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Making student pharmacists indispensable: The added value of introductory pharmacy practice experience students to patient care
Available online at www.sciencedirect.com
Currents in Pharmacy Teaching and Learning 7 (2015) 47–53
Research
http://www.pharmacyteaching.com
Making student pharmacists indispensable: The added value of introductory pharmacy practice experience students to patient care Paul C. Walker, PharmD, FASHPa,*, Michael D. Kraft, PharmD, BCNSPb, Kathy S. Kinsey, BS Pharmc, Alison van Kampen, PharmDb, Matthew Perez, PharmDb, Uzoma Okeagu, PharmDb, Asiedu Boateng, PharmDb, Nancy A. Mason, PharmDb a
Experiential Education and Community Engagement, College of Pharmacy, The University of Michigan, Ann Arbor, MI b College of Pharmacy, The University of Michigan, Ann Arbor, MI c Department of Pharmacy Services, The University of Michigan Health System, Ann Arbor, MI
Abstract Purpose: This study evaluated the impact of an admission medication reconciliation process conducted by student pharmacists during an introductory pharmacy practice experience (IPPE). Methods: Patients aged 18 years or older admitted to a general medicine service and who received medication reconciliation from a student pharmacist were included. Data were collected retrospectively from electronic medical records. Results: Student pharmacists performed medication reconciliation on 21.8% of 6395 patients admitted to the target service, directly involving the majority of patients/caregivers (78.9%) in the process. Potential medication discrepancies were found in 43.8% of patients; the average number of potential discrepancies found per patient was 1.0 ⫾ 1.6. The most common potential discrepancy was “omitted prescription medication.” Prescribers responded to notification about potential discrepancies by correcting or clarifying 74.9% of all potential discrepancies and 77.2% of discrepancies with the potential to causes severe patient discomfort or clinical deterioration. Conclusion: IPPE student pharmacists contributed to patient care by performing medication reconciliation on patient admission to hospital. Student pharmacists identified and facilitated correction of unrecognized medication issues that could have adversely impacted patient well-being. r 2014 Elsevier Inc. All rights reserved.
Keywords: Introductory pharmacy practice experience; Pharmacy students; Medication reconciliation
Student pharmacists are valuable and important to practice model transformation. Recommendations of the American Society of Health System Pharmacists (ASHP) Pharmacy Practice Model Summit (PPMI) convened to identify how pharmacy practice models need to change to * Corresponding author: Paul C. Walker, PharmD, FASHP, Experiential Education and Community Engagement, College of Pharmacy, The University of Michigan, 428 Church Street, Ann Arbor, MI 48109-1065. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.09.001 1877-1297/r 2014 Elsevier Inc. All rights reserved.
meet contemporary societal needs and to more effectively deliver patient care, recommended integration of student pharmacists into meaningful practice roles.1 Specifically, recommendation B24c states, “Every pharmacy department should develop a plan to allocate pharmacy student time to drug-therapy management services.”2 This is a direct call to more fully integrate student pharmacists into the pharmacy department’s work to better serve the needs of patients. ASHP’s policy, “Role of Students in Pharmacy Practice Models,” further emphasizes the role of students by encouraging “pharmacy practice leaders to incorporate
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P.C. Walker et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 47–53
students, including those in introductory and advanced pharmacy practice experiences and interns, into active, meaningful roles in new and evolving practice models.”3 In his 2011 Harvey K. Whitney address, Ashby4 recommended that students be made indispensable to the practice model and rearticulated key elements of pharmacy’s vision of the future that have emerged from both the PPMI and the 2011 Pharmacy Residency Capacity Stakeholders Conference. Among those key elements are the following: Activities for pharmacy students and pharmacy residents should support the educational goals for both groups though their active involvement in the care of patients.4 To achieve desired outcomes, the practice model should be team based, with a representation of specialist and generalist pharmacists, pharmacy residents, pharmacy students, and pharmacy technicians.4
Students comprise a resource that can help expand pharmacy’s capacity to care for patients, enable current services to be extended, and allow gaps in services to be filled. A recent commentary enumerated potential benefits to both students and experiential training sites that can result from effective engagement of advanced pharmacy practice experience (APPE) students in patient care.5 Mersfelder’s and Bouthillier’s6 recent review of 35 studies evaluating the contributions of APPE students to the work of experiential sites concluded that significant economic and clinical benefits may accrue to sites when APPE students are involved in patient care and that these benefits often exceed the costs invested by sites in supervising and training students. Stevenson et al.7 also describe benefits from the patient care activities of APPE students. In contrast, the impact of introductory pharmacy practice experience (IPPE) students, whose skill sets may differ from those of APPE students, has not been well described. According to the 2007 Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree, which were applicable at the time of this study, IPPEs “must involve actual practice experiences in community and institutional settings and permit students, under appropriate supervision and as permitted by practice regulations, to assume direct patient care responsibilities,” and they should “continue in a progressive manner leading to entry into the advanced pharmacy practice experiences.”8 Student pharmacists are required to complete a minimum of 300 IPPE hours in the first three years of the pharmacy curriculum.8 This requirement for early practice experiences has stretched the capacity of health systems to support these experiences and challenged colleges to identify creative ways to meet the requirement using existing, often scarce resources.9 IPPEs involving shadow experiences, service learning, vaccination programs, actual patient encounters in a variety of settings (inpatient venues, home, etc.) and other innovative approaches have been described.10–20
Effectively integrating IPPE students into practice models and involving them in direct patient care activities can help students meet educational requirements but should also provide benefit to the experiential site. However, little information about the benefit of IPPE students to the experiential site is available. Although Stevenson et al.7 included third-year pharmacy students enrolled in IPPE courses in their study, the contribution of IPPE students represented only a small percentage of overall interventions documented, and their specific impact was not reported. We have previously described the development and implementation of a direct patient care IPPE that engages third-year student pharmacists in the admission medication reconciliation process of at the University of Michigan Health System.20 The direct patient care IPPE enables students to achieve predefined curricular ability-based outcomes (Appendix) while engaging them in meeting the experiential site’s need to enhance admission medication reconciliation, which is required by national patient safety goals.21 This article describes the outcomes associated with a pharmacist-supervised P3 IPPE student admission medication reconciliation program. Methods The direct patient care IPPE is a structured 12-week course for P3 students. Prior to the IPPE course, students complete a communications course in which they develop communication and medication history-taking skills. During the course orientation, students receive a one-hour lesson on medication reconciliation, that consists of a discussion about medication reconciliation and active learning exercises in which they apply a structured approach to medication record review and discrepancy identification. On the first day at the hospital, students receive four hours of instruction in the medication reconciliation process, including how to use the hospital’s information systems, as we have previously described.20 1. Review the patient’s admission history, physical examination results, and other pertinent information. 2. Review medications being taken prior to admission as indicated by the physician’s admission history and physical examination results, as well as any home medication list documented in the Problem Summary List (PSL) section electronic medical record (the PSL provides a list of home medications that is maintained by the health system’s outpatient care providers) and current inpatient medications. 3. On the patient care unit, seek out and meet the patient’s nurse to address any questions (e.g., patient status or appropriateness of the timing of the interview) and determine if the patient is currently available for the interview. 4. Conduct a patient (or caregiver, if the patient was unable to communicate) interview including a medication
P.C. Walker et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 47–53
5. 6. 7. 8.
