administrative barriers in pharmacy

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An interesting paradox was noted with pharmacy and pharmacy technicians' reactions to the increased information available to them through the new system. California Privacy Statement, ABM, AJM, JEB, DM and ZA have all made significant contributions to the scientific content of this manuscript. PZ Minard LV, Deal H, Harrison ME, Toombs K, Neville H, Meade A. Common complaints included “bar codes not scanning” and the wireless scanner battery draining at inopportune times. One pharmacy leader explained, “As roles changed, certain people embraced the changes more than others. “It is not fair to cancel the Saturday and Sunday services. We analyzed the interview notes for common themes with the aid of ATLAS.ti software (Scientific Software Development, Berlin). Computers in ambulatory care: implications of physician practice patterns for system design. H Third, a shift in workforce capacity may be necessary, with a focus on clinicians who understand workflow issues well enough to redesign processes and are also trained to select appropriate technologies and manage vendor relationships. N 2015;15:83. . GJ (DOCX 13 kb), Coding guide. Pharmacotherapy. Conventional content analysis across all focus groups did not reveal different themes, and thus, we present our findings according to our primary data analysis plan. This finding is consistent with a study that has shown pharmacists’ self-perception as barriers to their extended roles [43]. Briefly, the analysis involved identifying contextualized brief statements related to the barriers and facilitators to medication safety activities, categorizing statements into TDF domains and mapping the underlying theoretical constructs within domains. Pharmacotherapy. Medication reconciliation as a medication safety initiative in Ethiopia: a study protocol. This practice was originally intended to limit the number of daily fills by increasing the volume of medications dispensed. These included hardware and software problems, and the role of vendors. Administrative barriers of trade are larger in poor countries than in rich ones. Development, implementation and diffusion of Ehr systems in Denmark. For example, another technician added, “My responsibilities have increased [to include checking the medication dose and frequency, tracking the medication and identifying and intercepting errors as opposed to just dispensing the medication] but not because someone told me to do something. Derived from the TDF, the factors identified in this study were clustered into six domains: ‘Knowledge’, ‘Skills’, ‘Environmental context and resources’, ‘Motivations and goals’, ‘Social influences’ and ‘Social/professional role’. Improving patient safety by identifying side effects from introducing Bar coding in medication administration. Also, in a geographically and organizationally coherent area like the pharmacy, systems may be so interconnected that it is impractical to implement components one at a time. Bussières AE, Patey AM, Francis JJ, Sales AE, Grimshaw JM, Canada PRIme Plus Team, et al. EG Cookies policy. According to Michie et al. Second, policy makers should actively promote knowledge sharing from the implementation process itself, as implementation challenges directly threaten the quality and safety of health information technology.16,17 Health information technology projects sponsored by various agencies within the federal government such as the office of the national coordinator for health information technology (ONCHIT) and the Agency for Healthcare Research and Quality (AHRQ) provide ideal mechanisms for this information exchange. Certain pharmacy technicians thought that they were not adequately trained and identified this as an obstacle to system implementation. First, the vendor should provide long-term on-site formal training and support that covers all shifts. This work was supported in part by a grant from the Agency for Healthcare Research and Quality # HS14053-02. . Using this code list, two independent reviewers iteratively coded a subset of three transcripts, modifying the code list and the code definitions as necessary, until they reached 89% reliability, defined as the fraction of phrases that were coded in an identical manner by both reviewers.41 One reviewer subsequently coded the entire set of field notes. First, in institutions where the numbers of specialists were fewer, the input from pharmacists was taken as crucial and thus, the rate of pharmacist’s acceptance was better. 