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2.  Management of Hospital Formularies in Ontario: Challenges within a Local Health Integration Network 
Background:
Expenditures on drugs dispensed and administered to patients in Canadian hospitals have been estimated at $2.4 billion per year. Pharmacy and therapeutics (P&T) committees play a key role in the evaluation and management of drug therapies in this setting. Hospitals differ with respect to the composition of these committees, their members’ expertise, and the processes used for making formulary decisions.
Objectives:
To examine the current processes for formulary drug review from the perspective of P&T committees and their individual members, and to examine the needs and preferences of these stakeholders related to evidence review and potential collaborative drug review processes within a large Local Health Integration Network (LHIN) in Ontario.
Methods:
Twenty-three sites within 10 hospital corporations in LHIN 4 (Hamilton Niagara Haldimand Brant) were recruited. A 2-part questionnaire was developed and pretested for clarity and comprehensiveness. The institution profile section of the questionnaire was to be completed by pharmacy directors and the P&T section by committee members.
Results:
Ten pharmacy directors and 28 committee members representing 10 P&T committees responded. A mean of 6.4 new drug requests were reviewed annually by each P&T committee. Across the LHIN, the workload associated with reviewing submissions for new drugs to be added to the formulary represented 0.84 full-time equivalent. The quality of clinical evidence in the drug submissions was rated more favourably than the quality of economic evidence; furthermore, the use of economic evidence was limited by a lack of health economics expertise within the committees. A centralized review process for the LHIN was perceived as beneficial to improve efficiency, the quality of review, and standardization, and also to reduce costs.
Conclusions:
Across the Hamilton Niagara Haldimand Brant LHIN, considerable time and resources are spent on the review of potential new drugs for addition to the hospitals’ formularies. A standardized formulary review process, with greater use of provincial and national drug reviews, would likely benefit all LHINs.
PMCID: PMC4924938  PMID: 27402997
pharmacy and therapeutics committee; hospital formulary; decision-making; pharmacoeconomics; survey; Canada; comité de pharmacologie et de thérapeutique; liste locale des médicaments; prise de décision; pharmacoéconomie; sondage; Canada
3.  Appropriateness of Dabigatran and Rivaroxaban Prescribing for Hospital Inpatients 
Background:
Recent approval of the new oral anticoagulants dabigatran and rivaroxaban has led to rapid changes in anticoagulant prescribing practices. Postmarketing reports have highlighted safety concerns with these agents, and their use outside of evidence-based recommendations was noted at the authors’ centre.
Objectives:
To determine the incidence of and risk factors associated with inappropriate prescribing of dabigatran and rivaroxaban.
Methods:
This retrospective cohort study investigated randomly selected dabigatran or rivaroxaban prescriptions for patients admitted to a tertiary teaching hospital between January 2010 and December 2012. Appropriateness of prescribing was determined from the documented indication, drug dosage, patient’s renal function, and presence of drug interactions, if applicable.
Results:
Among a total of 321 medication orders reviewed, the incidence of inappropriate use was 31.2% (34/109) for dabigatran and 26.9% (57/212) for rivaroxaban. Of the 97 reasons for inappropriate use that were identified, the most common were prescribing for an unapproved indication (49/97 [50.5%]), concomitant prescribing of another anticoagulant (22/97 [22.7%]), and high prescribed dose (9/97 [9.3%]). The prescribing service was found to be an independent risk factor for inappropriate prescribing (p = 0.041). Corrections were made to 23.1% (21/91) of the incorrect regimens before hospital discharge. In a sensitivity analysis using calculated ideal body weight to estimate renal function, the overall incidence of inappropriate prescribing increased to 31.5% (101/321).
Conclusions:
The proportion of patients with inappropriate prescribing of dabigatran or rivaroxaban in clinical practice was higher than expected. Educational interventions and pharmacy-led initiatives with a focus on appropriate indications, concomitant anticoagulant prescribing, and review of dosage regimens are recommended to improve patient safety.
PMCID: PMC4924939  PMID: 27402998
anticoagulants; prescribing patterns; medication safety; dabigatran; rivaroxabans; anticoagulants; habitudes de prescription; sécurité des médicaments; dabigatran; rivaroxaban
4.  Chemotherapy Order Entry by a Clinical Support Pharmacy Technician in an Outpatient Medical Day Unit 
Background:
Pharmacy technicians are expanding their scope of practice, often in partnership with pharmacists. In oncology, such a shift in responsibilities may lead to workflow efficiencies, but may also cause concerns about patient risk and medication errors.
