- Email: [email protected]
Design of hospital errors and omissions activities that include patient-specific medication related problems
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
Design of hospital errors and omissions activities that include patient-specific medication related problems
T
Julie B. Cooper , Courtney L. Bradley ⁎
Fred Wilson School of Pharmacy, High Point University, 1 University Parkway, High Point, NC 27685, United States
ARTICLE INFO
ABSTRACT
Keywords: Prescription verification Hospital pharmacy Pharmacy skills laboratory Medication safety Patient-centered Medication related problems Sterile products
Background and purpose: Medication-related problems persist in hospital settings. New types of errors have emerged with changing technology. There is a need for updated, realistic, and patient-specific activities to train student pharmacists to identify medication-related problems. Educational activity and setting: We describe efforts to redesign hospital errors and omissions activities in a clinical skills lab course. A hospital errors and omissions template is described with multiple-choice answer options redesigned to reinforce that each instance of dispensing in a hospital is an opportunity for patient-centered care. Findings: In the redesigned hospital errors and omissions activities, students identified the correct errors and omissions 77% of the time with an average point biserial of 0.491. Qualitative evaluation of student course evaluations and student self-selected learning goals suggest that students perceived the revised activity to be valuable. Summary: It is possible to create and deliver hospital errors and omissions activities that include patient-specific medication related problems.
Background and purpose Medication error remains a significant problem in hospitalized patients despite coordinated efforts to improve the quality of care.1 The primary role of the pharmacist for hospital patients is optimizing patients’ use of medications. Pharmacists’ prevention of medication-related problems (MRP) is a complex task requiring consistent application of the Pharmacists’ Patient Care Process integrating clinical thinking across the four domains of MRP: indication, efficacy, safety, and adherence.2,3 Competency-based medical education has led to the naming of entrustable professional activities (EPA) for pharmacy.4 The patient care provider domain EPA includes identification of MRPs. One instructional activity that is used to teach students to identify MRP and to assess their ability to perform this EPA is errors and omissions. Errors and omissions is a teaching method where a student pharmacist reviews an order and a corresponding product to identify potential MRPs. Published reports of errors and omissions activities used within pharmacy curricula have focused on legal labeling specifications, product selection, and appropriate branding in a community pharmacy setting. These activities are referred to as community errors and omissions.5,6 For example, Waitzman and Dinkins5 redesigned the community pharmacy errors and omissions activities at the University of North Carolina to make it more practical and realistic. Additionally, Hirsh and colleagues6 described a capstone course at Philadelphia College of Osteopathic Medicine School of Pharmacy that included errors and omissions in the Georgia State Board of Pharmacy Practical Examination multiple-choice format. Pharmacy school curricula also commonly contain errors and omissions activities derived from the hospital setting, referred to as hospital errors and omissions. For example, Kirwin and ⁎
Corresponding author. E-mail addresses: [email protected] (J.B. Cooper), [email protected] (C.L. Bradley).
https://doi.org/10.1016/j.cptl.2018.09.018
1877-1297/ © 2018 Elsevier Inc. All rights reserved.
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
colleagues7 described a simulated hospital pharmacy module in a skills laboratory course that included instruction on final verification of sterile products. Their assessment required students to describe errors in product preparation and suggest resolutions. Students’ self-reported confidence in their ability to verify prepared sterile products increased significantly after module completion. Metzger and colleagues8 described a simulated medication reconciliation and order verification activity using the training environment of an electronic medical record (EMR) during an introductory pharmacy practice experience. Verification of a patient's admission medication orders were discussed in a small group including reasons to reject an order and how to recommend alternatives to the provider. Published hospital errors and omissions activities are resource intensive and product focused. Recent changes in the practice of pharmacy include the transition to EMRs and an increase in medication dispensing automation. These advances have reduced some of the medication errors in published errors and omissions activities including order transcription, product selection and labeling. However, technology has created new types of problems pharmacists must learn to prevent, including patient identification and misleading directions.9 Furthermore, technology can create a separation between pharmacists and their patients, especially in the hospital setting. This separation may prevent pharmacists from thinking about each patient individually to identify patient-specific MRPs. The persistence of MRPs combined with the emergence of new types of errors highlight the need for updated, realistic and patient-specific activities to train pharmacists to identify MRP in the hospital setting. This report describes redesigned hospital errors and omissions activities that simulate MRP identification in an EMR. Redesigned activities were created to reinforce that each instance of dispensing in a hospital is an opportunity for patient-specific care. Our goal was to redesign the hospital errors and omissions activities to create a patient-specific format that would simulate a realistic, EMR based, hospital-dispensing scenario in which students were trained to identify patient-specific and product-specific MRPs. An additional goal was to create a format that was deliverable with minimal instructor resources using multiple-choice answers. This article is a report of the format that was developed and lessons learned throughout the process. Educational activity and setting At High Point University School of Pharmacy, a six-semester Clinical Skills Laboratory course series prepared students for practice through activities interweaving with content taught in concurrent first-, second-, and ultimately third-year courses. The skills developed in this course series were focused on providing quality patient-specific care. Activities included prescription preparation, prescription verification, patient and prescriber counseling through the use of standardized clients, medication therapy management, physical assessment, point-of-care devices, clinical documentation, and root cause analysis. Errors and omissions activities were used to develop and assess skills related to prescription verification. The community errors and omissions activities were introduced beginning in the first year (P1) fall semester and the hospital errors and omissions were introduced P1 spring semester. In the P1 2016 fall semester, the community errors and omissions activities began with a practice session that was followed by three graded sessions patterned after the method described in Waitzman and Dinkins.5 In the subsequent P1 spring semester, hospital errors and omissions was introduced in a separate pharmaceutics lab course taught concurrently with an introduction to sterile compounding over a four-week period. There were two practice sessions; one that consisted of two orders on week 8 and one that consisted of four orders on week 10. There was a graded session that consisted of four orders on week 11. The objective of both the P1 community pharmacy and the P1 hospital pharmacy errors and omissions activities was to identify product-related errors. There were no patient scenarios or answer choices related to patient-specific problems. Therefore, this product-specific design was referred to as original hospital errors and omissions. The redesign of the hospital errors and omissions occurred in 2017 during the second year (P2) fall semester, as instructors sought to