Advanced Pharmacy Practice Experiences (APPE) Objectives:



Advanced Pharmacy Practice Experiences (APPE) Objectives: Hospital/Health System RotationThe hospital rotation helps students integrate knowledge and theoretical concepts across the curriculum in an environment that encourages and requires interactions between students, preceptors and patients. Our goal is to enable students to safely and accurately perform the activities associated with the receipt, preparation and dispensing of medication orders, perform required drug control activities, support the mission of the pharmacy department and activities that maintain productive relationships with other departments in the hospital. This experience will allow the student to use a patient-centered approach in collaboration with other providers on the health care team to optimize medication outcomes.These experiences take place in hospitals or other systems of integrated pharmaceutical services. Emphasis is placed on the drug-use decision-making process, monitoring of individual patient drug therapy, formulary management, and the communication of information to other healthcare professionals and to patients. These experiences may include medication order processing, dispensing, sterile product preparation, clinical pharmacy services, inventory management, and medication administration.The items listed under these learning objectives are composed of both example and required activities that support the overarching goal of each objective. A concise list of specific, required activities is found in Appendix 1.Learning ObjectivesAt the end of the hospital/health system rotation the student should be able to:Describe the roles and responsibilities of pharmacists in an institutional pharmacy setting, the integration of clinical and distributive functions, the services offered by the department of pharmacy, and be adept with the terminology used in the settingDevelop and articulate a philosophy of institutional pharmacy practiceDemonstrate the ability to perform prescription processingCorrectly interpret a prescription order that is obtained in oral and/or written formAnalyze the prescription and patient chart (EHR) for appropriateness of therapyIdentify signs and symptoms of patient‘s chief complaint or diseaseEvaluate clinical status of patientCollect, analyze, and interpret demographics, medication history (including previous treatments), past medical history, medication allergies (including reaction description), adherence, healthcare coverage, family, social, and surgical historyUse appropriate open-ended questions during patient interview and express empathy toward patient Participate in physical assessment of patient(s) when appropriate (vital signs, foot exam, etc.)Discuss cost-benefit analysis and cost-effectiveness of therapyPerform any necessary mathematical calculations to verify appropriateness of doseDiscuss pathophysiology, anatomy/physiology, etiology, symptomatology, diagnosis, and treatment options for common conditions in the institutional settingIdentify the pharmacology, spectrum/indication, dosing, route of administration, target concentration (if narrow therapeutic index), pharmacokinetics, significant drug interactions, adverse side effects, contraindications, special precautions, and monitoring parameters for medicationsUse the patient’s chart to systematically identify and prioritize drug related problems, including but not limited to: identifying potential drug interactions (drug-drug, drug-food/herbal, drug-laboratory, etc.), need for additional therapy, unnecessary therapy, population specific precautions, adverse drug events, non-adherence, therapeutic duplication, drug misuse/abuse, allergies, drug efficacy and toxicity, and cost effectivenessPrioritize medication orders, considering workload and the clinical status of patients (i.e. STAT vs. routine orders)Know when to discontinue or restart medications when situations warrant per hospital policies and procedures (e.g. postoperatively, upon transfer or discharge)Prioritize and resolve drug related problems identified in the prescription dispensing processPreceptors should allow opportunities for the student to check final product prior to or after the licensed pharmacistAppropriately retrieve, interpret, intervene, and monitor patient/lab/medication data for the optimal medication management of the hospitalized patientIdentify drug related problems, medications requiring age or renal function dose adjustment, drug interactions, IV to PO substitution, therapeutic interchange, medication reconciliation, adverse drug reactions, and pharmacist run protocols (e.g. anticoagulants, antibiotics with pharmacokinetic consults such as vancomycin and aminoglycosides, TPNs)Develop a specific, measurable, achievable, and time-dependent monitoring plan for each patientIdentify frequency of monitoringAssist in facilitating the transition of care from one setting to another by communicating the pharmaceutical care plan to another pharmacist or other healthcare providerDiscuss and demonstrate medication use processes and the use of healthcare informatics used to manage a comprehensive, institutional pharmacy service, such as:General orientation process for all pharmacy employeesCart fill or equivalent drug deliveryBulk product dispensingPharmacovigilance activities, adverse drug reactions reporting and preventionReimbursement for services (as applicable)Joint