Objectives:
The primary objective was to compare the time spent on order entry and order-entry checking before and after training of a clinical support pharmacy technician (CSPT) to perform chemotherapy order entry. The secondary objectives were to document workflow interruptions and to assess medication errors.
Methods:
This before-and-after observational study investigated chemotherapy order entry for ambulatory oncology patients. Order entry was performed by pharmacists before the process change (phase 1) and by 1 CSPT after the change (phase 2); order-entry checking was performed by a pharmacist during both phases. The tasks were timed by an independent observer using a personal digital assistant. A convenience sample of 125 orders was targeted for each phase. Data were exported to Microsoft Excel software, and timing differences for each task were tested with an unpaired t test.
Results:
Totals of 143 and 128 individual orders were timed for order entry during phase 1 (pharmacist) and phase 2 (CSPT), respectively. The mean total time to perform order entry was greater during phase 1 (1:37 min versus 1:20 min; p = 0.044). Totals of 144 and 122 individual orders were timed for order-entry checking (by a pharmacist) in phases 1 and 2, respectively, and there was no difference in mean total time for order-entry checking (1:21 min versus 1:20 min; p = 0.69). There were 33 interruptions not related to order entry (totalling 39:38 min) during phase 1 and 25 interruptions (totalling 30:08 min) during phase 2. Three errors were observed during order entry in phase 1 and one error during order-entry checking in phase 2; the errors were rated as having no effect on patient care.
Conclusions:
Chemotherapy order entry by a trained CSPT appeared to be just as safe and efficient as order entry by a pharmacist. Changes in pharmacy technicians’ scope of practice could increase the amount of time available for pharmacists to provide direct patient care in the oncology setting.
PMCID: PMC4924940  PMID: 27402999
pharmacy technician; clinical support; chemotherapy order entry; time- and- motion studiese; technicien en pharmacie; soutien clinique; saisie d’ordonnances de chimiothérapie; études des temps et mouvements
5.  Factors Influencing Fourth-Year Pharmacy Students’ Decisions to Pursue a Hospital Pharmacy Residency 
Background:
The Canadian Society of Hospital Pharmacists promotes the recruitment of residency-trained pharmacists for work in hospitals and related health care settings. However, Quebec hospitals are still hiring non–residency trained pharmacists, in part because of a severe shortage of hospital pharmacists. To date, no studies have examined the factors influencing the career choices of fourth-year pharmacy students in Canada.
Objectives:
To identify motivating factors and barriers influencing students’ decision to pursue a hospital pharmacy residency.
Methods:
All 186 fourth-year students in the Faculty of Pharmacy, Université de Montréal, were invited by e-mail to participate in a validated and institutionally approved survey that was available online between March and May 2014.
Results:
Of the 138 respondents who returned a completed survey (74% response rate), 36 (26%) planned to apply for a hospital pharmacy residency. Those planning to apply for a residency were older (p = 0.037) and had more hospital work experience (36% versus 3%, p < 0.001) than those not planning to apply. The most important motivators for pursuing a residency were potential gains in knowledge (reported by 88% of respondents, whether or not they were planning to pursue a residency), experience (80%), and self-confidence (62%). The most frequently reported barriers were recognition that a hospital pharmacy residency is a highly demanding program (65%), having work available upon graduation from the undergraduate program (43%), and financial obligations (34%). Hospital experiential rotations influenced, either positively or negatively, 23 (72%) of the 32 students who changed their decision to pursue or not pursue residency training over the course of their studies.
Conclusions:
The potential gain in knowledge and experience acquired through residency, the fact that it is considered a highly demanding program, and having work available upon graduation from undergraduate studies were the most influential factors in fourth-year pharmacy students’ decision of whether to pursue a hospital pharmacy residency.
