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1.  Barriers and facilitators to recovering from e-prescribing errors in community pharmacies 
To explore barriers and facilitators to recovery from e-prescribing errors in community pharmacies and to explore practical solutions for work system redesign to ensure successful recovery from errors.
Cross-sectional qualitative design using direct observations, interviews, and focus groups.
Five community pharmacies in Wisconsin.
13 pharmacists and 14 pharmacy technicians.
Observational field notes and transcribed interviews and focus groups were subjected to thematic analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) work system and patient safety model.
Main Outcome Measures
Barriers and facilitators to recovering from e-prescription errors in community pharmacies.
Organizational factors, such as communication, training, teamwork, and staffing levels, play an important role in recovering from e-prescription errors. Other factors that could positively or negatively affect recovery of e-prescription errors include level of experience, knowledge of the pharmacy personnel, availability or usability of tools and technology, interruptions and time pressure when performing tasks, and noise in the physical environment.
The SEIPS model sheds light on key factors that may influence recovery from eprescribing errors in pharmacies, including the environment, teamwork, communication, technology, tasks, and other organizational variables. To be successful in recovering from eprescribing errors, pharmacies must provide the appropriate working conditions that support recovery from errors.
PMCID: PMC4312611  PMID: 25539495
2.  Exploring Information Chaos in Community Pharmacy Handoffs 
Research in social & administrative pharmacy : RSAP  2013;10(1):10.1016/j.sapharm.2013.04.009.
A handoff is the process of conveying necessary information in order to transfer primary responsibility for providing safe and effective drug therapy to a patient from one community pharmacist to another, typically during a shift change. The handoff information conveyed in pharmacies has been shown to be unstructured and variable, leading to pharmacist stress and frustration, prescription delays, and medication errors.
The purpose of this study was to describe and categorize the information hazards present in handoffs in community pharmacies.
A qualitative research approach was used to elicit the subjective experiences of community pharmacists. Community pharmacists who float or work in busy community pharmacies were recruited and participated in a face to face semi-structured interview. Using a systematic content data analysis, the study identified five categories of information hazards that can lead to information chaos, a framework grounded in human factors and ergonomics.
Information hazards including erroneous information and information overload, underload, scatter, and conflict, are experienced routinely by community pharmacists during handoff communication and can result in information chaos. The consequences of information chaos include increased mental workload, which can precipitate problematic prescriptions “falling between the cracks”. This can ultimately impact patient care and pharmacist quality of working life.
The results suggest that handoffs in community pharmacies result in information hazards. These information hazards can distract pharmacists from their primary work of assessing prescriptions and educating their patients. Further research on how handoffs are conducted can produce information on how hazards in the system can be eliminated.
PMCID: PMC3766497  PMID: 23665076
handoffs; community pharmacy; human factors; medication safety
3.  How do Community Pharmacies Recover from E-prescription Errors? 
The use of e-prescribing is increasing annually, with over 788 million e-prescriptions received in US pharmacies in 2012. Approximately 9% of e-prescriptions have medication errors.
To describe the process used by community pharmacy staff to detect, explain, and correct e-prescription errors.
The error recovery conceptual framework was employed for data collection and analysis. 13 pharmacists and 14 technicians from five community pharmacies in Wisconsin participated in the study. A combination of data collection methods were utilized, including direct observations, interviews, and focus groups. The transcription and content analysis of recordings were guided by the three-step error recovery model.
Most of the e-prescription errors were detected during the entering of information into the pharmacy system. These errors were detected by both pharmacists and technicians using a variety of strategies which included: (1) performing double checks of e-prescription information; (2) printing the e-prescription to paper and confirming the information on the computer screen with information from the paper printout; and (3) using colored pens to highlight important information. Strategies used for explaining errors included: (1) careful review of patient’ medication history; (2) pharmacist consultation with patients; (3) consultation with another pharmacy team member; and (4) use of online resources. In order to correct e-prescription errors, participants made educated guesses of the prescriber’s intent or contacted the prescriber via telephone or fax. When e-prescription errors were encountered in the community pharmacies, the primary goal of participants was to get the order right for patients by verifying the prescriber’s intent.
Pharmacists and technicians play an important role in preventing e-prescription errors through the detection of errors and the verification of prescribers’ intent. Future studies are needed to examine factors that facilitate or hinder recovery from e-prescription errors.