base the activities in an EMR environment and incorporate patient-specific MRP. Redesign began with a revised two-page order template for the hospital errors and omissions activities as seen in Figs. 1 and 2. In this revised template (on page one), students first encountered the setting where the activity occurred. One potential hospital setting included the sterile products area where student pharmacists verified either an admixed sterile product (Fig. 1) or a premade sterile product. Another potential hospital setting included the central inpatient pharmacy where student pharmacists verified a unit dose product (Fig. 2). Further on page one of the template, students encountered a header with a patient name and medical record number to simulate patient identification in the EMR. A patient scenario preceding the medication order created a patient focus for the activity. The order was displayed in a realistic, yet simplified, EMR order composer based on the order composer view in Epic™ (Verona, Wisconsin). Page two of the template included a realistic hospital label with explicit statements describing technology-based dispensing logic followed by images of the product as presented to the pharmacist for verification. The revised template was presented to the students with standardized multiple-choice options developed based on the Georgia State Board of Pharmacy errors and omissions assessment.10 The multiple-choice options were standardized based on hospital dispensing setting with different options for admixed sterile products, premade sterile products, and unit dose products (Table 1). Multiple-choice options included problems with patient identification, patient-specific problems, as well as product and dispensing errors. Patient-specific errors related to topics covered in concurrent pharmacotherapy courses. One example of a patient-specific error delivered in an order during the infectious disease module was a patient allergy to an ordered antibiotic. Further medication related problem examples for each multiple-choice option are described in Table 1. This patient-specific format was referred to as redesigned hospital errors and omissions. During the Clinical Skills Lab in the P2 fall semester, the redesigned hospital errors and omissions activities were delivered five times throughout the semester. The Clinical Skills Lab was designed so that students rotated through four to six different activities during a three-hour lab period. To accommodate a class size of 57 students, the lab was offered as two separate sections with 28–29 students in each section. On select weeks, redesigned hospital errors and omissions were included in the rotation of lab activities. 67
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
During these weeks, students also completed various other activities such as written cases, point-of-care devices, patient counseling, and others. In general, these redesigned hospital errors and omissions activities were 30-min in length with approximately eight to ten students simultaneously completing the activities individually. The redesigned hospital errors and omissions activities were first introduced on week five with an instructor led a review of the order template and direct instruction on how to utilize the standardized, multiple-choice answer options as a framework for verifying a hospital order. On the same day as the initial instructor overview, students completed an individual practice session consisting of four orders. During week 6, students completed a graded session consisting of four orders. Based on student comments provided during and after this graded session, a second practice session of four orders was created and delivered during week 10 with immediate feedback enabled. Students then completed another graded session of four orders during week 11. Finally, three orders were included on the end-of-semester practical exam during week 13. For all activities, all orders were provided to the students in a booklet printed such that when opened both template pages were visible simultaneously. Student responses were captured on paper during the first practice session. However, in all other sessions,
Fig. 1. Hospital errors and omissions template, sterile products area. 68
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Fig. 1. (continued)
student answers were recorded using ExamSoft (ExamSoft Worldwide, Inc.) to streamline delivery and individual student assessment. All graded sessions were followed by an instructor-led, structured debrief the following week. Resources required for these redesigned hospital errors and omissions activities were limited to faculty time. A faculty member developed the scenarios and order templates for both practice and graded sessions. Additionally, this same faculty member facilitated the sessions; however, this did not represent added time because this faculty member was already present for the lab session to facilitate other ongoing activities. The redesigned format was developed with several objectives including creating a more realistic hospital order scenario, incorporating the potential for both product-related errors and patient-specific MRP, and utilizing a format that was time and resource efficient. For assessment of the re-designed format, quantitative and qualitative data were collected. For assessment purposes, each order represented a single question. The percent correct, number of correct answers, and average answer time were collected to assess each question's difficulty. Additionally, point biserial values were collected to assess the discriminatory ability of each question. These quantitative values were described for each question within each assessment and summarized for both the original version and re-designed version with descriptive statistics. Based on department standards, it was determined that a reasonably difficult question had a percent correct between 30 and 80%. Based on previous experience with community errors and omission activities, it was determined to allow an average time to answer of five minutes per order. Similarly, it was determined that a question was able to 69
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Fig. 1. (continued)
meaningfully discriminate between students who knew the material and those who did not if the point biserial was above 0.3. The point biserial is a correlation coefficient measuring the relationship between correct and incorrect performance on an assessment question and performance on the entire assessment. It was hypothesized that the redesigned hospital errors and omission activities combined with appropriate student training and opportunity to practice would result in similar psychometrics to the original hospital errors and omissions activities. Therefore, our goal was to maintain consistent psychometrics for the redesigned hospital errors and omissions activities as measured by percent correct, average answer time, and point biserial. Additionally, a qualitative analysis was completed by reviewing select questions from two free response assignments to identify student comments related to the redesigned hospital errors and omissions activities. The first item reviewed was a question from the end-of-course evaluation that asked: “Based on your overall ratings of this course and what you have learned this semester, please describe more specifically what you perceive to be the particular strengths and any areas of improvement for this course.” The second item reviewed included one question from a required skills lab goal setting assignment which specifically asked: “After reflecting on your strengths and weaknesses, for the initial self-assessment, please write two specific goals that you would like to work on this semester”. These goals could have been academic or personal in nature. For both of these free response assignments, students were not specifically instructed to comment on the errors and omissions activities. Comments were manually coded to identify themes. This study was reviewed and granted an exempt status by the High Point University Institutional Review Board. Findings Quantitative assessment In the original format, students identified the correct errors and omissions 79% of the time with an average point biserial of 0.564 taking an average of 3 min 43 s to identify an average of 1.88 errors and omissions. Table 2 provides descriptive statistics for each assessment