9.
history. If patients/caregivers are not available or are unwilling or unable to participate in a medication history, perform medication reconciliation by comparing the medication list in the admission history with the current inpatient medication list and PSL medication list to determine if potential discrepancies exist. Identify potential discrepancies by comparing gathered information. Discuss potential discrepancies with preceptor. Create draft pharmacy notes in the electronic medical record to document medication reconciliation. Forward the pharmacy notes to the preceptor for editing and approval before the notes become part of the permanent medical record. If potential discrepancies are identified, page the responsible physician to inform that medication reconciliation has been completed and request that he/she review the pharmacy notes to address any discrepancies. If any urgent issues are identified, page the physician to request immediate action. (Original source20 r 2011, American Society of Health-System Pharmacists, Inc. All rights reserved. Excerpt reprinted with permission.)
One the first day at the site, each student works through all of these steps to complete medication reconciliation on one patient under the guidance of a preceptor. The College of Pharmacy schedules IPPE students to provide medication reconciliation services at the site four days each week, Monday through Thursday, during fall and winter semesters. Each individual student is assigned to a specific patient care area and spends four hours per week performing medication reconciliation in that area over the course of one semester. Through this experience, students complete 48 IPPE hours. At the time of implementation, admission medication reconciliation was performed throughout the hospital by nurses, physicians, physician assistants, and medical assistants. However, the process was not standardized; quality improvement initiatives conducted by the site found that
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lack of standardization contributed to errors, redundancies, missed information, and inefficiencies in patient care. A retrospective review of electronic medical records was conducted to evaluate the IPPE student medication reconciliation program. Data were collected for three semesters, beginning in September 2009 and ending in December 2010. A total of 24 student pharmacists performed medication reconciliation each semester; the data reflect the work of 72 student pharmacists. Patients 18 years of age or older who were admitted to a general medicine hospitalist service between September 14, 2009 and December 2, 2010 and who received medication reconciliation by student pharmacists, as evidenced by a medication reconciliation note in the medical record, were included in the study. Patients who received medication reconciliation during the study period were identified by electronically searching the clinical data repository for records containing a pharmacy medication reconciliation note. Demographic information was collected and studentwritten pharmacy medication reconciliation notes were reviewed to determine the total number of potential medication discrepancies, the average number of potential discrepancies per patient, and the types of potential discrepancies identified, shown in Table 1. A medication discrepancy was defined as any difference between the medication use history and the admission medication orders. How frequently students were able to perform medication reconciliation by speaking directly with a patient or caregiver to solicit an admission medication history was also determined. Two investigators (P.W. and N.M., both clinical pharmacists and college of pharmacy faculty) independently assessed the potential seriousness of each discrepancy using a scale of 1–3 as described by Cornish et al.22: (1) unlikely to cause discomfort or clinical deterioration; (2) potential to cause moderate discomfort or clinical deterioration; or (3) potential to result in severe discomfort or clinical deterioration. Factors considered in rating the potential for harm included the medication involved, patient’s diagnoses, reason for admission, type of discrepancy, and how the discrepancy would likely affect the patient’s health during
Table 1 Classification of potential medication discrepancies Classification
Description
Omitted medications
A home medication that was not prescribed on admission; further classified as prescription medication, over-the-counter (OTC) medication, and herbal medication The admission dose/frequency differs from the home dose/frequency
Discrepant/missing dose or frequency Discontinued medication prescribed on admission Unnecessary duplication Discrepant dosage form or route of administration
A home medication that is no longer taken by the patient was prescribed on admission A medication with the same or similar mechanism of action and indication is prescribed The dosage form prescribed on admission differs from the home dosage
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an average four-day hospitalization. Individual ratings were then compared. Disagreements in ratings were resolved by in-person discussion and the final ratings were determined by consensus; consensus was reached in all cases. To assess how prescribers responded to notification of potential discrepancies that needed to be clarified or resolved, patient records were reviewed to determine if documentation, including medication order changes, was provided to address or correct potential discrepancies within 24 hours after medication reconciliation was completed. Documentation provided within 24 hours of medication reconciliation was deemed to be in response to student pharmacist medication reconciliation. Prescriber changes made beyond 24 hours were not assessed. Descriptive statistics were used to describe the percentage of patients for whom medication reconciliation was performed, the percentage of patients who had a potential medication discrepancy, how often each type of medication discrepancy occurred, the types of medications involved in discrepancies, and the number of changes made to address any potential discrepancies. Analysis was performed using Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA). Interrater reliability for assessing the potential harm associated with discrepancies was analyzed using Cohen’s kappa statistic (κ); the analysis was performed using SPSS Statistics version 21 (IBM Corporation, Armonk, NY).23 The study was approved by the institutional review board.
Results During the study period, 6395 patients were admitted to the targeted general medicine service; student pharmacists performed medication reconciliation on 1392 (21.8%) of these patients. A convenience sample of 422 (30%) patients who received medication reconciliation by student pharmacists was randomly selected for inclusion in the study by using SQL query language in Oracle (Version 10G; Cisco Systems, Inc. San Jose, CA). Demographic and other descriptive information is detailed in Table 2. Student pharmacists performed medication reconciliation an average of 2.0 ⫾ 1.4 days after admission and met with 333 patients/caregivers (78.9% of cases) to perform medication reconciliation. In the remaining cases, patients/caregivers were not available or were unwilling or unable to participate in a medication history; in these cases, medication reconciliation was accomplished by comparing available medication lists (PSL medication list, medication list in the admission history, and medications prescribed on admission). Student pharmacists identified 415 potential medication discrepancies in 185 patients (43.8%). The average number of potential discrepancies per patient was 1.0 ⫾ 1.6 (range: 0–13). The most frequent type of potential discrepancy was “omitted prescription medication,” which comprised 50.8% of potential discrepancies (Table 3). Cardiovascular medications
were most frequently identified in potential discrepancies (16.5%), followed by general health supplements (15.7%), gastrointestinal drugs (10.8%), and analgesics (8.8%). Interrater reliability in the assessment of discrepancies to cause harm was fair (κ ¼ 0.344; 95% confidence interval, 0.262–0.426). Consensus was easily reached in areas of disagreement. Most of the potential discrepancies (62%) were classified as unlikely to cause patient discomfort or clinical deterioration, 32.6% were classified as having potential to cause moderate patient discomfort or clinical deterioration, and the remaining 5.4% were classified as having potential to result in severe patient discomfort or clinical deterioration. Prescribers responded to 311 (74.9%) of all potential discrepancies by correcting the discrepancy or documenting that the discrepancy was intentional. Prescribers documented a response to 17 (77.2%) of the potential discrepancies which may have been harmful to patient health.