PMCID: PMC4924941  PMID: 27403000
pharmacy education; residency training; pharmacy student; career choice; enseignement de la pharmacie; résidence; étudiant en pharmacie; choix de carrière
6.  Causes of Health Care Workers’ Exposure to Antineoplastic Drugs: An Exploratory Study 
Background:
The exposure of health care workers to antineoplastic drugs is associated with several adverse health effects, including reproductive toxicities and mutagenic effects. Recent studies have confirmed that Canadian health care workers are at risk of exposure to these agents. However, the causes leading to occupational exposure to antineoplastic drugs are unknown.
Objective:
To perform an exploratory study to ascertain the immediate and contributing causes of health care workers’ exposure to antineoplastic drugs.
Methods:
Participants were recruited from 6 acute care facilities in Vancouver, British Columbia. Those agreeing to participate were asked to complete a questionnaire about previous exposure to antineoplastic drugs while at work and to describe the circumstances of each exposure incident. Responses were qualitatively analyzed, and the causes of each incident were classified as immediate (unsafe work acts and/or unsafe working conditions) or contributing (related to the management of the organization, the environment, and/or the physical and mental status of the worker).
Results:
Completed questionnaires were received from 120 participants, 18 (15.0%) of whom reported having had previous occupational exposure to antineoplastic drugs. Qualitative analysis of the responses showed 4 categories of immediate causes (needlestick injury, spill, direct contact, and other unintended exposure) and 3 categories of contributing causes (poor communication, inadequate controls, and lack of training). Some incidents had multiple immediate and/or contributing causes.
Conclusions:
According to a review of the immediate and contributing causes identified in this study, many of the exposure incidents were deemed preventable. A “hierarchy of controls” should be implemented, including (in the following order) engineering controls, administrative controls, and personal protective equipment. The findings of this study can be used to develop job safety analyses, which can in turn be adopted in guidelines for safe handling of hazardous drugs. Future similar studies are suggested to ensure the generalizability of results.
PMCID: PMC4924942  PMID: 27403001
antineoplastic drugs; occupational exposure; causes; exploratory study; antinéoplasiques; exposition professionnelle; causes; étude préliminaire
7.  Domperidone-Associated QT Interval Prolongation in Non-oncologic Pediatric Patients: A Review of the Literature 
Background:
Domperidone is a prokinetic agent used to treat pediatric gastroesophageal reflux disease. Health Canada has issued warnings about an increased risk of domperidone-associated ventricular arrhythmias and sudden cardiac death. However, the supporting data referred only to adult patients; therefore, extrapolating the safety risks to pediatric patients is difficult.
Objective:
To summarize and evaluate the evidence for domperidone-associated QT interval prolongation, ventricular arrhythmias, and sudden cardiac death to determine the safety of this drug for pediatric patients.
Data Sources:
Two databases (MEDLINE [1946 to August 2015] and Embase [1980 to August 2015]) were searched with the following Medical Subject Headings and keywords: “domperidone”, “arrhythmias, cardiac”, “death, sudden, cardiac”, “electrocardiography”, “heart diseases”, “long QT syndrome”, “tachycardia, ventricular”, “torsades de pointes”, and “ventricular fibrillation”. The search was limited to studies conducted in humans under 18 years of age and published in English.
Study Selection and Data Extraction:
Original research included in this review reported on the cardiac-related safety of domperidone in nononcologic patients under 18 years of age.
Data Synthesis:
Of the 5 studies meeting the inclusion criteria (n = 137 patients), one reported a statistically significant change in the corrected QT (QTc) interval, but the clinical significance was unclear. Most of the studies reported rare occurrences of pathological QTc intervals in a limited number of patients. However, confounding factors (e.g., abnormal electrolyte level or concurrent medications) were not consistently considered. Potential bias might have been alleviated by blinding of electrocardiogram (ECG) assessors; however, this was not consistently implemented. The designs of the included studies did not allow assessment of causality. The results should be interpreted with caution.
Conclusions:
Although the available evidence is limited, pathological QTc intervals were noted among a small number of infants, which supports the possibility of domperidone-associated risk of prolonged QTc interval. Because of the potential severity of QT interval prolongation, individual assessment and routine ECG monitoring should be implemented for patients receiving domperidone.