in the original format conducted in spring 2017. In the redesigned format, students identified the correct errors and omissions 77% of the time with an average point biserial of 0.491 taking an average of 3 min 54 s to identify an average of one error and omission. Table 3 provides descriptive statistics for each assessment in the redesigned format conducted in fall 2017. Qualitative assessment Qualitative analysis yielded five unsolicited comments about hospital errors and omissions with two emergent themes. Three comments were from the course evaluation question out of 17 total comments received from 45 evaluations. Two comments were from the skills lab goal setting assignment received from all 57 students. Initial confusion about the activity was mentioned three times, twice in the evaluation, and once in the goal setting question. The practical value of the activity to the practice of pharmacy was noted three times once in the evaluation and twice in the goal setting question. Discussion Our aim was to redesign hospital errors and omissions activities to include patient-specific MRP in an updated realistic format. When comparing the results of the redesigned hospital errors and omissions activities to the original hospital errors and omissions activities, the redesign met specified standards for student performance assessment with slightly lower average percent correct and 70
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
point biserial. Further, the redesigned activities two-page order template took students slightly longer to identify a single correct answer per order than the original activities presented on a single page. Additionally, preliminary qualitative analysis of student opinion suggested that the re-designed activities were initially challenging but practically valuable. This report of a redesigned hospital errors and omission activity has significant limitations. This study evaluates a limited number of student encounters with the redesigned format after the initial attempt by these instructors to provide direct instruction to P2s in hospital errors and omissions affects the validity of our results. Further the small amount of qualitative data available for analysis has limited power to detect the full range of the student experience with this activity. Despite these limitations the redesigned practical format provided valuable information about how we might train pharmacists to identify MRPs in practice. The students’ previous experience with the original product focused hospital and community errors and omissions activities led to confusion about the nature of the MRP they encountered in the re-designed format with a patient scenario. At the time the redesigned
Fig. 2. Hospital errors and omissions template, central inpatient pharmacy. 71
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Fig. 2. (continued)
activities were initially deployed, instructors were unaware of introductory resources or readings to provide students prior to the activity. Therefore, direct instruction, similar to that employed by Metzger and colleagues, was used to prepare students for subsequent practice and graded activities. To enhance instructional design, instructors enabled the question feedback feature in Examsoft allowing students to provide instructors written comments for each order. Students were informed that comments were open but not specifically directed about what type of comments to write. Students commonly provided rationale for their answer selection allowing instructors to make revisions to the activity. Specific areas identified by this method for clarification included technologybased dispensing logic and confidence determining the absence of a patient-specific MRP. In response to this confusion, instructors created direct instructional content on hospital dispensing, provided additional practice opportunities to reinforce patient-specific MRPs and revised the template to include explicit statements about dispensing logic. Students noted initial challenges stating in the course evaluation: “There was a lot of initial confusion with hospital errors and omissions but in the end it was pretty good.” The week-by-week teaching and grading experiences of instructors during these re-designed activities also demonstrated that there was a need to provide multiple practice opportunities and dedicated instructional time. Student performance on later activities indicated that there was an ongoing need for immediate feedback in order to reinforce the intricacies of hospital-based verification and to train students how to apply the multiple-choice answer framework to approach MRP identification in the hospital setting. Faculty time spent in lab providing direct instruction and immediate feedback was significant but did not represent additional time, as they were 72
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Table 1 Redesigned hospital errors and omissions multiple-choice answer options based on inpatient dispensing settings. Answer choices
Setting
Template section
Description of problem and examples
Order was placed on the wrong patient.
UD ASP PSP UD ASP PSP
Patient profile, clinical scenario & order
Name and medical record number on order and label do not match patient profile
Patient profile & clinical scenario
Wrong medication was selected during order entry.
UD ASP PSP
Order
Wrong dosage form was selected during order entry.
UD ASP PSP UD ASP PSP UD ASP PSP
Clinical Scenario & order
A MRP of indication, effectiveness, safety or adherence based on review of the patient scenario and medication order (e.g., provider ordering the atrial fibrillation dose of apixaban in a patient with a new deep vein thrombosis; see Fig. 1) Ordered medication and the Products to dispense portion of the order do not match (e.g., order for NS contains free text note from ordering provider indicating addition of potassium 40 mEq, and products to dispense lists only NS Ordered wrong dosage form (e.g., patient receiving all medications via tube and order is for an extended release tablet)
UD ASP PSP ASP PSP
Product
Amount of medication drawn up/added for final dispense is not correct. Correct diluent was not chosen to prepare the IV.
ASP
Product
ASP
Product
Amount of diluent drawn up and/or added was not correct. Diluent was expired. Correct IV solution was not chosen.
ASP
Product
ASP ASP
Product Product
Correct volume of IV solution was not chosen.
ASP
Product
IV solution was expired Product may be dispensed, there are no errors.
SPA UD ASP PSP
Product N/A
Call the prescriber, there is a MRP identified in the patient profile, clinical scenario, or new medication order.
Wrong medication was chosen to dispense. Quantity dispensed is wrong.
Medication is expired. Expiration date applied to the final product is incorrect.
Product
Identity of product to dispense or used to prepare IV admixture does not match the ordered medication (e.g., order written for warfarin 2.5 mg tablet, and warfarin 5 mg tablet dispensed) Quantity of product to dispense does not match order or dispensing logic (e.g., dispensing logic indicates that the first dose of a twicedaily medication is to be delivered, and two doses of the medication are packaged to dispense) The medication presented to dispense or pulled for preparation is expired
Product
Product
After preparation, the expiration date applied to the final product to dispense is incorrect based on preparation instructions provided in template (see Fig. 2) Syringe presented with final product to dispense is drawn back to the wrong volume Diluent used does not match the preparation instructions (e.g., sterile water for injection suggested in preparation instructions, NS selected as diluent) Syringe presented with diluent used was drawn back to the wrong volume (see Fig. 2) The diluent used was expired Identity of solution used to prepare the IV admixture does not match the ordered base solution (e.g., NS 500 mL ordered as base solution, D5W 500 mL selected as base solution). Volume of solution used to prepare the IV admixture does not match the ordered volume (e.g., NS 500 mL was ordered as base solution, NS 250 mL selected as base solution) The IV solution used was expired No errors present
*UD, central inpatient pharmacy unit dose dispensing; ASP, admixed sterile product; PSP, premade sterile product; MRP, medication-related problem; IV, intravenous; NS, normal saline; D5W, 5% dextrose in water.