2012;7:38. Another contributor to resistance was negative perceptions about the technology. SAGE Open Med. To identify means to overcome communication barriers. Interview guides were translated from English versions to the local language (Amharic) by two non-official translators who are native speakers and working in the health care industry and validated by two of the research group (ABM, DM). Another reported, “I now have the ability to see dosing frequencies and understand the principles of drug regimens!” Increased information empowered the technicians and pharmacists to be more involved in the pharmacy processes, leading to an increased sense of involvement in patient care. As indicated above, these are six common barriers to timely medication administration we see frequently. But, this had been stopped for a while. All the authors have read and approved the final manuscript. 2007;27:481–93. In this instance, it might be difficult to determine the origin of barrier and facilitator and prioritize interventions [48]. Patient safety has become a hot-button topic in research and media during recent years. Aarts Research in Social and Administrative Pharmacy. However, in Ethiopia, this role has been launched recently and little is known regarding the current status of this extended service. 2011;4:377–82. Cullinan S, Fleming A, O'Mahony D, Ryan C, O'Sullivan D, Gallagher P, et al. On the other hand, HCPs who were supportive and ready to accept pharmacists’ input did have some know-how about clinical pharmacy or had been exposed to some form of sensitization workshops. PubMed  Barcode Medication Administration Understanding patient safety risks. Most of the solutions to medication errors, such as computerized physician order entry (CPOE) systems, have focused on reducing errors at the medication ordering stage.4,5 However, dispensing errors are estimated to occur at a rate of nearly 4%, of which only 80% are intercepted. DJ 2015;79:860–9. Gorman To address many of these technology issues, pharmacists and pharmacy leaders identified the role of vendors as a critical success factor. PubMed  Reddy Various mentions were given for this. For instance, medication review was done with a limited scope, and there were no organized ways to perform medication reconciliation. Available from: http://www.csa.gov.et. BMC Pediatr. Changing roles were also an important cause of resistance among staff as some had entirely different job descriptions with the new system. For example, these services were not done over the weakened and duty programs were stopped for a while, and participants believed this had imposed work burden when getting back to work on Monday. Electronic prescribing reduces prescribing error in public hospitals. C J Multidiscip Healthc. Cullen Research in Social and Administrative Pharmacy (RSAP) publishes monthly/twelve times per year, featuring original scientific reports, comprehensive review articles, proposed models, and provocative commentaries in the social and administrative pharmaceutical sciences.Topics of interest include outcomes evaluation of drug … Clinical pharmacists and inpatient medical care: a systematic review. To target other domains (e.g. We encouraged these people to become champions and placed them up on pedestals so that they could set an example for the others.”. 2015;10:e0136545. The use of information technology in improving medical performance. Adequate training, continuous improvement, and adaptation of workflow to address one's own needs mitigated process barriers. Pharm Pract. J BMJ Open. To the extreme, awareness issues from the pharmacy side were severe and its implication in the service delivery process was highly significant. A This case report describes barriers to, and facilitators of, the implementation of a pharmacy bar code scanning system to reduce medication dispensing errors at a large academic medical center. Unertl The level of acceptance was different from institution to institution. 2015;8:448. In this case example, the hospital chose a “big-bang” approach by implementing the entire bar code scanning system within a short time frame. Although there existed some level of recognition from various sides, yet there had been a lack of awareness regarding the role of hospital pharmacists in medication safety activities at the level of health bureau, regional or federal level. During ward visit, hospital pharmacists took medication history and used it for pharmaceutical care decisions; however, this was done inconsistently and the evidence-base was not clear to many. Pratt Cadogan CA, Ryan C, Francis JJ, Gormley GJ, Passmore P, Kerse N, et al. Regarding medication safety activities delivered by hospital pharmacists, it was mentioned that professional compatibility was not a concern but what matters was the lack of understanding of the profession’s mission in the eye of other health care cadres. Pharmacists' perceptions of the barriers and facilitators to the implementation of clinical pharmacy key performance indicators. One leader explained that “Scanning is an art. E A Another problem occurred when some products had bar codes on reflective surfaces that were difficult to scan. As compared to interns, the GPs [General practitioners] accept you better” [Referral hospital, Focus group#3]. French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie S, et al. CURRENT REFORM EFFORTS 5 Timeline for FIAS’s Work on Administrative Barriers 5 III. There were no remuneration schemes or incentives arranged for pharmacist’s cognitive services. For example, the region allows duty only for dispensing, and for this reason, at least to collect 500 or 600 birr for the duty program we are doing it rather than the clinical service. There existed considerable interrelationships between domains that were perceived to influence hospital pharmacists’ behaviours, and this may assist in designing behaviour change interventions that target common behavioural domains. 