pharmacist on a surgical unit By Nathaniel Morin start my day in the same way as many of my pharmacist colleagues across the hospital, reviewing my unit for new patients, orders, and triaging medication-related issues that need my attention. Before morning interdisciplinary rounds, I review charts and assess what I can do to make the biggest impact for the people admitted to my unit. In orthopedic surgery, we have a mix of elective and emergency surgeries. This means that the unit might look completely different than when I left the day before. We also have a high turnover, so prioritizing and efficiency is important. Today, we have eight new admissions – six elective hip or knee replacements, one hip fracture, and one septic arthritis – and my patients’ most urgent medication-related problems seem to be anticoagulation and diabetes control.


can apply for Additional Prescribing Authorization (APA). I have APA, so after I help John make his decision, I fill out and submit the Alberta Blue Cross special authorization forms, write a prescription for John myself, and start him on the anticoagulant in hospital, rather than asking a physician to do it for me. I find that using my APA allows me to use my abilities as the resident medication expert, to help lighten the workload for surgeons, physicians and nurse practitioners. Next I meet with Jane. Jane’s diabetes medication were held before her surgery, as is common practice to avoid hypoglycemia (low blood sugars) while fasting. When I saw her about a month ago in the pre-admission clinic, I was worried her blood sugars would be elevated at admission, and we made a plan to place a correction scale of insulin into her

BEFORE MORNING INTERDISCIPLINARY ROUNDS, I REVIEW CHARTS AND ASSESS WHAT I CAN DO TO MAKE THE BIGGEST IMPACT FOR THE PEOPLE ADMITTED TO MY UNIT. During our morning rounds, I meet with the orthopedic surgery hospitalist, the charge nurse, the patient’s nurse, the physiotherapist, and the occupational therapist. We discuss each patient on the unit and determine everyone’s needs. I bring forward medication-related problems that I prioritized earlier and make plans to resolve them with our hospitalist. After rounds today, I’ll meet with two of our patients: John and Jane. John has a low-burden pulmonary embolism provoked by his hip replacement surgery, and needs an anticoagulant. When I meet with John, we discuss the risks and benefits of different anticoagulants, his preferences, and together we select a treatment. We then discuss what symptoms should prompt a return to our Emergency Department. In Alberta, pharmacists 24 HOSPITAL NEWS JUNE 2019

chart for pre-operative use. Thankfully, Jane didn’t need insulin before surgery, but I’ll make sure she has another correction scale of insulin available for ongoing use because the body’s stress response after joint replacement can raise blood sugar levels to a point where it puts Jane at risk for post-operative infection. After meeting with John and Jane, I follow up with other patients, bring any concerns to the team, document my assessments and recommendations in patients’ charts, and answer questions from patients and the team. Then I’ll do my best to prepare for tomorrow – we have 12 new patients being admitted for elective surgery – but I’ll be ready for whatever comes my way, knowing my patients and my H team are relying on me. ■


In the Emergency Department:

The integral role of the pharmacy t By Angela von Chorus and Miranda Markle wo years ago, the Chinook Regional Hospital in Lethbridge, Alberta introduced clinically deployed pharmacy technicians to the Emergency Department. As clinically deployed pharmacy technicians we are often the first point of pharmacy contact for patients in the emergency department who are waiting to be transferred to an inpatient unit. As such, we are in an optimal position to gather comprehensive information about the medications a patient is actually taking (that information makes up the patient’s Best Possible Medication History, also known as a BPMH). A BPMH helps ensure that accurate and complete medication information for a patient is communicated consistently regardless of where care is given and who is providing it. Studies have shown that pharmacy technicians ob-


tain a medication history with as much accuracy and completeness as pharmacists or nurses. By optimizing workload assignments, with respect to pharmacy services in the emergency department, pharmacists and pharmacy technicians, along with nurses and physicians, can each perform the tasks suited to each profession for the benefit of the patient. What this means for pharmacy personnel is that pharmacists can provide their clinical expertise while the pharmacy technicians gather information to create a BPMH. The BPMH interview is the first opportunity to identify potential drug-related problems. Pharmacy technicians look for signs of duplicate therapy, wrong doses being taken, and other problems such as side effects, how well the patient understands information about their medications and how to

