Organized Health Care Settings Research Articles

NCPDP recommendations for standardizing dosing in metric units (mL) on prescription container labels of oral liquid medications, version 2.0.

PurposeBest practices and guidance are provided for standardizing dosing instructions on prescription container labels of oral liquid medications by eliminating use of U.S. customary (household) units and adopting metric units universally, with the goal of decreasing the potential for error and improving safety and outcomes when patients and caregivers take and administer these medications.SummaryDespite decades of best practice use of metric units in organized healthcare settings and advocacy by various professional societies, medication safety experts, and standards setting organizations, use of household units (e.g., teaspoon) on prescription container labeling instructions for oral liquid medications persists in community pharmacy settings. Five years after publication of the National Council for Prescription Drug Programs’ (NCPDP’s) original white paper advocating metric-only dosing, very few community pharmacy companies appear to require oral liquid dosing instructions be presented in metric-only units (mL). Error-prone dosing designations contribute to medication errors and patient harm. Use of both multiple volumetric units (e.g., teaspoonsful, tablespoonsful) and multiple abbreviations for the same volumetric units (e.g., mL, cc, mls; tsp, TSP, t) increases the likelihood of dosing errors. Opportunities for error exist with each administration of an oral liquid medication and, unless coordinated with dispensing of appropriate oral dosing devices and optimal counseling, can result in use of household utensils (e.g., uncalibrated teaspoons) or discordantly marked devices that can further exacerbate the risk of error. Since publication of NCPDP’s original white paper, new standards have been adopted governing official liquid volume representation, calibrated dosing devices, and e-prescribing software which support the elimination of non-metric units to reduce use of dosing practices that are error-prone. In each case, U.S. customary (household) units have been eliminated in official standards and certification requirements. Therefore, use of non-metric units for oral dosing of liquid medications no longer is an acceptable practice.ConclusionKey factors contributing to dosing errors with oral liquid medications include use of multiple volumetric units and abbreviations; failure to institute policies and procedures that eliminate the use of non-metric (e.g., household) units and universally adopt metric-only dosing instructions in all settings; failure to coordinate dosing instructions with dosing device markings, appropriate type (oral syringe versus cup), and optimal volumes (e.g., 1-, 5-, or 10-mL devices); failure to adequately counsel patients about appropriate measurement and administration of oral liquid medication doses; and use or error-prone practices such as missing leading zeros and elimination of trailing zeros in prescriptions and container labels. Adoption of this white paper’s recommendations will align dosing designations for oral liquid medications in all settings with current standards and attain universal metric-only practice.

An introduction to psychologists treating medically ill patients: Competent practice and seeking credentials in organized health care settings for routine or incidental practice.

An introduction to psychologists treating medically ill patients: Competent practice and seeking credentials in organized health care settings for routine or incidental practice.

An Information Paper on Pharmacist Prescribing Within a Health Care Facility

INTRODUCTION In the traditional model of health care, physicians have the authority to prescribe medications, order laboratory tests, and conduct or supervise procedures consistent with a patient’s diagnosis. More recently, prescribing privileges have been extended to other health care professionals, such as nurse practitioners (NP), expanded role nurses (ERN), clinical nurse specialists (CNS), registered midwives, and optometrists. While the roles of some of these health care professionals have evolved to fill gaps in the health care system where physicians are unavailable, most work within a hospital or specialized clinic affiliated with a health care facility. There is a continuing attempt in Canadian health care to contain or reduce costs by reducing patient length of stay in hospital and eliminating inefficiencies and duplication of effort. Pharmacists are increasingly aware that the current process of delivering health care to patients frequently results in drug therapy outcomes that are not as effective, appropriate, safe, or economical as possible and desirable.1-3 They have a responsibility to work toward establishing a better system that could improve the outcomes and cost-effectiveness of drug therapy. It has been postulated that by granting prescribing authority to pharmacists the fragmented and disjointed process of health care delivery could be improved. Improved medication management and continuity of care may be achieved by decreasing the number of steps a patient must take to obtain the optimal medication regimen for their condition.4 It has been argued that if pharmacists truly intend to practise and implement pharmaceutical care, then every pharmacist should be able to maximally utilize their extensive pharmaceutical knowledge by prescribing drugs.5 Having the authority to prescribe medications would facilitate the delivery of more effective pharmaceutical care by some pharmacists. Yet, given the present practice of most pharmacists, it has also been suggested that those with delegated prescribing authority have little advantage over those without it in the overall delivery of pharmaceutical care to patients.6 Currently, many pharmacists in organized health care settings in Canada have some form of authority and responsibility for prescribing. It is important to note that in a survey of Canadian institutions, the Canadian Society of Hospital Pharmacists Task Force on Pharmacist Prescribing found a significant amount of pharmacist prescribing occurring with limited control or regulation7 (see below). This paper is not intended to examine the current state of provincial legislation regarding prescribing authority in Canada. Various degrees of prescribing authority for pharmacists are currently being examined and implemented in a number of provinces (e.g., specially instructed and certified pharmacists prescribing post-coital contraception).