Table 2 Patient demographics Characteristic Age (years) Gender Male Female Ethnic background African American Asian Caucasian Hispanic Middle eastern Multiracial Pacific islander Unknown/other Admission source Emergency department Admitted from home Transfer from other hospital Transfer from skilled nursing facility Urgent care clinic Other Length of stay (days) Time to note after admission (days), mean Reconciled r24 hours after admission Reconciled 25–48 hours after admission Reconciled 49–96 hours after admission Reconciled 496 hours after admission Number of medications prior to admission
No. (%) of pts (N ¼ 422) Mean (SD) 59.4 (18.9) 167 (39.6) 255 (60.4) 70 3 333 5 4 2 1 4
(16.6) (0.7) (79) (1.2) (0.9) (0.5) (0.2) (0.9)
338 39 10 3
(80.1) (9.2) (2.4) (0.7)
2 (0.5) 30 (7.1) 5.1 (5.0) 2.0 (1.4) 121 (28.7) 154 (36.5) 79 (18.7) 68 (16.1) 10 (5.5)
P.C. Walker et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 47–53
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Table 3 Potential medication discrepancies identified
Type of discrepancy
Total discrepancies (%), N ¼ 415
Omitted prescription 211 (50.8) medication Discrepant dose 71 (17.8) Omitted OTC 51 (12.3) medication Discrepant frequency 40 (9.6) Incorrect medication 11 (2.7) prescribed Discontinued medication 9 (2.2) prescribed Omitted herbal 3 (0.7) medication Omitted dose 4 (1) Omitted frequency 4 (1) Discrepant dosage form/ 6 (1.4) route of administration Unnecessary medication 2 (0.5) duplication
Discrepancies with potential for severe Discrepancies with potential for severe discomfort or discomfort or clinical deterioration (%), clinical deterioration addressed by prescriber (%),a N ¼ 17 N ¼ 22 11 (50)
9 (81.1)
8 (36.4) –
7 (87.5) –
1 (4.5) 1 (4.5)
0 (0) 0 (0)
–
–
–
–
– – 1 (4.5)
– – 1 (100)
–
–
OTC ¼ over-the-counter. a Calculated as a percentage of total potentially harmful discrepancies within type of discrepancy.
Discussion Previous studies have demonstrated the ability of APPE students to perform medication reconciliation; this is the first report to document the effectiveness of IPPE students in admission medication reconciliation.24–26 Third-year IPPE student pharmacists contributed to patient care and the work of the experiential site by performing medication reconciliation to identify potential medication discrepancies and then acting to have discrepancies addressed by prescribers. Engaging student pharmacists in this way helped our pharmacy department extend its services. By performing medication reconciliation, students also worked towards achieving educational outcomes of our pharmacy curriculum. During the activity, students gathered and organized patient-specific information from patients and their caregivers, which allowed them to practice communication and medication history-taking skills. They directly communicated with almost 80% of patients or their caregivers in the medication reconciliation process. Gathering information from the medical record each week provided consistent exposure that enabled students to become familiar with how medical records are organized and how to find information needed for medication reconciliation. Students identified potential medication-related problems and, by discussing their findings with preceptors, practiced interpreting patient-specific data. Students also gained practical experience documenting pharmacist care in the medical record and
communicating with other health professionals and were mentored by preceptors through these processes. Students performed medication reconciliation on 21.8% of patients admitted to the medical services to which they were assigned. This was fewer patients than anticipated. Students were expected to develop proficiency in performing medication reconciliation quickly over the first few weeks of the semester and be able to perform the activity on at least three to five patients per day. We therefore expected students to have completed medication reconciliation on approximately 2500 patients (approximately 40% of admissions). Students only performed the activity for four hours per week and may have developed proficiency more slowly with the process and resources necessary for medication reconciliation, including the hospital’s information systems. Nonetheless, before student pharmacists were engaged in the process, admission medication reconciliation was performed inconsistently in these patients and the work of students using a standardized approach contributed substantially toward the health system’s goal of providing admission medication reconciliation for all patients. Ideally, admission medication reconciliation should be performed within 24 hours of admission. This goal was achieved in only 28.7% of patients, largely due to how student pharmacists were scheduled. Because of course schedules, students performed medication reconciliation four hours each day, Monday through Thursday; patients admitted between Thursday evening and Monday morning received medication reconciliation on Monday. This presents an
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opportunity for process improvement. Expanding the activity to seven days/week, increasing the time students devote to the activity, or exploring other ways to better integrate students and medication reconciliation into teams providing other pharmacy services to patients may improve the process. The frequency, types, and severity of potential medication discrepancies on admission identified by the student pharmacists are consistent with the findings of other studies. A recent systematic review of the literature found that 67% of patients admitted to hospital have at least one error in their medication histories taken on admission.27 Cornish et al.22 reported that 54% of patients experienced at least one unintended medication discrepancy on admission and found that 32.9% of the medication discrepancies had the potential to cause moderate discomfort or clinical deterioration and 5.7% cause serious harm. Cornish et al.,22 Carter et al.,28 and Mills and McGuffie29 all found that the most common discrepancy on admission to hospital was omission of medication (46%, 46%, and 60% of discrepancies, respectively), followed by discrepant dose (25%, 18%, and 12% of discrepancies, respectively). However, these studies had fewer discrepancy classifications than the present study and medication reconciliation was performed by pharmacists instead of student pharmacists. Interventions by third-year student pharmacists frequently resulted in changes in patient care. Prescribers addressed 74.9% of the discrepancies found by student pharmacists either by making a change to the patient’s medication profile or by stating a reason for the discrepancy in the medical record. This is similar to results achieved by APPE students performing medication reconciliation and suggests that the work of IPPE students improved the medication documentation on a substantial number of patients.24 The remaining discrepancies were not addressed, or information regarding how the prescriber addressed the discrepancy was not documented. This may mean that more discrepancies were corrected than we were able to detect, or that there was a reason for discrepancies in more cases than was recorded; we could not be certain of the reason. This study is limited as it relates to the biases inherent in retrospective methodology. Determining whether changes in a medication regimen are due to notification about potential medication discrepancies may be difficult, and determining the reasons underlying actions taken by prescribers following medication reconciliation (or actions not taken, in the event that no changes in medication orders were found) may not be accurate. We assumed that changes made to potential discrepancies within 24 hours of the completion of medication reconciliation were the result of student pharmacist communication to prescribers about the potential discrepancies; however, this may not have always been the case and we may have overestimated the rate of prescriber response. While we determined the total number of discrepancies addressed by prescribers, we did not document these data in a way that allows us to report the relative numbers that were intentional versus unintentional.