Commission on Healthcare Accreditation (JCAHO)Pharmacy and Therapeutics Committee and formulary managementSterile and non-sterile compounding, including pharmaceutical calculationsDemonstrate the ability to effectively communicate with patients, caregivers, and other healthcare providers to ensure quality patient careCommunicate to patients, caregivers, and other health-care providers (writing, speaking, and non-verbal communication) in a professional and persuasive manner to positively impact drug useEffectively collaborate with and oversee technical support staff (i.e. pharmacy technicians)Identify appropriate methods (e.g. active listening) for gathering informationProvide education in a clear, concise manner about the disease state, the proper management of the disease, and on the proper dosing, length of therapy, and possible side effects or interactions of medications at an appropriate audience levelDeliver a formal in-service to pharmacy staff on a therapeutics, treatment guideline, new drug entity, or other pharmacy-related topicMake recommendations concerning a patient’s care to healthcare professionals accurately, concisely with confidence, and with the preceptor’s approval.Obtain patient medication histories, perform medication reconciliation of patients admitted, and perform patient discharge counselingDocument activities related to patient care and interventions (as applicable)Utilize the most appropriate resources to complete a concise answer to drug information questions from health professionals and patients. Demonstrate competence and knowledge of current standards of institutional pharmacy and the roles of the following organizations and committees:United States Pharmacopeia (USP) General Chapter <797> Pharmaceutical Compounding – Sterile PreparationsThe Joint CommissionAmerican Society of Health-System Pharmacists (ASHP)Institutional policiesPharmacy and Therapeutics CommitteeDiscuss formulary management topicsPrepare a drug monograph or therapeutic class review in preparation for a pharmacology and therapeutics committee (as applicable)Participate in therapeutic protocol/guideline development (as applicable)Evaluate medication-use patterns in a specified patient populationParticipate in prospective and retrospective financial and clinical outcomes analysis to support formulary recommendations and therapeutic guidelinesAttend pharmacy-related meetings (Pharmacy and Therapeutic Committee, Patient Safety, etc.) as availableDemonstrate knowledge and skills regarding unit dose packaging, point-of-care dispensing, and intravenous admixture procedures if applicable Discuss the role of unit dose packaging in hospital systemDiscuss procedures and regulations for unit dose packaging Demonstrate proper garbing technique for preparing intravenous admixturesReview proper technique of cleaning sterile compounding hoodsUnderstand special handling, preparation and reconstitution, administration procedures, and compatibility for parenteral drug medications (standard and hazardous medications)Review stability information and selection of correct beyond use dateIdentify proper techniques for preparing sterile productsDemonstrate competency and accuracy in the preparation of compounded sterile products and other extemporaneous preparations according to site policies and established guidelines (e.g. USP <797> and <800>)Prepare, dispense, and compound non-sterile medications (including topical preparations, reconstituted medications, etc.) for dispensing in consideration of local, state, and federal laws as well as site specific policies and procedures (e.g. USP <795>)Demonstrate understanding regarding purchasing and inventory control systemsDiscuss methods of purchasing medications, contracts, and bid pricingDiscuss methods of automated medication management systems (Pyxis?, Omnicell?, etc.) for appropriately delivering medications from the pharmacy to patient care areasAppropriately restock a crash cart or emergency boxIdentify methods the institution uses to prevent drug diversion Discuss methods to control inventory for the institutionDiscuss storage methods for refrigerated and cytotoxic medicationsDiscuss and/or participate in the pharmacy’s quality improvement programPerform a medication use evaluation (MUE) and recommend specific actions to improve medication useConduct healthcare failure mode and effects analysis to identify and address potential points of error in the medication use processReview adverse drug event reports and identify areas for improvement or evaluationPerform a root cause analysis for a medication error or other misadventure/event that occurred at the site or in the literatureDescribe legal and regulatory requirements for the distribution, disposal, and transfer of controlled substancesReview legal requirements for purchasing controlled substances, including C-IIReview regulations for waste, disposal, and transfer of controlled substancesUtilize and adhere to site-specific policies and procedures as it pertains to medication procurement, storage, and securityDiscuss the policies and procedures related to quality assurance and medication safetyIdentify processes to identify quality assurance and medication safety issues (e.g. tall-man lettering, unapproved abbreviations, look-alike/sound-alike medications)Review mechanisms to prevent or resolve issues related to quality assurance and medication safety (e.g. medication error reporting)Discuss