Statement on Pharmacist Prescribing

The provision of health care to Canadians in institutions and organized health care settings involves the collaborative efforts of physicians, pharmacists, nurses, and other health care professionals. The focus of the pharmacist’s efforts in this interdisciplinary approach to patient care is to ensure the responsible provision of drug therapy for the purpose of achieving definite outcomes (pharmaceutical care). Ultimately, pharmacists share in the responsibility for patient outcomes from drug therapy. Pharmacists do not just provide basic dispensing functions and drug information services, but they also solve patientand medication-related problems and make decisions regarding drug prescribing, drug monitoring, and drug regimen adjustments. Consequently, CSHP advocates the role of pharmacists as capable prescribers and supports the pharmacist’s role in a collaborative prescribing model to improve patient health outcomes and increase the successful and efficient delivery of pharmaceutical care. A collaborative prescribing model requires that a cooperative practice relationship exist between a pharmacist and a physician or other health care professional with the legal authority to prescribe medications. Recognition of physician expertise in disease diagnosis and pharmacist expertise in pharmacotherapy and disease management, as the foundation for the establishment of a collaborative practice, optimizes the training and expertise of both of these health care professionals in the provision of patient care. In an ideal collaborative practice, the physician will diagnose and make initial treatment decisions for the patient and then the pharmacist will select, initiate, monitor, modify, continue, and discontinue pharmacotherapy as appropriate in order to achieve the desired patient outcomes. In this collaborative practice model, both the physician and the pharmacist share in the risk and responsibility for the patient outcomes achieved.

Tuberculosis in the veterans healthcare system: a six-year review and evaluation of programme effectiveness.

The Department of Veterans Affairs operates a large, centrally administered health care system consisting of 173 hospitals and 4 free standing outpatient clinics nationwide with approximately 945,115 hospital discharges, 24.2 million outpatient visits, and 2.86 million persons served annually over the time frame of the review. The purpose of the study was to define whether such a system could effect timely change in the incidence of tuberculosis (TB) using centralized programme planning and flexible field implementation. A retrospective review of the number of newly diagnosed cases of active TB treated at veterans health care facilities between 1 October 1990 and 30 September 1997 was determined by using a standardized annual case census. Intervention included implementation of the most current guidelines for the prevention of transmission of TB in the community and hospital setting, including administrative and engineering controls and a change in personal protective equipment. Centrally directed programme guidance, education, and funding were provided for field use in health care facilities of widely varying size and complexity. The numbers of total reported cases of TB decreased significantly (P < 0.001) throughout the veterans health care system (nationally and regionally), with the case rate decreasing at a rate significantly greater than that seen in the USA as a whole (P < 0.0001). TB associated with multi-drug resistance (isoniazid and rifampin) and HIV coinfection also significantly decreased over the study period. Therefore, a large, centrally administered health care system can effectively combat a re-emerging infectious disease and may also demonstrate a successful outcome greater than seen in other, perhaps less organized health care settings.

Clinical research: ASHP guidelines and future directions for pharmacists

ASHP guidelines on the pharmacist's role in clinical drug research and future directions for pharmacists in clinical drug research are described. Health-system pharmacists have a responsibility to the patient and to the institution to ensure that clinical research systems are sound, that patients are protected, and that research is conducted in a safe, effective way. ASHP guidelines list minimum standards that are essential for improving performance. The ASHP Guidelines on Clinical Drug Research, approved in November 1997, update information previously found in the ASHP Guidelines for the Use of Investigational Drugs in Organized Health-Care Settings, approved in 1990, but have an expanded focus. Additions include recognition of relevant business practices, implications of technology, and the expansion of clinical research beyond the academic health center. At a minimum, all pharmacists involved in clinical research should handle the record keeping for drug accountability, provide drug information to patients and to other health care providers, ensure the appropriate care of patients at sites not involved in the study, and provide accountability at nonpharmacy locations. Managing and coordinating clinical drug research is an area of growth that represents a great opportunity for clinical drug research. By providing baseline and higher-level pharmaceutical services for clinical research projects, pharmacists can help to ensure data accuracy and completeness and patient safety.