Finally, we did not assess the potential cost savings or actual improvement in patient care associated with student pharmacist medication reconciliation. Clinical interventions performed by student pharmacists have resulted in significant economic and clinical benefits to patients and to experiential education sites. Cost savings or cost avoidance range from $500–$6000 per student per acute care/inpatient APPE rotation.6 However, these savings result from a wide range of clinical activities including medication histories, recommendations to optimize drug therapy, and intravenousto-oral conversions; thus, the specific impact of students’ medication reconciliation activities is not known. Research assessing the clinical and economic benefits of student pharmacist medication reconciliation would provide further insight into the value student pharmacists add to patient care. Conclusions IPPE student pharmacists can contribute to patient care by accurately identifying potential medication discrepancies on admission and bringing them to the attention of prescribers, providing the opportunity for prescribers to address otherwise unrecognized issues that could adversely impact patient well-being. Integrating IPPE student pharmacists into the medication reconciliation process is beneficial for the patient and the health system.
Appendix. Ability-based outcomes applicable to the direct patient care IPPE ● Provide patient care in cooperation with patients, prescribers, and other members of an interprofessional health care team. ● Gather, organize, and interpret relevant patient or population specific data. ● Identify pharmacotherapy problems. ● Develop a therapeutic plan. ● Communicate and collaborate effectively with patients and other health care professionals to engender a team approach. ● Document pharmaceutical care activities and associated outcomes. ● Deliver comprehensive pharmaceutical care in a legal and ethical manner. ● Demonstrate professional skills, attitudes, and values and a sense of personal responsibility to patients, patient’s agents, and other health care providers. References 1. American Society of Health-System Pharmacists Pharmacy Practice Model Summit. Executive summary. Am J Health Syst Pharm. 2011;68(12):1079–1085. 2. The consensus of the pharmacy practice model summit. Am J Health Syst Pharm. 2011;68(12):1148–1152.
P.C. Walker et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 47–53 3. ASHP Policy Positions: Education and Training. Pharmacy resident and student roles in new practice models. 〈http://www. ashp.org/DocLibrary/BestPractices/EducationPositions.aspx〉; Accessed September 20, 2014. 4. Ashby DM. Permission granted. Am J Health Syst Pharm. 2011;68(16):1497–1504. 5. Rathburn RC, Hester EK, Arnold LM, et al. Importance of direct patient care in advanced pharmacy practice experiences. Pharmacotherapy. 2012;32(4):e88–e97. 6. Mersfelder TL, Bouthillier MJ. Value of the student pharmacist to experiential practice sites: a review of the literature. Ann Pharmacother. 2012;46(4):541–548. 7. Stevenson TL, Fox BI, Andrus M, Carroll D. Implementation of a school-wide clinical intervention documentation system. Am J Pharm Educ. 2011;75(5): Article 90. 8. American Council on Pharmaceutical Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree 〈http://www. acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adop ted_Jan152006.pdf〉; 2007 Accessed September 20, 2014. 9. American Society of Health-System Pharmacists, Scheckelhoff DJ, Bush CG, et al. Capacity of hospitals to partner with academia to meet experiential education requirements for pharmacy students. Am J Health Syst Pharm. 2008;65(21):e53-e71. 10. Bucci KK, Maddox RW, Holmes TH, Broadhead WF, Tse CJ. Implementation and evaluation of a shadow program for PharmD students. Am J Pharm Educ. 1993;57(1): 44–49. 11. Chisholm MA, McCall CY, Francisco GE, Poirier S. Student exposure to actual patients in the classroom. Am J Pharm Educ. 1997;61(4):364–370. 12. Levin GM, Kane MP, Fortin L. Preclinical exposure in a baccalaureate program in pharmacy. Am J Pharm Educ. 1996;60(2):179–182. 13. Chisholm MA, Wade WE. Using actual patients in the classroom to develop positive student attitudes toward pharmaceutical care. Am J Pharm Educ. 1999;63(3):296–299. 14. Turner CJ, Jarvis C, Altiere R, Clark L. A patient-focused and outcomes-based experiential course for first-year pharmacy students. Am J Pharm Educ. 2000;64(3):312–319. 15. Chisholm MA, DiPiro T, Fagan SC. An innovative introductory pharmacy practice experience model. Am J Pharm Educ. 2003;67(1): Article 22.
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16. Turner CJ, Altiere R, Clark L, Dwinnell B, Barton AJ. An interdisciplinary introductory pharmacy practice experience course. Am J Pharm Educ. 2004;68(1): Article 10. 17. Jarvis C, James VL, Giles J, Turner CJ. Nutrition and nurturing: a service-learning nutrition pharmacy course. Am J Pharm Educ. 2004;68(2): Article 43. 18. Turner CJ, Ellis S, Giles J, et al. An introductory pharmacy practice experience emphasizing student-administered vaccinations. Am J Pharm Educ. 2007;71(1): Article 03. 19. Wuller WR, Luer MS. A sequence of introductory pharmacy practice experiences to address the new standards for experiential learning. Am J Pharm Educ. 2008;72(4): Article 73. 20. Walker PC, Kinsey KS, Kraft MD, Mason NA, Clark JS. IPPE: improving student education and patient care through an innovative introductory pharmacy practice experience. Am J Health Syst Pharm. 2011;68(8):655 658, 660. 21. The Joint Commission. National Patient Safety Goals effective January 1, 2013. 〈http://www.jointcommission.org/assets/1/6/ HAP_NPSG_Chapter_2014.pdf〉; Accessed September 20, 2014. 22. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424–429. 23. Fleiss JL, Levin B, Paik MC. Statistical Methods for Rates and Proportions, 3rd ed., Hoboken, NJ: John Wiley & Sons, Inc; 2003. 24. Padiyara RS. Student pharmacists and medication reconciliation upon hospital admission: proposing a way to meet ASHP 2015 objective 1.1. J Am Pharm Assoc (2003). 2008;48(6):701. 25. Mersfelder TL, Bickel RJ. Inpatient medication history verification by pharmacy students. Am J Health Syst Pharm. 2008;65(23):2273–2275. 26. Lubowski TJ, Cronin LM, Pavelka RW, et al. Effectiveness of a medication reconciliation project conducted by PharmD students. Am J Pharm Educ. 2007;71(5): Article 94. 27. Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510–515. 28. Carter MK, Allin DM, Scott LA, Grauer D. Pharmacist-acquired medication histories in a university hospital emergency department. Am J Health Syst Pharm. 2006;63(24):2500–2503. 29. Mills PR, McGuffie AC. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admission. Emerg Med J. 2010;27(12):911–915.