PMCID: PMC4045654  PMID: 24373898
Electronic prescribing; E-prescribing; Medication Errors; Error Recovery; Community Pharmacy
4.  E-Prescribing Errors in Community Pharmacies: Exploring Consequences and Contributing Factors 
To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors.
Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10.
Pharmacy staff detected 75 e-prescription errors during the 45 hour observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information.
Study findings suggest that a wide range of e-prescribing errors are encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies.
PMCID: PMC4144335  PMID: 24657055
Electronic Prescribing; Medication Errors; Medication Safety; Contributing Factors; Consequences
5.  Using Think Aloud Protocols to Assess E-Prescribing in Community Pharmacies 
Innovations in pharmacy  2012;3(3):88-.
Think aloud protocol has rarely been used as a method of data collection in community pharmacies.
The aim of the report is to describe how think aloud protocols were used to identify issues that arise when using e-prescribing technology in pharmacies. In this paper, we report on the benefits and challenges of using think aloud protocols in pharmacies to examine the use of e-prescribing systems.
Sixteen pharmacists and pharmacy technicians were recruited from seven community pharmacies in Wisconsin. Data were collected using direct observation alongside think aloud protocol. Direct observations and think aloud protocols took place between January-February, 2011. Participants were asked to verbalize their thoughts as they process electronic prescriptions.
Participants identify weaknesses in e-prescribing that they had previously not conceived. This created heightened awareness for vigilance when processing e-prescriptions. The main challenge with using think aloud protocols were interruptions in the pharmacy. Some participants found it difficult to remember to continue verbalizing during think aloud sessions.
The use of think aloud protocols as method of data collection is a new way for understanding the issues related to technology use in community pharmacy practice. Think aloud protocol was beneficial in providing objective information on e-prescribing not based on pharmacist’s or technician’s opinion of the technology. This method provided detailed information and also a wide variety of real time challenges with e-prescribing technology in community pharmacies. Using this data collection method can help identify potential patient safety issues when using e-prescribing and suggestions for redesign.
PMCID: PMC4031678  PMID: 24860689
Think aloud protocol; Electronic prescribing; Community pharmacy
7.  Facilitating collaboration between pharmacists and physicians using an iterative interview process 
To elicit and describe mutually agreed upon common problems and subsequent solutions resulting from a facilitated face-to-face meeting between pharmacists and physicians.
Descriptive, exploratory, non-experimental study.
Wisconsin from October to December 2011.
Physicians and community pharmacists
Face-to-face semi-structured interviews with pharmacists and physicians from the same community, informed by previous individual interviews.
Main outcome measure
Methods to enhance collaboration and barriers to implementing collaboration between pharmacists and physicians
Physicians and pharmacists generated ideas in which collaboration could improve patient care, including controlled substance monitoring, medication adherence, collaborative practice agreements for point of service issues, and a mechanism for urgent communication. Methods on how to collaborate on these issues were also discussed.
Bringing physicians and pharmacists together for a face-to-face interaction that was informed by information gained in previous individual interviews successfully stimulated conversation on ways in which each profession could help the other provide optimal patient care. This interaction appeared to dispel assumptions and build trust. Results of this project may provide pharmacists with the confidence to reach out to their physician colleagues.
PMCID: PMC3998751  PMID: 24362573
Collaboration; community pharmacist; physician
8.  E-prescribing: Characterization of Patient Safety Hazards in Community Pharmacies Using a Sociotechnical Systems Approach 
BMJ quality & safety  2013;22(10):816-825.
To characterize safety hazards related to e-prescribing in community pharmacies.
The Sociotechnical Systems (STS) framework was used to investigate the e-prescribing technology interface in community pharmacies by taking into consideration the social, technical and environmental work elements of a user’s interaction with technology. This study focused specifically on aspects of the social subsystem.
Study Design and Setting
The study employed a cross-sectional qualitative design and was conducted in seven community pharmacies in Wisconsin. Direct observations, think aloud protocols, and group interviews were conducted with 14 pharmacists and 16 technicians, and audio-recorded. Recordings were transcribed and subjected to thematic content analysis guided by the sociotechnical systems theoretical framework.