PMCID: PMC4924943  PMID: 27403002
domperidone; QT interval prolongation; arrhythmia; pediatrics; dompéridone; allongement de l’intervalle QT; arythmie; pédiatrie
17.  Accepting the Torch 
PMCID: PMC5085316  PMID: 27826149
18.  Accepter le flambeau 
PMCID: PMC5085317  PMID: 27826150
19.  Un vent de changement 
PMCID: PMC5085332  PMID: 27826165
20.  Winds of Change 
PMCID: PMC5085333  PMID: 27826166
21.  Antipsychotic Drug Use and Screening for Delirium in Mechanically Ventilated Patients in Canadian Intensive Care Units: An Observational Study 
Background:
Critically ill patients frequently experience delirium, and antipsychotic drugs are often used to manage symptoms.
Objectives:
To describe the use of antipsychotic drugs and delirium screening tools in mechanically ventilated, critically ill adult patients in Canadian intensive care units (ICUs) and to identify factors associated with the use of antipsychotic drugs.
Methods:
Pharmacists from 51 Canadian ICUs prospectively collected data on antipsychotic use and delirium screening in all patients for whom invasive mechanical ventilation was initiated during a chosen 2-week period occurring sometime in 2008 or 2009.
Results:
Data were collected for a total of 712 patients, of whom 115 (16.2%) received at least one dose of an antipsychotic. The antipsychotic prescribed, the total daily dose, and the administration schedule varied across sites. Delirium screening tools, validated for use in mechanically ventilated patients and endorsed by professional society guidelines, were part of routine care in a minority of ICUs (7/51 [13.7%]), and delirium screening was documented for few patients overall (41/712 patients [5.8%]). In a multivariable analysis, administration of antipsychotics was independently associated with longer duration of mechanical ventilation (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.07–1.17), daily interruption of sedation (OR 1.71, 95% CI 1.01–2.90), and use of physical restraints (OR 2.15, 95% CI 1.27–3.65).
Conclusion:
A minority of mechanically ventilated patients in Canadian ICUs received antipsychotic drugs, and screening for delirium with validated tools was rare. Antipsychotic drug use was independently associated with longer duration of mechanical ventilation, daily interruption of sedation, and use of physical restraints.
PMCID: PMC4853177  PMID: 27168631
antipsychotic; delirium; screening; mechanical ventilation; intensive care; antipsychotique; délire; dépistage; ventilation mécanique; soins intensifs
22.  Evaluation of Heparin Anticoagulation Protocols in Post–Renal Transplant Recipients (EHAP-PoRT Study) 
Background:
Disturbances in hemostasis are common among renal transplant recipients. Because of the risk of thromboembolism and graft loss after transplant, a prophylactic heparin protocol was implemented at St Paul’s Hospital in Vancouver, British Columbia, in 2011. Therapeutic heparin is sometimes prescribed perioperatively for patients with preexisting prothrombotic conditions. There is currently limited literature on the safety and efficacy of heparin use in the early postoperative period.
Objectives:
The primary objectives were to document, for patients who underwent renal transplant, the incidence of major bleeding and of thrombosis in those receiving therapeutic heparin, prophylactic heparin, and no heparin anticoagulation in the early postoperative period and to compare these rates for the latter 2 groups. The secondary objectives included a comparison of the risk factors associated with major bleeding and thrombosis.
Methods:
Adult patients who received a renal transplant at St Paul’s Hospital between January 2008 and July 2013 were included in this retrospective cohort study. Electronic health records and databases were used to divide patients into the 3 heparin-use cohorts, to identify cases of major bleeding and thrombosis, and to characterize patients and events. The Fisher exact test was used for the primary outcome analysis, and descriptive statistics were used for all other outcomes.
Results:
A total of 547 patients were included in the analysis. Major bleeding was observed in 6 (46%) of the 13 patients who received therapeutic heparin; no cases of thrombosis occurred in these patients. Major bleeding occurred in 8 (3.0%) of the 266 patients who received prophylactic heparin and 9 (3.4%) of the 268 who received no heparin (p > 0.99). Thrombosis occurred in 1 (0.4%) and 3 (1.1%) of these patients, respectively (p = 0.62). Major bleeding occurred more frequently among patients with a low-target heparin protocol, but 61% of values for partial thromboplastin time were above target. A larger proportion of deceased-donor transplant recipients who had major bleeding were taking antiplatelet agents, relative to living-donor transplant recipients.