already present in lab to facilitate other activities. Instructors noted a decrease in time clarifying common mistakes and decreased time answering student questions as the semester progressed. Another challenge was creating a fair assessment that was time efficient to grade and strongly discriminating. The use of multiplechoice answers enabled instructors to implement assessment of the re-designed hospital errors and omissions in ExamSoft enabling efficient grading and evaluation. One common point of confusion was the presence of a patient-specific MRPs. Importantly in this redesigned activity, students were presented with multiple distinct patient-specific MRPs across the various orders presented in multiple activities and these errors all required students to select the same single patient-specific MRP answer choice: “Call the prescriber, there is a MRP identified in the patient profile, clinical scenario, or new medication order”. Additionally the unique set of multiplechoice answer options presented for each distinct hospital setting may have created confusion. All three hospital practice settings were presented to the students in the initial practice activities and subsequent activities included orders from at least two hospital practice settings. Learning how to identify MRPs in multiple settings simultaneously may have increased confusion. Despite these limitations, as the P2 fall semester progressed and as the instructor provided more targeted de-briefing, students asked fewer questions and documented fewer comments. Instructors have planned revisions of the multiple-choice options to distinguish specific types of patient-specific MRPs and reorder the delivery of the redesigned activities to allow students to practice one hospital dispensing setting at a time. While errors and omissions activities are a common pedagogy, it is not known if errors and omissions activities prevent MRPs in 73
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Table 2 Question analysis of original hospital errors and omissions activities. Class and activities
Order
P1 Spring 2017 – session 1 – week 8 practice P1 Spring 2017 – session 2 – week 10 practice (n = 59)
Completed on paper, no electronic results
P1 Spring 2017 – Session 3 - Week 11 Graded (n = 59)
P1 Spring 2017 average
% Correct
Point biserial
Number of correct answers
Average answer time
1 2 3 4
75% 95% 78% 93%
0.72 0.40 0.72 0.38
3 1 3 1
5:44 3:16 2:42 1:03
1 2 3 4 4
58% 88% 80% 68% 79%
0.68 0.56 0.65 0.40 0.564
2 1 1 3 1.88
5:48 5:12 4:21 1:39 3:43
P1 = pharmacy year 1. Table 3 Question analysis of redesigned hospital errors and omissions activities. Class and activities
Order
P2 Fall 2017 session 1 – week 5 Practice P2 Fall 2017 session 2 -week 6 graded (n = 57)
Completed on paper, no electronic results
P2 Fall 2017 session 3 – week 10 practice (n = 57)
P2 Fall 2017 session 4 - week 11 graded (n = 57)
P2 Fall 2017 session 5 - week 13 graded (n = 56)
P2 fall 2017 average
% Correct
Point biserial
Number of correct answers
Average answer time
1
93%
0.36
1
2:32
2 3 4a 1
39% 54% 100%a 35%
0.71 0.37 0.00a 0.59
1 1 1 1
4:03 5:43 3:19 4:24
2 3 4 1
72% 83% 100% 86%
0.61 0.54 0.60 0.50
1 1 1 1
6:03 3:21 2:30 3:16
2 3 4 1
91% 96% 96% 46%
0.60 0.57 0.57 0.69
1 1 1 1
2:58 3:04 2:08 6:47
2 3
71% 91%
0.47 0.18
1 1
4:43 3:46
3.75
77%
0.491
1
3:54
a
Credit given to all exam takers. P2 = pharmacy year 2.
practice.11 Errors and omissions activities are an example of deliberate practice. Ericsson12 defines deliberate practice as “individualized training activities specially designed by a coach or teacher to improve specific aspects of an individual's performance through repetition and successive refinement.” Deliberate practice has been extensively described in the training of musicians. Recently, deliberate practice has been applied to physician EPAs such as reading X-rays, performing patient interviews and surgery.12 Application of deliberate practice in medical education supports the hypothesis that deliberate practice through specifically designed hospital errors and omissions activities may be an effective pedagogy to train pharmacists to prevent MRPs. While the pharmacist's role in distribution quality control remains significant in many practice settings, product focused errors and omissions in community or hospital settings may not train the pharmacist to his or her professionally licensed scope of practice. Underscored by the expansion of automation and increased technician authority in many states, it is possible that labeling and branding focused errors and omissions minimizes the opportunity that exists in these activities to train patient-specific critical thinking essential to optimize patients’ medication use. In order to prepare our students to advance the pharmacist's role in safe medication use in all settings, it is 74
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
time for an update to our errors and omissions framework to include patient-specific MRPs. To maximize the opportunity that errors and omissions activities provide, further research is needed regarding how the most expert pharmacists identify MRP in all EMR team based care settings where pharmacists provide direct patient care. Further definition of expert performance will enable the further development of activities that provide deliberate practice in order to train student pharmacists to prevent patient-specific MRP. Summary It is possible to create and efficiently deliver hospital errors and omissions activities that include patient-specific MRPs. Further investigation of errors and omissions activities is necessary to determine if their use can train and assess pharmacists’ ability to identify and prevent MRP in clinical settings. Conflict of interest None. Disclosures None. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.cptl.2018.09.018. References 1. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. New Engl J Med. 2010;363(22):2124–2134. 2. Cipolle RJ, Strand L, Morley P. Pharmaceutical Care Practice: The Patient-Specific Approach to Medication Management. 3rd ed. New York, NY: McGraw Hill Professional; 2012:230–231. 3. Joint Commission of Pharmacy Practitioners. Pharmacists’ patient care process. Published May 2014. https://www.pharmacist.com/sites/default/files/files/ PatientCareProcess.pdf. Accessed 26 September 2018. 4. Haines ST, Pittenger AL, Stolte SK, et al. Core entrustable professional activities for new pharmacy graduates. Am J Pharm Educ. 2017;81(1) https://doi.org/10. 5688/ajpe811S2. 5. Waitzman JA, Dinkins MM. A prescription analysis exercise in a pharmaceutical care laboratory course. Am J Pharm Educ. 2013;77(2) https://doi.org/10.5688/ ajpe77232. 6. Hirsch AC, Parihar HS. A capstone course with a comprehensive and integrated review of the pharmacy curriculum and student assessment as a preparation for advanced pharmacy practice experiences. Am J Pharm Educ. 2014;78(10) https://doi.org/10.5688/aj7410180. 7. Kirwin JL, DiVall MV, Guerra C, et al. A simulated hospital pharmacy module using an electronic medical record in a pharmaceutical care skills laboratory course. Am J Pharm Educ. 2013;77(3):62. https://doi.org/10.5688/ajpe77362. 8. Metzger NL, Chesson MM, Momary KM. Simulated order verification and medication reconciliation during an introductory pharmacy practice experience. Am J Pharm Educ. 2015;79(7) https://doi.org/10.5688/ajpe79796. 9. Molitor R, Friedman S. Electronic prescription errors in an ambulatory pharmacy. J Managed Care Pharm. 2011;17(9):714–715. 10. Georgia Board of Pharmacy Candidate Information Bulletin. Published 2005. http://gbp.georgia.gov/sites/gbp.georgia.gov/files/related_files/document/ Candidate%20Information%20Bulletin%20-%20Licensure%20Exam.pdf. Accessed 26 September 2018. 11. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260–273. 12. Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert performance approach with deliberate practice. Acad Med. 2015;90(11):1471–1486.