Currents in Pharmacy Teaching and Learning 7 (2015) 47–53
Research
http://www.pharmacyteaching.com
Making student pharmacists indispensable: The added value of introductory pharmacy practice experience students to patient care Paul C. Walker, PharmD, FASHPa,*, Michael D. Kraft, PharmD, BCNSPb, Kathy S. Kinsey, BS Pharmc, Alison van Kampen, PharmDb, Matthew Perez, PharmDb, Uzoma Okeagu, PharmDb, Asiedu Boateng, PharmDb, Nancy A. Mason, PharmDb a
Experiential Education and Community Engagement, College of Pharmacy, The University of Michigan, Ann Arbor, MI b College of Pharmacy, The University of Michigan, Ann Arbor, MI c Department of Pharmacy Services, The University of Michigan Health System, Ann Arbor, MI
Abstract Purpose: This study evaluated the impact of an admission medication reconciliation process conducted by student pharmacists during an introductory pharmacy practice experience (IPPE). Methods: Patients aged 18 years or older admitted to a general medicine service and who received medication reconciliation from a student pharmacist were included. Data were collected retrospectively from electronic medical records. Results: Student pharmacists performed medication reconciliation on 21.8% of 6395 patients admitted to the target service, directly involving the majority of patients/caregivers (78.9%) in the process. Potential medication discrepancies were found in 43.8% of patients; the average number of potential discrepancies found per patient was 1.0 ⫾ 1.6. The most common potential discrepancy was “omitted prescription medication.” Prescribers responded to notification about potential discrepancies by correcting or clarifying 74.9% of all potential discrepancies and 77.2% of discrepancies with the potential to causes severe patient discomfort or clinical deterioration. Conclusion: IPPE student pharmacists contributed to patient care by performing medication reconciliation on patient admission to hospital. Student pharmacists identified and facilitated correction of unrecognized medication issues that could have adversely impacted patient well-being. r 2014 Elsevier Inc. All rights reserved.
Keywords: Introductory pharmacy practice experience; Pharmacy students; Medication reconciliation
Student pharmacists are valuable and important to practice model transformation. Recommendations of the American Society of Health System Pharmacists (ASHP) Pharmacy Practice Model Summit (PPMI) convened to identify how pharmacy practice models need to change to * Corresponding author: Paul C. Walker, PharmD, FASHP, Experiential Education and Community Engagement, College of Pharmacy, The University of Michigan, 428 Church Street, Ann Arbor, MI 48109-1065. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.09.001 1877-1297/r 2014 Elsevier Inc. All rights reserved.
meet contemporary societal needs and to more effectively deliver patient care, recommended integration of student pharmacists into meaningful practice roles.1 Specifically, recommendation B24c states, “Every pharmacy department should develop a plan to allocate pharmacy student time to drug-therapy management services.”2 This is a direct call to more fully integrate student pharmacists into the pharmacy department’s work to better serve the needs of patients. ASHP’s policy, “Role of Students in Pharmacy Practice Models,” further emphasizes the role of students by encouraging “pharmacy practice leaders to incorporate
48
P.C. Walker et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 47–53
students, including those in introductory and advanced pharmacy practice experiences and interns, into active, meaningful roles in new and evolving practice models.”3 In his 2011 Harvey K. Whitney address, Ashby4 recommended that students be made indispensable to the practice model and rearticulated key elements of pharmacy’s vision of the future that have emerged from both the PPMI and the 2011 Pharmacy Residency Capacity Stakeholders Conference. Among those key elements are the following: Activities for pharmacy students and pharmacy residents should support the educational goals for both groups though their active involvement in the care of patients.4 To achieve desired outcomes, the practice model should be team based, with a representation of specialist and generalist pharmacists, pharmacy residents, pharmacy students, and pharmacy technicians.4
Students comprise a resource that can help expand pharmacy’s capacity to care for patients, enable current services to be extended, and allow gaps in services to be filled. A recent commentary enumerated potential benefits to both students and experiential training sites that can result from effective engagement of advanced pharmacy practice experience (APPE) students in patient care.5 Mersfelder’s and Bouthillier’s6 recent review of 35 studies evaluating the contributions of APPE students to the work of experiential sites concluded that significant economic and clinical benefits may accrue to sites when APPE students are involved in patient care and that these benefits often exceed the costs invested by sites in supervising and training students. Stevenson et al.7 also describe benefits from the patient care activities of APPE students. In contrast, the impact of introductory pharmacy practice experience (IPPE) students, whose skill sets may differ from those of APPE students, has not been well described. According to the 2007 Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree, which were applicable at the time of this study, IPPEs “must involve actual practice experiences in community and institutional settings and permit students, under appropriate supervision and as permitted by practice regulations, to assume direct patient care responsibilities,” and they should “continue in a progressive manner leading to entry into the advanced pharmacy practice experiences.”8 Student pharmacists are required to complete a minimum of 300 IPPE hours in the first three years of the pharmacy curriculum.8 This requirement for early practice experiences has stretched the capacity of health systems to support these experiences and challenged colleges to identify creative ways to meet the requirement using existing, often scarce resources.9 IPPEs involving shadow experiences, service learning, vaccination programs, actual patient encounters in a variety of settings (inpatient venues, home, etc.) and other innovative approaches have been described.10–20
Effectively integrating IPPE students into practice models and involving them in direct patient care activities can help students meet educational requirements but should also provide benefit to the experiential site. However, little information about the benefit of IPPE students to the experiential site is available. Although Stevenson et al.7 included third-year pharmacy students enrolled in IPPE courses in their study, the contribution of IPPE students represented only a small percentage of overall interventions documented, and their specific impact was not reported. We have previously described the development and implementation of a direct patient care IPPE that engages third-year student pharmacists in the admission medication reconciliation process of at the University of Michigan Health System.20 The direct patient care IPPE enables students to achieve predefined curricular ability-based outcomes (Appendix) while engaging them in meeting the experiential site’s need to enhance admission medication reconciliation, which is required by national patient safety goals.21 This article describes the outcomes associated with a pharmacist-supervised P3 IPPE student admission medication reconciliation program. Methods The direct patient care IPPE is a structured 12-week course for P3 students. Prior to the IPPE course, students complete a communications course in which they develop communication and medication history-taking skills. During the course orientation, students receive a one-hour lesson on medication reconciliation, that consists of a discussion about medication reconciliation and active learning exercises in which they apply a structured approach to medication record review and discrepancy identification. On the first day at the hospital, students receive four hours of instruction in the medication reconciliation process, including how to use the hospital’s information systems, as we have previously described.20 1. Review the patient’s admission history, physical examination results, and other pertinent information. 2. Review medications being taken prior to admission as indicated by the physician’s admission history and physical examination results, as well as any home medication list documented in the Problem Summary List (PSL) section electronic medical record (the PSL provides a list of home medications that is maintained by the health system’s outpatient care providers) and current inpatient medications. 3. On the patient care unit, seek out and meet the patient’s nurse to address any questions (e.g., patient status or appropriateness of the timing of the interview) and determine if the patient is currently available for the interview. 4. Conduct a patient (or caregiver, if the patient was unable to communicate) interview including a medication
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5. 6. 7. 8.
