Quality improvement and reconciliation process for automated dispensing cabinet medication overrides

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To describe a pharmacist-led reconciliation process for automated dispensing cabinet (ADC) medication override setting maintenance at an academic medical center. Summary ADC override management requires alignment of people, processes, and technology. This evaluation describes system-wide improvements to enhance institutional medication override policy compliance by establishing a formalized evaluation and defined roles to streamline ADC dispense setting management. A pharmacist-led quality improvement initiative revised the institutional medication override list to improve medication dispensing practices across an academic medical center campus with a pediatric hospital and 2 adult hospitals. This initiative included removal of patient care unit designations from the medication override list, revision of institutional override policy, creation of an online submission form, and selection of ADC override metrics for surveillance. A conceptual framework guided decisions for unique dosage forms and interdisciplinary engagement. Employing this framework revised workflows for stakeholders in the medication-use process through clinical pharmacist evaluation, existing shared governance structure communication, and pharmacy automation support. The revised policy increased the number of medications available for override from 80 to 106 (33% increase) and unique dosage forms from 166 to 191 (15% increase). The total number of medication dispense settings was reduced from 5,600 to 541 (90% decrease). The proportion of override dispenses compliant with policy increased from 59% to 98% (P < 0.001). Median monthly ADC overrides remained unchanged following policy revision (P = 0.995). ADC override rate reduction was observed across the institution, with the rate decreasing from 1.4% to 1.2% (P < 0.001). Similar ADC override rate reductions were observed for adult, pediatric, and emergency department ADCs. Conclusion This initiative highlights pharmacists’ role in leading institutional policy changes that influence the medication-use process through ADC dispensing practices. A pharmacist-led reconciliation process that removed practice area designations from our medication override policy streamlined ADC setting maintenance, increased the compliance rate of ADC override transactions, and provided a formalized process for future evaluation of medication overrides.

Optimization of the medication-use process for fentanyl patches at a small community hospital

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To describe a community hospital pharmacy department’s novel approach to addressing safe use of fentanyl patches in acute and subacute care patients. Summary Beginning in 2017, improvement opportunities were identified within the medication-use process for fentanyl patches at Cleveland Clinic Euclid Hospital. Prescribing was addressed through development of a procedure requiring an opioid status verification by a pharmacist for all fentanyl patch orders. This procedure includes determination of indication, review of prior opioid use, and documentation within the medical record. At baseline in 2017, 11 of 45 fentanyl patches were initiated for acute pain. In the first year of the procedure, 1 of 13 orders was initiated for acute pain, and in the second year 2 of 24 orders for fentanyl patches were initiated for acute pain. With each review, the pharmacy department identified additional safety and clinical education opportunities. Subsequently, inventory and dispensing practices for patches were assessed. The hospital’s inventory was decreased and dispensing practices were altered to mitigate accessibility of the patches. This resulted in a decrease of 73.65% in the on-hand quantity from 2018 to 2020. The overall morphine milligram equivalents (MME) per 24 hours of this dosage form available in the hospital were reduced from 56,073.6 MME in 2018 to 13,557.6 MME in 2020 (75.82% decrease). Conclusion Evaluation of the fentanyl patch medication-use process and pharmacy-driven interventions resulted in an increase in appropriate utilization of fentanyl patches and a decrease in accessible MME of this potent dosage form.

Community pharmacies, drug stores, and antibiotic dispensing in Indonesia: a qualitative study

Background Inappropriate dispensing of antibiotics at community pharmacies is an important driver of antimicrobial resistance (AMR), particularly in low- and middle-income countries. Thus, a better understanding of dispensing practices is crucial to inform national, regional, and global responses to AMR. This requires careful examination of the interactions between vendors and clients, sensitive to the context in which these interactions take place. Methods In 2019, we conducted a qualitative study to examine antibiotic dispensing practices and associated drivers in Indonesia, where self-medication with antibiotics purchased at community pharmacies and drug stores is widespread. Data collection involved 59 in-depth interviews with staff at pharmacies and drug stores (n = 31) and their clients (n = 28), conducted in an urban (Bekasi) and a semi-rural location (Tabalong) to capture different markets and different contexts of access to medicines. Interview transcripts were analysed using thematic content analysis. Results A common dispensing pattern was the direct request of antibiotics by clients, who walked into pharmacies or drug stores and asked for antibiotics without prescription, either by their generic/brand name or by showing an empty package or sample. A less common pattern was recommendation to use antibiotics by the vendor after the patient presented with symptoms. Drivers of inappropriate antibiotic dispensing included poor knowledge of antibiotics and AMR, financial incentives to maximise medicine sales in an increasingly competitive market, the unintended effects of health policy reforms to make antibiotics and other essential medicines freely available to all, and weak regulatory enforcement. Conclusions Inappropriate dispensing of antibiotics in community pharmacies and drug stores is the outcome of complex interactions between vendors and clients, shaped by wider and changing socio-economic processes. In Indonesia, as in many other LMICs with large and informal private sectors, concerted action should be taken to engage such providers in plans to reduce AMR. This would help avert unintended effects of market competition and adverse policy outcomes, as observed in this study.

