Group - University of Washington
|Group |Problem Definition |
|1 |Group # 1: Diagnosis Requirement on Prescription |
| |Name: Atla Adera, Shawna Austin, Jessica Fiedelak, Reina Nakasone, My Phan, Inna Vasilyev, Jenny Wong |
| | |
| |1. Describe the problem |
| |According to the study To Err Is Human: Building a Safer Health System cited in the Institute of Medicine report, 44,000 to 98,000 Americans die |
| |annually due to medication errors. In addition, medication errors also ranks number 8 in the leading causes of death in the United States and estimated|
| |costs range from $17 to $29 billion as a result of medication errors.[1] |
| |Based on the Institute for Safe Medication Practices (ISMP), one of the common things leading to medication errors is communication failure.1 This |
| |includes bad handwriting, misinterpretation of the prescription, drugs with similar names and multiple uses, and the use of abbreviations. Having the |
| |indication on the prescription would greatly reduce the number of medication errors due to problems discussed above. |
| |This is even more important when considering the perspectives from both patients and pharmacists. For instance, when the prescription is brought to the|
| |community pharmacies, pharmacists don't normally have the patient's diagnosis, or indication, for the prescription. This type of information is very |
| |crucial to make judgments of whether the drug is appropriate for the treatment. Prescriptions are required to have certain information such as |
| |strength, dose, quantity, etc, but often do not have the indication.[2] This creates a problem when strength and dosage are appropriate only for |
| |certain conditions. The role of the pharmacist is the last line of communication to make sure the patient receives the right treatment. By not having |
| |the diagnosis information, even a small difference in dosage and strength can cause serious harm to the patient. It is true that pharmacist can call |
| |the prescriber to get the information they need before filling a prescription but this takes time and will thus cost money. |
| |From the patient's perspective, some patients may not like having the diagnosis on the prescription because they feel it would violate their privacy. |
| |However, since a pharmacist is part of the healthcare team there is no violation of privacy in having the pharmacy employees see the diagnosis, and in |
| |fact many patients may come to realize the large role a pharmacist plays in their safety and health. |
| | |
| |2. Delineate the boundaries of the problem |
| |There has been no requirement of having diagnosis on a prescription since before pharmacy became a profession. When the profession began pharmacists |
| |were only responsible for counting pills and minor compounding activities. Since the pharmacy became a profession pharmacists have become much more |
| |knowledgeable about many facets of healthcare. This leads to greater safety for their patients. |
| |Currently, we have WAC 246-871-050 to control the minimum requirement of information on the prescription2. It does not currently require diagnosis to |
| |be a part of the prescription, although diagnosis adds to the pharmacist’s knowledge, and thus the safety of the patient. |
| |Not having diagnosis on the prescription can be the source of medication errors and can cause delays in the time it takes to fill a prescription as |
| |well as add challenges to the counseling a pharmacist provides. For instance, knowing the diagnosis for the patient allows the pharmacy to process |
| |insurance, like DSHS, without waiting to ask the patient or their doctor. Often a patient will not know their diagnosis, and actually getting in touch |
| |with the doctor can take up a lot of time for both the pharmacy and prescriber personnel. Knowing the diagnosis allows the pharmacist to double check |
| |if the patient is receiving the right medication, strength, and dosing schedule for the patient and diagnosis. |
| |This is a national problem, but Washington has never shied away from being the first to increase the happiness and safety of their patients, even if it|
| |means changing the way things have stood for many years. The nation is eager to find solution to medical errors, including those that occur in the |
| |dispensing process. Washington is innovative enough to take this step forward towards preventing medication errors, which have been largely ignored |
| |until recently, but have been a safety hazard to patients since people began practicing medicine. |
| | |
| |3. Develop a fact base |
| |It is hard to disagree that medication errors are a major problem. According to the report of the Institute of Medicine, To Err Is Human: Building A |
| |Safer Health System, released in November 1999, more people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS. The US |
| |healthcare spends $ 37.6 billion annually on costs associated with medical errors with medication errors contributing $ 2 billion.1 |
| |The American Hospital Association identifies having incomplete patient information as one of the causes for medication error.[3] Not knowing the |
| |diagnosis for a particular prescription or previous diagnoses of conditions a patient may still be experiencing falls under incomplete patient |
| |information. By having more complete information, such as diagnosis, pharmacists can prevent many of the 7000 deaths |
| |that occur annually in the United States due to drug errors.[4] |
| | |
| |4. Describe your goals and objectives for resolving the problem and how you might measure change. |
| |Being part of the health care team, pharmacists have strived in many ways to deliver the safest and fastest pharmaceutical care to their patients. We |
| |believe requiring diagnosis on the prescription would provide safer and faster care by meeting a few goals. |
| |These goals include reducing medication related errors and making patient counseling more effective. The objectives would include less medication |
| |errors being reported to |
| |the Board of Pharmacy and other institutions of health, and a higher medication compliance being reported. |
| |There are already many reports being done constantly on medication errors and their cost, both in money and in quality of life, by many different |
| |organizations and institutions. Improvements in these scores after diagnosis becomes a requirement of a prescription could show that this requirement |
| |is increasing medication safety. Many pharmacies keep track of the average number of prescriptions they fill daily, which when divided by the hours |
| |spent working on these gives an average amount of time spent per prescription. If the diagnosis requirement is saving time then the pharmacy should be|
| |able to process more prescriptions per day, and thus spend less time on each prescription. Studies could also be done on patient compliance, which is |
| |a favorite topic of several University of Washington School of Pharmacy professors. |
| | |
| |5. Identify the Policy Envelope |
| |There are many variables at work in medication dispensing errors. These variables may include staffing, lack of information, poor or incorrect |
| |information, and how busy the pharmacy filling the prescription is. Although requiring diagnosis will not help staffing it will provide important |
| |information to the pharmacist, who will then not have to call the prescriber or prescriber’s staff, from whom they could receive poor or incorrect |
| |information. This requirement helps busy pharmacies by cutting down the time it takes to fill a prescription, which allows for more time to be spent |
| |on very important things like safety checks or patient counseling. |
| |Many pharmacies will like the idea of cutting the time it takes to fill a prescription because in the long run it can lead to a greater cash flow. |
| |Cutting back medication errors will decrease the cost of medication errors to pharmacies, hospitals, and other healthcare institutions. Prescribers |
| |will have to take the extra few seconds to add the diagnosis to a prescription, but this saves them the time of getting a telephone call or fax later |
| |of which much more time must be spent to locate the patient’s file and retrieve the necessary information. The other major interest in this |
| |requirement will come from companies that are currently manufacturing and testing prescriber order entry systems, as well as businesses that have |
| |already implemented prescriber order entry systems. It’s true that this would add another required field, but many already include an optional field |
| |where the indication can be entered. These manufacturers would be interested in finding whether or not diagnosis will be required as quickly as |
| |possible, due to the way that pharmacies are moving away from paper prescriptions and more toward computerized prescriptions. |
| | |
| |6. What are the potential costs and benefits to resolving the problem? |
| |Despite our best intentions, economy is always a factor when deciding whether a new procedure or policy should be implemented. There are some costs |
| |associated with requiring a medication’s indication to be placed on all prescriptions. One, there is the cost associated with creating a new |
| |standardized prescription form that would include a space to write the indication. While forms without such a prompt could be used, this would likely |
| |increase the rate of prescribers forgetting to include the indication and would result in a phone call. The cost associated with revising paper |
| |prescriptions, however, could be circumvented if this information was standardized for online electronic prescriptions. If this proposal was included |
| |at the onset of developing the software and technology no additional cost should be added. Other minor costs include adjusting pharmacy software to |
| |include a field for entering the indication or code, but this is likely minor. The benefits are decreased pharmacist’s time spent on the phone calling |
| |prescribers to clarify prescriptions. In a study by Ingrim et. al.,[5] it was estimated that a pharmacist spent between ten to eleven minutes per |
| |telephone call to verify or get information that was missing from a prescription. This could result in many lost salary hours per day that a pharmacist|
| |could be spending in providing more direct patient care. Finally, the most important benefit is the possible reduction of medication errors. This could|
| |save money in not having to re-process erroneously filled prescriptions, not to mention possible healthcare costs associated with treating a patient |
| |following an adverse event (doctor visit, medication to correct symptoms from adverse event, etc.). |
|2 |Pharm 543 Law & Ethics: Problem Definition. |
| |Group : 2 Time frame that a prescription for Schedule II drugs is valid |
| |Group Members: Aimee Breitfelder, Candace Kim, Christopher McCowan, Uzoma Okeke, Diana Regina, Christopher Schaffner, Naomi Sweeney, Lincoln Wright. |
| | |
| |Drugs in Schedule II of the Controlled Substance Act1 such as morphine, methadone, oxycodone, and amphetamine are those substances that have some |
| |approved medical use. However, they have a high potential for abuse with severe ability to cause psychological or physical dependence.[6],2 Many of |
| |these drugs are prescribed for the treatment of severe pain. Therefore, it is expected that it should be filled in a timely manner for immediate |
| |treatment. |
| |The current problem with the law, regarding Schedule II (CII) prescriptions, is that the written prescription is valid for one year from the date it is|
| |written. Since CIII and CIV prescriptions are only valid for six months after the date that they are written, it is logical that CII prescriptions |
| |should have an even shorter time frame during which they may be filled. This discrepancy in the law increases the likelihood that CII medications will |
| |not be used by the patient in the manner they were originally intended. For example, a patient may see his or her physician because of severe pain and |
| |may receive a prescription for a CII narcotic. This patient may choose not to fill the prescription because the pain is markedly improved in a few |