Interprofessional e Building a foundation for t

By Kathleen MacMillan, Gaithre Kalainathan and Carl Ko atient care improves with interprofessional collaboration. But did you know that so does learning improve when students participate in interprofessional health education (IPHE)? IPHE has increased student awareness of different professions and their scopes of practice within health care, and has improved their understanding of how our professions can be better integrated into the overall health care team. As an example, hospital pharmacists are able to work with physicians and nurse practitioners under collaborative practice agreements, wherein the pharmacist can use their expertise to the fullest through an expanded scope. This awareness of how different profes-


sions can be leveraged to create more positive healthcare outcomes, is likely to contribute to us seeking out interprofessional collaborative opportunities during our future practice.

IPHE FOR HEALTH PROFESSION STUDENTS From our perspective as students, we see the benefits of IPHE first hand. For us, we have learned the challenges and barriers that other professions face through our peers, and are better able to empathize with them. In the professional world, we can take this knowledge and be better prepared to work with our colleagues from different disciplines, fostering a more psychologically www.hospitalnews.com



e y technician take them, or whether financial constraints affect their ability to properly take the medication. Information about identified problems is then given to the pharmacist or other appropriate member of the interdisciplinary team for assessment and management. The BPMH interview also presents an ideal opportunity to educate the patient on the importance of creating a medication list and to discuss strategies for keeping it up to date. Pharmacy technicians are drug distribution experts and therefore have an understanding of which drugs are included on the hospital formulary, which drugs are currently available, and which ones have therapeutic interchanges: all of this helps patients have a seamless transition in care. Our knowledge of the hospital’s drug inventory also allows us to expedite

drug procurement by recognizing what is ward stock and what needs to be sent from the dispensary. The Clinically Deployed Pharmacy Technician’s knowledge of different dosage forms and routes of administration allows us to work with nurses and physicians to enhance medication delivery. The clinically deployed pharmacy technician’s role also promotes interdisciplinary collaboration. This can involve educating staff on the BPMH process, on the use pharmacy resources, and on drug shortage information and therapeutic interchanges. Pharmacy technicians help to facilitate interdepartmental collaboration by attending emergency department interdisciplinary meetings to address pharmacy-related issues. Although our primary focus is to work with patients in the emergency department who are

waiting to be moved to an inpatient care unit we often find opportunities to work with patients who do not need to be admitted to hospital. Some of what we do involves communicating with the patient’s community pharmacy, educating patients, and referring patients to other services. Having the opportunity to work as part of an interdisciplinary team to provide direct patient care has thus far

been the most rewarding experience for us as regulated pharmacy technicians. Our role in the emergency department positively impacts the patient’s journey through the healthcare system by delivering safe and effective care. As pharmacy technicians develop and expand their scope of practice, future opportunities will present themselves and we, as regulated professionals, need to be H ready. â–


l education:


or the future Carl Kooka

safe environment for all. We believe that IPHE allows students to become better problem solvers, as we are able to look at problems from multiple perspectives, consult our peers as well as faculty members from other disciplines, and collaborate to come up with system-level solutions.

DEVELOP BETTER LEADERS Student leadership on IPHE not only improves one’s ability to work on a team but also promotes collaboration among future health professionals. Any profession can and should be able to take a leading role on the interprofessional team when the situation warrants their expertise and guidance. In this way, the www.hospitalnews.com

patient will receive the best possible care, as everyone’s knowledge will be utilized to the fullest. Working on an interprofessional collaborative team has provided us with several advantages as we enter the workforce. The three authors of this article were fortunate to partake in a variety of IPHE initiatives during our time in university. Through these, we met a variety of students and faculty members in various disciplines. We are excited to take what we have learned and implement it into our practice, spreading the culture of interprofessional collaboration. We believe that all healthcare students should be exposed to IPHE during H their education. â–