a method used to report adverse drug events (e.g. MedWatch), including for vaccines (e.g. VAERS)Describe the impact of pharmacist involvement in medication safety and qualitySummarize current National Patient Safety Goals and articulate goals related to medication use, pharmaceutical care, and pharmacy’s role in eachDescribe national standards, guidelines, best practices, and established principles and process relate to quality and safety. (e.g. use of appropriate abbreviations, leading decimal, storage of look/sound alike medications, high alert medications and storage of concentrated potassium in patient-care area etc.)Discuss the management of investigational drugs (pharmacist’s role in storage, distribution, and record keeping)Discuss and/or participate in the management of medical emergenciesDiscuss institutional pharmacy management principlesApply federal and state pharmacy laws and regulationsDiscuss the role of human resource management to manage pharmacists, technicians, and other personnel as appropriate, medication resource management, pharmacy data management systems, pharmacy workload, and financial performance as it relates to the department of pharmacyDescribe the intra-institutional relationship of pharmacy services with other departments and/or servicesDiscuss bioterrorism and disaster preparedness and managementWork through drug shortage solutionsDemonstrate the ability to effectively work with other healthcare professionals and patients as part of a team to provide patient careIdentify the roles and responsibilities of pharmacists and other healthcare professionals on the healthcare team, as well as their different approaches to patient care and problem solvingRound with the healthcare team and respond to codes per site protocolProvide effective verbal, visual, written, and nonverbal communication to patients and other healthcare providersExamine and reflect on personal knowledge, skills, abilities, motivation and emotions that could enhance or limit personal professional groupsDeliver a formal oral presentation to groups of healthcare professionals Prepare written informational materials for healthcare professionalsDemonstrate empathy, assertiveness, effective listening skills, and self-awarenessUtilize the most appropriate resources to respond to drug information questionsEvaluate the pharmacist’s contributions to the healthcare teamAccept responsibility for patient careDeliver care in a legal and ethical manner and demonstrate cultural competencyFollow HIPAA regulations, demonstrating confidentiality for all interactionsIdentify, resolve, and report medication errors and adverse drug reactions and understand when and how legal resources are usedEvaluate and resolve ethical dilemmas with defensible rationale, including intervention in life-threatening situationsIdentify barriers to appropriate patient-centered care (cultural, educational, financial, etc.) and potential solutionsApply ethical principles to the care of the patient, including showing respect for different patient groups and cultural/ethnic/religious traditionsDisplay an open-minded attitude to cultural perspectives different from his/her ownIdentify health disparities and inequities in access to quality care, as well as reduction strategiesUnderstand the development and implementation of pharmacy services in the institutional setting, including health promotion and disease prevention activitiesScreen patients for eligibility for a CDC recommended immunizationIdentify ways to increase vaccinations for at-risk populations (e.g. pregnant women, immunocompromised, geriatric, pediatric)Participate in the design, development, marketing, and/or reimbursement of a business plan to provide a new service or enhance an existing patient care service, contributing to the determination of need, feasibility, and/or sources of funding/resourcesDemonstrate professionalism Display professional behavior at all times, demonstrating integrity, trustworthiness, and fairnessDisplay a professional demeanor, demonstrating a positive attitude, be nonjudgmental, avoid promoting gossip and rumor, controlling emotions appropriately, and carry self with a professional presenceDress in a professional manner and be well-groomed for workDemonstrate a professional work ethic, with a commitment to excellenceArriving to the site on time, prepared for all rotation activitiesBe able to modify behavior accordingly when presented with different situationsDisplay an eagerness to learnBe responsible, reliable, and finish all assignments on timeEngage in effective time management, able to multi-task, and be organizedEngages in innovative activities by using creative thinking to envision better ways of accomplishing professional goalsRespond to constructive criticism from other professionals, colleagues, preceptors, and patients, and be open-minded to recommendations for improvementDemonstrate critical thinking skills, solving problems and revising solutionsDemonstrates responsibility for creating and achieving shared goals, regardless of current role and positionDemonstrate accountability through self-learning and self-assessment abilities and habits, creating S.M.A.R.T. goals and maintaining personal health and well-beingMaintain a professional experience binder and experience summaryMaintain professional responsibility, speaking out against questionable practices, and advocate such action in othersArticulate own