Pharmacy Practice <p><strong>Pharmacy Practice</strong> is a free full-text peer-reviewed journal with a scope on pharmacy practice. <strong>Pharmacy Practice</strong> is published quarterly. <strong>Pharmacy Practice <span style="text-decoration: underline; color: #ff0000;">does not charge any publication fee to the author</span><span style="text-decoration: underline;"><span style="color: #ff0000; text-decoration: underline;">s</span></span></strong>.</p> Centro de Investigaciones y Publicaciones Farmaceuticas en-US Pharmacy Practice 1885-642X <p>The authors hereby transfer, assign, or otherwise convey to Pharmacy Practice: (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print pr epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to <strong>Pharmacy Practice</strong> with this document.</p> <p>Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a <a href="" target="_blank" rel="noopener">Creative Commons Attribution License</a> (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.</p> Pharmacist recommendations for prophylactic enoxaparin monitoring and dose adjustment in trauma patients admitted to a surgical intensive care unit <p><strong>Background</strong>: There is limited information describing pharmacist participation in prophylactic enoxaparin monitoring in the surgical intensive care unit (SICU).</p> <p><strong>Objective</strong>: Our study sought to: 1) characterize pharmacist recommendations for enoxaparin monitoring in trauma patients admitted to the SICU, 2) describe the frequency that medical providers accept pharmacist recommendations for enoxaparin monitoring in trauma patients admitted to the SICU, and 3) illustrate the frequency that trauma patients admitted to our SICU service achieve anti-factor Xa trough concentrations (AFXa-TRs) of 0.11 - 0.20 IU/mL following pharmacist recommendation to adjust prophylactic enoxaparin dosing.</p> <p><strong>Methods</strong>: Adult patients who had an AFXa-TR drawn after at least three consecutive prophylactic enoxaparin doses between June 1, 2017 and March 1, 2018 were identified through chart review and included in this study. Patients were excluded based on the following criteria: 1) age less than 18 years, 2) anti-factor Xa (AFXa) level not representative of a trough concentration, 3) AFXa-TR not representative of steady state concentration, and 4) non-trauma based prophylactic enoxaparin dosing.&nbsp; This study was exempt from IRB review.</p> <p><strong>Results</strong>: The final analysis consisted of 42 patients. A pharmacist provided at least one recommendation in 97.6% (41/42) of trauma patients with enoxaparin monitoring during their SICU stay. In total, a pharmacist made 170 recommendations, mean of 4.2 (SD 1.8) recommendations per patient. Recommendations were: 1) obtain an AFXa-TR, n=90; 2) adjust enoxaparin dose based on AFXa-TR, n=58; and 3) maintain enoxaparin dose based on AFXa-TR, n=22. Medical providers accepted 89.4% (152/170) of pharmacist recommendations for enoxaparin monitoring. Dose adjustments were made in 33 patients following pharmacist recommendation; of these, 27 had a repeat AFXa-TR following at least one dose adjustment. Target AFXa-TRs were achieved in 19/27 patients, indicating 70.4% had recommended AFXa concentrations.</p> <p><strong>Conclusions</strong>: Pharmacists provided recommendations for prophylactic enoxaparin monitoring and dose adjustment in trauma patients admitted to the SICU. Medical providers regularly accepted pharmacist recommendations and trauma patients commonly achieved target AFXa-TR following pharmacist recommendation for dose adjustment. Further research is required to identify the optimal enoxaparin dose for VTE prophylaxis in trauma patients.</p> Ali Scrimenti Robert W. Seabury Christopher D. Miller Lucy Ruangvoravat William Darko Luke A. Probst Gregory M. Cwikla Copyright (c) 2019 Pharmacy Practice and the Authors 2019-10-31 2019-10-31 1541 1541 Characteristics of significant events identified by pharmacy students while on early immersion pharmacy practice experiences <p><strong>Objective</strong>: The purpose of this study was to characterize and classify significant events of pharmacy students who completed an early practice experience.