Conclusion:
Therapeutic use of heparin increased the risk of bleeding among renal transplant recipients, but there were no cases of thrombosis. Prophylactic use of heparin did not increase the risk of bleeding and prevented proportionately more cases of thrombosis relative to no anticoagulation; this result supports the continued use of prophylaxis.
PMCID: PMC4853178  PMID: 27168632
kidney transplantation; heparin; postoperative anticoagulation; hemorrhage; thrombosis; transplantation rénale; héparine; anticoagulation postopératoire; hémorragie; thrombose
23.  Opinions of Hospital Pharmacists in Canada Regarding Marijuana for Medical Purposes 
Background:
Canada’s most recent Marihuana for Medical Purposes Regulations have changed the way in which patients access marijuana. Furthermore, if authorized by the person in charge of the hospital, a pharmacist practising in a hospital may now place orders with licensed producers for dried marijuana for in-hospital use by patients. As use of this product increases, hospital pharmacists may have an increased role in the care of patients who are using marijuana for medical purposes.
Objectives:
The primary objective of this study was to determine the opinions of hospital pharmacists in Canada regarding marijuana for medical purposes. The secondary objective was to assess the factors influencing these opinions.
Methods:
An online survey was made available in early 2015 to licensed hospital pharmacists in Canada through individual provincial and territorial pharmacy regulatory bodies, pharmacist associations, hospital pharmacy directors, the Canadian Society of Hospital Pharmacists, and the Association des pharmaciens des établissements de santé du Québec. Responses were based on a 5-point Likert style scale, ranging from “completely agree” to “completely disagree”.
Results:
A total of 769 valid survey responses were received. Among the respondents, 44.6% (333/747) agreed that marijuana is safe, whereas 55.2% (411/745) agreed that it is effective. Only 17.2% (129/748) agreed that they were knowledgeable about marijuana for medical purposes, and about 65% of respondents reported no formal training in this area. Factors that influenced respondents’ opinions were age, education, area of clinical practice, province of work, and personal experience.
Conclusion:
Many Canadian hospital pharmacists agreed that marijuana for medical purposes is safe and effective, yet few considered themselves knowledgeable about this substance, with more than half reporting no formal training on the topic.
PMCID: PMC4853179  PMID: 27168633
medical marijuana; Marihuana for Medical Purposes Regulations; hospital pharmacists; safety; efficacy; knowledge; marihuana à des fins médicales; Règlement sur la marihuana à des fins médicales; pharmaciens d’hôpitaux; sécurité; efficacité; connaissance
24.  Use of the International Pharmaceutical Federation’s Basel Statements to Assess and Advance Hospital Pharmacy Practice: A Scoping Review 
Background:
The Basel statements of the International Pharmaceutical Federation, which provide the first global, unified vision for the hospital pharmacy profession, have recently been revised. Originally released in 2008, the Basel statements have since been made available in 21 languages, and thus have the potential for great impact around the world.
Objective:
To conduct a scoping review to examine the extent and nature of research activity related to the Basel statements.
Methods:
Google Scholar, PubMed, and International Pharmaceutical Abstracts were searched using the key term “Basel statements” for relevant research articles. From each included study, data were extracted on geographic location, study design, study outcomes, and use of the Basel statements.
Results:
The search strategy generated 113 results. Further refinement resulted in 14 English-language articles that met the inclusion criteria. Four of these articles focused on adapting the Basel statements to European practice, an initiative of the European Association of Hospital Pharmacists that led to development of the European statements of Hospital Pharmacy. Six studies focused on monitoring hospital pharmacy practice in Uganda, the Pacific island countries, and the Western Pacific Region. These studies provide valuable baseline data to measure and track the development of hospital pharmacy practices in their respective countries and regions. The remaining 4 studies used qualitative methods to explore the barriers to and facilitators of implementation of the Basel statements in South Africa, China, and Australia.
Conclusion:
The Basel statements have led to multiple initiatives around the world, involving more than 70 countries. The European and Western Pacific regions have been the most active. Current initiatives should be continued to ensure identification and resolution of issues related to sustaining their use over time.
PMCID: PMC4853180  PMID: 27168634
Basel statements; International Pharmaceutical Federation; hospital pharmacy practice; scoping review; global; déclarations de Bâle; Fédération internationale pharmaceutique; pratique de la pharmacie hospitalière; examen de la portée; mondial

Results 1-25 (769)