| |short hours. However, a few months later a new injury may arise that produces severe pain. Instead of seeing his or her physician and possibly having a|
| |serious problem correctly diagnosed, the patient chooses to fill the old CII prescription. Although the patient will receive relief from the pain, the |
| |medication may be covering up a more serious condition. Conversely, a patient who chose not to fill the [7]prescription may later fill it for use by |
| |someone else. A second problem with the current law is that it allows individuals who obtain CII medications, for the purpose of unlawful distribution,|
| |a greater time frame in which they may have a prescription filled. |
| |As the current law stands, the pharmacist may be placed in a potentially difficult situation when deciding if they should fill a CII prescription that |
| |has been written some time ago. By shortening the duration that the prescription is valid, the pharmacist will have clear guidelines as to whether he |
| |or she should accept the prescription. |
| |So where did this discrepancy in the law come from? Before Title 21 C.F.R section 1300 was written there were no restrictions on how long a CII was |
| |valid. If a CII prescription was a month or more old or if no date was written on the prescription a pharmacist was required to call the physician to |
| |verify that the prescription should still be dispensed.[8] The reasoning behind this was to discourage the filling of a prescription that had been |
| |unused and was now being filled for someone else in pain. 3 When Title 21 was written the issue of expiration of CII drugs was overlooked. Other |
| |controlled medications such as CIII or CIV's were given a six month expiration according to 1306.22 of the title. This left the problem of determining |
| |the valid filling time of a CII to the individual boards of pharmacy. In Washington state the expiration of CII's is currently based on WAC |
| |246-869-100(2) (d). It states that no prescription is valid after a year from the date it was written. This leaves CII prescriptions with an expiration|
| |of one year, six months longer than CIII's and C IV’s, which are supposed to be less addicting than the CII's. Therefore, due to the hazards that the |
| |current law poses, we suggest a change. |
| |Many states have taken the initiative to remedy this ongoing problem by implementing fill time requirements that go above and beyond that of our state |
| |of Washington. Schedule II drugs have some of the strictest time limits for filling in states such as Texas, Delaware, Illinois, and Vermont. These |
| |states have implemented laws that state schedule II controlled drugs shall not be filled more than seven days after issuance of the prescription. |
| |Vermont is the exception to this, having a stricter time limit of five days. Other states, such as West Virginia, California, and Louisiana, have time |
| |requirements ranging from one month to six months.[9] |
| |The goal in limiting Schedule II filling time is to provide a consistent system for pharmacists to implement when patients delay in presenting a CII |
| |prescription. By limiting the time that the prescription is valid, pharmacists will no longer be required to assess and determine the existence of a |
| |patient’s medical condition and potentially be liable for dispensing a drug that is no longer necessary. Furthermore, the proposed modification would |
| |prevent inter-pharmacy variability, when one pharmacy accepts the prescription and another does not. This will prove to be more consistent and less |
| |confusion will occur. Accordingly, this change in the law may lead to a decrease in patients addicted to these drugs. It may also lead to a decrease in|
| |reported adverse events related to filling CII prescriptions that do not coincide with the prescribed indication. |
| |However, the impact of the proposed change extends beyond the pharmacist as both the primary care provider and the patient would potentially be |
| |affected. The possibility of detrimental effects for the primary care provider and the patient would most likely be an issue for patients taking |
| |maintenance medications, including patients taking CII drugs for an indication other than pain, such as Ritalin for ADD. The physician may be affected |
| |as it could result in an increased number of patient visits if they require additional prescriptions. The patient may be affected when they are refused|
| |a prescription that they feel they have the right to fill. However, the proposed modification to the law would be for the purpose of reducing abuse |
| |potential rather than causing unnecessary burden. Therefore, ways to overcome that burden, such as allowing post dated prescriptions to be written for |
| |maintenance medications, would be needed to offset the potential barrier. |
| |Although, there are issues relating to the proposed change that could be objected by some, such as the potential barrier to medications for patients on|
| |maintenance medications, there are innumerable benefits to resolving the problem. Above and beyond the decreased inadvertent abuse potential of CII’s |
| |by patients filling a CII prescription later or patients distributing CII's to friends and family, there are also benefits by decreasing the risk of |
| |illegal diversion of narcotics if unfilled CII prescriptions fall into the wrong hands. Therefore, the proposed changes to the filling of CII drugs is |
| |a logical choice that will provide long term benefits to pharmacists, the rest of the health care team, and the patient. |
|3 |Pharm 543 Problem Definition Assignment |
| |Group 3, Introduction of CPR Certification for Pharmacy Licensure in Washington State |
| |Group Members: Kellie Dillin, Anna Knopp, Elena Meeker, Jamie Mensik, Lindsey O’Malley, Jason Orthel, Kevin McDermott |
| | |
| |1. Describe the problem |
| |Pharmacists are vital members of the healthcare team. As the most easily accessible healthcare professional, pharmacists come in contact with a wide |
| |variety of individuals, who seek or require healthcare services. As a result of their thorough education, pharmacists function as safeguards for their|
| |patients, ensuring that people under their care are not exposed to harmful medications, inappropriate doses, or dangerous interactions. More than |
| |ever, a growing number of community members are coming to pharmacists with questions regarding health screenings, lifestyle issues, and counseling. |
| |Against this background, one key aspect of education and training appears to be lacking for many of the pharmacists licensed in Washington State. |
| |Cardiopulmonary resuscitation (CPR) is a simple act, used by those who claim to be healthcare providers, to help maintain the life of an individual, as|
| |expected by members of the community if the need were to arise. Given that pharmacists are such important members of the healthcare field, who come in|
| |contact with a vast number of patients, and the fact that Washington is such a progressive state, it is now time to ask why current CPR is not required|
| |of pharmacists licensed in Washington. |
| |Pharmacists are highly educated healthcare professionals that must always be recognized as knowledgeable, trustworthy caregivers who are focused on |
| |protecting and prolonging patient lives. It is time to address and remedy the above-mentioned gap in training, which in turn, places their patients at|
| |risk. As healthcare providers, all pharmacists have the duty, and should have the ability, to know and administer CPR. There is no valid reason for |
| |pharmacists to be exempt from this issue of care. Washington State should require current CPR certification for all able-bodied licensed pharmacists, |
| |regardless of practice setting. |
| | |
| |2. Delineate the boundaries of the problem |
| |Since pharmacists have never been required to stay certified in cardiopulmonary resuscitation (CPR) as a condition for license issuance and renewal in |
| |the State of Washington, there have always been pharmacies without a staff member certified to respond in case of an acute cardiac or respiratory |
| |emergency. This problem is present across the rest of the United States. Successful change is most likely to be fostered at the state level. In the |
| |State of Washington, we are known for enacting new standards to improve our profession’s ability to serve the public. By requiring current CPR |
| |certification as a condition of license issuance and renewal in the State of Washington, we have the potential to foster a model for improved patient |
| |care across the country. |
| | |
| |3. Develop a fact base |
| |In the United States, over 680 people are victims of sudden cardiac death each day.[10] However, if patients receive early CPR and defibrillation |
| |within 3-5 minutes of cardiac arrest, followed by early advanced care, their chances of survival can increase by over 50%. Indeed, cardiopulmonary |
| |resuscitation (CPR) is internationally recognized as a valuable life-saving tool. The International Liason Committee on Resuscitation (ILCOR), a group |
| |composed of seven resuscitation associations, including the American Heart Association, performed a review of several international studies in 2001. |
| |This review indicated that cardiac arrest victims who receive bystander CPR are about 2.5 times more likely to survive than those who do not.[11] The |
| |most recent studies support this evidence as well. The third phase of large Canadian trial published in the New England Journal of Medicine this summer|
| |found that cardiac arrest victims were 3.7 times more likely to leave the hospital alive if they received bystander CPR. As a result, this study |
| |concluded that public health officials should dedicate increased resources to CPR training and promotion.[12] Unfortunately, most cardiac arrest |
| |victims do not receive bystander CPR, and statistics have shown that, even when it is given, the quality of CPR is far from ideal.2 |
| |Pharmacists, as widely accessible healthcare professionals, are in a prime position to help meet the urgent need for increased bystander CPR. While CPR|
| |certification may be required of many hospital pharmacists by their employers, no regulations exist to regulate the certification of community |
| |pharmacists. It is this latter group that is of particular importance, as community pharmacists serve patients outside medical centers and thus would |
| |be ideally suited to perform CPR until the arrival of the emergency medical team. We propose that all pharmacists, with a few notable exceptions, be |
| |required to obtain and maintain current CPR certification as part of their continuing education requirements.[13] |
| |4. Describe your goals and objectives for resolving the problem and how you might measure the change. |
| |The current situation regarding cardiopulmonary resuscitation (CPR) and pharmacists is that only some pharmacists are CPR certified. Furthermore, most |
| |pharmacists that are CPR certified are satisfying the requirements for the immunization certification available in this state. As a group promoting |
| |pharmacists as health care professionals, our goal is to require that all pharmacists are certified in CPR and maintain this certification annually as |
| |part of continuing education. One of the main benefits of this project will be that citizen access to CPR will be increased. Many high risk patients |
| |visit community pharmacies on a regular basis and will be in a safer environment with CPR certified pharmacists. Although we will not be gathering |
| |statistics to measure the outcome of our project, we are certain that our project is in the best interest of our patients and will help further our |
| |profession. |
| |Identify the policy envelope |
| |The problem of allowing Pharmacists to practice without CPR training is difficult to measure. However, the benefits of requiring such training could |
| |potentially be realized in one incident. Pharmacists provide pharmaceutical care to a variety of patients each day, including populations susceptible |