75
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
Design of hospital errors and omissions activities that include patient-specific medication related problems
T
Julie B. Cooper , Courtney L. Bradley ⁎
Fred Wilson School of Pharmacy, High Point University, 1 University Parkway, High Point, NC 27685, United States
ARTICLE INFO
ABSTRACT
Keywords: Prescription verification Hospital pharmacy Pharmacy skills laboratory Medication safety Patient-centered Medication related problems Sterile products
Background and purpose: Medication-related problems persist in hospital settings. New types of errors have emerged with changing technology. There is a need for updated, realistic, and patient-specific activities to train student pharmacists to identify medication-related problems. Educational activity and setting: We describe efforts to redesign hospital errors and omissions activities in a clinical skills lab course. A hospital errors and omissions template is described with multiple-choice answer options redesigned to reinforce that each instance of dispensing in a hospital is an opportunity for patient-centered care. Findings: In the redesigned hospital errors and omissions activities, students identified the correct errors and omissions 77% of the time with an average point biserial of 0.491. Qualitative evaluation of student course evaluations and student self-selected learning goals suggest that students perceived the revised activity to be valuable. Summary: It is possible to create and deliver hospital errors and omissions activities that include patient-specific medication related problems.
Background and purpose Medication error remains a significant problem in hospitalized patients despite coordinated efforts to improve the quality of care.1 The primary role of the pharmacist for hospital patients is optimizing patients’ use of medications. Pharmacists’ prevention of medication-related problems (MRP) is a complex task requiring consistent application of the Pharmacists’ Patient Care Process integrating clinical thinking across the four domains of MRP: indication, efficacy, safety, and adherence.2,3 Competency-based medical education has led to the naming of entrustable professional activities (EPA) for pharmacy.4 The patient care provider domain EPA includes identification of MRPs. One instructional activity that is used to teach students to identify MRP and to assess their ability to perform this EPA is errors and omissions. Errors and omissions is a teaching method where a student pharmacist reviews an order and a corresponding product to identify potential MRPs. Published reports of errors and omissions activities used within pharmacy curricula have focused on legal labeling specifications, product selection, and appropriate branding in a community pharmacy setting. These activities are referred to as community errors and omissions.5,6 For example, Waitzman and Dinkins5 redesigned the community pharmacy errors and omissions activities at the University of North Carolina to make it more practical and realistic. Additionally, Hirsh and colleagues6 described a capstone course at Philadelphia College of Osteopathic Medicine School of Pharmacy that included errors and omissions in the Georgia State Board of Pharmacy Practical Examination multiple-choice format. Pharmacy school curricula also commonly contain errors and omissions activities derived from the hospital setting, referred to as hospital errors and omissions. For example, Kirwin and ⁎
Corresponding author. E-mail addresses: [email protected] (J.B. Cooper), [email protected] (C.L. Bradley).
https://doi.org/10.1016/j.cptl.2018.09.018
1877-1297/ © 2018 Elsevier Inc. All rights reserved.
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
colleagues7 described a simulated hospital pharmacy module in a skills laboratory course that included instruction on final verification of sterile products. Their assessment required students to describe errors in product preparation and suggest resolutions. Students’ self-reported confidence in their ability to verify prepared sterile products increased significantly after module completion. Metzger and colleagues8 described a simulated medication reconciliation and order verification activity using the training environment of an electronic medical record (EMR) during an introductory pharmacy practice experience. Verification of a patient's admission medication orders were discussed in a small group including reasons to reject an order and how to recommend alternatives to the provider. Published hospital errors and omissions activities are resource intensive and product focused. Recent changes in the practice of pharmacy include the transition to EMRs and an increase in medication dispensing automation. These advances have reduced some of the medication errors in published errors and omissions activities including order transcription, product selection and labeling. However, technology has created new types of problems pharmacists must learn to prevent, including patient identification and misleading directions.9 Furthermore, technology can create a separation between pharmacists and their patients, especially in the hospital setting. This separation may prevent pharmacists from thinking about each patient individually to identify patient-specific MRPs. The persistence of MRPs combined with the emergence of new types of errors highlight the need for updated, realistic and patient-specific activities to train pharmacists to identify MRP in the hospital setting. This report describes redesigned hospital errors and omissions activities that simulate MRP identification in an EMR. Redesigned activities were created to reinforce that each instance of dispensing in a hospital is an opportunity for patient-specific care. Our goal was to redesign the hospital errors and omissions activities to create a patient-specific format that would simulate a realistic, EMR based, hospital-dispensing scenario in which students were trained to identify patient-specific and product-specific MRPs. An additional goal was to create a format that was deliverable with minimal instructor resources using multiple-choice answers. This article is a report of the format that was developed and lessons learned throughout the process. Educational activity and setting At High Point University School of Pharmacy, a six-semester Clinical Skills Laboratory course series prepared students for practice through activities interweaving with content taught in concurrent first-, second-, and ultimately third-year courses. The skills developed in this course series were focused on providing quality patient-specific care. Activities included prescription preparation, prescription verification, patient and prescriber counseling through the use of standardized clients, medication therapy management, physical assessment, point-of-care devices, clinical documentation, and root cause analysis. Errors and omissions activities were used to develop and assess skills related to prescription verification. The community errors and omissions activities were introduced beginning in the first year (P1) fall semester and the hospital errors and omissions were introduced P1 spring semester. In the P1 2016 fall semester, the community errors and omissions activities began with a practice session that was followed by three graded sessions patterned after the method described in Waitzman and Dinkins.5 In the subsequent P1 spring semester, hospital errors and omissions was introduced in a separate pharmaceutics lab course taught concurrently with an introduction to sterile compounding over a four-week period. There were two practice sessions; one that consisted of two orders on week 8 and one that consisted of four orders on week 10. There was a graded session that consisted of four orders on week 11. The objective of both the P1 community pharmacy and the P1 hospital pharmacy errors and omissions activities was to identify product-related errors. There were no patient scenarios or answer choices related to patient-specific problems. Therefore, this product-specific design was referred to as original hospital errors and omissions. The redesign of the hospital errors and omissions occurred in 2017 during the second year (P2) fall semester, as instructors sought to base the activities in an EMR environment and incorporate patient-specific MRP. Redesign