9.
history. If patients/caregivers are not available or are unwilling or unable to participate in a medication history, perform medication reconciliation by comparing the medication list in the admission history with the current inpatient medication list and PSL medication list to determine if potential discrepancies exist. Identify potential discrepancies by comparing gathered information. Discuss potential discrepancies with preceptor. Create draft pharmacy notes in the electronic medical record to document medication reconciliation. Forward the pharmacy notes to the preceptor for editing and approval before the notes become part of the permanent medical record. If potential discrepancies are identified, page the responsible physician to inform that medication reconciliation has been completed and request that he/she review the pharmacy notes to address any discrepancies. If any urgent issues are identified, page the physician to request immediate action. (Original source20 r 2011, American Society of Health-System Pharmacists, Inc. All rights reserved. Excerpt reprinted with permission.)
One the first day at the site, each student works through all of these steps to complete medication reconciliation on one patient under the guidance of a preceptor. The College of Pharmacy schedules IPPE students to provide medication reconciliation services at the site four days each week, Monday through Thursday, during fall and winter semesters. Each individual student is assigned to a specific patient care area and spends four hours per week performing medication reconciliation in that area over the course of one semester. Through this experience, students complete 48 IPPE hours. At the time of implementation, admission medication reconciliation was performed throughout the hospital by nurses, physicians, physician assistants, and medical assistants. However, the process was not standardized; quality improvement initiatives conducted by the site found that
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lack of standardization contributed to errors, redundancies, missed information, and inefficiencies in patient care. A retrospective review of electronic medical records was conducted to evaluate the IPPE student medication reconciliation program. Data were collected for three semesters, beginning in September 2009 and ending in December 2010. A total of 24 student pharmacists performed medication reconciliation each semester; the data reflect the work of 72 student pharmacists. Patients 18 years of age or older who were admitted to a general medicine hospitalist service between September 14, 2009 and December 2, 2010 and who received medication reconciliation by student pharmacists, as evidenced by a medication reconciliation note in the medical record, were included in the study. Patients who received medication reconciliation during the study period were identified by electronically searching the clinical data repository for records containing a pharmacy medication reconciliation note. Demographic information was collected and studentwritten pharmacy medication reconciliation notes were reviewed to determine the total number of potential medication discrepancies, the average number of potential discrepancies per patient, and the types of potential discrepancies identified, shown in Table 1. A medication discrepancy was defined as any difference between the medication use history and the admission medication orders. How frequently students were able to perform medication reconciliation by speaking directly with a patient or caregiver to solicit an admission medication history was also determined. Two investigators (P.W. and N.M., both clinical pharmacists and college of pharmacy faculty) independently assessed the potential seriousness of each discrepancy using a scale of 1–3 as described by Cornish et al.22: (1) unlikely to cause discomfort or clinical deterioration; (2) potential to cause moderate discomfort or clinical deterioration; or (3) potential to result in severe discomfort or clinical deterioration. Factors considered in rating the potential for harm included the medication involved, patient’s diagnoses, reason for admission, type of discrepancy, and how the discrepancy would likely affect the patient’s health during
Table 1 Classification of potential medication discrepancies Classification
Description
Omitted medications
A home medication that was not prescribed on admission; further classified as prescription medication, over-the-counter (OTC) medication, and herbal medication The admission dose/frequency differs from the home dose/frequency
Discrepant/missing dose or frequency Discontinued medication prescribed on admission Unnecessary duplication Discrepant dosage form or route of administration
A home medication that is no longer taken by the patient was prescribed on admission A medication with the same or similar mechanism of action and indication is prescribed The dosage form prescribed on admission differs from the home dosage
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an average four-day hospitalization. Individual ratings were then compared. Disagreements in ratings were resolved by in-person discussion and the final ratings were determined by consensus; consensus was reached in all cases. To assess how prescribers responded to notification of potential discrepancies that needed to be clarified or resolved, patient records were reviewed to determine if documentation, including medication order changes, was provided to address or correct potential discrepancies within 24 hours after medication reconciliation was completed. Documentation provided within 24 hours of medication reconciliation was deemed to be in response to student pharmacist medication reconciliation. Prescriber changes made beyond 24 hours were not assessed. Descriptive statistics were used to describe the percentage of patients for whom medication reconciliation was performed, the percentage of patients who had a potential medication discrepancy, how often each type of medication discrepancy occurred, the types of medications involved in discrepancies, and the number of changes made to address any potential discrepancies. Analysis was performed using Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA). Interrater reliability for assessing the potential harm associated with discrepancies was analyzed using Cohen’s kappa statistic (κ); the analysis was performed using SPSS Statistics version 21 (IBM Corporation, Armonk, NY).23 The study was approved by the institutional review board.
Results During the study period, 6395 patients were admitted to the targeted general medicine service; student pharmacists performed medication reconciliation on 1392 (21.8%) of these patients. A convenience sample of 422 (30%) patients who received medication reconciliation by student pharmacists was randomly selected for inclusion in the study by using SQL query language in Oracle (Version 10G; Cisco Systems, Inc. San Jose, CA). Demographic and other descriptive information is detailed in Table 2. Student pharmacists performed medication reconciliation an average of 2.0 ⫾ 1.4 days after admission and met with 333 patients/caregivers (78.9% of cases) to perform medication reconciliation. In the remaining cases, patients/caregivers were not available or were unwilling or unable to participate in a medication history; in these cases, medication reconciliation was accomplished by comparing available medication lists (PSL medication list, medication list in the admission history, and medications prescribed on admission). Student pharmacists identified 415 potential medication discrepancies in 185 patients (43.8%). The average number of potential discrepancies per patient was 1.0 ⫾ 1.6 (range: 0–13). The most frequent type of potential discrepancy was “omitted prescription medication,” which comprised 50.8% of potential discrepancies (Table 3). Cardiovascular medications
were most frequently identified in potential discrepancies (16.5%), followed by general health supplements (15.7%), gastrointestinal drugs (10.8%), and analgesics (8.8%). Interrater reliability in the assessment of discrepancies to cause harm was fair (κ ¼ 0.344; 95% confidence interval, 0.262–0.426). Consensus was easily reached in areas of disagreement. Most of the potential discrepancies (62%) were classified as unlikely to cause patient discomfort or clinical deterioration, 32.6% were classified as having potential to cause moderate patient discomfort or clinical deterioration, and the remaining 5.4% were classified as having potential to result in severe patient discomfort or clinical deterioration. Prescribers responded to 311 (74.9%) of all potential discrepancies by correcting the discrepancy or documenting that the discrepancy was intentional. Prescribers documented a response to 17 (77.2%) of the potential discrepancies which may have been harmful to patient health.