</p> <p><strong>Methods</strong>: Significant event analyses (SEAs) were reflections submitted by students about events that they found impactful during their early practice experiences. An online repository has stored 287 SEAs submitted by first year pharmacy students for later use in a pharmacy course. For this study, all significant events were read and coded according to the pre-specified themes and tones (positive, negative, neutral, hybrids) of the event. Themes used were derived from prior literature characterizing major themes from other health professional students’ experiences. Additional themes were added by authors for those that did not fit into the pre-set categories. All themes of the narratives were subsequently categorized. To assure confirmability, the investigators conferred to discuss new themes that emerged and events that were ambiguous. To assure credibility, an external audit of a sample of the coded SEAs was completed. Upon reaching consensus between primary reviewer and secondary reviewers, data were reported as frequencies and percentages. This study received ethics clearance from the Office of the University Registrar and was deemed exempt by the University Institutional Review Board.</p> <p><strong>Results</strong>: A total of 1,055 coded responses were analyzed. The majority of SEAs were positive in tone (n=190, 66.2%) and many were hybrids of negative-turned-positive emotions (n=62, 21.6%). The most common major content theme was “patients and the provision of patient care” (n=412, 39.1%), followed by “pharmacy students and their behavior” (n=260, 24.6%). The most prevalent subthemes were “learning by doing” (n=134, 12.7%) and “feelings of usefulness or uselessness” (n=111, 10.5%).</p> <p><strong>Conclusions</strong>: The majority of students framed significant events in their pharmacy practice experiences in a positive light, even from challenging interactions. The events that resonated most frequently with these students centered around patient interactions and providing patient care. These results will be useful for pharmacy educators developing pharmacy school curriculums to better prepare students to excel and feel more comfortable in direct patient care experiences.</p> Philip T. Rodgers Vivian Cheng Antonio A. Bush Charlene Williams Copyright (c) 2019 Pharmacy Practice and the Authors 2019-11-26 2019-11-26 1571 1571 Facilitators and barriers in implementing medication safety practices across hospitals within 11 European Union countries <p><strong>Background</strong>: The study was carried out as part of&nbsp; the European Network for Patient Safety (EUNetPas) project in 2008-2010.</p> <p><strong>Objective</strong>: To investigate facilitators and barriers in implementation process of selected medication safety practices across hospitals within European Union countries.&nbsp;</p> <p><strong>Methods</strong>: This was an implementation study of seven selected medication safety practices in 55 volunteering hospitals of 11 European Union (EU) member states. The selected practices were: two different versions of medicine bed dispensation; safety vest; discharge medication list for patients; medication reconciliation at patient discharge; medication reconciliation at patient admission and patient discharge, and sleep card. The participating hospitals submitted an evaluation report describing the implementation process of a chosen practice in their organisation. The reports were analysed with inductive content analysis to identify general and practice-specific facilitators and barriers to the practice implementation.</p> <p><strong>Results</strong>: Altogether 75 evaluation reports were submitted from 55 hospitals in 11 EU member states. Implementation of the medication safety practices was challenging and more time consuming than expected. The major reported challenge was to change the work process because of the new practice. General facilitators for successful implementation were: existence of safety culture, national guidelines and projects, expert support, sufficient resources, electronic patient records, interdisciplinary cooperation and clinical pharmacy services supporting the practice implementation.</p> <p><strong>Conclusions</strong>: The key for the successful implementation of a medication safety practice is to select the right practice for the right problem, in the right setting and with sufficient resources in an organization with a safety culture.</p> Carita Linden-Lahti Anna-Riia Holmström Pirjo Pennanen Marja Airaksinen Copyright (c) 2019 Pharmacy Practice and the Authors 2019-12-04 2019-12-04 1583 1583 Medication follow-up in newborns with extremely low birth-weight <p><strong>Objective</strong>: The medication follow-up in infants with extremely low birth-weight in a neonatal intensive care unit is described, identifying drug-related problems (DRP), drug-related negative outcomes, and the relationship between the occurrence of DRP and birth-weight of newborns and their impact on pharmacotherapy and length of hospital stay.