began with a revised two-page order template for the hospital errors and omissions activities as seen in Figs. 1 and 2. In this revised template (on page one), students first encountered the setting where the activity occurred. One potential hospital setting included the sterile products area where student pharmacists verified either an admixed sterile product (Fig. 1) or a premade sterile product. Another potential hospital setting included the central inpatient pharmacy where student pharmacists verified a unit dose product (Fig. 2). Further on page one of the template, students encountered a header with a patient name and medical record number to simulate patient identification in the EMR. A patient scenario preceding the medication order created a patient focus for the activity. The order was displayed in a realistic, yet simplified, EMR order composer based on the order composer view in Epic™ (Verona, Wisconsin). Page two of the template included a realistic hospital label with explicit statements describing technology-based dispensing logic followed by images of the product as presented to the pharmacist for verification. The revised template was presented to the students with standardized multiple-choice options developed based on the Georgia State Board of Pharmacy errors and omissions assessment.10 The multiple-choice options were standardized based on hospital dispensing setting with different options for admixed sterile products, premade sterile products, and unit dose products (Table 1). Multiple-choice options included problems with patient identification, patient-specific problems, as well as product and dispensing errors. Patient-specific errors related to topics covered in concurrent pharmacotherapy courses. One example of a patient-specific error delivered in an order during the infectious disease module was a patient allergy to an ordered antibiotic. Further medication related problem examples for each multiple-choice option are described in Table 1. This patient-specific format was referred to as redesigned hospital errors and omissions. During the Clinical Skills Lab in the P2 fall semester, the redesigned hospital errors and omissions activities were delivered five times throughout the semester. The Clinical Skills Lab was designed so that students rotated through four to six different activities during a three-hour lab period. To accommodate a class size of 57 students, the lab was offered as two separate sections with 28–29 students in each section. On select weeks, redesigned hospital errors and omissions were included in the rotation of lab activities. 67
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
During these weeks, students also completed various other activities such as written cases, point-of-care devices, patient counseling, and others. In general, these redesigned hospital errors and omissions activities were 30-min in length with approximately eight to ten students simultaneously completing the activities individually. The redesigned hospital errors and omissions activities were first introduced on week five with an instructor led a review of the order template and direct instruction on how to utilize the standardized, multiple-choice answer options as a framework for verifying a hospital order. On the same day as the initial instructor overview, students completed an individual practice session consisting of four orders. During week 6, students completed a graded session consisting of four orders. Based on student comments provided during and after this graded session, a second practice session of four orders was created and delivered during week 10 with immediate feedback enabled. Students then completed another graded session of four orders during week 11. Finally, three orders were included on the end-of-semester practical exam during week 13. For all activities, all orders were provided to the students in a booklet printed such that when opened both template pages were visible simultaneously. Student responses were captured on paper during the first practice session. However, in all other sessions,
Fig. 1. Hospital errors and omissions template, sterile products area. 68
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Fig. 1. (continued)
student answers were recorded using ExamSoft (ExamSoft Worldwide, Inc.) to streamline delivery and individual student assessment. All graded sessions were followed by an instructor-led, structured debrief the following week. Resources required for these redesigned hospital errors and omissions activities were limited to faculty time. A faculty member developed the scenarios and order templates for both practice and graded sessions. Additionally, this same faculty member facilitated the sessions; however, this did not represent added time because this faculty member was already present for the lab session to facilitate other ongoing activities. The redesigned format was developed with several objectives including creating a more realistic hospital order scenario, incorporating the potential for both product-related errors and patient-specific MRP, and utilizing a format that was time and resource efficient. For assessment of the re-designed format, quantitative and qualitative data were collected. For assessment purposes, each order represented a single question. The percent correct, number of correct answers, and average answer time were collected to assess each question's difficulty. Additionally, point biserial values were collected to assess the discriminatory ability of each question. These quantitative values were described for each question within each assessment and summarized for both the original version and re-designed version with descriptive statistics. Based on department standards, it was determined that a reasonably difficult question had a percent correct between 30 and 80%. Based on previous experience with community errors and omission activities, it was determined to allow an average time to answer of five minutes per order. Similarly, it was determined that a question was able to 69
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Fig. 1. (continued)
meaningfully discriminate between students who knew the material and those who did not if the point biserial was above 0.3. The point biserial is a correlation coefficient measuring the relationship between correct and incorrect performance on an assessment question and performance on the entire assessment. It was hypothesized that the redesigned hospital errors and omission activities combined with appropriate student training and opportunity to practice would result in similar psychometrics to the original hospital errors and omissions activities. Therefore, our goal was to maintain consistent psychometrics for the redesigned hospital errors and omissions activities as measured by percent correct, average answer time, and point biserial. Additionally, a qualitative analysis was completed by reviewing select questions from two free response assignments to identify student comments related to the redesigned hospital errors and omissions activities. The first item reviewed was a question from the end-of-course evaluation that asked: “Based on your overall ratings of this course and what you have learned this semester, please describe more specifically what you perceive to be the particular strengths and any areas of improvement for this course.” The second item reviewed included one question from a required skills lab goal setting assignment which specifically asked: “After reflecting on your strengths and weaknesses, for the initial self-assessment, please write two specific goals that you would like to work on this semester”. These goals could have been academic or personal in nature. For both of these free response assignments, students were not specifically instructed to comment on the errors and omissions activities. Comments were manually coded to identify themes. This study was reviewed and granted an exempt status by the High Point University Institutional Review Board. Findings Quantitative assessment In the original format, students identified the correct errors and omissions 79% of the time with an average point biserial of 0.564 taking an average of 3 min 43 s to identify an average of 1.88 errors and omissions. Table 2 provides descriptive statistics for each assessment in the original format conducted in spring 