ASHP Technical Assistance Bulletin on Use of Controlled Substances in Organized Health Care Settings

ASHP Technical Assistance Bulletin on Use of Controlled Substances in Organized Health Care Settings

Reassessing the membership structure of ASHP

In this discussion paper, the ASHP Board of Directors suggests that it is time for the American Society of Hospital Pharmacists to move to another stage in the development of its membership structure. In 1975, ASHP broadened its purview to represent pharmacists who practice in all types of organized health-care settings. The Board has observed that ASHP members today often identify more strongly with their specific practice type or specialty than with "hospital pharmacy" or "pharmacy practice in organized health-care settings." Further, such members prefer to engage in organizational activities with peers from their specific area of practice. This has led the Board to examine the membership structure of the Society in an effort to improve ASHP's effectiveness in exercising leadership for pharmacy practice in organized health-care settings. The Board suggests for consideration by ASHP members two types of changes in membership structure: (1) the creation of sections and (2) the establishment of affiliation arrangements with national organizations that share ASHP's orientation toward pharmacy practice in organized health-care settings. The Board recognizes that membership sections would have to be given substantial autonomy for them to be effective. The Board believes that a pilot or experimental approach should be used in making changes in membership structure, with explicit evaluation after a period of time. The Specialty Practice Group and Practice Management Group programs are also being reassessed by the Board. Finally, the full name of ASHP will be reconsidered.

ASHP technical assistance bulletin on assessing cost-containment strategies for pharmacies in organized health-care settings

ASHP technical assistance bulletin on assessing cost-containment strategies for pharmacies in organized health-care settings

Medicare and Medicaid fraud and abuse regulations

Specific business arrangements that are protected under legislation and regulations governing parties doing business with Medicare or Medicaid are discussed. Regulations implementing the Medicare and Medicaid Patient Protection Act of 1987 specify practices and activities that are not subject to criminal penalties under the antikickback provisions of the Social Security Act or to exclusion from Medicare or state health-care programs. As of July 29, 1991, all organized health-care settings that receive payments from either Medicare or state health-care programs must comply with these regulations. The final rule sets forth "safe harbors"--exceptions to prohibitions against (1) kickbacks, bribes, rebates, and other illegal activities involving remunerations for patient referrals and (2) inducements to purchase or lease goods paid for by Medicare or state health-care programs. The safe harbors comprise 11 broad categories--investment interests, space rental, equipment rental, personal services and management contracts, purchase of a medical practice, referral services, warranties, discounts, employees, group purchasing organizations, and waiver of deductibles and coinsurance. Implications for pharmacy are discussed. These regulations will affect the purchase of pharmaceuticals by institutional pharmacies. Each institution should review its current practices to determine whether they are within the safe harbors.

ASHP statement on pharmaceutical research in organized health-care settings

ASHP statement on pharmaceutical research in organized health-care settings

ASHP guidelines for the use of investigational drugs in organized health-care settings

ASHP guidelines for the use of investigational drugs in organized health-care settings

ASHP statement on the pharmacist's clinical role in organized health-care settings

Journal Article ASHP statement on the pharmacist's clinical role in organized health-care settings Get access American Journal of Hospital Pharmacy, Volume 46, Issue 11, 1 November 1989, Pages 2345–2346, https://doi.org/10.1093/ajhp/46.11.2345 Published: 01 November 1989

Pharmacy implications of the revised OSHA Hazard Communication Standard

Provisions of the recently revised federal Occupational Safety and Health Administration (OSHA) Hazard Communication Standard that are important to pharmacy practice in organized health-care settings are described. OSHA announced on February 15, 1989, that the revision of August 24, 1987, was effective immediately; the provisions apparently pre-empt individual states' hazardous-substances regulations. According to the standard, manufacturers must determine whether chemicals they produce are hazardous; a pharmacy compounding drug mixtures may be a manufacturer. Chemicals determined by the manufacturers to be hazards must be labeled as hazards; for drugs that are already labeled according to FDA requirements, such labeling is not needed. The rule exempts drugs in a retail establishment that are packaged for sale to consumers, but it does not address workers' use of such non-prescription products in patient care. Tablets are exempt. Employers must maintain a written hazard communication program. Manufacturers and distributors are required to provide material safety data sheets on all hazardous chemicals, and employers must keep copies of these data sheets available. Documents to assist employers in complying with the regulations are available from OSHA. Judicial challenges to the regulation continue. ASHP is monitoring developments and applications to assist pharmacy departments in interpreting and complying with the regulations.