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Pharmacist prescribing: Opportunities to optimize patient care through appropriate medication therapy By Shirin Abadi ith the aging population and high demands for the use of limited healthcare dollars, healthcare professionals need to work at the top of their license to truly make a positive difference for patients. Because pharmacists are not able to independently prescribe in most provinces in Canada, they are required to contact the prescriber for a revised prescription, if there needs to be a change in the medication type, dose, route, frequency and duration of therapy, as well as for discontinuation of medications. The problem with this approach is that it can be very time-consuming and costly


to the healthcare system. With more than 10 per cent of emergency department visits in Canada being due to medication-related issues, particularly in the elderly, and with the shortage of family physicians in some regions of Canada, enabling pharmacist prescribing to ease some of the pressures in the healthcare system would make perfect sense. Pharmacists learn more about medication therapy than any other healthcare professional, so it would seem logical for them to be able to prescribe, particularly if they feel confident in their knowledge, skills, and experience in prescribing medications,

How Will Pharmacist Prescribing Help You at Your Hospital and Clinic Visit? Medications affect everyone

Pharmacists are the medication experts

1 in 15

Pharmacists have at least 5 years of university training

Canadians use at least 5 medications1

Prescribing will allow pharmacists to help you...

Pharmacists are part of your healthcare team

Adjust doses

They collaborate with doctors, nurses, and other providers

to reach your goals 1 in 4 seniors take at least

10 medications2

Stop medications Research shows pharmacists, with the right tools, improve patient health5

that are not working or are no longer needed

Hospital and clinic pharmacists review medical chart and lab values to recommend best treatments for your care

1 in 9 emergency department visits are due to medication harm3

There are already over

1000 pharmacists Canadians spend

$2.6 billion

working with doctors and nurses in BC hospitals

Pharmacists improve patient safety and access to healthcare

Provide you with treatment options when you need them

on preventable medicationrelated hospitalizations4 And BC is hiring

more pharmacists Pharmacist prescribing reduces harm and costs associated with medications

to work in medical clinics with family doctors to improve your care



If pharmacists can collaborate with doctors to prescribe, everyone will beneďŹ t.

for serious side effects and prevent them where possible


1 Rotermann M et al (Statistics Canada). Prescription medication use by Canadians aged 6 to 79. Health Reports 2014; 25: 3-9. Available at: www.statcan.gc.ca/pub/82-003-x/2014006/article/14032-eng.htm 2 Canadian Institute for Health Information. Drug use among seniors in Canada, 2016. Available at: https://www.cihi.ca/sites/default/files/document/drug-use-among-seniors-2016-en-web.pdf. 3 Zed PJ, Abu-Laban RB, Balen RM, et al. Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study. CMAJ 2008; 178(12):1563-9. 4 Doran DM, Hirdes JP, Blais R et al. Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study. BMC Health Serv Res 2013; 13:227. 5 Canadian Pharmacists Association. A review of pharmacy services in Canada and the health and economic evidence. Feb 2016. https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/Pharmacy%20Services%20Report%201.pdf

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and are supported by the healthcare team, members of the public, and local and provincial governments to do so. There are numerous daily examples of how pharmacists identify and resolve drug therapy problems in a variety of settings, including hospitals, primary care clinics, outpatient pharmacies, and others. In Alberta, pharmacists have been able to prescribe prescription drugs (but not controlled substances) and blood products for the past several years and the impact of pharmacist prescribing on patient health outcomes has been very positive, including improvements in blood pressure control, cholesterol control, diabetes control, heart health, asthma, anticoagulation therapy, and more Studies have demonstrated that pharmacists can prescribe to the same standards as medical doctors, while being more adherent to dosing guidelines and protocols. In addition, prescribing by pharmacists has significantly reduced medication errors, thus improving patient safety, while saving healthcare dollars. Currently, in Canada, pharmacists have varying degrees of expanded scope of practice, as governed by the