| |to cardiac accidents. Clearly, these patients stand to benefit from any expertise the Pharmacist is able to provide. |
| |While some may express concern regarding the liability issues of performing CPR, the Pharmacy Profession also stands to gain by providing yet another |
| |community service. In addition, we propose that CPR training should be counted toward CE (continuing education) credits, providing a more tangible |
| |benefit. |
| |The institution of mandatory CPR training for Pharmacists is not a radical policy proposal. RCW 18.64.005 empowers the Board of Pharmacy to determine |
| |requirements for licensure in the state of Washington and similar CE requirements already exist.[14] For example, seven hours of AIDS education must be|
| |completed prior to licensure.[15] The board also mandates the completion of 15 CE hours per year in order to maintain licensure.[16] Including a CPR |
| |requirement among these regulations would benefit both patients and the profession. |
| |6. What are the potential costs and benefits to resolving the problem? |
| |An important part of policy analysis is determining the cost to benefit ratio. Many organizations will not implement a new program unless it will |
| |benefit financially from the endeavor. The policy requiring continued CPR certification for pharmacists has a potential to impact various diverse |
| |pharmacy settings including hospital, clinic, independent, and chain stores. The administrative goals of these organizations are different, which may |
| |impact their acceptance of this plan. It is therefore important to make the certification program financially sound, even beneficial, to get unanimous|
| |support for our policy. |
| |The policy we propose will not be a financial burden to any of the above stated corporations because many CPR certification classes are available at no|
| |cost to participants. The training is essentially free. The policy has a potential to be economically beneficial because we propose to make it count |
| |for continued education (CE) credits, which are required for all pharmacists. If the pharmacist can fulfill the CPR requirement and get 2 CE credits |
| |for free, then we believe the corporations will be advocates for our plan. |
|4 |Pharmacy 543 Assignment #2 |
| |Group #4 Recommendation for Minimum Patient Counseling Guidelines |
| |Melissa Buss, Tracy Chen, Rhea Coquia, Stephanie Kormeier, Ken Lau, Chris Stevens-Brodl, Shannon Wittke, Judd Wright |
| | |
| |Describe the Problem |
| |Pharmacists have a professional obligation to ensure that patients leave the pharmacy understanding how to correctly use their medications. Washington |
| |law requires pharmacists to counsel patients for each prescription, but the extent of the counseling is not clearly defined. Many pharmacists do not |
| |give thorough directions to patients or persuade them to comply with the prescribed therapy. Patients who use their medications incorrectly may not |
| |achieve therapeutic results and may even harm themselves. Washington law should define a set of minimum counseling guidelines for the pharmacists to |
| |use. Better counseling laws would reduce prescription non-adherence, ultimately reducing costs to the health care system and improving the health of |
| |patients. |
| |Delineate the Boundaries of the Problem |
| |The Washington State Board of Pharmacy has required pharmacists to provide patient counseling on all new prescriptions and as needed on refill |
| |prescriptions for approximately 29 years.1 In 2000 the law was amended from providing oral explanation on the directions for use and additional |
| |information, to direct patient counseling to promote safe and effective administration of the medication. In 2001, it was amended again to clarify that|
| |the pharmacist is responsible for providing sufficient patient counseling to promote proper medication administration to facilitate an appropriate |
| |therapeutic outcome, but not to determine the optimal therapeutic outcome for any patient.2 |
| |However, without a set of minimal standard for patient counseling to assure that the right patients are receiving the right medications and given |
| |sufficient information to properly administer the medications, not only is patient safety at great risk, treatment adherence can also be compromised if|
| |pharmacists only read the directions from the label without actively interacting with patients. The potential for medication errors is on the rise due |
| |the number of drugs that both look and sound alike. Costs associated with medication adverse events can be greatly reduced if patients are counseled |
| |correctly when they pick up their prescription medication. |
| |Develop a Fact Base |
| |The following is a list of the kind of evidence we need for our argument to be persuasive, and some ideas about where to find it: |
| |Evidence |
| |Resource |
| | |
| |Number of prescriptions dispensed in state/year |
| |WA BOP, IOM, CDC? |
| | |
| |Number of non-Medicaid prescriptions dispensed in state/year |
| |Medicaid, IOM |
| | |
| |Number of adverse drug events/year occurring in outpatient setting |
| |IOM |
| | |
| |Cost of above adverse events, in lives and economically |
| |Literature |
| | |
| |Rate of adherence or nonadherence to prescribed drug regimens |
| |Literature |
| | |
| |Cost of nonadherence: hospital admissions for uncontrolled chronic disease, work days lost, extended or additional tx, lawsuits |
| |Literature |
| | |
| |Martha Dye-Whelan (lawsuits?) |
| | |
| |Public opinion of benefit of pharmacist counseling |
| |PubMed, published studies |
| | |
| |Anticipated cost of implementing standards |
| |Published reports on costs of OBRA ’90 to pharmacies |
| | |
| |Patient counseling laws in other states |
| | |
| |NABP |
| | |
| |Describe Your Goals and Objectives for Resolving the Problem, and How You Might Measure Change |
| |The objective of this legislation is to reduce medication errors by pharmacists and technicians. Our goal would be to reduce the current number |
| |reported to the Board of Pharmacy by 20 % in two years. The measurement would be a count of reports of a specified type (e.g. medication errors where |
| |the patient actually took/was administered an incorrect drug/dose/strength). |
| |The goal of this project is to compose a set of minimum counseling guidelines to be followed by pharmacists. These guidelines will apply to patients |
| |who are receiving new and refilled prescription. By following these guidelines, pharmacies will automatically provide high quality patient care and |
| |increase the therapeutic efficacy of the medication. It is our hope that through these guidelines, there will be an increase in the respect community |
| |pharmacists receive from the public; thus increasing the number of citizens seeking consultations with their pharmacist regarding over-the-counter |
| |products as well as prescription items. In order to assess the effectiveness of these guidelines, pharmacies will be required to include self stamped |
| |surveys in patients’ prescription bags. This survey will include questionnaires regarding the service (counseling) they received in the pharmacy as |
| |well as the effect of that service to their recovery. The pharmacy will also be subject to random inspections by a member of the board of pharmacy or |
| |its representative. This inspection maybe conducted as much as once a month or as little as once a year. |
| |Identify the Policy Envelope |
| |Expanding counseling services to patients relies upon the need for adequate staffing in the pharmacy so that work can continue while the pharmacist is |
| |busy interacting with his/her patients. If implemented, we would expect to see pharmacists spending an increasing portion of their day involved in |
| |direct patient contact. In an era where patient privacy is of paramount concern, the establishment of separate patient counseling rooms or counters |
| |would reflect an increased focus on the exchange of medical information between patients and their pharmacist. We might also expect to see an increased|
| |willingness on the part of insurance companies to compensate pharmacists for expanded counseling services that may be required for some patients under |
| |certain situations. |
| |The most important stakeholders in this issue are, of course, the patients themselves. While many patients still refuse the offer to be counseled on |
| |their medications by a pharmacist, and are within their rights to do so, many others wish to take a more active role in their health care and rely upon|
| |pharmacists for important drug information that their primary care provider may not know or may not have the time to explain. |
| |Pharmacists obviously have a stake in this issue as well. Depending upon the volume of workload, many pharmacists are under considerable time |
| |constraints and may not believe they have enough time to counsel patients in more detail. But there is reason to suspect that certain segments of the |
| |profession are ready and willing to take on the task. Research suggests that among pharmacists, those who have recently graduated from pharmacy school |
| |are already more likely to convey to their patients adequate information about a drug, its intended use, side effects, and precautions than any other |
| |subgroup within the profession. |
| |Insurance companies can also be expected to be impacted by expanded regulations regarding counseling. The trend is toward greater demand for |
| |reimbursement to pharmacists for the time spent counseling; if the law is changed to require more extensive counseling services, we can expect greater |
| |pressure on insurance companies to compensate pharmacists for the additional work that may be required. |
| |What are the Potential Costs and Benefits to Resolving the Problem |
| |Costs: |
| |Decreased availability to fill prescriptions due to counseling requirements leads to demand for more pharmacists and/or technicians. In the short term |
| |this may result in more medication errors. Mandating counseling from what is currently in the realm of professional judgment to a legal minimum may |
| |ultimately lower society's respect for the judgment of those professionals. |
| |Benefits: |
| |Counseling creates an additional check which should lead to correct medication usage and can potentially decrease costs related to adverse events |
| |(because there are fewer adverse events when meds are used correctly). Requirement "forces" companies to make more labor available to fulfill |
| |counseling duties, possibly shifting pharmacist duties from counting and bottling to Drug Utilization Reviews and counseling. |
| |WSR 00-16-108. Proposed Rules. Department of Health. |
| |WSR 01-04-055. Permanent Rules. Department of Health. |
|5 |Pharm 543 Laws & Ethics: Problem Definition |
| |Group Number 5 – Intern Preceptor Relations |
| |Group Members: Katharine Monaco, Katy Lashua, Meghin Gjerswold, Sovanny That, Christopher Stephens, Alen Chen, Jaqueline Dierck. |
| |1. Describe the problem |
| |Interns and preceptors do not spend enough one-on-one time together in training. This is based on personal experiences of several interns. |
| |2. Delineate the boundaries of the problem |
| |The problem has existed for as long as there have been interns. It is linked to preceptor time limitations and work load. It is also linked to |
| |preceptors not knowing what their responsibilities to interns are. This problem is ubiquitous. |
| |3. Develop a fact base |
| |We hope to contact the Board of Pharmacy regarding complaints filed against preceptors by their respective interns as well as complaints filed against |
| |interns as a result of improper training. Interviews of interns and preceptors about how the training process is going can also be provided as |
| |evidence. |
| |4. Describe your goals and objectives for resolving the problem, and how you |
| |might measure change. |
| |· To establish a specific minimum time requirement for preceptors to spend with their interns on a monthly basis – documentation from both parties |
| |required. |
| |· Increase the requirements for preceptor licensing. |
| |· Change the evaluation forms so interns and preceptors can rate or grade their experiences with one another. |