Three major themes that may increase the potential for medication errors with e-prescribing were identified and described. The three themes included: (1) increased cognitive burden on pharmacy staff, such as having to memorize parts of e-prescriptions or having to perform dosage calculations mentally; (2) interruptions during the e-prescription dispensing process; and (3) communication issues with prescribers, patients, and among pharmacy staff. Pharmacy staff reported these consequences of e-prescribing increased the likelihood of medication errors.
This study is the first of its kind to identify patient safety risks related to e-prescribing in community pharmacies using a sociotechnical systems framework. The findings shed light on potential interventions that may enhance patient safety in pharmacies and facilitate improved e-prescribing use. Future studies should confirm patient safety hazards reported and identify ways to utilize e-prescribing effectively and safely in community pharmacies.
PMCID: PMC3966066  PMID: 23708439
Electronic Prescribing; Pharmacy; Health Information Technology; Patient Safety; Sociotechnical Systems
9.  E-Prescribing: A Focused Review and New Approach to Addressing Safety in Pharmacies and Primary Care 
Research in social & administrative pharmacy : RSAP  2012;9(6):10.1016/j.sapharm.2012.09.004.
E-prescribing, the health information technology (HIT) that enables prescribers to electronically transmit prescriptions to community pharmacies has been touted as a solution for improving patient safety and overall quality of care. However, the impact of HIT, such as e-prescribing on medication errors in acute care settings has been widely studied and show that if poorly designed or implemented, HIT can pose a risk to patient safety by introducing a source of medication errors. Unlike acute care settings, safety issues related to e-prescribing in primary care settings (where e-prescriptions are generated and transmitted) and pharmacies (where e-prescriptions are received) have not received as much attention in the literature. This paper provides a focused review of patient safety issues related to using e-prescribing systems in primary care and pharmacies. In addition, the paper proposes using human factors engineering concepts to study e-prescribing safety in pharmacies and primary care settings to identify safety problems and recommendations for improvement.
PMCID: PMC3709012  PMID: 23062769
10.  Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing 
This paper explored pharmacy staff perceptions of the strengths and weaknesses of electronic prescribing (e-prescribing) design in retail pharmacies using the sociotechnical systems framework. This study examined how adoption of e-prescribing technology is affecting clinical practice and patient care.
Materials and methods
Direct observations and think aloud protocols were used to collect data from seven retail pharmacies.
Pharmacists and pharmacy technicians reported strengths of e-prescribing design that facilitated pharmacy work which included: legibility, ease of archiving, quick access to prescriptions and consistency in the format of electronic prescriptions (e-prescriptions). Design weaknesses and potential hazards to patient care associated with e-prescribing systems were due to differences between pharmacy and prescriber computer systems which resulted in the selection of wrong patient or drug (name, directions, dose, strength, formulation, package sizes). There were unique strengths and weaknesses in the design of e-prescriptions peculiar to the three pharmacy computer systems examined in this study.
Findings from this study can help inform policy on creating e-prescribing design standards for pharmacy. e-Prescribing system developers can use the results of this study to identify and apply the most usable features of the three main pharmacy computer systems to design systems that support dispensing efficiency and safety.
This is the first study to highlight design flaws with e-prescribing in retail pharmacies. The sociotechnical systems framework was useful in providing an indepth understanding of the pharmacist and pharmacy technician's interface with e-prescribing technology. This information can be used by policy makers to create e-prescribing standards for pharmacies.
PMCID: PMC3534455  PMID: 22753809
Electronic prescribing; pharmacy; health information technology; medication safety; sociotechnical systems
11.  The Prescription Handoff in Community Pharmacy: a Study of its Form and Function 
To describe and explore handoffs in community pharmacy.
Descriptive, exploratory, non-experimental study
Wisconsin, August – October, 2008
Community pharmacists
Brief, face-to-face, Semi-structured interviews
Main outcome Measure
Information on characteristics of handoffs, including the reasons for handoffs, what kind of information is shared during handoffs, and how information is shared.
The overarching reasons handoffs are done in community pharmacy are because some of the necessary information is confusing, contradictory, or absent, and/or the drug product is not in stock. Handoff information typically consists of a description of the problem, the current status of the problem, what information are still needed, and future steps to resolve the problem. Handoffs can occur synchronously during a shift change or asynchronously when one pharmacist signs out at the end of the day, and another pharmacist opens the pharmacy the next morning. While synchronous handoffs are generally verbal in nature, asynchronous handoff information is primarily conveyed via paper or electronic notes on the dispensing computer system.