CSHP BC Branch cshpbc@gmail.com

legislation in the province in which they practice. These may range from limited prescribing rights, such as renewal, adjustment and substitution of prescriptions, to prescribing for minor ailments, to prescribing prescription medications Internationally, pharmacists practicing in other jurisdictions, such as United Kingdom, New Zealand, and the United States have collaborative and/or independent prescribing rights. The Canadian Society of Hospital Pharmacists (CSHP)-BC Branch has been working hard to advocate for improving the care of patients through enabling pharmacist prescribing authority in collaborative settings. The attached infographic, courtesy of CSHP-BC Branch, explains how pharmacist prescribing can assist patients with improving health outcomes, improving medication safety and reducing healthcare costs. It is hoped that with the necessary legislative changes and public support, we can optimize pharmacists’ abilities to make a positive impact on patient care, through enabling prescribing to overcome some of the challenges that our healthcare system is currently facH ing and continues to struggle with. ■www.hospitalnews.com



















New approaches

to clinical training of students atients and staff in hospitals often see or meet many people in the hospital. Among the mix are students who need the experience of real-life practice to apply what they’ve learned in school, and to continue their learning outside the classroom or lab. The people who instruct, train, supervise, and mentor the students are preceptors. In pharmacy, most preceptors work in areas where they provide care to patients, such as hospitals, community pharmacies, and ambulatory clinics. They can also work in other settings, for example, managers, drug information centers and universities. Precepting a student allows pharmacists and pharmacy technicians to promote the pharmacy profession, educate the future workforce, and feel personal satisfaction. Hospital pharmacists and pharmacy technicians are important to introduce and mentor students in providing patient care within the hospital



setting. CSHP is committed to supporting preceptors in their precepting role. Precepting in pharmacy generally uses a traditional 1:1 model of one preceptor helping one student at a time. Newer models, like peer assisted learning, near-peer model and co-precepting, are becoming more popular and can offer advantages to students and preceptors. Students who are in either a pharmacy technician or pharmacist program must complete a minimum number of hours of pharmacy practice experiences in community and institutional settings to meet the requirements set by their educational program and to be licensed after graduation. Check out the possibilities! The following infographic walks preceptors through options available to them for precepting. Want to learn more? A series of guidebooks were created and can be found at http://www.afpc.info/ content/novel-models-precepting-preH ceptor-resources â– JUNE 2019 HOSPITAL NEWS 27

Exploring the role of

renal transplant pharmacists By Kathryn Peterson work as a pharmacist in the transplant clinic at Health Sciences Centre in Winnipeg, MB. It may surprise you that many days pass during which I do not come into contact with a single pill. If not dispensing medications, what is the purpose of a pharmacist? “Pharmacists are essential to the function of our program. The transplant physician counts on their input for daily rounds and ward visits.” says Dr. David Rush, MD, Director, Transplant Manitoba Adult Kidney Program Literature shows clinical pharmacy services have a significant impact on patient care by improving disease management and providing cost


savings to the healthcare system. In 2008, Transplant Manitoba hired a full-time clinical pharmacist as part of its collaborative care team. This role has evolved and expanded over the past 11 years, and now includes two pharmacists sharing time between the adult and pediatric renal transplant programs. Working within an interdisciplinary team in our renal transplant clinic is an incredibly rewarding and challenging experience that allows me to flex my clinical skills and improve patient care daily. These four key areas highlight the unique role my clinical pharmacy team brings to the renal transplant program:


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EDUCATION AND TEACHING TOOLS Renal transplantation involves an extensive and complex medication regimen in order to prolong transplant survival. Our pharmacists spend at least one hour with newly transplanted patients to discuss the new medications prescribed. We provide simplified teaching sheets and customized dosing calendars to emphasize the importance of adherence and ensure patients understand doses and common side effects of their new medications. This intensive teaching allows patients the opportunity to ask questions and gives them the tools to empower them to succeed. Close follow-up is provided at subsequent patient visits, in partnership with our nurses, in order to ensure full comprehension. We also provide teaching to the nursing staff and inpatient pharmacists on topics specific to transplant.