| |Change can be measured by evaluating the number of complaints filed with the board of pharmacy. |
| |5. Identify the policy envelope |
| |Variables: Staffing, medication errors, competency of interns |
| |Stakeholders: All involved – interns, preceptors, pharmacy staff, patients |
|6 |PHARM 543: Rescheduling Pseudoephdrine to Schedule V |
| |Group 6 |
| |Members: Nick Dire, , Tasha Wong, Thoa Vo, Melanie Petilla, Jason Boyd, Huong Nguyen, Joyce Wang |
| | |
| |1. According to the National Drug Intelligence Center (NDIC), a subgroup of the DEA, methamphetamine poses the largest drug threat to Washington due to|
| |its wide availability and low cost. It is the drug most associated with violent crimes in Washington and its abuse rate has been declared “high” by 45 |
| |out of 53 state and local law enforcement agencies included in the 2002 NDIC National Drug Threat Survey. Since 1998, the state’s methamphetamine |
| |production, which highly relies on attaining over-the-counter ephedrine or pseudoephedrine products such as Sudafed, has increased three fold ranking |
| |us third only to California and Missouri. |
| |As pharmacists and healthcare providers, we believe we have the ability to help fight Washington’s increasing methamphetamine problem by regulating the|
| |distribution of Sudafed and other pseudoephedrine over-the-counter products. Though we support the proper use of the medication, we propose classifying|
| |Sudafed as a schedule V drug in order to provide more stringent standards for increased regulation. |
| | |
| |2. Methamphetamine is a derivative of amphetamine. Amphetamine can be traced back to 1887, where it was first synthesized in Germany. However, it had |
| |no medical purpose until the late 1920’s when tests were done to determine its potential uses. |
| |Amphetamine’s first use was an inhaler to treat congestion in the 1930’s. In 1937, it was also available by prescription in a tablet form and marketed |
| |as Benzedrine. However, it was abused and used by non-asthmatics that were looking to get a new “high”. It was also converted into tablet form by |
| |prescription only in 1937. |
| |In 1919, the Japanese discovered how easy methamphetamine, a more potent derivative, was to make. In addition, due to its high water solubility they |
| |used to inject its contents into the body. In the U.S., they produce it under the name Desoxyn. |
| |It became more widely used during World War II. It became popular due to the fact that it was easily accessible in tablet form and keep the men going |
| |during the ordeal. |
| |In the 1950’s, dextroamphetamine (Dexedrine) and methamphetamine (Methedrine) were synthesized legally. They were also very readily accessible to the |
| |public. Thus along with the increase in use came the increase of abuse. They became the “cure all” for treating everything from weight to depression. |
| |However, there was a dramatic shift in the 1960s once it could be injected. In order to combat this increase the 1970 Controlled Substances Act was |
| |passed which restricted the legal production of methamphetamine used for injection classifying it as a Schedule II drug, meaning that it has a high |
| |potential for abuse. |
| |In the U.S., methamphetamine has been called the “Crack of the 90’s” since there has been an increase of its distribution and abuse in the past few |
| |years. This is indicated by investigations, seizures, price, purity, and abuse data. President Bill Clinton took action against its distribution when |
| |he signed the Methamphetamine Control Act of 1996. Here the law states that the chemicals used in production of methamphetamine are regulated. It also |
| |increased the consequences of producing or distributing it. |
| |In July of 2000, the Methamphetamine Anti-Proliferation Act was passed which reinforces sentencing and gives training to Federal as well as State law |
| |enforcement dealing with methamphetamine investigations involving clandestine methamphetamine laboratory. In addition, continues to aid substance abuse|
| |prevention efforts and increase controls on distribution of the product. |
| |Methamphetamine is addictive and can be synthesized easily using products that are readily accessible all across the U.S. In 1997 the National |
| |Household Survey on Drug Abuse (NHSDA) estimated that there were about 5.3 million Americans that have tried it at one point in time. |
| | |
| | |
| |3. Methamphetamine labs are a problem in the state of Washington. There are already laws in place in the revised code of Washington to protect against|
| |the sale of pseudoephedrine, because of its use in the manufacturing of methamphetamine: Finding -- 2004 c 52: "The legislature finds that quantities |
| |of ephedrine, pseudoephedrine, and phenylpropanolamine continue to be sold at the wholesale and retail levels far in excess of legitimate consumer |
| |needs. The excess quantities being sold are most likely used in the criminal manufacture of methamphetamine. It is therefore necessary for the |
| |legislature to further regulate the sales of these drugs, including sales from out-of-state sources, in order to reduce the threat that methamphetamine|
| |presents to the people of the state." [2004 c 52 § 1.] |
| | |
| |According to the National Drug intelligence Center in Feb 2003 edition of Washington Drug Intelligence Center, Methamphetamine production in the state |
| |of Washington is a very large problem. In 2002 the state is ranked 3rd after California and Missouri in number of Methamphetamine labs that were |
| |discovered and dissolved. |
| |Since this law has been enacted in the state of Oklahoma, statistics are being collected and reported. The Oklahoma state board of pharmacy has |
| |numbers that show a decrease in the number of methamphetamine labs in the state after the law went into effect. According to the Kansas City Star the |
| |number of meth labs has decreased by 124 and saved tax-payers almost $500,000 in clean-up costs since enacting the law in April of 2004 (6 months ago).|
| |Because of the new law, there have been increases in the sales of pseudoephedrine in neighboring states. Mark Woodward, spokesman for the Oklahoma |
| |Bureau of Narcotic and Dangerous Drugs Control is quoted in the article as saying, “It emphasizes the importance for surrounding states to also pass |
| |this law. If we can get some of these other states on board, that's going to really, really help." |
| | |
| | |
| | |
| |Sales from convenience stores is a problem and our law would stop sales from convenience stores. Pierce County identified a major bust of a |
| |convenience store by the DEA resulting in the seizure of almost 400,000 tablets of pseudoephedrine. (Alcohol and drug abuse institute at the UW) |
| | |
| | |
| | |
| |Methamphetamine is a dangerous drug and represents a major challenge to agencies with police powers. 90.9% of State and local law enforcement agencies|
| |in the Pacific region of the United States ranked methamphetamine as their greatest drug threat. Law enforcement agencies also said that cocaine and |
| |methamphetamine were the largest contributors to violent crimes.(National Drug intelligence Center). |
| | |
| | |
| | |
| |4. Our concern is that methamphetamine use is on the rise in Washington because |
| |users can easily access products containing pseudoephedrine, the main ingredient |
| |in meth. Therefore, by making pseudoephedrine into a schedule V drug, we hope to |
| |decrease pseudoephedrine sales by wholesalers by 10%, by retailers by 20%, and |
| |by out-of-state sources by 10% in the next year. By reducing the sales of |
| |pseudoephedrine, we hope to reduce the number of meth labs in Washington by 10% |
| |in a period of 1 year. |
| | |
| |5. Pseudoephedrine is one of the precursor drugs used to make methamphetamine. In 2001, at the request of the governor, the Legislature passed a low |
| |restricting the sale pseudoephedrine products. (RCW 69.43.110) There are still some unprofessional conducts which violated the law by selling more than|
| |the allowable amount of pseudoephedrine products. The variables which can be measured regarding the problems are the illegal manufacturing and abuse of|
| |methamphetamine in Washington State, the lacking of controlled pseudoephedrine transactions by the pharmacists because pseudoephedrine products are OTC|
| |products, lacking of strong enforcement of selling pseudoephedrine products. |
| | |
| | |
| |6. There are potential costs and benefits when classifying pseudoephedrine as a schedule five drug. For example, retail stores can better regulate the |
| |amount of pseudoephedrine sales in the store by keeping it behind the counter, requiring photo ID, and maintaining proper documentation on the sales of|
| |the drugs. This reduces the amount of loss that could occur due to the potential of embezzlement by those seeking the drug for illegal uses. With |
| |decrease loss, retail stores will not have to raise the price on these drugs to accommodate for the loss, which will be beneficial to the consumers. |
| |Moving pseudoephedrine to a schedule five status can also significantly decrease the number of methamphetamine labs in the community. Methamphetamine |
| |use has been linked to a higher crime rate and increase in environmental dumping. The result of making pseudoephedrine and pseudoephedrine containing |
| |products less accessible for the drug seekers is a safer and cleaner community. A benefit for pharmacists is that they can provide counseling of the |
| |drugs and address any concerns with the patient on their medications. |
|7 |Pharm 543 Group 7 |
| |Problem Definition for Verbal Communication Law Revision |
| |Kristen SooHoo, Christy Weiland, Jennifer Fidler, Virginia Krause, Trang Le, Anh Nguyen, Vinh Phan |
| | |
| |1. |
| |21 CFR 1306.03 b states that “A prescription issued by an individual practitioner may be communicated to a pharmacist by an employee or agent of the |
| |individual practitioner.” In current medical practice, a practitioner’s agent is often a receptionist or medical assistant who has very sparse drug |
| |knowledge, if any. When an agent with little or no drug knowledge calls in a prescription to a pharmacy, there is a potential that the agent will |
| |misread, misunderstand, or miscommunicate the practitioner’s prescription to the pharmacist. This poses a threat to patient safety by increasing the |
| |potential for a medication error to occur. |
| |Furthermore, when a practitioner’s agent calls in a prescription to a pharmacist, sometimes the agent does not know the drug strength, dose, or |
| |directions. When the pharmacist asks the agent to clarify one of the above details, the agent, not having drug knowledge or the ability to use |
| |professional judgment in this instance, must either put the pharmacist on hold to check with the practitioner or call the pharmacist back. This wastes |
| |the agent’s, practitioners, and pharmacist’s time and resources. By legally limiting pharmacists to only accept prescriptions over the telephone from |
| |practitioners or registered nurses, the number of potential medication errors and wasted time and resources can be significantly reduced. |
| | |
| |2. |
| |Prescription errors are a chronic problem for all healthcare providers across the nation. Prescription errors have been steadily increasing over the |
| |past several years.[17] There are as many as 7,000 deaths annually in the United States from incorrect prescriptions, according to Carmen Catizone of |
| |the National Association of Boards of Pharmacy. He told The Washington Post that as many as 5 percent of the 3 billion prescriptions filled each year |
| |are incorrect. With the number of prescriptions expected to climb to 4 billion by 2004 and the number of pharmacists steadily decreasing, there are |
| |bound to be "problems down the road," Catizone said.[18] While the number of pharmacists is decreasing there is an increase in new drugs, the number of|
| |prescriptions, patient awareness, access to healthcare and improved technology. These factors all contribute to an increased risk for prescription |