Our results suggest that handoffs do take place in community pharmacies and that the process is unstructured and variable. Future studies should fully characterize this process and explore possible strategies for improvement.
PMCID: PMC3624986  PMID: 23229978
handoff communication; community pharmacy
13.  Relationship between E-Prescriptions and Community Pharmacy Workflow 
To understand how community pharmacists use electronic prescribing (e-prescribing) technology; and to describe the workflow challenges pharmacy personnel encounter as a result of using e-prescribing technology.
Cross-sectional qualitative study.
Seven community pharmacies in Wisconsin from December 2010 to March 2011
16 pharmacists and 14 pharmacy technicians (in three chain and four independent pharmacies).
Think-aloud protocol and pharmacy group interviews.
Main outcome measures
Pharmacy staff description of their use of e-prescribing technology and challenges encountered in their daily workflow related to this technology.
Two contributing factors were perceived to influence e-prescribing workflow: issues stemming from prescribing or transmitting software, and issues from within the pharmacy. Pharmacies experienced both delays in receiving, and inaccurate e-prescriptions from physician offices. Receiving an overwhelming number of e-prescriptions with inaccurate or unclear information resulted in significant time delays for patients as pharmacists contacted physicians to clarify wrong information. In addition, pharmacy personnel reported that lack of formal training and the disconnect between the way pharmacists verify accuracy and conduct drug utilization review and the presentation of e-prescription information on the computer screen significantly influenced the speed of processing an e-prescription.
E-prescriptions processing can hinder pharmacy workflow. As the number of e-prescriptions transmitted to pharmacies increases due to legislative mandates; it is essential that the technology that supports e-prescriptions (both on the prescriber and pharmacy operating systems) be redesigned to facilitate pharmacy workflow processes and to prevent unintended consequences, such as increased medication errors, user frustration, and stress.
PMCID: PMC3623613  PMID: 23229979
E-prescribing; electronic prescribing; community pharmacy; workflow
14.  A qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach 
Although lack of time, trained personnel, and reimbursement have been identified as barriers to pharmacists providing cognitive pharmaceutical services (CPS) in community pharmacies, the underlying contributing factors of these barriers have not been explored. One approach to better understand barriers and facilitators to providing CPS is to use a work system approach to examine different components of a work system and how the components may impact care processes.
The goals of this study were to identify and describe pharmacy work system characteristics that pharmacists identified and changed to provide CPS in a demonstration program.
A qualitative approach was used for data collection. A purposive sample of 8 pharmacists at 6 community pharmacies participating in a demonstration program was selected to be interviewed. Each semistructured interview was audio recorded and transcribed, and the text was analyzed in a descriptive and interpretive manner by 3 analysts. Themes were identified in the text and aligned with 1 of 5 components of the Systems Engineering Initiative for Patient Safety (SEIPS) work system model (organization, tasks, tools/technology, people, and environment).
A total of 21 themes were identified from the interviews, and 7 themes were identified across all 6 interviews. The organization component of the SEIPS model contained the most (n = 10) themes. Numerous factors within a pharmacy work system appear important to enable pharmacists to provide CPS. Leadership and foresight by the organization to implement processes (communication, coordination, planning, etc.) to facilitate providing CPS was a key finding across the interviews. Expanding technician responsibilities was reported to be essential for successfully implementing CPS.
To be successful in providing CPS, pharmacists must be cognizant of the different components of the pharmacy work system and how these components influence providing CPS.
PMCID: PMC3351586  PMID: 21824822
Medication therapy management; Community pharmacy; Human factors; Work systems
15.  Commentary on the Federal Government's Role in Influencing E-prescribing Use and Research 
Electronic prescribing (e-prescribing) is one of the most studied areas of health information technology due to advocacy for its use by influential organizations such as the Institute of Medicine (IOM). In the United States, the federal government has played a significant role in encouraging use of e-prescribing technology and in stimulating associated research nationwide. The federal government has increased e-prescribing research initiatives through agencies such as the Agency for Healthcare Research and Quality (AHRQ) and the Health Resources and Services Administration (HRSA). Initial initiatives focused on the development of standards for e-prescribing systems and implementation. In recent times, e-prescribing research initiatives have become more focused on identifying unintended consequences of using this technology and identifying new possibilities of use that were previously not envisioned. Continuous studies of how healthcare professionals are interfacing with this new technology, how systems have been implemented, and the impact of this technology on healthcare processes and outcomes are crucial.