Table 2 Patient demographics Characteristic Age (years) Gender Male Female Ethnic background African American Asian Caucasian Hispanic Middle eastern Multiracial Pacific islander Unknown/other Admission source Emergency department Admitted from home Transfer from other hospital Transfer from skilled nursing facility Urgent care clinic Other Length of stay (days) Time to note after admission (days), mean Reconciled r24 hours after admission Reconciled 25–48 hours after admission Reconciled 49–96 hours after admission Reconciled 496 hours after admission Number of medications prior to admission
No. (%) of pts (N ¼ 422) Mean (SD) 59.4 (18.9) 167 (39.6) 255 (60.4) 70 3 333 5 4 2 1 4
(16.6) (0.7) (79) (1.2) (0.9) (0.5) (0.2) (0.9)
338 39 10 3
(80.1) (9.2) (2.4) (0.7)
2 (0.5) 30 (7.1) 5.1 (5.0) 2.0 (1.4) 121 (28.7) 154 (36.5) 79 (18.7) 68 (16.1) 10 (5.5)
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Table 3 Potential medication discrepancies identified
Type of discrepancy
Total discrepancies (%), N ¼ 415
Omitted prescription 211 (50.8) medication Discrepant dose 71 (17.8) Omitted OTC 51 (12.3) medication Discrepant frequency 40 (9.6) Incorrect medication 11 (2.7) prescribed Discontinued medication 9 (2.2) prescribed Omitted herbal 3 (0.7) medication Omitted dose 4 (1) Omitted frequency 4 (1) Discrepant dosage form/ 6 (1.4) route of administration Unnecessary medication 2 (0.5) duplication
Discrepancies with potential for severe Discrepancies with potential for severe discomfort or discomfort or clinical deterioration (%), clinical deterioration addressed by prescriber (%),a N ¼ 17 N ¼ 22 11 (50)
9 (81.1)
8 (36.4) –
7 (87.5) –
1 (4.5) 1 (4.5)
0 (0) 0 (0)
–
–
–
–
– – 1 (4.5)
– – 1 (100)
–
–
OTC ¼ over-the-counter. a Calculated as a percentage of total potentially harmful discrepancies within type of discrepancy.
Discussion Previous studies have demonstrated the ability of APPE students to perform medication reconciliation; this is the first report to document the effectiveness of IPPE students in admission medication reconciliation.24–26 Third-year IPPE student pharmacists contributed to patient care and the work of the experiential site by performing medication reconciliation to identify potential medication discrepancies and then acting to have discrepancies addressed by prescribers. Engaging student pharmacists in this way helped our pharmacy department extend its services. By performing medication reconciliation, students also worked towards achieving educational outcomes of our pharmacy curriculum. During the activity, students gathered and organized patient-specific information from patients and their caregivers, which allowed them to practice communication and medication history-taking skills. They directly communicated with almost 80% of patients or their caregivers in the medication reconciliation process. Gathering information from the medical record each week provided consistent exposure that enabled students to become familiar with how medical records are organized and how to find information needed for medication reconciliation. Students identified potential medication-related problems and, by discussing their findings with preceptors, practiced interpreting patient-specific data. Students also gained practical experience documenting pharmacist care in the medical record and
communicating with other health professionals and were mentored by preceptors through these processes. Students performed medication reconciliation on 21.8% of patients admitted to the medical services to which they were assigned. This was fewer patients than anticipated. Students were expected to develop proficiency in performing medication reconciliation quickly over the first few weeks of the semester and be able to perform the activity on at least three to five patients per day. We therefore expected students to have completed medication reconciliation on approximately 2500 patients (approximately 40% of admissions). Students only performed the activity for four hours per week and may have developed proficiency more slowly with the process and resources necessary for medication reconciliation, including the hospital’s information systems. Nonetheless, before student pharmacists were engaged in the process, admission medication reconciliation was performed inconsistently in these patients and the work of students using a standardized approach contributed substantially toward the health system’s goal of providing admission medication reconciliation for all patients. Ideally, admission medication reconciliation should be performed within 24 hours of admission. This goal was achieved in only 28.7% of patients, largely due to how student pharmacists were scheduled. Because of course schedules, students performed medication reconciliation four hours each day, Monday through Thursday; patients admitted between Thursday evening and Monday morning received medication reconciliation on Monday. This presents an
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opportunity for process improvement. Expanding the activity to seven days/week, increasing the time students devote to the activity, or exploring other ways to better integrate students and medication reconciliation into teams providing other pharmacy services to patients may improve the process. The frequency, types, and severity of potential medication discrepancies on admission identified by the student pharmacists are consistent with the findings of other studies. A recent systematic review of the literature found that 67% of patients admitted to hospital have at least one error in their medication histories taken on admission.27 Cornish et al.22 reported that 54% of patients experienced at least one unintended medication discrepancy on admission and found that 32.9% of the medication discrepancies had the potential to cause moderate discomfort or clinical deterioration and 5.7% cause serious harm. Cornish et al.,22 Carter et al.,28 and Mills and McGuffie29 all found that the most common discrepancy on admission to hospital was omission of medication (46%, 46%, and 60% of discrepancies, respectively), followed by discrepant dose (25%, 18%, and 12% of discrepancies, respectively). However, these studies had fewer discrepancy classifications than the present study and medication reconciliation was performed by pharmacists instead of student pharmacists. Interventions by third-year student pharmacists frequently resulted in changes in patient care. Prescribers addressed 74.9% of the discrepancies found by student pharmacists either by making a change to the patient’s medication profile or by stating a reason for the discrepancy in the medical record. This is similar to results achieved by APPE students performing medication reconciliation and suggests that the work of IPPE students improved the medication documentation on a substantial number of patients.24 The remaining discrepancies were not addressed, or information regarding how the prescriber addressed the discrepancy was not documented. This may mean that more discrepancies were corrected than we were able to detect, or that there was a reason for discrepancies in more cases than was recorded; we could not be certain of the reason. This study is limited as it relates to the biases inherent in retrospective methodology. Determining whether changes in a medication regimen are due to notification about potential medication discrepancies may be difficult, and determining the reasons underlying actions taken by prescribers following medication reconciliation (or actions not taken, in the event that no changes in medication orders were found) may not be accurate. We assumed that changes made to potential discrepancies within 24 hours of the completion of medication reconciliation were the result of student pharmacist communication to prescribers about the potential discrepancies; however, this may not have always been the case and we may have overestimated the rate of prescriber response. While we determined the total number of discrepancies addressed by prescribers, we did not document these data in a way that allows us to report the relative numbers that were intentional versus unintentional.
