Lecture 5

Shahid Rashid
 Introduction
• It was the best of times; it was the worst of
times ( Charles Dickens, A tale of two cities)
• Meaning ? How best times? How worst times?
• Opportunities for enhancing quality and value
makes It the best of times
• Current challenges in health care makes it
worst of times
• Pharmacist role in health care?
• Pharmacists role as promoters of quality and
value
• Value driven health care based on two things
transparency of quality and transparency of
costs
• Meaning of quality and value?
• For pharmacy quality no adapted set of
measures. By the way why it is important?
• Every dollar spend on pharmaceuticals….
• We spend another dollar on treating the problems that
stem from suboptimal medications use and therefore
waste billions of dollar
• So in the absence of set of measures pharmacy quality
has to follow trails of physicians, hospitals, and long
term care providers for quality improvements
• Pharmacy Quality Alliance (PQA) efforts in 2006 to
2007 to identifying potential measures of pharmacy
quality and pilot testing these measures with
organizations experienced in quality measurement. As
a result 15 measures demonstrated favorable
attributes for performance measurement
• Our objective will be to explore
• To what extent can pharmacists improve the quality and
safety of medication utilization?
• Why focus on pharmacy?
• Medications are one of the key tools in the therapeutic
management of disease. However, they are not always used
in an ideal or appropriate manner. When medications are
not used appropriately patients may experience adverse
events or fail to achieve their therapeutic goals. In turn this
results in suboptimal quality of life and wasted resources
for society.
• Helper and strand used term drug related morbidity to
describe the phenomenon of therapeutic malfunction
• Drug related morbidity accounts for at least 7% of hospital
admissions
• Drug related morbidity is often preceded by drug realted
problem. A DRP is an event involving drug treatment that
actually or potentially interferes with the patient
experiencing an optimum outcome of medical care Strand
et al delineated eight categories of DRPS
• Untreated indications: patient is in need of a drug that was
not prescribed.
• Improper drug selection: the wrong drug is being used.
• Subtherapeutic dosage: too little of an appropriate drug is
being used
• Over dosage: the patient receives too much of an
appropriate drug
• Failure to receive drug: the patient does not
obtain / use the drug that was prescribed.
• Adverse drug reaction: an unintended and
potentially harmful effect of a drug
• Drug interactions: undesireable consequences of
drug-drug or drug-food interactions
• Drug use without indication: the patient is taking
a drug for which he or she has no medical need
• DRP may arise due to Inappropriate
prescribing, inappropriate dispensing /
administration of the drug, inappropriate
behavior by patient, inappropriate monitoring
of patient
• A framework for examining quality of medication use
• Hepler and Grainger – Rousseau’s conceptualization
of a pharmaceutical care system offers a good
framework for examining the qualityof medication
use.
• Three key elements to the proper functioning of a
pharmaceutical care system
• Initiating therapy
• Monitoring therapy
• Managing ( correcting) therapy
• Problems with initiating therapy ( If patient
fails to recognize a potential health problem
that could be treated with medication. If
patient is unable to communicate the true
nature of issue an accurate assessment of
the problem becomes difficult
• What if the provider lack necessary skills or
equipment to accurately diagnose the
problem
• Once the diagnosis is made the clinician then
needs to decide whether a drug is warranted for
treating the patient. If so selection of the drug (
along with appropriate dose , route, duration,
and instruction) can be challenging
• Paradox of choice thousands of drugs and
characteristics of patient (age , weight, renal
function and cognative function)
• Plus payers drug choice (Insurance companies)
• Lack of a consistent dispensing process, or
unclear roles within the process
• A workload that exceeds the capacity of the
personnel and dispensing process
• Excessive distractions in the dispensing process
• Unclear hand written prescriptions
• Similar drug names that can easily be confused
• Products or packaging that look identical
• Lack of training for personnel
• Failure to communicate with patients
• The next phase pharmacist is charged with
confirming the appropriateness of the drug and
then dispensing the product this is done by
“prospective drug utilization review” (PDUR)
• Sometime drugs are available with nurses who
directly dispense them with out having feed
back from pharmacist
• Dispensing related medication errors often
result from a combination of human factors and
systems failures. For example
• According to Thomson Reuters, if all patients
received the same level of care as
• those treated in the top 100 facilities, the
benefits would be enormous1:
• ◾ More than 186,000 lives could be saved.
• ◾ Approximately 56,000 patients could be
complication free.
• ◾ More than $4.3 billion could be saved.
• ◾ The average patient stay would decrease by
nearly half a day.
• The role of the pharmacist continues to evolve and
expand beyond the task of traditional dispensing.
Recent studies support the value of pharmacist-
provided services in areas such as medication
management, medication reconciliation, preventive
care, educational and behavioral counseling,
transitions of care, medication adherence, and
collaborative patient care models. These services,
provided in various healthcare settings such as
community pharmacies, health-system pharmacies and
ambulatory clinics, ensure safe and effective use of
medications for patients.
• "Pharmacy is a dynamic profession, and the
role of the pharmacist continues to evolve as
pharmacists move from being medication
dispensers to patient-focused and outcome-
oriented care providers.
• Pharmacists serve in a vast variety of roles,
but with one common goal of ensuring public
health
 Medication error ( to err is human
building safer health care system
report)
• Medical errors are common – one medication
error per patient per day
• Medical errors are tragic--- over 7000
preventable deaths occur each year due to
this
• Medical errors are expensive --- resulting in
annual cost of $17 - 37 billion
• Medical errors are preventable at least
400000 adverse drug events
Drug related problems
Consequences of drug related
problems
Various drug related problems
associated with errors
Types of medication errors
 Drug related Issues
• Administrative errors
• Adverse drug event (ADE, Injury)/Adverse drug
reaction /Allergic drug reaction
• Dispensing errors
• Drug misadventure
• Drug related morbidity
• Error of commission
• Error of omission
• Prescribing error
•
 PDSA Cycle
• A well recognized process for improving the
safety of medication ise systems consist of
four steps
• Plan, do , study, and act
• This process starts by asking following
questions
• What do we want to accomplish?
• How will we know when we are successful?
• What changes will result in success?
PDSA Cycle of Quality Improvement
 Plan
• Bottom up approach is typically preferred
where everyone potentially involved in the
process is consulted and engaged in the
change – especially frontline healthcare
workers. Why the frontline health care
workers?
• They know the problems and ways to fix them
• DO ( Plan needs to be implemented)
• Implementation must be done on small scale
• STUDY checks the effects of change on safety
measures