2017. In the redesigned format, students identified the correct errors and omissions 77% of the time with an average point biserial of 0.491 taking an average of 3 min 54 s to identify an average of one error and omission. Table 3 provides descriptive statistics for each assessment in the redesigned format conducted in fall 2017. Qualitative assessment Qualitative analysis yielded five unsolicited comments about hospital errors and omissions with two emergent themes. Three comments were from the course evaluation question out of 17 total comments received from 45 evaluations. Two comments were from the skills lab goal setting assignment received from all 57 students. Initial confusion about the activity was mentioned three times, twice in the evaluation, and once in the goal setting question. The practical value of the activity to the practice of pharmacy was noted three times once in the evaluation and twice in the goal setting question. Discussion Our aim was to redesign hospital errors and omissions activities to include patient-specific MRP in an updated realistic format. When comparing the results of the redesigned hospital errors and omissions activities to the original hospital errors and omissions activities, the redesign met specified standards for student performance assessment with slightly lower average percent correct and 70
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
point biserial. Further, the redesigned activities two-page order template took students slightly longer to identify a single correct answer per order than the original activities presented on a single page. Additionally, preliminary qualitative analysis of student opinion suggested that the re-designed activities were initially challenging but practically valuable. This report of a redesigned hospital errors and omission activity has significant limitations. This study evaluates a limited number of student encounters with the redesigned format after the initial attempt by these instructors to provide direct instruction to P2s in hospital errors and omissions affects the validity of our results. Further the small amount of qualitative data available for analysis has limited power to detect the full range of the student experience with this activity. Despite these limitations the redesigned practical format provided valuable information about how we might train pharmacists to identify MRPs in practice. The students’ previous experience with the original product focused hospital and community errors and omissions activities led to confusion about the nature of the MRP they encountered in the re-designed format with a patient scenario. At the time the redesigned
Fig. 2. Hospital errors and omissions template, central inpatient pharmacy. 71
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Fig. 2. (continued)
activities were initially deployed, instructors were unaware of introductory resources or readings to provide students prior to the activity. Therefore, direct instruction, similar to that employed by Metzger and colleagues, was used to prepare students for subsequent practice and graded activities. To enhance instructional design, instructors enabled the question feedback feature in Examsoft allowing students to provide instructors written comments for each order. Students were informed that comments were open but not specifically directed about what type of comments to write. Students commonly provided rationale for their answer selection allowing instructors to make revisions to the activity. Specific areas identified by this method for clarification included technologybased dispensing logic and confidence determining the absence of a patient-specific MRP. In response to this confusion, instructors created direct instructional content on hospital dispensing, provided additional practice opportunities to reinforce patient-specific MRPs and revised the template to include explicit statements about dispensing logic. Students noted initial challenges stating in the course evaluation: “There was a lot of initial confusion with hospital errors and omissions but in the end it was pretty good.” The week-by-week teaching and grading experiences of instructors during these re-designed activities also demonstrated that there was a need to provide multiple practice opportunities and dedicated instructional time. Student performance on later activities indicated that there was an ongoing need for immediate feedback in order to reinforce the intricacies of hospital-based verification and to train students how to apply the multiple-choice answer framework to approach MRP identification in the hospital setting. Faculty time spent in lab providing direct instruction and immediate feedback was significant but did not represent additional time, as they were 72
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Table 1 Redesigned hospital errors and omissions multiple-choice answer options based on inpatient dispensing settings. Answer choices
Setting
Template section
Description of problem and examples
Order was placed on the wrong patient.
UD ASP PSP UD ASP PSP
Patient profile, clinical scenario & order
Name and medical record number on order and label do not match patient profile
Patient profile & clinical scenario
Wrong medication was selected during order entry.
UD ASP PSP
Order
Wrong dosage form was selected during order entry.
UD ASP PSP UD ASP PSP UD ASP PSP
Clinical Scenario & order
A MRP of indication, effectiveness, safety or adherence based on review of the patient scenario and medication order (e.g., provider ordering the atrial fibrillation dose of apixaban in a patient with a new deep vein thrombosis; see Fig. 1) Ordered medication and the Products to dispense portion of the order do not match (e.g., order for NS contains free text note from ordering provider indicating addition of potassium 40 mEq, and products to dispense lists only NS Ordered wrong dosage form (e.g., patient receiving all medications via tube and order is for an extended release tablet)
UD ASP PSP ASP PSP
Product
Amount of medication drawn up/added for final dispense is not correct. Correct diluent was not chosen to prepare the IV.
ASP
Product
ASP
Product
Amount of diluent drawn up and/or added was not correct. Diluent was expired. Correct IV solution was not chosen.
ASP
Product
ASP ASP
Product Product
Correct volume of IV solution was not chosen.
ASP
Product
IV solution was expired Product may be dispensed, there are no errors.
SPA UD ASP PSP
Product N/A
Call the prescriber, there is a MRP identified in the patient profile, clinical scenario, or new medication order.
Wrong medication was chosen to dispense. Quantity dispensed is wrong.
Medication is expired. Expiration date applied to the final product is incorrect.
Product
Identity of product to dispense or used to prepare IV admixture does not match the ordered medication (e.g., order written for warfarin 2.5 mg tablet, and warfarin 5 mg tablet dispensed) Quantity of product to dispense does not match order or dispensing logic (e.g., dispensing logic indicates that the first dose of a twicedaily medication is to be delivered, and two doses of the medication are packaged to dispense) The medication presented to dispense or pulled for preparation is expired
Product
Product
After preparation, the expiration date applied to the final product to dispense is incorrect based on preparation instructions provided in template (see Fig. 2) Syringe presented with final product to dispense is drawn back to the wrong volume Diluent used does not match the preparation instructions (e.g., sterile water for injection suggested in preparation instructions, NS selected as diluent) Syringe presented with diluent used was drawn back to the wrong volume (see Fig. 2) The diluent used was expired Identity of solution used to prepare the IV admixture does not match the ordered base solution (e.g., NS 500 mL ordered as base solution, D5W 500 mL selected as base solution). Volume of solution used to prepare the IV admixture does not match the ordered volume (e.g., NS 500 mL was ordered as base solution, NS 250 mL selected as base solution) The IV solution used was expired No errors present
*UD, central inpatient pharmacy unit dose dispensing; ASP, admixed sterile product; PSP, premade sterile product; MRP, medication-related problem; IV, intravenous; NS, normal saline; D5W, 5% dextrose in water.