ASHP guidelines for pharmaceutical research in organized health-care settings

Journal Article ASHP guidelines for pharmaceutical research in organized health-care settings Get access American Journal of Hospital Pharmacy, Volume 46, Issue 1, 1 January 1989, Pages 129–130, https://doi.org/10.1093/ajhp/46.1.129 Published: 01 January 1989

ASHP Statement on the Pharmacist's Clinical Role in Organized Health-Care Settings

ASHP Statement on the Pharmacist's Clinical Role in Organized Health-Care Settings

A Review of Cost-Benefit and Cost-Effectiveness Analyses of Clinical Pharmacy Services

This paper discusses the purpose and methodology of the economic evaluation techniques of cost-benefit (CBA) and costeffectiveness analysis (CEA). It then reviews applications of the techniques in 22 evaluative studies, published between 1978 and mid-1987, of clinical pharmacy services in organized health care settings. Major conclusions are that CBA and CEA have not been extensively adopted in the evaluation of clinical pharmacy services and that the studies which have been done are lacking in rigor.

Opinions of Pharmacy, Medicine, and Pharmaceutical Industry Leaders about Hypothetical Therapeutic-Interchange Legislation

The beliefs of representatives of organized pharmacy and medicine and the pharmaceutical industry about the effect of hypothetical therapeutic-interchange legislation on various health-care issues were studied. Questionnaires designed to gauge respondents' beliefs about the impact of two hypothetical bills (A and B) concerning selection of therapeutic alternates by pharmacists were mailed to the directors of 307 organizations in April 1986. Bill A would permit pharmacists in any setting to select therapeutic alternates. Bill B would permit therapeutic interchange by pharmacists within organized health-care settings in accordance with guidelines approved by physicians. Issues addressed included the efficient delivery of health care, professional liability, interprofessional and pharmacist-patient relationships, and competition and profitability in the pharmaceutical industry. The response rate was 63% (194 usable responses). Bill A received some support from representatives of state pharmaceutical associations only. However, bill B was supported by respondents from state pharmaceutical associations, state hospital pharmacy societies, boards of pharmacy, and generic manufacturers. Respondents from medical associations and member companies of the Pharmaceutical Manufacturers Association (PMA) were concerned about the impact of the hypothetical bills on the quality of drug therapy and the efficiency of health-care delivery. Respondents from medical associations also were concerned about the impact of the bills on physician liability. The responses from the medical associations and the PMA-member companies suggest that a program should be developed to educate physicians about the process used by pharmacists and physicians to develop guidelines for therapeutic interchange in various practice settings.

A review of cost-benefit and cost-effectiveness analyses of clinical pharmacy services.

This paper discusses the purpose and methodology of the economic evaluation techniques of cost-benefit (CBA) and cost-effectiveness analysis (CEA). It then reviews applications of the techniques in 22 evaluative studies, published between 1978 and mid-1987, of clinical pharmacy services in organized health care settings. Major conclusions are that CBA and CEA have not been extensively adopted in the evaluation of clinical pharmacy services and that the studies which have been done are lacking in rigor.

The Joint Commission Looks to the Future

Since early in this century, the medical profession has provided firm leadership in promoting high-quality patient care in the nation's hospitals. During the past two decades, this effort has steadily spread to involve a wide spectrum of organized health care settings. In this issue of the Journal , Roberts and colleagues 1 describe the historical evolution of the Joint Commission on Accreditation of Hospitals and its role in effecting this professional mandate. While the achievements of the Joint Commission are note-worthy, there is little basis for self-satisfaction in the current health care climate. In today's altered environment for patient care, resource limitation, changing and sometimes perverse reimbursement incentives, the professional liability crisis, and increased competition for patients have led to the elevation of quality of care to the status of a major public policy issue in this country. Public and professional concerns about the potential adverse impacts of these forces on