| |errors. That is why it is imperative that we implement a law that will limit the agents that can call in a prescription to practitioners and |
| |registered nurses. |
| | |
| |3. |
| |Miscommunication between the doctor’s office and the pharmacy can result in errors in dispensing. A study by University of Manchester, UK has shown |
| |that 24% of errors were a result of misreading the prescription[19]. We can minimize these errors by improving communication through limiting which |
| |type of healthcare employee can call in a new prescription to the pharmacy. |
| |In another case study by Dr. David Bates of Brigham and Women’s Hospital in |
| |Boston, MA, we can see that there is equal frustration by physicians over medication errors.[20] Since we believe this group of providers will be our |
| |most difficult audience to convince, we intend to show that they will appreciate this change as much as pharmacists. Dr. Bates explains the phases of |
| |outpatient “medication process” include “prescribing, transcribing, dispensing, administering and monitoring.” The proposed addition to our current |
| |law will affect the transcribing stage of the process. In this case, an error was made when a medical assistant called in a new prescription which was|
| |taken by a pharmacy technician. Neither person had received adequate training to carry out this responsibility. In Washington, it is illegal for a |
| |technician to receive new prescriptions; however, with the numbers of medication errors that are occurring, it is important to refine the prescription |
| |translation/writing process in whatever ways we can. |
| |Currently, the US federal law allows physicians to delegate this task to any of their employees.[21] We will investigate how other regions have dealt |
| |with this issue. For example, in British Columbia, the law states that pharmacies can only take prescriptions directly from the practitioner or their |
| |voice recording.[22] In developing evidence to convince the Washington Board of Pharmacy that we need to restrict verbal order authority, we will find|
| |further studies from PubMed and Medline. We will also consult with pharmacists in local pharmacies to understand how they feel about this proposed |
| |policy. |
| | |
| |4. |
| |There are three main goals we hope to accomplish by implementing this law. The first goal is to reduce medication errors that occur from phoned in |
| |prescriptions from an employee that lacks education or experience with drug names, prescription directions, interactions, etc. The second goal is to |
| |create a more direct relationship between the patient, physician and pharmacist. This increase in communication will allow for improved patient care, |
| |where we are all working together to enhance the patient’s quality of life. Finally, we hope that this law will save time and money for the pharmacist |
| |and the patient. |
| |If appropriate personnel communicate the medication order, there will be less chance of miscommunication and medication errors. The pharmacist can also|
| |spend their time on other important issues. The frequency of medication errors requires another checkpoint step. If the pharmacy is the only place for |
| |checkpoints, we have a step involved in obtaining a new prescription that has no check on it. In order to improve patient safety, educated medical |
| |professionals, including anyone with prescribing authority and their nurses, should be calling in new prescriptions. |
| |After implementing this law, we could measure the number of medication errors that occur from phoned in prescriptions and either compare it to the |
| |number of errors prior to the law, or compare it to the number of errors in other states that do not have this regulation. |
| | |
| |5. |
| |There are several measurable variables regarding the current regulation of a prescription being translated to a pharmacist by an agent of the |
| |individual practitioner such as medication errors, lost time and money. This problem could be measured by the amount of medication errors pharmacists |
| |receive due to incorrect information like drug name, dosing, directions, or any other information significant to the patient from a non-trained |
| |employee of the prescriber. Other measurable variables are the time and financial loss experienced by the pharmacy and prescriber when prescription |
| |information is verbally transferred and the pharmacist needs clarification or has additional inquiries. This requires the agent to talk to the doctor, |
| |clarify the information, and relay it back to the pharmacist. Not only does this process take time, but it also costs the pharmacy to have their |
| |pharmacists, who get paid hourly, spending their time on prescription clarification instead of more productive matters. If a doctor or nurse calls in |
| |the prescription to begin with, he or she should be able to answer many of the questions the pharmacist may have regarding the prescription or the |
| |patient. |
| |The most important person who should have an interest in the risk of medication errors is the patient, because he/she is the one who could potentially |
| |have an adverse event due to an error in prescription translation. However, the average patient is not aware of the possible errors, so I think the |
| |most vocal stakeholders will be the prescribers’ offices. This change in policy would force the offices to change the duties of their staff. This would|
| |increase the amount of work for the nurses and prescribers and decrease the amount of work for the others in the office. Since nurses’ and prescribers’|
| |time is worth more financially, in regards to business, it will also result in an increase cost for the office. Other stakeholders in this policy |
| |include the pharmacist and pharmacy interns. Requiring prescriptions to be phoned in by only prescribers or registered nurses will allow pharmacists to|
| |feel more confident that information is being verbally transferred correctly. |
| | |
| |6. |
| |Resolving this problem would possibly require increased staff for the prescribers. The major cost of resolving this problem is a higher wage that is |
| |expected for a more educated individual. However, there are great benefits to this more stringent requirement. Resolving this problem will reduce the |
| |inefficient use of time for order clarification among nurses, doctors, pharmacists, and other staff involved throughout the process, which in turn |
| |reduces the cost in staffing. Furthermore, there will be a decrease in healthcare costs from the resulting reduction of medication errors. |
|8 |Group 8: Clearing Confusion: Identifying PAs Authorized to Prescribe Schedule II Medications. |
| | |
| |Rick Bockovich, Julie Duong, Sunshine Gascon, Yvonne Hewett, Esther Labib-Kiyarash, Leonie Neville, Allison Pham, Janna Tseng |
| | |
| |1. Describe the problem: |
| |Under current Washington state law WAC 246-918-035, licensed certified physician assistants (PA-Cs) may prescribe controlled substances, including |
| |Schedule II drugs. Those persons licensed before July 1, 1999 and persons possessing an interim PA permit may or may not have prescriptive authority in|
| |this state. |
| | |
| |Although a credential search database is available through the Washington State Department of Health web site, all providers are listed as "physician |
| |assistant" only. No distinction is made between providers who may legally prescribe Schedule II medications and those who may not. This information is |
| |available directly from the Medical Quality Assurance Commission on weekdays only. |
| | |
| |This poses a problem for pharmacists because we are legally liable to dispense only those prescriptions which come from legitimate sources. Pharmacists|
| |need access to accurate provider information, including prescriptive authority, through an expanded search engine or web site. By ascertaining the |
| |validity of Schedule II prescriptions from physician assistants, pharmacists can protect themselves and potentially, their patients. |
| | |
| |2. Delineate the boundaries of the problem: |
| |There is no existing system for pharmacies to determine the prescriptive authority and scope of practice of Physician Assistants. |
| | |
| |3. Develop the fact base: |
| |In order to estimate the scope of the problem we will assemble anecdotal evidence based on group member experience. In addition articles from journals|
| |such as Health Service Research 2003 edition will be used in an attempt to quantify the number of Pas practicing in Washington State and the quantity |
| |and level of care being provided. |
| | |
| |An unpublished and unfinished study prepared by the Board of Medicine in Virginia and presented to the Joint Commission on the Health Care will be used|
| |to illustrate that this problem is not limited to Washington State. |
| | |
| |4. Describe goals and objectives for resolving the problem and how to measure change: |
| |Our goal is to establish a database or resource for pharmacies, that will be available at any hour, that will clearly state the prescriptive authority |
| |and scope of practice for all PAs practicing within Washington State. |
| | |
| |Change can be measured by increased productivity and a reduction in the number of prescriptions that fail to be processed due to uncertainties |
| |concerning prescriptive authority. |
| | |
| |5. Identify the policy envelope: |
| |The biggest variable that can be measured regarding this problem is time. Pharmacists lose valuable time trying to find out if a PA is authorized to |
| |prescribe schedule II medications. This takes away from time that should be spend performing important tasks such as drug utilization reviews and |
| |patient counseling. Just as pharmacists lose valuable time, so do patients. Patients want their prescriptions filled in a timely manner. They already |
| |don’t understand the time necessary to accurately fill a prescription. In addition, pharmacists spend too much of that time on issues such as |
| |insurance. |
| |It makes sense to establish a list or website that is accessible to pharmacies containing information on PA’s so that precious time isn’t wasted on |
| |this task too. Another variable that can be measured is money. How much money is spent on the resources needed to find out whether a PA is authorized |
| |to prescribe a CII or not? Examples of resources used are labor, computers, internet, and phone line. Lost customer base is also a variable that can be|
| |measured. Sick customers are not the most patient of customers. An extra five minutes might be the difference between them staying loyal to the |
| |pharmacy or choosing to go elsewhere. The final variable that can be measured is licensure. A pharmacist is putting his license on the line when he |
| |fills an unauthorized CII prescription. |
| | |
| |As evident from the variables discussed above, the stakeholders involved are the pharmacists, the pharmacies where they work, and the customers who get|
| |their prescriptions filled there. |
| | |
| |6. Costs & Benefits related to solving the problem: |
| |Instalation or creation of an online database will require time and resources. It will require computers to host the site (which already exist within |
| |the DOH), people to put up the information and update it (which also already exist within the DOH), and people to maintain the infrastructure upon |
| |which the site is based (again, already in the DOH). |
| | |
| |Establishment of an open database which clearly states the prescriptive authority and scope of practice for all PAs that practice within Washington |
| |State will enable pharmacists to fill and process prescriptions in a more timely manner. |
|9 |Pharm 543: Problem Definition |
| |Group 9: Revision of Schedule II Prescription Expiration Date |
| |Group Members: Brionne Alvord, Carson Huntoon, Nicole Miller, Dora Banjanin, Cori Nelson, Angie Lambert, Abdi Tache |
| | |
| |1. Describe the Problem |
| | |
| |Currently, due to an oversight in Washington State law, PracAct RCW 69.50.308, Schedule II prescription drugs have an expiration date of 12 months from|
| |the date written. This law has no mention of Schedule II drugs, which are more addictive and have a greater abuse potential, then the Schedule III and |