2017;17:359. Much debate around this issue has been documented in the literature.17 Although our work cannot universally endorse the big bang approach, in this case it seemed to be a reasonable choice. The greatest perceived barriers to the provision of pharmacy services involved financial and administrative considerations. “…those [pharmacists] who have knowledge about the service, and know what the service is about, support the service we are doing. For example, inadequate training, process flow issues, and technology shortcomings contributed to resistance as pharmacy staff felt overwhelmed and developed negative perceptions about the technology. Implement Sci. On the other hand, environmental constraints identified in the current study were prominent, and there was none which was mentioned as facilitator in the context of resource issues. Mekonnen AB, McLachlan AJ, Brien JE. Bates Medication errors in the Middle East countries: a systematic review of the literature. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A, et al. Ammenwerth [45] have also confirmed that Ethiopian graduate pharmacists are very much enthusiastic to promote clinical pharmacy service but the challenge is the minimal effort made at the level of institutions. AJM, JEB, DM and ZA critically reviewed and revised the manuscript. In an effort to get the pharmacy technicians familiar with scanning, the pharmacy implemented bar code-assisted dispensing for medications destined for the neonatal intensive care unit (NICU) 1 year before full deployment of the bar code scanning system. 2012;7:82. Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing. Search for other works by this author on: Correspondence: Eric Poon, MD, MPH, Division of General Medicine and Primary Care, Brigham and Women's Hospital, 3/F 1620 Tremont St, Boston, MA 02120 (Email: Incidence of adverse drug events and potential adverse drug events. The underpinning theoretical model used in this study is the Theoretical Domains Framework (TDF). If the government is committed, for example, to order every health care professional to review our recommendation, like nurses, are checking the progress notes of physicians, physicians should also review the progress notes of clinical pharmacists, and give their decision as accepted or rejected. 2002;59:2070–7. prescribing behaviour [32, 35], prescribing and dispensing behaviour [35] and ADE reporting [33]), our study included a range of bundled interventions, also termed as clinical pharmacy services. As with any large project, the pharmacy bar code scanning system implementation had to overcome a few unexpected challenges, which usually involved workflow redesign. Fortunately, the team also identified many strategies to overcome it. Cook To what extent do you think these entries barriers protect established pharmaceutical companies from new competitors? PubMed  PubMed Central  Fortunately, our informants identified many strategies to overcome these barriers. The respondents who reported a desire to have more training available made suggestions ranging from formal training sessions to simulation laboratories to “super-users”. “With seniors, there is no problem to accept your recommendation. In addition, those HCPs who believed in team and collaborative works were the most likely candidates for promoting clinical pharmacy services. “We suffered so much when we studied CP and the work is challenging, but we are treated as previous pharmacists who studied a little bit advanced courses. Participants reported that ward-based hospital pharmacy services were limited in scope and delivered inconsistently. Two interviewees were pharmacy leaders, four were pharmacists and four were technicians. J Clin Pharm Ther. However, most pharmacists hesitated whether this had been met, given the lack of government funding and support for these services. PubMed Central  Even though most technicians were familiar with scanning and were given additional informal training, this was a challenging period. Technology has great potential to reduce medication errors in hospitals. In a large hospital, these error rates can translate to more than 45,000 undetected dispensing errors annually.6–8. Acad Med. Most importantly, although all participants frequently and consistently reported the ‘Environmental context and resources’ domain without variation in their views, it was found that there existed some important interlinks with the domains judged to be relevant. Electronic medical Record implementation barriers encountered during implementation. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the theoretical domains framework. Our results are consistent with barriers to CPOE system implementations that are reported in the literature.18,24,25 Ash reported that when clinicians have access to more information with which to make decisions, and when the system fits with their workflow, they tend to use it. I don't think it was the additional information on the labels [that changed how we work together but it was instead] a result of needing each other to get the system implemented.” This collaboration and teamwork further fostered self-motivation and information sharing. Barriers and facilitators to hospital pharmacists’ engagement in medication safety activities: a qualitative study using the theoretical domains framework. Implement Sci. A theory based identification of such factors provides a theoretically robust evidence base to inform implementation of an intervention [30]. Champions were well-respected pharmacists and technicians who took on leadership roles during system implementation by encouraging users to look beyond any immediate frustrations, working through hurdles with them, and reminding them of the system's downstream benefits. Pharmacy Students’ Attitudes towards Learning Communication Skills - a Study among Nordic Pharmacy Students. Telles et al. Before, we did weekend services, and even there was duty program and we did CP service and those things at least moralize us” [Referral hospital, Focus group#1]. Increasing the uptake of evidence into clinical practice and improving patient outcomes needs behaviour change. Pharmacy management systems used by community pharmacies often limit electronic documentation to medication dispensing information. The authors declare that they have no competing interests. JA Beso 2014;83:572–80. In 2010, we wrote a commentary titled “Are Pharmacists the Ultimate Barrier to Pharmacy Practice Change?” 3 In that article, we suggested that pharmacists’ personality traits, including lack of confidence, fear of new responsibility, paralysis in the face of ambiguity, need for approval and risk aversion, were the heretofore unspoken barriers … Mekonnen AB, Yesuf EA, Odegard PS, Wega SS. To err is human: building a safer health system. The role of information technology in pharmacy practice is dynamic and not likely to lose relevance in the coming years. W Islam R, Tinmouth AT, Francis JJ, Brehaut JC, Born J, Stockton C, et al. Increased time and resources would have been required to ensure that the training was appropriate for a range of skill sets and tailored to individual differences in learning curves. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. Despite these promising results, few hospital pharmacies have implemented bar code scanning technology. “From the perspective of staff, I am feeling like a person giving free service” [Referral hospital, Focus group#1]. Overall, environmental constraints were highly referred by hospital pharmacists as being a major barrier to the delivery of medication safety activities. E The mean clinical experience and age of the participants were 2.4 and 25.8 years, respectively (Table 1). J Pharm Policy Pract. JL The channel structure of the pharmaceutical industry, in part because of the level of regulation applicable to it, has the potential for idiosyncratic strategic behaviour. Bouvy JC, De Bruin ML, Koopmanschap MA. Also, the scanning system eliminated the pharmacists' need to spend a significant portion of time double-checking drugs that were manually dispensed or manually cross-checking the patient and medication. For example, most participants believed that what they were doing was a mere initiative from their side and not a cascaded role that was approved and endorsed by the government. . volume 11, Article number: 2 (2018) Maybe [the leadership] did not get as much buy-in up front as we could have.” Clear communication around workload expectations during the implementation process may mitigate much of these misunderstandings and the resulting staff resistance. Fernandez-Llamazares CM, Calleja-Hernández MÁ, Manrique-Rodríguez S, Pérez-Sanz C, Durán-García E, Sanjurjo-Sáez M. Prescribing errors intercepted by clinical pharmacists in paediatrics and obstetrics in a tertiary hospital in Spain. We present this case report to capture our lessons learned during a recent successful implementation of a pharmacy bar code scanning system at a large academic center. Duncan EM, Francis JJ, Johnston M, Davey P, Maxwell S, McKay GA, et al. If given the support from the management, participants considered this as their major driving force for their motivation. Article  Through five