viewpoint when dealing with controversial topicsRepresent and advance the profession of pharmacy through education, advocacy, and identifying innovations that support the goals of the profession10. Demonstrate the ability to utilize pharmacokinetic principles to recommend appropriate medication dosingReview intravenous medications that require drug level monitoring and effects of subtherapeutic and supratherapeutic dosingCorrectly perform calculations to tailor patient specific dosing Identify medications that need to be renally and/or hepatically adjusted Demonstrate the ability to review appropriate medical literature and clinical practice guidelines and apply data to practice situationInterpret site-relevant primary literature and demonstrate understanding of biostatistical principles Utilize current clinical practice guidelines and relevant primary literature to form conclusions or recommendations for individual patients and patient populationsConduct appropriate literature searches to find information Apply evidence-based medicine concepts to patient assessments and assignments and understand when/how to make recommendations outside of guidelinesDemonstrate knowledge of clinical guidelines for the treatment of acute conditions common to the practice siteAppendix 1. Required activitiesAt a minimum, students should complete the following activities on most or typical Hospital-Health System rotations. The specific number of each activity is at the conservative discretion of the school, the site, or the preceptor:Evaluate medication orders for accuracy, completeness, and overall appropriateness of therapy prior to dispensingDispense (and check) medication ordersRespond to drug information inquiries from patients and caregivers or healthcare professionalsAttend inter-departmental meetings (Pharmacy and Therapeutics Committee, Patient Safety Committee, etc.)Demonstrate proper aseptic technique by preparing IV piggybacks (IVPB) and large volume parenteralsDocument clinical interventions utilizing an acceptable form approved by the preceptor and/or college of pharmacyComplete a rotation specific projectCase presentation with professional handouts Complete an evidence based medicine assignment or article review (journal club)Evidence based medicine assignment may be a formal, written drug information response, drug monograph, or newsletterComplete SOAP notes and/or self-reflective writing assignmentAppendix 2. Optional activitiesDevelop a patient safety initiative.Ask your preceptor to identify the department policies that are covered during orientation for a newly hired pharmacist. Choose at least 3 of these policies that you are not currently familiar with. After review of these policies discuss the formulation and application of these policies with one of your site preceptors. Given a listing of health care practitioners including attending physicians, medical fellows, residents and interns, hospitalists, medical and surgical subspecialties, advanced practice nurses, physician assistants, nurses, respiratory therapists, physical therapists, occupational therapists, discuss the role of each of these clinicians and develop a plan to interact with each of these providers in your future role as a pharmacist. Review your notes describing the Practice Advancement Initiative (PAI) as developed by ASHP. Describe the changes in pharmacy practice that would result from adoption of the PAI. Explain the areas where you are in agreement and in disagreement with the PAI. If the PAI is not adopted describe how this outcome will affect your future practice of pharmacy. Given a medication order, describe the process for: transcription interpretation (if necessary), record keeping, preparation, verification and dispensing to a health care provider. What roles do pharmacists have in enhancing the efficiency and the safety of this process? Prepare a flowchart to describe the relationship between the use of direct dispensing, automated cabinets, automated carousels, robots, floor stock, and cart exchange for providing unit dose oral and direct injectable medications to patients. (Note: your practice site likely will not use every one of these methods.) Discuss the relative safety, efficiency, timeliness and user-friendly aspects of each of these methods. Compare the perspective of the pharmacist to the perspective of the patient’s nurse, and to the perspective of the patient. Review the policy manual for preparation and dispensing of sterile products. Compare the process for preparing IV admixtures to the process for IV compounding. Describe the policies at your site for IV compounding. Many hospital pharmacies have adopted a practice model that considers all pharmacists to be clinical pharmacists. Discuss why this describes the prevailing concepts in contemporary practice. Do you agree with this concept? Why/why not? ASHP recently recommended that a Post Graduate Year One (PGY1) residency become a minimum qualification for a career in hospital pharmacy. If you are personally interested in hospital pharmacy, describe how you can become a stronger residency candidate. What makes a pharmacist a good preceptor? How are you planning to develop your pharmacy practice so that future students consider you to be an excellent preceptor? What makes a pharmacist a good supervisor and leader of pharmacy technicians? How are you planning to develop your pharmacy practice so that both your departmental