</p> <p><strong>Methods</strong>: A descriptive and exploratory study was performed in which medication follow-up of a population of infants with extremely low birth-weight admitted to the neonatal intensive care unit of a government-run maternity hospital was carried out by clinical pharmacists. Monitoring comprised assessment of patients’ pharmacotherapy needs through visits to the neonatal unit, evaluation of prescriptions and information on medical records, identification of issues associated with pharmacotherapy and follow-up of the newborns’ clinical evolution to determine whether desired results were achieved.</p> <p><strong>Results</strong>: The subjects were 33 infants characterized by extremely low weight at birth. Analysis of patients' pharmacotherapy showed that 39.4% (n=13) of the neonates presented some type of DRP, totaling 37 DRPs and a mean of 2.8 problems/patient. Fourteen drugs were identified with the occurrence of DRP. Vancomycin and cefepime were the most prevalent, with 18.9% (n=7). Occurrence of DRPs and several clinical characteristics of newborns and their pharmacotherapy were compared. The most prevalent drug-related negative outcomes identified were "untreated health problem" (40%, n=10) and "quantitative ineffectiveness" (32%, n=8). Pharmaceutical interventions were performed for all problems associated with pharmacotherapy, with a prevalence of "treatment day count correction" and "dose correction", both with 21.6% (n=8), and "correction of dosage" (16.2%, n=6).</p> <p><strong>Conclusion</strong>: The research evidenced the role of the clinical pharmacist in the solution and prevention of drug-related problems, contributing with the multidisciplinary team to obtain a safe and effective pharmacotherapy. Further, current study confirmed that there is an association between the characteristics of the newborns under analysis (eg. birth-weight, pharmacotherapy) and the occurrence of drug-related problems.</p> Catarine V. Loureiro Marta M. Fonteles Mylenne B. Mascarenhas Elana F. Chaves Paulo Y. Firmino Copyright (c) 2019 Pharmacy Practice and the Authors 2019-11-20 2019-11-20 1584 1584 Drug and therapeutics committees in Jordanian hospitals: a nation-wide survey of organization, activities, and drug selection procedures <p><strong>Background</strong>: Drug and Therapeutics Committees (DTCs) were founded about a century ago as a guide for dealing with drugs in hospitals. Since then, it has shown a vital role in rational drug use in terms of regulatory and educational activities.</p> <p><strong>Objective</strong>: To describe structures, functions, and activities of hospital DTCs.&nbsp;</p> <p><strong>Methods</strong>: A questionnaire was developed based on previous studies. Questions consisted of information on respondents’ demographics; structures, functions, and activities of DTCs; drug selection process and resources used, and factors and criteria used in drug selection.</p> <p><strong>Results</strong>: The overall response rate was 95%. DTCs were mainly present in most large hospitals (45%). All DTCs had hospital pharmacists in their structure and most of them (66%) met monthly. The main responsibilities of DTCs were related to general prescribing policies. The number, frequency, and severity of adverse drug reactions were the most reported criteria for the drug selection process. Legal implications for practical, economic, and organizational factors were the most important factors that were reported for drug selection.&nbsp;</p> <p><strong>Conclusions</strong>: DTCs are mainly present in most large hospitals. The main responsibilities of the DTC in Jordanian hospitals are general prescribing policies, drug selection, hospital formulary editing, and reporting of ADR to external authorities.</p> Qais Alefan Somayya Alshareef Samah Al-Shatnawi Copyright (c) 2019 Pharmacy Practice and the Authors 2019-11-03 2019-11-03 1590 1590 A nationwide web-based survey of a sample of Italian community pharmacists' perceptions and opinions about online sales of medicines and falsified drugs <p><strong>Background:</strong> Throughout Europe, legal online pharmacies increasingly sell online drugs as well as other products such as dietary supplements. Online sale of pharmaceuticals however is closely connected to the phenomenon of drug falsification.</p> <p><strong>Objective:</strong> The aim of this study was to assess the opinions of a sample of Italian community pharmacists towards the sale of pharmaceuticals on the web, as well as their knowledge and experience with falsified drugs.</p> <p><strong>Methods:</strong> A self-administered questionnaire was distributed by means of an online platform between October 2016 and January 2017. Collected information included: demographics, workplace and role, opinions towards the online sale of pharmaceuticals, whether the pharmacy has a website, knowledge and opinions about falsified drugs.