iterative readings of the field notes, we developed a code list to characterize the factors that influenced the system implementation. Lipworth W, Taylor N, Braithwaite J. They were instead able to focus on collaborating with the technicians and resolving any discrepancies that the system revealed. Part II. Article  These errors may occur during any stage of the medication use process including ordering, transcribing, dispensing, administering, and monitoring. Fortunately, in the current study, the domains that have been found with some interrelationships were included in the priority list of behaviours for possible intervention. II. et al. Kitzinger J. Qualitative research. Our case suggests that these principles hold true not only for physicians but also for pharmacists and pharmacy technicians with varying backgrounds, responsibilities and levels of education. Westbrook J, Reckmann M, Li L, Runciman W, Burke R, Lo C, et al. Implications for prevention. Available from: http://apps.who.int/medicinedocs/documents/s22467en/s22467en.pdf. With regard to social/professional role, there had been numerous unfinished assignments that due attention, according to the participants. Ash Koppel Trainings were arranged occasionally; however, most were not suitable to the interest of strengthening clinical pharmacy services. Int Arch Med. Medication errors in the southeast Asian countries: a systematic review. Hsieh HF, Shannon SE. Shawahna R, Rahman NU, Ahmad M, Debray M, Yliperttula M, Decleves X. These domains included ‘Knowledge’, ‘Skills’, ‘Environmental context and resources’, ‘Motivation and goals’, ‘Social influences’, and ‘Social/professional role’. First, hospital leaders need to consider the true cost of technology implementation, beyond just software and hardware. “So, the changes I have seen at the management is like incentives for us” [Mixed hospitals, Focus group#8]. Poon Carcillo . The theoretical domains that were judged to be relevant were identified by considering the frequencies of the beliefs reported, the presence of conflicting beliefs, and evidence of strong beliefs that may influence the behaviour under investigation [34]. Forty-four hospital pharmacists took part in eight focus groups, comprising four to nine participants per group (Table 1). 2016;9:7. Also, medication errors and adverse drug events in Ethiopia are believed to be significant public health problems [7,8,9,10,11], and studies in this regard are increasingly been published. For example, the pharmacy information system was originally set up to dispense medications at standardized times each day. Hospital pharmacists expressed their beliefs from the broader array of these services, and beliefs for each of the afro mentioned domains should have been thus, viewed from that angle. . Tonnesen Like most implementations of a new technology, several technical problems affected system implementation. This study has several strengths and limitations. We conducted a qualitative analysis of the barriers to, and facilitators of, the pharmacy bar code scanning system implementation, taking a close look at sources of resistance and how to overcome them. Jaggi “He [the hospital manager] is ambitious to develop the service more. (DOCX 13 kb). . Actually, the main prescribing authority rests on them. People need to practice to get used to the technique.” Consequently, as the technicians gained more experience with scanning, their comfort level with the new system increased. Leape Alemayehu B. Mekonnen. Computerized physician order entry systems in hospitals: Mandates and incentives. The TDF has been extensively applied across a range of clinical behaviours such as prescribing, adverse drug event reporting, and transfusion behaviours [32,33,34,35]. Eshetie TC, Hailemeskel B, Mekonnen N, Paulos G, Mekonnen AB, Girma T. Adverse drug events in hospitalized children at Ethiopian university hospital: a prospective observational study. 2008;6:20–4. Qual Saf Health Care. 2013;1:2050312113502959. 2010;19:42e47. MAS enhances patient care service offerings, ... barriers, such as transportation restrictions, injection phobias, or other physical or psychological challenges, and they could AC The … They are not clinical based” [Referral hospital, Focus group#3]. Blumenthal 2012;7:86. Participants represented from eight hospitals, the majority of whom were males (n = 39). 