MEDICATION REVIEWS Pharmacists have the unique ability of viewing the patient through the lens of the medications they take. Each patient’s medication fill record is screened by the clinical pharmacist to ensure adherence and assess the indication for every medication at each clinic visit. This focused approach identifies many opportunities to optimize management of common conditions including: diabetes, hypertension, cardiovascular disease, gout and anticoagulation. We not only look for gaps in care, but also focus on “deprescribing” unnecessary medication to ease the pill burden on patients. In conversation with patients and our physicians, we are usually able to stop or lower the dose of at least one medication. In one extreme case, I was able

reduce a patient’s pill burden by 9 tablets per day. This has a major impact on quality of life for individual patients and is an immensely satisfying part of my job. Medication optimizations and recommendations are discussed daily in our multidisciplinary team rounds. Pharmacists play a key role in public health initiatives by identifying vaccination requirements for our high-risk population and discuss these with patients.

SEAMLESS CARE Transplant patients are frequently admitted and discharged from hospital. Canadian studies show that up to 40 per cent of patients experience unintentional medication discrepancies at discharge. Our clinical pharmacists are involved in all discharge prescriptions from our primary teaching hospital and provide discharge teaching to transplant patients. This facilitates the transfer from hospital to clinic and aids in transitions of care. Pharmacists also discuss medication cost and coverage, in collaboration with our social worker, to avoid gaps in care for our patients.

DEVELOPMENT AND RESEARCH PROTOCOL Standardized protocols are a major aspect to ensure equal care is provided to each patient and pharmacists have contributed to the development, review and revision of many medication-related protocols and order sets. Pharmacists are often known for being detail-oriented and this is definitely an asset in protocols. We are actively involved in several research initiatives through our program including one retrospective review of implementing universal infection prophylaxis in our H patient population. ■ www.hospitalnews.com



drug diversion in hospitals pioids and other controlled substances are essential drugs in hospitals. They are used to treat acute and severe pain in our emergency departments, operating rooms, labour and delivery suites, and other areas throughout the hospital. Unfortunately, these drugs are sometimes targets for diversion – transferring a drug from a lawful use to an unlawful use. Patients, visitors, or staff may pilfer these drugs for their own personal use or sometimes for purposes of trafficking. We can’t keep everything locked in the pharmacy vault because health professionals need quick access to these drugs, so we rely on a mix of physical security measures, policies and procedures, and education. The Canadian Society of Hospital Pharmacists (CSHP) recently published Controlled Drugs and Substances in Hospitals and Healthcare Facilities: Guidelines on Secure Management and Diversion Prevention. This guidance document helps hospitals meet their obligations under the law, as well as accreditation standards and professional standards. The guidelines were developed in collaboration with many other groups, including nurses, anesthesiologists, emergency physicians, paramedics, dentists, regulators, and law enforcement.


Unfortunately, these drugs are sometimes targets for diversion – transferring a drug from a lawful use to an unlawful use. prevent this at every step. We need to develop a culture of continuous quality improvement. Just as we’ve done with medication errors and medication safety, we need to move away from denying that there’s a problem and pointing fingers when something happens; instead, we need to educate our colleagues on what to watch for and how to report, and we need dedicated interdisciplinary committees that review and act on the reports, with a view to improving the system and making it safer. Drug diversion can be dangerous for patients if their intended treatment is substituted with a less potent drug, a lower dose, or no drug at all; or if an injectable drug is tampered with by a person who has a communicable disease such as hepatitis C or HIV. However, drug diversion can be dangerous for the diverter as well. Most health professionals who divert drugs do so because they have a substance use disorder, and many are only discovered after a fatal overdose. We need staff to be alert to any warning signs from

• Store controlled substances securely, ensure all keys are accounted for at all times and passwords are not shared. • Segregate duties. For example, do not have the same person ordering drugs and receiving drugs. • Keep rigorous records that can be easily audited. Document with

double signatures every time stock changes hands. • Conduct regular and frequent counts of stock on hand in pharmacy and in patient care areas. • Reconcile records against each other; e.g., amount purchased by pharmacy, received by pharmacy, dispensed to patient care area, received by patient care area, administered to patient, wasted or returned, and currently on hand. • Conduct audits. Verify all of the above with frequent and random checks in various parts of the H facility. ■

For more information, access the guidelines at www.cshp.pharmacy/ opioid-guidelines. Together, we’ll have a stronger, safer system.