</p> <p><strong>Results:</strong> A total of 668 community pharmacists completed the questionnaire (mean age: 48.5, SD 12.4 years, 52.3% women). Favourable opinions about online sale of pharmaceuticals were expressed by 4.9% of participants for prescription drugs, 25.4% for nonprescription drugs, and 51.6% for other products. Favourable opinions occurred more often among males and owners/directors of pharmacies in comparison to females and employees, and among pharmacists working in pharmacies with websites doing e-commerce. Knowledge about falsified drugs was limited, with 24.5% of respondents failing to indicate that falsified drugs may contain less or different ingredients, 46.4% less and/or different excipients, and 72.3% ignoring that falsified drugs may be lethal. One in 3 respondents didn't know about falsified drugs in Italy, however 51 participants had previous experience with falsified drugs and 21 provided specific information.</p> <p><strong>Conclusions:</strong> Italian community pharmacists have low confidence in the online sale of pharmaceuticals, as well as alarmingly limited knowledge about falsified drugs, even if many of them reported previous experiences. Results may support targeted interventions to increase pharmacists' knowledge about pharmaceuticals and the web, as well as concerning falsified drugs, and suggest community pharmacies as key components of integrated systems aimed at monitoring falsified drugs.</p> Simona Lombardo Franca Marino Marco Cosentino Copyright (c) 2019 Pharmacy Practice and the Authors 2019-11-30 2019-11-30 1593 1593 Appraisal of the entrustable professional activities (EPAs) patient care provider domain by North Dakota pharmacists <p><strong>Background</strong>: Entrustable Professional Activities (EPAs) are the latest addition to a list of professional competencies that pharmacy educational organizations support, and accreditation organizations require, for assessment by colleges and schools of pharmacy.</p> <p><strong>Objective</strong>: The study’s objective is to assess the use of Core EPAs in the patient care domain (by practice setting, position, and preceptor status) in contemporary pharmacy practice.</p> <p><strong>Methods</strong>: This survey assessed the EPA activities of pharmacists practicing in North Dakota. The pharmacists were asked “how many times in the past 30 days have you delivered the following services in your practice setting?” Response options were: 0, 1, 2, 3, 4, and 5 or more times.</p> <p><strong>Results</strong>: Of 990 potential respondents, 457 pharmacists (46.1%) returned a survey, and 107 (10.8%) answered every survey item in the patient care domain. Respondents reported that the highest rated activity items “Collect information to identify a patient's medication-related problems and health-related needs,” and “Analyze information to determine the effects of medication therapy, identify medication-related problems, and prioritize health-related needs” were performed an average of 3.9 times per week (SD=1.8), and 3.8 times per week (SD=2.0), respectively. Both of these items, were reported for 70% of the respondents at 5 or more times per week. For these items, the highest reported practice setting was ‘other’ practice settings (e.g., long-term care, community health centers) followed by chains, hospitals, and independent pharmacies. By position, clinical pharmacists and preceptors reported the highest activity levels for most EPAs and supportive example tasks.&nbsp;</p> <p><strong>Conclusions</strong>: This study provides empirical evidence suggesting (but not proving) that EPAs have potential as a means to assess outcomes in pharmacy education and practice. Our study sets the stage for future work that further refines and assesses core EPA activities and supportive example tasks to measure the impact of how this process relates to outcomes of care.</p> David M. Scott Michael P. Kelsch Macey Hanel Daniel L. Friesner Copyright (c) 2019 Pharmacy Practice and the Authors 2019-12-01 2019-12-01 1607 1607 Factors associated with quality of life among community pharmacists in Lebanon: results of a cross-sectional study <p><strong>Objective</strong>: The objective of this study was to assess the quality of life and the factors associated with it among community pharmacists in Lebanon.</p> <p><strong>Methods</strong>: This cross-sectional study was carried out between March and July 2018, enrolling 435 pharmacists, using a proportionate random sample of community pharmacies from all districts of Lebanon. The validated Arabic translation of the Short-Form 12 (SF12v2) was used to derive 2 summary scores: physical and mental component summaries (PCS and MCS).