2013;33:11–21. To some degree, pharmacists are interested in information technology because we can envision it increasing efficiency in our daily tasks and improving our access to vital information. We also understand that you are frequently asked to do more … While other studies focused on some specifically targeted behaviours (e.g. From the perspective of managerial support, managers overlooked clinical services but more focused on dispensing roles and that was attributed majorly to the lack of staff to take over the dispensing role. Using the theoretical domains framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study. For example, training requirements are less uniform than those of physicians during CPOE implementation due to a larger variation in education and skill level within a pharmacy. C 2005;14:26–33. PN However, creating something out of nothing was challenging, and lacked remuneration, and a concern among the majority of hospital pharmacists. Using information technology to reduce rates of medication errors in hospitals. J of Pharm Policy and Pract 11, 2 (2018). Physical barriers, such as a speech impediment, poor mental ability, deafness and poor sight, can be easily identified and we make allowances when dealing with such people. Introducing focus groups. Drug Saf. Vermeulen KM, van Doormaal JE, Zaal RJ, Mol PG, Lenderink AW, Haaijer-Ruskamp FM, et al. Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Korach OL, et al. Springer Nature. JP JS She graduated from MCPHS University Boston in 2015. The Ethiopian health care system is challenged by poor health care financing, and close to 80% of the health expenditure is dependent on out-of-pocket expense [28], and the population mainly receives health services from public health institutions. MC statement and Lorenzi Venkataraman Franz Most participants were very much enthusiastic for their extended roles and were positive towards the future of the profession; however, competing priorities along with the lack of remuneration and awareness (of other health care professionals) regarding the profession’s role were barriers to service delivery. The hospital pharmacy employs sixty-one full time equivalent pharmacists and 45 full time equivalent pharmacy technicians. “We are going far from the place where we are, but other HCPs follows patients at their own site” [District hospital, Focus group#6]. 2013;17:R266. 2012;5:15. Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors. The hospital pharmacist plays a prominent role in cutting adverse drug events, and medication errors [20], and medication safety activities, such as drug use evaluation, admission medication histories, adverse drug reaction management, and participation in medical rounds are believed to be associated with reduced mortality rates [21]. Many informants reported other cases where continuous improvement principles were successfully incorporated into the system implementation process. 2. PubMed Google Scholar. Although this is not necessarily an administrative barrier, it may indicate that health professionals should look to raise awareness and provide comprehensive training for INSPECT users. However, the issue of medication reconciliation was new to the local setting, and we intended to ask our interviewees from the broader perspective rather than as an isolated element, and interview questions had been designed, accordingly. By allowing the technicians to optimize their own workflow, the pharmacy leaders overcame these unexpected challenges and fostered a collaborative working environment. Shabot This region is inhabited by approximately 20 million people and comprised of 19 public hospitals, and 796 health centers [27]. In contrast to other studies which also judged beliefs about capabilities [49], beliefs about consequences [33, 49], memory/attention and decision processes [32, 35, 49] as relevant domains for a successful medication safety intervention, these domains in our study were described infrequently (‘Memory/attention and decision processes’) and varied little (‘Beliefs about capabilities’), and participants were confident enough in the positive impact of clinical pharmacy services (‘Beliefs about consequences’). Using the Theoretical Domains Framework (TDF), we aimed to identify the barriers and facilitators to hospital … T Franklin BD J Poon MM DW 2016;11:e0152903. One pharmacist commented: “During identifying DTPs [drug therapy problems] and any other problems related to medications, they are considering like we are pointing the one who is responsible for the care of the patient” [Mixed hospitals, Focus group#8]. Ash Wilson RM, Michel P, Olsen S, Gibberd RW, Vincent C, El-Assady R, et al. 2015;10:161. There were also participants expressed their views that managers acknowledged the importance of clinical pharmacy services and highly appreciated it but because of the staff shortage matters, those pharmacists who were working in the hospital wards were assigned to the dispensing rooms. 2016;6:e012322. The main problem is with other staffs below seniors; they need an approval from seniors. Ash . And because of this, most pharmacists preferred dispensing to clinical services. Han Karsh “…we are working for the benefit of the profession, not for us, we are paying our life, and we are wishing only the best future” [District hospital, Focus group#6].“…we are working expecting the future might be bright” [District hospital, Focus group#6].

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