PMCID: PMC3329207  PMID: 22737095
16.  Exploring the impact of an automated prescription-filling device on community pharmacy technician workflow 
To explore community pharmacy technician workflow change after implementation of an automated robotic prescription-filling device.
At an independent community pharmacy in rural Mayville, WI, pharmacy technicians were observed before and 3 months after installation of an automated robotic prescription-filling device. The main outcome measures were sequences and timing of technician workflow steps, workflow interruptions, automation surprises, and workarounds.
Of the 77 and 80 observations made before and 3 months after robot installation, respectively, 17 different workflow sequences were observed before installation and 38 after installation. Average prescription filling time was reduced by 40 seconds per prescription with use of the robot. Workflow interruptions per observation increased from 1.49 to 1.79 (P = 0.11), and workarounds increased from 10% to 36% after robot use.
Although automated prescription-filling devices can increase efficiency, workflow interruptions and workarounds may negate that efficiency. Assessing changes in workflow and sequencing of tasks that may result from the use of automation can help uncover opportunities for workflow policy and procedure redesign.
PMCID: PMC3304454  PMID: 21896459
Automation; community pharmacy; task analysis; dispensing
17.  Development of a Scale to Measure Pharmacists’ Self-Efficacy in Performing Medication Therapy Management Services 
Measuring community pharmacists’ self-efficacy in performing medication therapy management (MTM) services can be useful for tailoring interventions and predicting participation.
To identify relevant survey constructs related to the Wisconsin Pharmacy Quality Collaborative (WPQC) MTM program and to evaluate scale validity.
The 31-item MTM Self-efficacy Scale was developed using previous research, identifying critical program components, and beta-testing. After administration to pharmacists in the 53 WPQC pilot sites, summary statistics and exploratory factor analysis (EFA) were conducted. Parallel analysis was used to determine the optimal number of factors. Internal consistency reliabilities were calculated.
Baseline participation rate was 94% (N=76). The 11-point scale (0–10) item means ranged from 2.83±3.05 to 7.82±2.19. Parallel analysis produced a 3-factor solution, accounting for 56% of the variance. Low factor loadings or unacceptably high cross-loadings resulted in 17 item deletions. The final EFA on the remaining 14 items retained the original 3-factor solution and increased the proportion of explained variance (72%). The factors relate to MTM tasks (alpha = 0.92), personal interactions (alpha = 0.86), and goal setting (alpha = 0.84). Overall Cronbach’s alpha = 0.90.
Constructs for measuring self-efficacy were identified that may aid in future research predicting whether pharmacists engage in and persist in providing MTM services.
PMCID: PMC2904078  PMID: 20511114
Self-efficacy; Medication therapy management; Community pharmacy; Scale validation; Research methods
18.  An Elective Course in Personal Finance for Health Care Professionals 
To create, implement, and assess an elective course on the principles and applications of personal finance.
A 1.5 unit (15 hours total) elective course was designed using active-learning pedagogy, lecture, and group discussion. Homework assignments were designed to provide practical tools and materials that students could individualize and apply to their personal financial goals.
Student satisfaction, using a standard course evaluation form, revealed consistent high ratings. Student enrollment increased from 19 students in its initial year to 90 students in its fourth year. Student knowledge, assessed using the Jump$tart Financial Literacy Survey, indicated significant knowledge acquisition.
Many pharmacy students are ill equipped to effectively handle the complex financial decisions they face after graduation. This course provides students with practical tools to identify appropriate ways to achieve their financial goals and critically evaluate financial advice and advisors.
PMCID: PMC2690872  PMID: 19513143
personal finance; elective; curriculum; professional development
19.  Gamma Interferon Fails To Induce Expression of Indoleamine 2,3-Dioxygenase and Does Not Control the Growth of Chlamydophila abortus in BeWo Trophoblast Cells  
Infection and Immunity  2002;70(5):2690-2693.
The BeWo trophoblast cell line does not constitutively express the tryptophan degrading enzyme indolamine 2,3-dioxygenase (IDO), nor can IDO expression be induced by gamma interferon. This correlates with the inability of BeWo cells to control the growth of Chlamydophila abortus, in contrast to effects observed in HeLa cells treated with gamma interferon.
PMCID: PMC127909  PMID: 11953413

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