</p> <p><strong>Results</strong>: Lebanese community pharmacists scored a mean PCS-12 and MCS-12 of 48.9 (SD 7.1) and 48.8 (SD 8.5), respectively. Higher age (Beta= -0.08), having a PhD degree (Beta= -4.54), higher depression score (Beta= -0.25), higher emotional work fatigue (Beta= -0.13) and higher physical work fatigue (Beta=-0.14) were significantly associated with lower physical QoL (lower PCS-12 scores).</p> <p>Increased stress (Beta= -0.17), higher insomnia (Beta= -0.21), higher depression (Beta= -0.2) and working for over 40 hours per week (Beta= -0.2) were significantly associated with lower mental QoL (lower mental MCS-12 scores).</p> <p><strong>Conclusions</strong>: Our research has found a strong correlation between quality of life and psychological factors, including stress, burnout, insomnia, and depression among community pharmacists.</p> Hala Sacre Sahar Obeid Georges Choueiry Eva Hobeika Rita Farah Aline Hajj Marwan Akel Souheil Hallit Pascale Salameh Copyright (c) 2019 Pharmacy Practice and the Authors 2019-10-28 2019-10-28 1613 1613 A comparison of clinical pharmacist management of type 2 diabetes versus usual care in a federally qualified health center <p><strong>Background</strong>: Clinical pharmacists have demonstrated their ability to improve patient outcomes over usual care for patients with type 2 diabetes and glycemic levels above goal, though reasons for this are not well defined. Numerous medications exist for the management of patients with type 2 diabetes and different patterns of medication use by clinical pharmacists may explain these benefits.</p> <p><strong>Objective</strong>: The objective of this study was to compare pharmacotherapy approaches to managing patients with uncontrolled type 2 diabetes receiving basal insulin by a clinical pharmacist versus usual care by a physician or advanced practice provider in a federally qualified health center.</p> <p><strong>Methods</strong>: A retrospective cohort study of patients 18 to 85 years old with type 2 diabetes,&nbsp; A1C ≥9%, receiving basal insulin was conducted. Patients were grouped into two cohorts: (1) those who received clinical pharmacist care and (2) those who received usual care from a physician or advanced practice provider. The primary outcome evaluated the proportion of patients treated with the addition of a non-basal insulin medication. Type of medication changes or additions as well as change in A1C and change in weight were also analyzed. Outcomes were evaluated at six months post-index A1C.</p> <p><strong>Results</strong>: A total of 202 patients were identified (n=129 in the usual care group and n=73 in the clinical pharmacist group). A non-basal insulin medication was added in 29% of patients receiving usual care versus 41% of patients receiving clinical pharmacist care (adjusted p=0.040). Usual care providers more frequently added metformin, sulfonylureas and thiazolidinediones, while clinical pharmacists more frequently added prandial insulin, DPP-4 inhibitors, GLP-1 agonists, and SGLT-2 inhibitors. A1C decreased 1.6% in the clinical pharmacist group versus 0.9% in the usual care group (adjusted p=0.055). No significant change in weight was observed between the clinical pharmacist and usual care group (0.2 kg versus -1.0 kg, respectively; adjusted p=0.175).</p> <p><strong>Conclusions</strong>: Pharmacotherapy approaches to managing patients with uncontrolled type 2 diabetes varied between clinical pharmacists and other clinician providers. For patients already on basal insulin, clinical pharmacists were more likely to intensify therapy with the addition of non-basal insulin, including more frequent initiation of prandial insulin and by adding newer antihyperglycemic agents.</p> Rhianna M. Fink Emanuela V. Mooney Joseph J. Saseen Sarah J. Billups Copyright (c) 2019 Pharmacy Practice and the Authors 2019-12-03 2019-12-03 1618 1618 Challenges with accessing health care for young children presumed to have malaria in the rural district of Butaleja, Uganda: a qualitative study <p><strong>Objective</strong>: A qualitative study was conducted to gain insight into challenges reported by Butaleja households during a previous household survey. Specifically, this paper discusses heads of households’ and caregivers’ perceptions of challenges they face when seeking care for their very young children with fever presumed to be malaria.