| |IV drugs. On the other hand, both Schedule III and IV prescription drugs have a six month expiration date. Our goal is to have stricter regulation of |
| |the Schedule II drugs, by adopting a prescription expiration date that is seven days from the date written. This change would make Schedule II |
| |prescribing laws more consistent with the prescribing laws of the other scheduled drugs and that of other states. States such as California, Texas and |
| |Illinois[23], have implemented the seven day prescription expiration date and have been successful in reducing the number of problems associated with |
| |the abuse and misuse of Schedule II prescriptions. |
| |A Drug Enforcement Agency Testimony on December 11, 2001, before the House Committee on Appropriation, suggests a correlation between drug abuse |
| |potential and a state's ability to monitor prescribing[24]. The states mentioned above, have a lower number of OxyContin® prescriptions written; a |
| |Schedule II drug, which has the highest abuse potential and tends to be the abused drug of choice. It is believed that the low number of OxyContin® |
| |prescriptions written, is due to the stringent prescription monitoring programs, along with the short validity of the prescription of the Schedule II |
| |drugs. |
| |As pharmacists, our chief values are to be more consistent with the Controlled Substance Act and to be confluent with the states that have already |
| |adopted similar regulations. In addition, changing the validity length of prescriptions, would automatically establish stricter guidelines for |
| |monitoring the use of Schedule II drugs. The RCW’s omission of the reasonable expiration date for the Schedule II drugs increases the medical |
| |community’s liability, and decreases patient safety. Changing this issue would also affect drug abusers, because “drug-seeking behavior” would be |
| |easier to identify and help can be administered promptly. |
| |In our proposal, Stimulant Schedule II drugs used for treatment of Attention Deficit Hyperactive Disorder and Attention Deficit Disorder would be |
| |exempt from the “seven day expiration date”. These prescriptions would have a six month expiration date. This exemption is necessary for the |
| |convenience of the patients on these chronic medications, but provides for physician monitoring, and making the Schedule II law consistent with current|
| |Schedule III and IV laws. |
| | |
| |2. Delineate the Boundaries of the Problem |
| | |
| |The United States Controlled Substances Act does not delineate any time limit on filling Schedule II drugs, it only states that they must not be |
| |refilled. The Washington Controlled Substances Act took on almost the same wording as the federal, resulting in an omission of a time limit. As a |
| |result, this federal “oversight” has become a statewide problem. Other states have adopted their own laws about time limits of filling Schedule II |
| |drugs, from 5 days to 6 months. There is wide variability of Schedule II fill limits. Washington has yet to make any changes to the federal law of a |
| |one year limit. Washington’s current law regarding expiration of Schedule II drug prescriptions promotes problems such as ailments being treated |
| |inappropriately and incorrectly due to late fills. It increases the chances of drugs being used for different indications other than intended. It may|
| |also aid in drug hoarding and abuse. There have been lawsuits about schedule drugs being filled late and drug abuse. This is bringing attention and |
| |urgency to this issue, as it is a “glitch” that needs to be fixed as soon as possible. |
| | |
| |3. Develop a Fact Base |
| | |
| |What are some other states doing in regards to Schedule II expiration? |
| |West Virgina-WV BReg §15-2-7 |
| |a. Prescriptions. “A prescription for a Schedule II controlled substance is valid for ninety (90) days from the date issued. A pharmacist may fill the |
| |prescription after ninety (90) days if the prescriber confirms to the pharmacist that he or she still wants the prescription filled and the pharmacist |
| |documents upon the prescription that the confirmation was obtained.” |
| |Texas-TX PracAct Sec. 481.074 |
| |d. “…a person may not fill a prescription for a controlled substance listed in Schedule II after the end of the seventh day after the date on which the|
| |prescription is issued.” |
| |Delaware-DE BReg 4 |
| |h. Expiration of Prescriptions. “Prescriptions for controlled substances in Schedules II and III will become void unless dispensed within seven (7) |
| |days of the original date of the prescription or if the original prescriber authorizes the prescription past the seven (7) day period.” |
| |Louisiana-LA BReg 2525 |
| |B. “A prescription for a controlled dangerous substance listed in Schedule II, III, IV, V shall expire six months after the date written.” |
| |Vermont-VT BReg 3.700 |
| |“No prescription for a schedule II controlled drug shall be filled more than five days after issuance of the prescription.” |
| |Virginia-VA BReg 18 VAC 110-20-290 |
| |A. “A prescription for a Schedule II drug shall be dispensed in good faith but in no case shall it be dispensed more than six months after the date on |
| |which the prescription was issued.” |
| |2. What are the Schedule II abuses and prevalence seen nationally and locally? |
| |A. The Drug Enforcement Agency (DEA) intends to monitor the prescribing practices of Schedule II medications to look for illicit drug abuse. At the |
| |same time, it does not presume to know when a patient in pain is in need of Schedule II narcotics and leaves this up to the good judgment of the |
| |medical professional. This is an interesting article in it demonstrates the DEA’s desire to work with states and regulatory agencies to protect |
| |patients with chronic pain and to identify problematic patterns of drug use.[25] |
| | |
| |B. An article addresses the problematic use of oxycodone in recent years and how the use of polypharmacy[26] contributing to deaths from addiction. |
| |This article also emphasizes that the largest impact from the abuse of oxycontin is on legitimate patients with chronic malignant pain, who are unable |
| |to rely on effective treatment regimens due to “opiophobia”.[27] |
| | |
| |C. The 2002 National Survey on Drug Use and Health (NSDUH) reported illicit drug use at 19.5 million for Americans ages 12 and older.[28] While |
| |marijuana remains the drug of choice for abusers, national trends statistically confirm an increased use of psychotherapeutics, particularly within the|
| |class of narcotic analgesics. In 2002 NSDUH determined that 70% of illicit drug users who did not use marijuana chose psychotherapeutics, and within |
| |that class, 71% used pain relievers.[29] |
| | |
| |The significant abuse of narcotics and opiates has specifically permeated Washington. Narcotic/analgesic combinations outnumbered incidence of heroin |
| |abuse in Seattle in 2001.[30] According to the National Institute on Drug Abuse, Seattle ranked the highest of the national big cities that year in its|
| |increase of narcotic analgesic and opiate use, a rate of 123 percent.[31] The potency of these drugs is also evident in the number of deaths in King |
| |County relative to the total drug-induced deaths from the years 1999 to 2001. The Drug Abuse Warning Network of the Department of Human and Health |
| |Services reported 21 deaths in King County in 1999 from narcotic analgesics as the single drug involved in death; this number dramatically increased to|
| |53 and 57 in 2000 and 2001, respectively, with methadone and oxycodone used most frequently.[32] In 2001 narcotic analgesics alone accounted for 39% of|
| |the total drug-induced deaths in King County.[33] These prescription-only drugs when abused are fatal. |
| | |
| |Rising illicit use of Schedule II drugs is leading to unintentional deaths. The Department of Human and Health Services further notes in the 2001 |
| |Mortality Data that 74% of the drug-induced deaths were accidental and unexpected.[34] The extent of this expanding abuse unfortunately reaches beyond |
| |current illicit drug users. The National Survey on Drug Use and Health approximated 4.7 percent (11 million) of Americans 12 and over within 2002 drove|
| |at least once under the influence of an illegal drug; an astonishing 18% of 21 year olds reported having driven under the influence that year.[35] The |
| |effects of substance abuse are no longer confined to individuals as an increasing number willingly interact with society while intoxicated with harmful|
| |agents that seriously alter physical and mental function. |
| | |
| |The trends are pushing toward substantially increased abuse of Schedule II narcotic analgesics and opiates. Realizing the potency of these drugs and |
| |their potential harm and fatality for both illicit drug users and those within their association in society, Schedule II drugs must require at least |
| |the same restrictions as the less frequently abused and less harmful and far reaching Schedule III to V medications. |
| | |
| |D. It is also of note that court cases have been filed suing manufacturers of Schedule II’s (most notably Purdue, manufacturer of OxyContin®) for |
| |damages due to addiction to opiates. See 4 below. |
| | |
| |3. What are current guidelines for prescribing schedule II medications for control of pain? |
| |A. The National Guideline Clearinghouse has used Washington States Labor and Industry Board guidelines to set a standard of practice in the prescribing|
| |an dispensing of controlled substance for the relief of chronic non-malignant pain. The guidelines specifically outline a method of documentation and |
| |evaluating information to provide the best therapy possible to prevent pain, but to avoid an addiction. Included are: “a finite treatment plan that |
| |does not exceed six weeks, description of reported pain relief from each medication, justification of the continued use of each controlled substances, |
| |and documentation of attempts at weaning,” to name a few. It also states that in cases of acute traumatic pain that “schedule II drugs should be |
| |prescribed for no longer than 2 weeks.”[36] |
| | |
| |B. The World Health Organization has guidelines on the prescribing for chronic non-malignant pain. This emphasizes the precautious necessary properly |
| |treat pain by avoiding under-treatment yet preventing addiction.[37] |
| | |
| |C. Purdue Pharma along with the Federal Food and Drug Administration (FDA) has revised the product information insert to include a black boxed warning|
| |as to the high abuse potential of OxyContin®. They have also clarified the indications for use to emphasize the inappropriate use of this in patients |
| |with acute pain not requiring continual pain relief.[38] |
| |4. What issues have been raised in the process of judicial review? |
| |A. Katherine A. Hoover, appellant, v. The Agency For Health Case Administration, etc., Appelle. |
| |This case illustrates the difficulty doctors’ face when prescribing controlled substances to patients with chronic pain. Hoover, a doctor licensed to |
| |practice in the state of Florida, had her license suspended by the Department of Business and Professional Regulation for excess dispensing of Schedule|
| |II narcotics. Hoover appealed the board’s decision which was reversed in the Third District Court of Appeals, because the agency did not establish the |
| |necessary burden of proof to revoke her license.[39] |
| | |
| |B. Foister, et al., v. Purdue Pharma, L.P., et al. Several patients in state of Kentucky are accusing Purdue of not providing the information necessary|
| |to advise of their product OxyContin®’s abuse potential. All plaintiffs are admitted to an opiate addiction and “drug seeking” behavior prior to taking|
| |OxyContin®. Purdue was awarded the favor of the court for being unable to establish the oxycodone containing drug to be the source of these |
| |addictions.[40] |
| | |
| |C. Dee v. Wal-Mart Stores, Inc. This case highlights the importance of patients filling prescriptions for indicated uses. Nicole Dee was prescribed |