already present in lab to facilitate other activities. Instructors noted a decrease in time clarifying common mistakes and decreased time answering student questions as the semester progressed. Another challenge was creating a fair assessment that was time efficient to grade and strongly discriminating. The use of multiplechoice answers enabled instructors to implement assessment of the re-designed hospital errors and omissions in ExamSoft enabling efficient grading and evaluation. One common point of confusion was the presence of a patient-specific MRPs. Importantly in this redesigned activity, students were presented with multiple distinct patient-specific MRPs across the various orders presented in multiple activities and these errors all required students to select the same single patient-specific MRP answer choice: “Call the prescriber, there is a MRP identified in the patient profile, clinical scenario, or new medication order”. Additionally the unique set of multiplechoice answer options presented for each distinct hospital setting may have created confusion. All three hospital practice settings were presented to the students in the initial practice activities and subsequent activities included orders from at least two hospital practice settings. Learning how to identify MRPs in multiple settings simultaneously may have increased confusion. Despite these limitations, as the P2 fall semester progressed and as the instructor provided more targeted de-briefing, students asked fewer questions and documented fewer comments. Instructors have planned revisions of the multiple-choice options to distinguish specific types of patient-specific MRPs and reorder the delivery of the redesigned activities to allow students to practice one hospital dispensing setting at a time. While errors and omissions activities are a common pedagogy, it is not known if errors and omissions activities prevent MRPs in 73
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
Table 2 Question analysis of original hospital errors and omissions activities. Class and activities
Order
P1 Spring 2017 – session 1 – week 8 practice P1 Spring 2017 – session 2 – week 10 practice (n = 59)
Completed on paper, no electronic results
P1 Spring 2017 – Session 3 - Week 11 Graded (n = 59)
P1 Spring 2017 average
% Correct
Point biserial
Number of correct answers
Average answer time
1 2 3 4
75% 95% 78% 93%
0.72 0.40 0.72 0.38
3 1 3 1
5:44 3:16 2:42 1:03
1 2 3 4 4
58% 88% 80% 68% 79%
0.68 0.56 0.65 0.40 0.564
2 1 1 3 1.88
5:48 5:12 4:21 1:39 3:43
P1 = pharmacy year 1. Table 3 Question analysis of redesigned hospital errors and omissions activities. Class and activities
Order
P2 Fall 2017 session 1 – week 5 Practice P2 Fall 2017 session 2 -week 6 graded (n = 57)
Completed on paper, no electronic results
P2 Fall 2017 session 3 – week 10 practice (n = 57)
P2 Fall 2017 session 4 - week 11 graded (n = 57)
P2 Fall 2017 session 5 - week 13 graded (n = 56)
P2 fall 2017 average
% Correct
Point biserial
Number of correct answers
Average answer time
1
93%
0.36
1
2:32
2 3 4a 1
39% 54% 100%a 35%
0.71 0.37 0.00a 0.59
1 1 1 1
4:03 5:43 3:19 4:24
2 3 4 1
72% 83% 100% 86%
0.61 0.54 0.60 0.50
1 1 1 1
6:03 3:21 2:30 3:16
2 3 4 1
91% 96% 96% 46%
0.60 0.57 0.57 0.69
1 1 1 1
2:58 3:04 2:08 6:47
2 3
71% 91%
0.47 0.18
1 1
4:43 3:46
3.75
77%
0.491
1
3:54
a
Credit given to all exam takers. P2 = pharmacy year 2.
practice.11 Errors and omissions activities are an example of deliberate practice. Ericsson12 defines deliberate practice as “individualized training activities specially designed by a coach or teacher to improve specific aspects of an individual's performance through repetition and successive refinement.” Deliberate practice has been extensively described in the training of musicians. Recently, deliberate practice has been applied to physician EPAs such as reading X-rays, performing patient interviews and surgery.12 Application of deliberate practice in medical education supports the hypothesis that deliberate practice through specifically designed hospital errors and omissions activities may be an effective pedagogy to train pharmacists to prevent MRPs. While the pharmacist's role in distribution quality control remains significant in many practice settings, product focused errors and omissions in community or hospital settings may not train the pharmacist to his or her professionally licensed scope of practice. Underscored by the expansion of automation and increased technician authority in many states, it is possible that labeling and branding focused errors and omissions minimizes the opportunity that exists in these activities to train patient-specific critical thinking essential to optimize patients’ medication use. In order to prepare our students to advance the pharmacist's role in safe medication use in all settings, it is 74
Currents in Pharmacy Teaching and Learning 11 (2019) 66–75
J.B. Cooper, C.L. Bradley
time for an update to our errors and omissions framework to include patient-specific MRPs. To maximize the opportunity that errors and omissions activities provide, further research is needed regarding how the most expert pharmacists identify MRP in all EMR team based care settings where pharmacists provide direct patient care. Further definition of expert performance will enable the further development of activities that provide deliberate practice in order to train student pharmacists to prevent patient-specific MRP. Summary It is possible to create and efficiently deliver hospital errors and omissions activities that include patient-specific MRPs. Further investigation of errors and omissions activities is necessary to determine if their use can train and assess pharmacists’ ability to identify and prevent MRP in clinical settings. Conflict of interest None. Disclosures None. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.cptl.2018.09.018. References 1. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. New Engl J Med. 2010;363(22):2124–2134. 2. Cipolle RJ, Strand L, Morley P. Pharmaceutical Care Practice: The Patient-Specific Approach to Medication Management. 3rd ed. New York, NY: McGraw Hill Professional; 2012:230–231. 3. Joint Commission of Pharmacy Practitioners. Pharmacists’ patient care process. Published May 2014. https://www.pharmacist.com/sites/default/files/files/ PatientCareProcess.pdf. Accessed 26 September 2018. 4. Haines ST, Pittenger AL, Stolte SK, et al. Core entrustable professional activities for new pharmacy graduates. Am J Pharm Educ. 2017;81(1) https://doi.org/10. 5688/ajpe811S2. 5. Waitzman JA, Dinkins MM. A prescription analysis exercise in a pharmaceutical care laboratory course. Am J Pharm Educ. 2013;77(2) https://doi.org/10.5688/ ajpe77232. 6. Hirsch AC, Parihar HS. A capstone course with a comprehensive and integrated review of the pharmacy curriculum and student assessment as a preparation for advanced pharmacy practice experiences. Am J Pharm Educ. 2014;78(10) https://doi.org/10.5688/aj7410180. 7. Kirwin JL, DiVall MV, Guerra C, et al. A simulated hospital pharmacy module using an electronic medical record in a pharmaceutical care skills laboratory course. Am J Pharm Educ. 2013;77(3):62. https://doi.org/10.5688/ajpe77362. 8. Metzger NL, Chesson MM, Momary KM. Simulated order verification and medication reconciliation during an introductory pharmacy practice experience. Am J Pharm Educ. 2015;79(7) https://doi.org/10.5688/ajpe79796. 9. Molitor R, Friedman S. Electronic prescription errors in an ambulatory pharmacy. J Managed Care Pharm. 2011;17(9):714–715. 10. Georgia Board of Pharmacy Candidate Information Bulletin. Published 2005. http://gbp.georgia.gov/sites/gbp.georgia.gov/files/related_files/document/ Candidate%20Information%20Bulletin%20-%20Licensure%20Exam.pdf. Accessed 26 September 2018. 11. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260–273. 12. Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert performance approach with deliberate practice. Acad Med. 2015;90(11):1471–1486.
75