</p> <p><strong>Methods</strong>: Eleven focus groups (FGs) were carried out with household members (five with heads of households and six with household caregivers) residing in five sub-counties located across the district. Purposive sampling was used to ensure the sample represented the religious diversity and geographical distance from the peri-urban center of the district. Each FG consisted of five to six participants. The FGs were conducted at a community centre by two pairs of researchers residing in the district and who were fluent in both English and the local dialect of Lunyole. The discussions were recorded, translated, and transcribed. Transcripts were reviewed and coded with the assistance of QDA Miner (version 4.0) qualitative data management software, and analyzed using thematic content analysis.</p> <p><strong>Results</strong>: The FG discussions identified four major areas of challenges when managing acute febrile illness in their child under the age of five with presumed malaria: (1) difficulties with getting to public health facilities due to long geographical distances and lack of affordable transportation; (2) poor service once at a public health facility, including denial of care, delay in treatment, and negative experiences with the staff; (3) difficulties with managing the child’s illness at home, including challenges with keeping home-stock medicines and administering medicines as prescribed; and (4) constrained to use private outlets despite their shortcomings.</p> <p><strong>Conclusions</strong>: Future interventions may need to look beyond the public health system to improve case management of childhood malaria at the community level in rural districts such as Butaleja. Given the difficulties with accessing quality private health outlets, there is a need to partner with the private sector to explore feasible models of community-based health insurance programs and expand the role of informal private providers.</p> Asa Rahimi Rosemin Kassam Zhong Dang Richard Sekiwunga Copyright (c) 2019 Pharmacy Practice and the Authors 2019-12-04 2019-12-04 1622 1622 Creation and validation of a semi-quantitative instrument to assess the confidence of pharmacists in medication consultation for patients with depression: The Pharmacists' Confidence scale about Medication Consultation for Depressive patients (PCMCD) <p><strong>Objectives</strong>: To develop a semi-quantitative instrument to assess pharmacists’ confidence in medication counseling for patients with depression, The Pharmacists' Confidence scale about Medication Consultation for Depressive patients (PCMCD), and investigated its validity.</p> <p><strong>Methods</strong>: Following discussions with practicing pharmacists, we developed a 12-item questionnaire to assess pharmacists’ confidence in medication counseling for patients with depression. We launched web-based cross-sectional survey during November and December 2018 to 77 pharmacists employed at drug chain stores in Kansai area. Factor analysis was performed to evaluate the configuration concept validity. The least-squares method was used for factor extraction, and the resulting factors were subjected to direct oblimin rotation, with a factor loading cut-off of 0.4. To assess internal consistency, Cronbach’s alpha values were calculated for each of the extracted factors (subscales). A multiple regression analysis was performed using simultaneous forced entry, with the scores obtained for each subscale as dependent variables and responder attributes as independent variables in order to investigate the factors associated with each subscale.</p> <p><strong>Results</strong>: During the factor analysis procedure, four questions were excluded by the cut-off rule. Eventually, a model with three subscales was identified, with a cumulative sum of squared loadings being 61.9%. The subscales were termed “relationship building,” “comprehension of condition,” and “information provision” based on the nature of the questions relevant for each of them. The Cronbach’s alpha values for these subscales were 0.92, 0.73, and 0.72, respectively. The average inter-item correlation was 0.378. In addition, multiple regression analysis revealed that there were significant correlations between pharmacist career and both relationship building and information provision.</p> <p><strong>Conclusions</strong>: The PCMCD model demonstrated a satisfactory construct validity and internal consistency. This model will provide an excellent tool for assessing pharmacists’ confidence in depression care.</p> Masaki Shoji Atsuko Fujiwara Mitsuko Onda Copyright (c) 2019 Pharmacy Practice and the Authors 2019-12-04 2019-12-04 1628 1628 Role of board certification in advancing pharmacy practice Samuel G. Johnson Copyright (c) 2019 Pharmacy Practice and the Authors 2019-12-08 2019-12-08 1767 1767