Finally, we did not assess the potential cost savings or actual improvement in patient care associated with student pharmacist medication reconciliation. Clinical interventions performed by student pharmacists have resulted in significant economic and clinical benefits to patients and to experiential education sites. Cost savings or cost avoidance range from $500–$6000 per student per acute care/inpatient APPE rotation.6 However, these savings result from a wide range of clinical activities including medication histories, recommendations to optimize drug therapy, and intravenousto-oral conversions; thus, the specific impact of students’ medication reconciliation activities is not known. Research assessing the clinical and economic benefits of student pharmacist medication reconciliation would provide further insight into the value student pharmacists add to patient care. Conclusions IPPE student pharmacists can contribute to patient care by accurately identifying potential medication discrepancies on admission and bringing them to the attention of prescribers, providing the opportunity for prescribers to address otherwise unrecognized issues that could adversely impact patient well-being. Integrating IPPE student pharmacists into the medication reconciliation process is beneficial for the patient and the health system.
Appendix. Ability-based outcomes applicable to the direct patient care IPPE ● Provide patient care in cooperation with patients, prescribers, and other members of an interprofessional health care team. ● Gather, organize, and interpret relevant patient or population specific data. ● Identify pharmacotherapy problems. ● Develop a therapeutic plan. ● Communicate and collaborate effectively with patients and other health care professionals to engender a team approach. ● Document pharmaceutical care activities and associated outcomes. ● Deliver comprehensive pharmaceutical care in a legal and ethical manner. ● Demonstrate professional skills, attitudes, and values and a sense of personal responsibility to patients, patient’s agents, and other health care providers. References 1. American Society of Health-System Pharmacists Pharmacy Practice Model Summit. Executive summary. Am J Health Syst Pharm. 2011;68(12):1079–1085. 2. The consensus of the pharmacy practice model summit. Am J Health Syst Pharm. 2011;68(12):1148–1152.
P.C. Walker et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 47–53 3. ASHP Policy Positions: Education and Training. Pharmacy resident and student roles in new practice models. 〈http://www. ashp.org/DocLibrary/BestPractices/EducationPositions.aspx〉; Accessed September 20, 2014. 4. Ashby DM. Permission granted. Am J Health Syst Pharm. 2011;68(16):1497–1504. 5. Rathburn RC, Hester EK, Arnold LM, et al. Importance of direct patient care in advanced pharmacy practice experiences. Pharmacotherapy. 2012;32(4):e88–e97. 6. Mersfelder TL, Bouthillier MJ. Value of the student pharmacist to experiential practice sites: a review of the literature. Ann Pharmacother. 2012;46(4):541–548. 7. Stevenson TL, Fox BI, Andrus M, Carroll D. Implementation of a school-wide clinical intervention documentation system. Am J Pharm Educ. 2011;75(5): Article 90. 8. American Council on Pharmaceutical Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree 〈http://www. acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adop ted_Jan152006.pdf〉; 2007 Accessed September 20, 2014. 9. American Society of Health-System Pharmacists, Scheckelhoff DJ, Bush CG, et al. Capacity of hospitals to partner with academia to meet experiential education requirements for pharmacy students. Am J Health Syst Pharm. 2008;65(21):e53-e71. 10. Bucci KK, Maddox RW, Holmes TH, Broadhead WF, Tse CJ. Implementation and evaluation of a shadow program for PharmD students. Am J Pharm Educ. 1993;57(1): 44–49. 11. Chisholm MA, McCall CY, Francisco GE, Poirier S. Student exposure to actual patients in the classroom. Am J Pharm Educ. 1997;61(4):364–370. 12. Levin GM, Kane MP, Fortin L. Preclinical exposure in a baccalaureate program in pharmacy. Am J Pharm Educ. 1996;60(2):179–182. 13. Chisholm MA, Wade WE. Using actual patients in the classroom to develop positive student attitudes toward pharmaceutical care. Am J Pharm Educ. 1999;63(3):296–299. 14. Turner CJ, Jarvis C, Altiere R, Clark L. A patient-focused and outcomes-based experiential course for first-year pharmacy students. Am J Pharm Educ. 2000;64(3):312–319. 15. Chisholm MA, DiPiro T, Fagan SC. An innovative introductory pharmacy practice experience model. Am J Pharm Educ. 2003;67(1): Article 22.
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16. Turner CJ, Altiere R, Clark L, Dwinnell B, Barton AJ. An interdisciplinary introductory pharmacy practice experience course. Am J Pharm Educ. 2004;68(1): Article 10. 17. Jarvis C, James VL, Giles J, Turner CJ. Nutrition and nurturing: a service-learning nutrition pharmacy course. Am J Pharm Educ. 2004;68(2): Article 43. 18. Turner CJ, Ellis S, Giles J, et al. An introductory pharmacy practice experience emphasizing student-administered vaccinations. Am J Pharm Educ. 2007;71(1): Article 03. 19. Wuller WR, Luer MS. A sequence of introductory pharmacy practice experiences to address the new standards for experiential learning. Am J Pharm Educ. 2008;72(4): Article 73. 20. Walker PC, Kinsey KS, Kraft MD, Mason NA, Clark JS. IPPE: improving student education and patient care through an innovative introductory pharmacy practice experience. Am J Health Syst Pharm. 2011;68(8):655 658, 660. 21. The Joint Commission. National Patient Safety Goals effective January 1, 2013. 〈http://www.jointcommission.org/assets/1/6/ HAP_NPSG_Chapter_2014.pdf〉; Accessed September 20, 2014. 22. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424–429. 23. Fleiss JL, Levin B, Paik MC. Statistical Methods for Rates and Proportions, 3rd ed., Hoboken, NJ: John Wiley & Sons, Inc; 2003. 24. Padiyara RS. Student pharmacists and medication reconciliation upon hospital admission: proposing a way to meet ASHP 2015 objective 1.1. J Am Pharm Assoc (2003). 2008;48(6):701. 25. Mersfelder TL, Bickel RJ. Inpatient medication history verification by pharmacy students. Am J Health Syst Pharm. 2008;65(23):2273–2275. 26. Lubowski TJ, Cronin LM, Pavelka RW, et al. Effectiveness of a medication reconciliation project conducted by PharmD students. Am J Pharm Educ. 2007;71(5): Article 94. 27. Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510–515. 28. Carter MK, Allin DM, Scott LA, Grauer D. Pharmacist-acquired medication histories in a university hospital emergency department. Am J Health Syst Pharm. 2006;63(24):2500–2503. 29. Mills PR, McGuffie AC. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admission. Emerg Med J. 2010;27(12):911–915.