Dispensing Antibiotics without Prescription at Community Pharmacies and Accredited Drug Dispensing Outlets in Tanzania: A Cross-Sectional Study

Worldwide, antimicrobial resistance is increasing rapidly and is associated with misuse of antimicrobials. The HATUA study (a broader 3-country study) investigated the antibiotic dispensing practices of pharmaceutical providers to clients, particularly the propensity to dispense without prescription. A cross-sectional study using a ‘mystery client’ method was conducted in 1148 community pharmacies and accredited drugs dispensing outlets (ADDO) in Mwanza (n = 612), Mbeya (n = 304) and Kilimanjaro (n = 232) in Tanzania. Mystery clients asked directly for amoxicillin, had no prescription to present, did not discuss symptoms unless asked [when asked reported UTI-like symptoms] and attempted to buy a half course. Dispensing of amoxicillin without prescription was common [88.2, 95%CI 86.3–89.9%], across all three regions. Furthermore, the majority of outlets sold a half course of amoxicillin without prescription: Mwanza (98%), Mbeya (99%) and Kilimanjaro (98%). Generally, most providers in all three regions dispensed amoxicillin on demand, without asking the client any questions, with significant variations among regions [p-value = 0.003]. In Mbeya and Kilimanjaro, providers in ADDOs were more likely to do this than those in pharmacies but no difference was observed in Mwanza. While the Tanzanian government has laws, regulations and guidelines that prohibit antibiotic dispensing without prescription, our study suggests non-compliance by drug providers. Enforcement, surveillance, and the provision of continuing education on dispensing practices is recommended, particularly for ADDO providers.

Assessment of veterinary drugs dispensing practices in veterinary clinics in Gondar town, North West Ethiopia: a cross sectional study

<p class="abstract"><strong>Background:</strong> Dispensing practice plays a major role in the provision of rational drug therapy. This study aimed to assess the veterinary drug dispensing practice by pharmacists and other veterinarian assistance in veterinary clinic Gondar town.</p><p class="abstract"><strong>Methods:</strong> A cross-sectional prospective descriptive study was carried out in the OPD of three public veterinary clinics in Gondar town for three months. The health facility indicators were examined by ensuring the good dispensing practices in three veterinary clinic and availability of essential drug list.</p><p class="abstract"><strong>Results:</strong> The average consultation time was 13 min and 50 sec. The average dispensing time was 5 min and 3 sec calculated from 100 prescriptions. The percentage of drugs dispensed was 97.50% and percentage of drugs adequately labeled was high from the dispensed drugs (74.4%). The average patients with drug dosage knowledge were very low (25%). The result of the study revealed that the two veterinary clinic health facilities do not have any essential drug list. Out of three, one of them has a key drug from the WHO list 1 (30%) drug was available.</p><p class="abstract"><strong>Conclusions:</strong> The overall good dispensing practices at three veterinary clinics is low. Training, supportive supervision through continuous medical education, regular up-to-date medicine information and standard treatment guideline, and therapeutic audit are required for improvement of medicine use by prescriber and dispensers.</p>

Assessment of Knowledge, Qualification, Experience, and Medication Dispensing Practices in South Karachi, Pakistan