| |Duragesic® 50 mcg patches for a Caesarian delivery, which she did not fill. However, 4 months later she had the prescription filled at a Wal-Mart |
| |Pharmacy for pain induced by a fractured ankle. The pharmacist did not question the time elapsed from the date the prescription was written; the |
| |patient used the prescription that night and died from hypoventilation. The Court of Appeals found the pharmacist guilty of negligence due to not |
| |addressing the patient’s lack of education for opiate medications.[41] |
| | |
| |D. McCauley v. Purdue Pharma, L.P. This is another case of opioid dependent patients seeking restitution from Purdue from the use of OxyContin®. The |
| |most interesting thing in this case was the experts stating that “patients who used opioid analgesics for pain relief as prescribed developed addiction|
| |only if they had a prior history of substance abuse.” The case was granted in favor of Pharma for reasons sited above in B.[42] |
| | |
| |5. Why are schedule II stimulants used to treat ADHD and ADD exempt from 7 day expiration, but will have a limit of six months placed upon it? |
| |(Working on this topic- patient/parent issues) |
| |4. Describe your goals and objectives for resolving the problem and how you might measure change |
| | |
| |Our goal is to reduce the expiration date on Schedule II prescriptions. By changing the law we hope to minimize substance abuse, reduce adverse drug |
| |interactions and limit controlled substance diversion. Our objective is to change the expiration date on Schedule II prescriptions from one year to |
| |seven days. We can measure change by observing if the expiration date on Schedule II prescriptions decreases and by how much it decreases. |
| | |
| |5. Identify the policy envelope: |
| | |
| |Variables that can be measured regarding this problem include the number of adverse drug reactions due to late CII prescription fills. Another |
| |variable that can be monitored is the time between the date of when a prescription was written and the date when it was filled. The most important |
| |variable is simply the expiration date for Schedule II prescriptions. |
| |There are several stakeholders in this problem. Patients are at risk because of the current situation. Patients may not realize the danger of filling|
| |a CII prescription for an unintended use. Parents would be interested if their children are on CII medications. More specifically, if the child was |
| |on a medication for ADHD parents may be concerned about increased visits to the doctor’s office. Doctors are also interested in this situation. They |
| |should be concerned about their patients filling CII prescriptions for non-diagnosed reasons. Doctors would also be interested since limiting the |
| |length of a CII prescription may require more office visits and more prescription writing. The community in general should be concerned since drug |
| |abuse can result in billions of dollars spent on crime prevention, treatment programs and other healthcare costs. The DEA would also have an interest |
| |in this situation since they monitor prescribing and dispensing of controlled substances. |
|10 |Pharm 543: Problem Definition |
| |Group 10: Alternative & Complimentary Medicines Curriculum Change |
| |Group Members: Stephanie Decker, Shea Beal, Jennifer Glasco, Misty Kelley, Kristi Metz, Brian Myers, Joey Niedner |
| | |
| |Describe the problem |
| | |
| |Our project will focus on the addition of alternative and complimentary medicines as required curriculum at the University of Washington School of |
| |Pharmacy and recommended by the accrediting organization that proposes curricular suggestions. We will define alternative and complimentary medicines |
| |as any folk medicine, herbals, botanicals, dietary supplements, minerals, vitamins, and plant remedies. |
| |Alternative and complimentary medicines (defined from now on as “supplements”) have created several concerns regarding patient safety. Depending on the|
| |supplement, harmful interactions with drugs, diseases, and foods can result if a patient is not careful or does not understand that such an adverse |
| |event is possible. To make matters worse, generally pharmacists do not possess adequate knowledge of these supplements and may not be able to recognize|
| |a possible adverse event or make recommendations. |
| |The bottom line is that these supplements are out there and are being used by a large number of people, most of which are seniors, which is the portion|
| |of the population that consumes the majority of prescription and OTC drugs. Both health care professionals and patients are uneducated regarding the |
| |safety and use of supplements. |
| | |
| |Delineate the boundaries of the problem |
| | |
| |Supplement use has been around for as long as drugs have, however, with the trend towards self treating becoming more popular, they will have a more |
| |pronounced impact on the safety of patients who do not consult a healthcare professional when mixing supplements with drugs. The pharmacist is the most|
| |available healthcare professional, yet many lack the knowledge to properly counsel and recommend supplements with regard to existing drug therapy. A |
| |class at the UW has been offered regarding this subject; however it is only two credits and is not required. |
| |This project is linked to a larger, nationally felt, problem. Supplement use, marketing, and industry is poorly regulated and not well understood. |
| |Pharmacists are not learning about these issues in school and aren’t required to take any continued education courses pertaining to supplements either.|
| |Ill prepared pharmacists, unregulated advertising, increased availability, and the tendency for patients to self treat all contribute to this problem. |
| | |
| |Develop a fact base |
| | |
| |The Handbook of Nonprescription Drugs contains information regarding the regulation of supplements by the FDA. It covers the DSHEA act of 1994 and the |
| |relative frequency of use in various populations, which indicate in increased market for supplements that will only grow. Also, information from Dr. |
| |Elmer’s Alternative Medicines course will be used to establish our fact base. |
| | |
| |Describe your goals and objectives for resolving the problem, and how you might measure change |
| | |
| |Our goal is to have Pharmacist’s graduate from their schools with a solid foundation in the knowledge of supplements so that they can properly advise |
| |patients in their use. We will measure change on whether or not the Accreditation Council for Pharmacy Education (ACPE) recommends a general knowledge |
| |of supplements as required curriculum. |
| | |
| |Identify the policy envelope |
| | |
| |Some variables regarding this issue pertain to providing proper instruction in alternative medicine information. There may not be an ample supply of |
| |instructors qualified to teach in this area due to the fact that it has never been a required area of study in pharmacy schools. The people and |
| |organizations that will be interested are the students and faculty of the University of Washington School of Pharmacy and the students and faculty of |
| |all pharmacy schools around the country. |
| | |
| |What are potential costs and benefits to resolving the problem |
| | |
| |Potential costs involving this scenario may involve hiring new faculty qualified to teach material pertaining to supplements. This in turn could change|
| |tuition. However, a review of curriculum at the University of Washington School of Pharmacy is on the horizon and it may be possible to change the |
| |current Alternative Medicines class from non required elective to a required elective, such as PHARM 412 (OTC drugs). Change the curriculum via this |
| |format may only change cost slightly if at all. However, this does not answer the cost for other universities around the country. |
| |The benefits from this change in curriculum will increase the safety of supplement use if a pharmacist is consulted. Ideally, reduced drug, disease, |
| |and food interactions will be reduced, which will result in increased patient health. |
|11 |Pharm 543 MTMS |
| |Group 11 |
| |Margaret Sopalski, Lisa Choe, George Gunther, Michelle Mai, Kathleen Amazona, Yen Duong, Jeong Park |
| | |
| |Describe the problem |
| |Over the past 20 years, there has been a shift in the philosophy of pharmacy |
| |practice from clinical to that of pharmaceutical care. This progression in our profession expounds the idea that we are trained professionals in the |
| |specialty of drug information and therapy, and therefore we should play an active and positive role in our patients’ lives where drug management and |
| |therapy are concerned. |
| |Along with the progression of our profession is the concept of being able to bill for pharmacy services other than dispensing. These other services |
| |include performing a comprehensive review of a patient’s medication and management of that medication; creating a program with the patient that will |
| |assist in the patient’s compliance with a medication regiment. The basis for billing is that patients would be able to receive these services if |
| |insurance would assist in payment, as well as compensating pharmacists for their time taken away from dispensing. |
| |The problem that exists in the MTMS portion of the Medicaid bill is that it states “any health care professional” as being able to bill for MTMS |
| |services. As students, we fill that pharmacists are the members of the healthcare team that are best suited for providing MTMS services because of our|
| |extensive education in drug pharmacology, drug therapeutics, and drug information. We do not deny that there maybe some specialists, such as a |
| |certified diabetes educator, that may have more knowledge than a regular ARNP for example, and therefore we feel that the language should be changed to|
| |state “a pharmacist or certified specialist in the area of disease or drug”. |
| | |
| | |
| |2. Delineate the boundaries of the problem |
| |The problem has existed ever since the doctor of pharmacy program was implemented, which gave pharmacists more training in various pharmacy services. |
| |There are no historical antecedents, yet the issue arose six months ago when the CFR was put up for open comment. Now that pharmacists have more |
| |extensive training prior to licensure, they must choose between providing pharmacy services for free, but of benefit to the patient, or dispensing a |
| |prescription, which brings in most of the retail revenue and profit. As profit keeps an enterprise afloat, many pharmacists have chosen not to provide |
| |pharmacy services to the full extent of their capabilities. |
| | |
| |3. Develop a fact base |
| |The issue of allowing pharmacists to bill for medication therapy and management services has been around for years. Pharmacists may be able to finally |
| |have the opportunity to bill for such services through the ongoing Medicare part D addendum. Having the chance to be recognized as the provider of |
| |choice with regards to patients’ medication therapy and management is an area worth pursuing. |
| |Aside from dispensing medications, pharmacists are now proving their capabilities through their personal interactions with patients. These interactions|
| |can include such pharmacy services as dyslipidemia management, and diabetes, osteoporosis and blood pressure screenings. These current services |
| |provided by pharmacists are one of the many examples where pharmacists are vital in improving patient health outcomes and quality of life in patients. |
| |One of Project ImPACT’s (Improve Compliance and Persistence with Therapy) endeavors focused on hyperlipidemia management and demonstrated the |
| |usefulness and influence pharmacists had in improving cholesterol levels in patients.[43] In addition, another Project ImPACT success, on osteoporosis |
| |screening, showed the accuracy and effectiveness of pharmacists to screen for patients at high risk for osteoporosis.[44] As pharmacists we have access|
| |to drug information, and are proficient in the training and education required of drug therapy management. There fore we are able to provide optimal |
| |care for patients in monitoring and managing disease states and chronic conditions. |