ĶǒƬȭ ƋɁȧȧƬʁƋǔŘǚ ɡʁƬǞǚǚƬƞ ʊ˿ʁǔȭǷƬʊ ŘʁƬ ȭɁǜ Ř˸ŘǔǚŘŽǚƬ ǜǒƬ ȭƬ˾ǜ ŽƬʊǜ ɁɡǜǔɁȭ ǔʊ Ęȭǔǜ ƞɁʊƬ ʊ˿ʁǔȭǷƬʊɡʁƬɡŘʁƬƞŽ˿ǜǒƬɡǒŘʁȧŘƋ˿Ɩ

COLLABORATION ACROSS THE HEALTH SYSTEM IS IMPORTANT BECAUSE DRUG DIVERSION IS NOT JUST A “PHARMACY PROBLEM” – IT’S EVERYONE’S RESPONSIBILITY. Collaboration across the health system is important because drug diversion is not just a “pharmacy problem” – it’s everyone’s responsibility. We need to think about all of the points in the system where drugs can go missing, and how we can www.hospitalnews.com

their colleagues and to feel that filing a report will lead to their colleague being helped rather than shamed and blamed. What are some of the fundamental principles of preventing drug diversion in our hospitals?

ñʁŘ˾ǔÀƬƞʸ ă˿ʁǔȭǷƬǞǚǚǔȭǷūǚŘŽƬǚǚǔȭǷȧŘƞƬƬŘʊ˿NJ DĞĚy>ŝŶĐ͘нϭ͘ϱϭϰ͘ϲϵϱ͘ϳϰϳϰͮŝŶĨŽƐΛŵĞĚdžů͘ĐŽŵͮǁǁǁ͘ŵĞĚdžů͘ĐŽŵ JUNE 2019 HOSPITAL NEWS 29


Coordinating a response to a critical drug shortage: How do we do it? By Tania Mysak and Tracey Simpson rug shortages happen every day, for many reasons such as natural disasters, manufacturing problems, business decisions, and so on (see www.drugshortagescanada.ca). Managing them requires a lot of care and consideration because they have been associated with increased errors and patient harm. It therefore should not come as a surprise that hospital pharmacy departments have standard procedures to manage drug shortages. Typically, this involves seeking alternate vendors, tightening stock management, engaging with clinicians to define restrictions for use and identifying alternatives, implementing a broad communication strategy, and increasingly, researching opportunities to compound the product ourselves.


ALTERNATE VENDORS Sometimes an alternate brand of drug is available to mitigate a drug shortage. If the drug is not available from any manufacturers, therapeutic alternatives are identified and any remaining drug supply is conserved for patients who need it most. The situation becomes more difficult to manage if therapeutic alternatives are not available, prompting the pharmacy department to involve the Provincial/Territorial Drug Shortage Task Team. At this point, the Chair of the Task Team and Health Canada’s Drug Shortages Unit work together to iden30 HOSPITAL NEWS JUNE 2019

tify critical shortages and create mitigating strategies. Finding drugs that can be imported into Canada, with the help of Health Canada is one solution that is considered. Such approvals, however, are rare, and pharmacy departments must look to other solutions. In rare cases, procuring stock from community pharmacies may be considered or sharing stock amongst the provinces.

STOCK MANAGEMENT Careful stock management is critical during a drug shortage. Understanding current inventory and usage patterns helps pharmacy departments determine how strictly stock needs to be managed through the shortage. Staff may be asked to sequester wardstock back to the pharmacy department and complete regular stock counts with results tabulated centrally for monitoring. In areas with regionalized or provincial health authorities, the centralized governance structure allows monitoring and potential stock redistribution within the authority to areas of need.

CLINICIAN ENGAGEMENT Whenever a drug shortage occurs, clinicians are consulted for therapeutic alternatives and encouraged to use them where possible. Depending on the severity of the shortage, existing utilization patterns may rapidly deplete stock. In these circumstances, clinicians may also be engaged to

strategize potential restrictions for use of the shorted drug. This may include updating existing protocols and order sets to drive behavior and preserve stock for the most critical needs.