Background: Drug stores in Pakistan are run by dispensers with varied knowledge, qualification, and experience. The current study was sought to explore the knowledge, qualification, experience, and dispensing practices among dispensers working in drugstores in South Karachi, Pakistan. Methods: A cross-sectional survey was carried out using a structured questionnaire. Data were collected from medical stores in South Karachi which were then categorized, coded, and analyzed using SPSS version 23. Relationship among different study variables with pharmacist’s availability and personal experience was assessed using statistical non-parametric Chi-square test. A total of 385 samples obtained using a simple random sampling method were included in the study. However, only 210 responses on questionnaire were complete which were then selected for study analysis between October and December 2018. Results: Of the 210 surveyed drugstores, 9% of their staff had studied only till primary school, 5.7% till the eighth grade, 25.2% up to secondary school level, 26.7% till higher secondary school level, 15.7% had non-professional education, and 8.1% were professional graduate. Only 9% of them had a degree in Pharm. D or B. Pharm, while 0.5% had a post-graduation qualification. Furthermore, 44.8% of pharmacies had a valid pharmacy license but the pharmacist was physically absent in 91% of the drugstores. Majority of pharmacies did not maintain appropriate temperature (refrigerator and/or room temperature). Majority of dispensers did not review prescription particulars before dispensing medications and also dispensed medications on older prescriptions as well as without prescription. Conclusion: In conclusion, the overall knowledge and practices of dispensers working in drugstores was poor. However, the presence of pharmacist was associated with good dispensing practices to a certain extent.

Community Pharmacies, Drug Stores, and Antibiotic Dispensing in Indonesia: A Qualitative Study

Background Inappropriate dispensing of antibiotics at community pharmacies is an important driver of antimicrobial resistance (AMR), particularly in low- and middle-income countries. Thus, a better understanding of dispensing practices is crucial to inform national, regional, and global responses to AMR. This requires careful examination of the interactions between vendors and clients, sensitive to the context in which these interactions take place. Methods In 2019, we conducted a qualitative study to examine antibiotic dispensing practices and associated drivers in Indonesia, where self-medication with antibiotics purchased at community pharmacies and drug stores is widespread. Data collection involved 60 in-depth interviews with staff at pharmacies and drug stores (n = 31) and their clients (n = 29), conducted in an urban (Bekasi) and a semi-rural location (Tabalong) to capture different markets and different contexts of access to medicines. Interview transcripts were analysed using thematic content analysis. Results A common dispensing pattern was the direct request of antibiotics by clients, who walked into pharmacies or drug stores and asked for antibiotics without prescription, either by their generic/brand name or by showing an empty package or sample. A less common pattern was recommendation to use antibiotics by the vendor after the patient presented with symptoms. Drivers of inappropriate antibiotic dispensing included poor knowledge of antibiotics and AMR driving patient demand, financial incentives to maximise medicine sales in an increasingly competitive market, the unintended effects of health policy reforms, and weak regulatory enforcement. Conclusions Inappropriate dispensing of antibiotics in community pharmacies is the outcome of complex interactions between vendors and clients, shaped by wider and changing socio-economic processes. Concerted action should be taken to address this complexity and involve such providers in the development and implementation of AMR national action plans.

Medical abortion kit dispensing practices of community pharmacies in Pokhara Metropolitan, Nepal

Background Medical abortion (MA) refers to the use of medicines to terminate the pregnancy. There is an urgent need to spread safe abortion services in the community. This study assessed the MA kit dispensing practices of community pharmacies in Pokhara Valley, Nepal. Methods A cross-sectional descriptive study was conducted in Pokhara Valley, Nepal from December 2017 to November 2018. Among the community pharmacies of Pokhara Valley, 115 community pharmacies were selected using a consecutive sampling method. A semi-structured questionnaire was used to collect data. MA kit and related information were requested by simulated male clients visiting the community pharmacies. The information obtained from the pharmacy workers was recorded in the data collection sheet. Results Nine brands of MA kit from eight manufacturing companies were found in practice in Pokhara Valley, out of those only five (56%) were registered in Nepal. Seven brands were sold at more than the labeled price. The pharmacy workers asked about the gestational age and confirmation of pregnancy in all the cases. Most of them counseled the clients on the frequency, duration, and direction of use. Dispensing practice and level of counseling were found to be significantly correlated (r = 0.40, p value = 0.01). Conclusion Despite the awareness of the pharmacy workers on the MA kit, most of them provided limited information to the clients. Nearly half unregistered MA kits were found in practice at the community pharmacies. Thus, the Department of Drugs Administration and other concerned authorities must provide relevant training and awareness programs to the pharmacy workers of the community pharmacies for preventing the malpractice of MA kit. The Government of Nepal must restrict the illegal entry of unregistered brands and assure the standards of MA kit by regulating drug acts and policies effectively.