| | |
| |4. Describe your goals and objectives for resolving the problem and how you might measure change. |
| |The goal is to let pharmacists be recognized as primary providers of medication therapy management. Pharmacists are the health care professional with |
| |specialized academic and professional training focused exclusively on pharmaco-therapeutics and medication therapy management. Pharmacists who work in|
| |a collaborative relationship with physicians, nurses, and other practitioners can enhance appropriate use of medications, patients’ compliance, and |
| |reduce potential adverse events and overall healthcare cost. |
| |Objectives: To provide a foundation for billing of pharmacy services. To increase the number of pharmacists practicing MTMS. To improve patient health|
| |outcomes. |
| | |
| |5. Identify the policy envelope |
| |Many medication therapy management services such as diabetes education require extensive education, training, experiences, and specific protocol. If |
| |other healthcare providers such as nurses were allowed to bill for MTMS, then the quality of MTMS would be more difficult to control and measure. The |
| |standards of pharmacy services would not only be established by pharmacists, but also by other healthcare providers. The differences in standards may |
| |jeopardize the high quality that patients need in pharmacy services. |
| |In order to justify the billing of high quality, pharmacy services, such services should be provided by pharmacists only. If the services were provided|
| |under other healthcare providers’ standards, then the billing of those services should be processed under their own billing code, and not be billed as |
| |MTMS. |
| | |
| |6. Potential costs and benefits: |
| | |
| |Cost- Potential to increase tension between pharmacist and other health care providers if MTMS is inclusive only for pharmacists. |
| | |
| |Cost: The increased volume of pharmacy services may reduce the volume of prescription filling. |
| | |
| |Cost: Disenfranchising our partners on the health care team so that pharmacists are not able to lobby for progressive change in legislation on scope of|
| |practice. |
| | |
| |Benefit- Pharmacists will be recognized for the services being provided and will be a more reliable resource for other health care providers. |
| | |
| |Benefit: Pharmacies have access to a variety of products, providing patients more choices and providing supplies more efficiently compared to other |
| |healthcare providers. |
| | |
| |Benefit: Allowing only pharmacists to bill for MTMS might increase the need for the physicians and pharmacists to work collaboratively, creating more |
| |collaborative work agreements (CWA) and thus benefiting both professions. |
| | |
| |Benefit: Patients will be able to schedule appointments with pharmacists more quickly than physicians. |
| | |
| |Benefit: Pharmacists can take a more proactive role in initiating, modifying or changing a patients drug therapy (with physician approval) increasing |
| |patients’ health outcomes. |
| | |
| |Benefits: By providing MTMS, pharmacists can prove their capabilities not only to the patients to but to other health care providers as well, and |
| |improve relations between the health care team. |
|12 |Pharm 543 - Group 12 |
| |Title: Clarification of the role of the pharmacist in the offering of patient counseling |
| |Members: Ping Zeng, Hoa Tran, Nadia Ordonez, Phong Tran, Richard Dyke, Angelique Williams, |
| |Cathy Taketa |
| | |
| |1. Describe the problem |
| |In the Washington State Pharmacy Lawbook 2003, WAC 246-869-220, it is unclear that the pharmacist is the only individual in the pharmacy that can make |
| |the patient-counseling offer. The law does not address the role of technicians and assistants in offering the provision of patient counseling by a |
| |pharmacist. From a pharmacist’s perspective, uncertainty regarding legal obligations and restrictions for themselves and the staff that they supervise|
| |is unacceptable in light of the fact that personal licensure is at stake. The need for clarification arises from the disparity between the law, as |
| |enforced by the Washington State Board of Pharmacy (i.e. the Board), and the actual practice of pharmacy. In addition, it is also unclear whether the |
| |offer of counseling on refill prescriptions must also be made by a pharmacist. |
| | |
| |2. Delineate the boundaries of the problem |
| |It is believes that this uncertainty has existed since WAC 246-869-220 became effective on September 30, 1991. While this problem might appear to be |
| |primarily a community pharmacy issue, it also has implications for outpatient hospital pharmacies. |
| | |
| |3. Develop a fact base |
| |Two types of evidence will be necessary to persuade others of the existence and severity of this problem. First, demonstration that pharmacists in |
| |Washington State are unsure concerning their legal requirement to make the offer of counsel to patients on all prescriptions. This evidence can be |
| |gathered either directly through interviews with pharmacists or indirectly through observation of pharmacy practice in both the community and |
| |outpatient hospital pharmacy. Second, public records concerning disciplinary action taken against pharmacists in Washington State for failure to |
| |dispense in a manner consistent with the Board’s interpretation of the Law. |
| | |
| |4. Describe your goals and objectives for resolving the problem, and how you might measure change. |
| |The goal of this project is to eliminate any uncertainty concerning a pharmacist’s legal obligations concerning the dispensing of prescriptions. |
| |Subsequently, this should reduce the number of licenses that are suspended in the state for “failure to dispense.” |
| | |
| |5. Identify the policy envelope |
| | |
| |The variables that can be measured concerning the problem include staffing (i.e. are technicians making the offer of counseling as a time saving |
| |measure at pharmacies that are understaffed) |
| | |
| |6. What are the potential costs and benefits to resolving the problem? |
| |The potential costs of resolving this problem include education or reeducation of pharmacists regarding the law as it applies to the dispensing of |
| |prescriptions. This information could be communicated through a newsletter or mass mailing or possibly as part of a required continuing education |
| |course. The primary benefit of resolving this problem is the reduction in the number of pharmacists who lose their license for failure to properly |
| |dispense a prescription. This would also serve to preserve access to pharmaceutical care services by maintaining the number of practicing pharmacists.|
-----------------------
[1] Jackson M, Reines W. A Systematic Approach to Preventing Medication Errors. Available from .
[2] Drug Distribution and Control, Washington Administrative Code (WAC) 246-871-050. Pharmacy Lawbook 2003. Washington State Department of Health, Board of Pharmacy (p. 170).
[3] Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD.
[4] Nordenberg, T. Make No Mistake: Medical Errors Can Be Deadly Serious. Available from .
[5] Ingrim NB, Hokanson JA, Guernsey BG, Doutre WH, Blair Cw Jr., Verrett TJ. Physician noncompliance with prescription-writing requirements. Am J Hosp Pharm. 1983 Mar;40(3):414-7.
[6] Washington State Legislature, “Uniformed Controlled Substances Act”
2Washington State Legislature, “Uniformed Controlled Substances Act”
[7] A phone interview with Jack an RPh at Union Center Pharmacy, Seattle, WA 12 Oct 2004.
[8] The National Association of Boards of Pharmacy. .
[9] Cardiopulmonary Resuscitation (CPR) Statistics. [Internet] Dallas (TX): American Heart Association; c2004 [cited 2004 11 Oct]. Available at:
[10] Chamberlain DA, Hazinski MF; European Resuscitation Council; American Heart Association; Heart and Stroke Foundation of Canada; Resuscitation Council of Southern Africa; Australia and New Zealand Resuscitation Council; Consejo Latino-Americano de Resusucitación. Education in Resuscitation: An ILCOR Symposium: Utstein Abbey: Stavanger, Norway: June 22–24, 2001.Circulation 2003;108:2575-2594.
[11] Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M; Ontario Prehospital Advanced Life Support Study Group. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004;351:647-56.
[12] Administrative procedures and requirements for credentialed health care providers; Washington Administrative Code, Chapter 246-12 (2003). (Washington State Legislature, )
[13] RCW 18.64.005. Pharmacy Law Book, 2003. Washington State Department of Health, pg. 2.
[14] WAC 246.863.120. Pharmacy Law Book, 2003. Washington State Department of Health, pg. 152.
[15] WAC 246.861.090. Pharmacy Law Book, 2003. Washington State Department of Health, pg. 147.
[16] HealthMinderNews/Dec2002/page2.html. Accessed 10-9-04
[17] . Accessed 10-9-04
[18] Ashcroft DM, Quinlan P, Blenkinsopp A. Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies. Pharmacoepidemiol Drug Saf. 2004 Sep 6
[19] Bates MD, A 40 year old woman notices a medication error
[20] Persons entitled to issue prescriptions. 21CFR1306.03. Revised April, 1, 1998.
[21] British Columbia Legislation By Laws. Law 5: Community Pharmacy 38.2.4
[22]TX PracAct Sec. 481.074., CA PracAct 11166, IL PracAct 570/312
[23] Hutchinson, Asa. DEA Congressional Testimony--Drug Enforcement Administration Before the House Committee on Appropriations. [Internet]. Alexandria [VA]. December 11, 2001. [cited 2004 Oct 8]. Available from:
[24] Woodward, Terrance. Prepared Witness Testimony—The Committee on Energy and Commerce [Internet]. Washington D.C. [District of Columbia]. 2001 Aug 28 [cited 2004 Oct 7]. 3 pages. Available from: http//energycommerce.107/hearings/0828200Hearings363/Woodworth596.htm.
[25] This article defines polypharmacy as multiple drug use.
[26] Robert, Teri. OxyContin: The Saga Continues! [Internet]. [cited 2004 Oct 5]. Available from: .
[27] U.S. Department of Health and Human Services—Substance Abuse and Mental Health Services Administration. Section 2. Illicit Drug Use. Results from the 2002 National Survey on Drug Use and Health: National Findings.
[28] SAMHSA. Results from the 2002 National Survey on Drug Use and Health
[29] National Institutes of Health. Epidemiologic Trends in Drug Abuse Advance Report, December 2002. National Institute on Drug Abuse.
[30] NIH. Trends in Drug Abuse Advance Report, December 2002.
[31] U.S. Department of Health and Human Services—Substance Abuse and Mental Health Services Administration. Mortality Data from the Drug Abuse Warning Network, 2001.
[32] SAMHSA. Drug Abuse Warning Network, 2001.
[33] SAMHSA. Drug Abuse Warning Network, 2001.
[34] SAMHSA. Results from the 2002 National Survey on Drug Use and Health
[35] Guidelines for outpatient prescription of controlled substances, schedules II-IV, for workers on time-loss [Internet]. Washington State Department of Labor and Industries - State/Local Government Agency [U.S.]. 1992 (revised 1999 Jun; republished 2002 Aug) [cited 2004 Oct 8]. 8 pages. NGC:003225. Available from: .
[36] Achieving balance in national opioids control policy—Guidelines for assessment [Internet]. World Health Organization. 2004 Jul 28 [cited 2004 Oct 9]. 2 pages. Available from: .
[37] Dear Doctor Letter [Internet]. Food and Drug Administration-[US]. 2001 Jul 18 [cited 2004 Oct 5]. Available from: .
[38] Hoover v. The Agency for Health Care Administration. 1996 Fla. Accessed: . [2004 Oct 9].
[39] Foister, et al., v. Purdue Pharma, L.P., et al. 2003 Dec 30 KY. Accessed via Lexis-Nexis at [cited 2004 Oct 7].
[40] Dee v. Wal-Mart Stores, Inc. 2004 June 30. Accessed via Lexis-Nexis at [cited 2004 Oct 7].
[41] McCauley v. PurduePharma, L.P. 2004 August 18. Accessed via Lexis-Nexis at [cited 2004 Oct 7].
[42] Blumi BM, McKenney JM, Cziraky MJ. Pharmaceutical service and care results in Project ImPACT: Hyperlipidemia. J Am Pharm Assoc 2000;40:157-65.
[43] Goode JK, Swiger K, Blumi BM. Regional osteoporosis screening, referral, and monitoring program in community pharmacies: Findings from Project ImPACT: Osteoporosis. J Am Pharm Assoc 2004 Mar/Apr;44(2):152-60.
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