COMMUNICATION STRATEGY Communication strategies are implemented to inform all pharmacy managers, nursing units and other clinical areas, describing the shortage and conservation strategies including the alternatives to be used in lieu of the shorted drugs. Enhanced communications through medical staff networks or on local websites can also be considered depending on the shortage severity. In cases where there is heightened potential for patient harm, a proactive external communications approach can be taken to inform and regularly update government of the shortage and the coordinated efforts being undertaken to mitigate risk.

COMPOUNDING Finally, as a last resort, some pharmacy departments consider the risks of compounding an alternative product for patient use. The success of this response depends on the existence of a validated formulation, availability of pharmaceutical grade ingredients for human use, suitable compounding facilities, qualified personnel, and results of quality control tests. In circumstances where the shorted drug is

required to be sterile, additional testing is required to ensure a safe product.

THE GLASS IS HALF FULL Even though drug shortages require a lot of attention to safely manage them, some good occasionally comes of them. A shortage can create an organizational awareness that commonly used and relatively inexpensive products are at risk for inappropriate use. It can identify safer and more effective alternatives and optimize prescribing practices. A shortage can also highlight the advantages of a centrally coordinated organization at the level of a region or province. Such organizations are able to quickly communicate, recall, and sequester stock from all sites in the organization. Relationships forged in regional networks can be used to engage stakeholders in brainstorming conservation strategies and gaining critical “buy-in” to manage the problem collaboratively. Technical compounding expertise can be leveraged to create and validate processes to compound product at the appropriate sites (with appropriate personnel), and then made available to all sites within the organization. By using the expertise and efforts of a dedicated team to manage the inventory, alternatives, communication, and other elements of managing a shortage, pharmacy departments help sites and staff to continue their daily work of providing quality patient care and avert poH tential harm. ■ www.hospitalnews.com



hospital pharmacy here are almost 600 hospitals in Canada, and more than half have fewer than 50 beds, according to the Canadian Institute for Health Information. This speaks to the vast geographic expanse that is our country, and the reality that many Canadians do not live in dense metropolitan areas with large, tertiary-care teaching hospitals. There is a need to ensure adequate hospital care closer to home, thus the small, rural, hometown community hospital remains. Pharmacy staffing at these hospitals is variable – some have two to three pharmacists working fulltime onsite, along with a full complement of pharmacy technicians, while others are staffed remotely through contracts with larger hospitals or private companies.


WHATEVER THE METHOD OF STAFFING, THE PHARMACISTS WORKING AT THESE HOSPITALS MUST BE WELL-INFORMED WHEN IT COMES TO GENERAL MEDICINE PHARMACY PRACTICE. Whatever the method of staffing, the pharmacists working at these hospitals must be well-informed when it comes to general medicine pharmacy practice. Specialization isn’t an option, because patients are coming in with a variety of medical issues, and these hometown hospitals provide that general care patients need. Working in a hometown hospital has its advantages and disadvantages. There is less staff, so the pharmacist

must often juggle both clinical and administrative responsibilities. On the other hand, there is less staff, and fewer layers of bureaucracy, so there’s often an opportunity to be nimble and to quickly adopt new processes. These hometown hospitals have a smaller catchment area, so the pharmacist can really get to know the patients for whom they are providing care, especially those with chronic conditions that result in repeated hospitalizations.

Regardless of the size of a hospital, pertinent legislative and quality standards must be met. The Canadian Society of Hospital Pharmacists offers peer networking through their Small Hospital Pharmacy Specialty Network, which allows pharmacists working in these smaller hospitals to access and share information amongst themselves. A classic phrase in small hospital practice is “Why reinvent the wheel?â€? Sharing information is vital, because otherwise the workload might be overwhelming. If you’ve ever worked in a hometown hospital, you’ll know what a pleasure it is to care for the people who live and work in your community, those you might later see at the grocery store or a soccer game. Although these hospitals are small, they are vital and highly valH ued in their communities. â–

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2019 Annual Hospital Pharmacists Supplement  

2019 Annual Hospital Pharmacists Supplement