leadership and the staff pharmacy technicians consider you to be an excellent supervisor? What is a tech check tech system? Discuss the advantages and disadvantages of a tech check tech system. Summarize the process for adding a medication to the formulary. Compare an open formulary to a closed formulary. What would be the process for verifying and providing a non-formulary medication in an open formulary? In a closed formulary? Describe a situation when a pharmacist should and when a pharmacist should NOT provide a non-formulary medication. Describe how you would discuss your decision with the prescriber. How does your practice site manage drug shortages? Describe a process for conserving medications that are known to be in short supply. What is the best way to determine the most appropriate alternative medication? What is the role of the hospital pharmacist in identifying alternative medications? Describe the role of the pharmacy department for providing medications to patients that are a) investigational drugs; b) that are assigned to a Risk Management and Mitigation Strategy (REMS); c) that are available only from a specialty pharmacy. Do you think that these medications should go through the formulary process? Why/why not? Many hospital pharmacy departments conduct drug use evaluations (DUE/ MUE) or drug use analysis. This type of analysis has often been compared to a type of study design known as a case series. What is the purpose of conducting a drug use analysis? Participate in and describe the purpose and the findings of a drug use analysis conducted at your practice site. Define a culture of safety. Why do you think it is important to investigate the cause of potential errors even when they might not have caused harm in a particular situation? Explain what preventing systematic errors means. Compare two examples of forcing functions to two examples of increasing vigilance as methods to reduce the frequency of errors. Which model of hospital pharmacy practice would you prefer to work under and why? Attend an interdisciplinary committee meeting with your preceptor and write up the benefits of what is being worked on or what has been accomplished.Select a medication error reduction goal in collaboration with your preceptor. Develop a possible implementation plan to help reduce the error. Discuss with the preceptor the impact of a medication error on a patient’s health and the pharmacist’s role in medication error reduction.Discuss the technique for compounding and dispensing cytotoxic agents. Identify policies and additional safeguards performed during this process.Describe the process for drug procurement and inventory control. Compare/contrast the differences with that of a controlled substance.Investigate what information is contained on a material safety data sheet (MSDS). Why are these sheets/information required by the Occupational Safety and Health Administration (OSHA)? Where is this information kept at the site?Appendix 3. Optional learning materialsRecommended textbooks and other learning resources for Cleveland Clinic APPE rotations:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. McGraw-Hill, New York, NY, 2017.Koda-Kimble MA, Young LY, Kradjan WA, Guglielmo BJ, Alldredge BK, Corelli RL, Williams BR, editors. Applied Therapeutics: The Clinical Use of Drugs. 10th ed. Lippincott Williams & Wilkins, New York, NY, 2013.Kasper DL, Braunwald E, Fauci A, Hauser S, Longo D, Jameson JL, editors. Harrison’s Principles of Internal Medicine. 19th ed. McGraw-Hill, New York, NY, 2015.Lacy CL, Armstrong LL, Goldman MP, Lance LL, editors. Drug Information Handbook. 26th ed. Lexi-Comp, Inc., Hudson, OH, 2017-18. (Pocket edition and PDA version also available.)Soric MM. Maximize Your Rotations: ASHP’s Guide to IPPEs, APPEs and Beyond. ASHP, 2013.DiCenzo R, editor. Clinical Pharmacist’s Guide to Biostatistics and Literature Evaluations. 2nd ed. ACCP, 2015.Bauman JL and Sims KA, editors. The ACCP Field Guide to Becoming a Standout Pharmacy Residency Candidate. ACCP, 2012.Aparasu RR and Bentley JP, editors. Principles of Research Design and Drug Literature Evaluation. Jones and Bartlett Learning LLC, 2015.Guyatt G, Rennie D, Meade MO, et al. User’s Guide to the Medical Literature. 3rd ed. New York: McGraw-Hill Education Medical, 2015.Aborns JP, editor. Peripheral Brain for the Pharmacist 2017-2018. APhA.Reiders T. The Pharmacy Professional’s Guide to Resumes, CVs and Interviewing. 3rd ed. APhA, 2011.Basic Skills in Interpreting Laboratory Data, 4th Edition, M. Lee (ed) American Society of Health-System Pharmacists, Publisher; ISBN: 1585281808 (Copyright Feb 2009)Goodman & Gilman's The Pharmacological Basis of Therapeutics, 11th Edition, L.S. Goodman, et al (eds).Applied Therapeutics: The Clinical Use of Drugs, 9th Edition, Koda-Kimble, MA., Young, L. (eds) Lippincott Williams & Wilkins ISBN: 0781765552 (2008)Handbook of Nonprescription Drugs, 15th Edition, L.V. Allen Jr., et al (eds) Amer Pharmaceutical Assn, Publisher; ISBN: 1-582120749 (Copyright 2006)Medical Terminology, 2nd Ed: A Programmed Approach to the Language of Health Care, M.C. Willis (editor), Williams & Wilkins Publishers; ISBN: 0781745101 (Copyright 2005)Pharmacotherapy Casebook, 8th or 9th Edition, T.L. Schwinghammer, et al (eds). McGraw-Hill Professional Publishing, ISBN: 9780071746267 (August 2011) Available on Access Pharmacy. ................
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