Ambulatory care settings, pharmacists

Pharmacists and technicians play a major role in medication safety in modern pharmacy practice. After summarizing several studies performed in hospitals and long-term care facilities, Allan and Barker (1990) estimated that medication errors occur at a rate of about 1 per patient per day. In a more recent study performed in ambulatory pharmacies, they found an overall dispensing accuracy rate for prescription medications of 98.3 percent (Allan, Barker, and Carnahan, 2003). While most of these errors probably have minimal clinical relevance and do not affect patients adversely, many experts believe that medication error rates may be higher in the ambulatory care setting because errors may not always be evident to the health professionals who work there. For example, medication errors can occur when a patient purchases nonprescription medications without speaking with the pharmacist about any potential interactions with his or her prescription medications or if patients fail to verify the appropriate dose of the over-the-counter (OTC) medication. 

When pharmacists and technicians interpret prescriptions and medication orders, newly marketed drugs are a particular problem. Staff members are not as familiar with names of the drugs, and they tend to misinterpret them as older drugs. It is important that up-to-date education on all new medications is provided to the pharmacy staff, including any potential for error that may exist with these new products. In the ambulatory care setting, physicians can write both the generic and trade names legibly on the prescription, and they can add the intended purpose of the medication to further alert pharmacy staff to the correct medication name. 

Figure 26.2 is a flowchart of appropriate, safe, effective, and efficient use of medications in the hospital setting (12). It incorporates the role of the prescriber, nurse, pharmacist, and patient in a typical inpatient environment. It also depicts the role of the organization s pharmacy and therapeutics committee and quality improvement functions, which will be discussed later in this chapter. The decision to treat a patient in a hospital or extended-care facility typically adds a nurse or other healthcare provider (respiratory therapist, etc.) to the trio described in the ambulatory care setting. Every time that individual has to read, interpret, decide, or act is yet another opportunity for a mistake to occur. Each of the steps in the medication use process provides an opportunity for correct or incorrect interpretation and implementation of the tactics that support the therapeutic plan. With this many opportunities for medication misadventures to occur, it is easy to understand why tracking and improving quality are important aspects of medication use. 

This article is an extension of a previous American College of Clinical Pharmacy (ACCP) White Paper on Clinical Pharmacy Practice in the Noninstitutional Setting.That white paper described the functions that should be expected of clinical pharmacists in ambulatory care settings. This article assists practitioners and administrators who want to establish and evaluate services in ambulatory care and primary care settings. This article... 

About the Author Dr. Mosavin is Chair of the Department of Pharmaceutical Sciences and Associate Professor in the Department of Pharmacotherapy and Outcomes Science at Loma Linda University s School of Pharmacy. Dr. Mosavin received a B.S. in Pharmacy from the University of Kansas, a Ph.D. in Pharmaceutical Sciences from the University of Wisconsin—Madison, and an MBA from the University of Chicago. Dr. Mosavin has experience in pharmaceutical industry, hospital pharmacy, and ambulatory care pharmacy settings. His research interests encompass economic evaluation of health care delivery systems and the role of pharmacists in these systems (especially as it relates to management of chronic diseases by pharmacists). Another key area of his research is analysis of economic gains achieved by health information technology implementation in ambulatory care pharmacy practice. 

Most of the strategies discussed thus far can be applied to community pharmacy settings. However, this is not the only setting in which pharmacists offer value-added services. There are two specific practice settings that offer unique compensation strategies for ambulatory care pharmacists the physician office and the hospital-based outpatient clinic. 

The job activities, range of careers, and work settings for ambulatory care pharmacists vary as much as disease... 

The work settings for pharmacists in ambulatory and primary care clinics also vary. More recently, for example, pharmacists can be found in private physician offices or large teaching hospitals. Anywhere ambulatory care is being provided by physicians, nurse practitioners, or physician assistants, there is opportunity for pharmacist involvement. 

One benefit of practicing as an ambulatory care pharmacist is that there are a variety of practice settings. These practice sites vary from physician office buildings to physician residency training programs, as well as large hospitals and retail pharmacies. 

The majority of pharmacists who pursue residency training do so in the area of pharmacy practice. These residencies sometimes focus on a particular practice setting, such as ambulatory care. Pharmacists may also pursue specialty training in a certain topic (e.g., pharmacokinetics), in the care of a specific patient population (e.g., pediatrics), or in a specific disease area (e.g., oncology). 

Veterans Affairs pharmacists serve in a number of clinical roles including, but not limited to, pharmacist-run ambulatory clinics, members of interdisciplinary care teams, patient education, pharmacokinetic evaluations, therapeutic consultation, and research. These services are provided in various inpatient, long-term, and ambulatory patient care settings. Most clinical pharmacists will have advanced professional degrees (M.S. or Pharm.D.), postgraduate training, and/or sufficient professional experience. Clinical pharmacy specialists are... 

The focus on disease state management and outcomes will require that data on a patient s dmg therapy be accessible to both hospital and ambulatory care providers. The pharmacist can play an integral role in the coordination and dissemination of these data. For example, institutional pharmacists will need to establish communication links with pharmacy providers in other settings to ensure optimal and seamless care. ... 

The typical work settings for clinical pharmacists in a health system include acute care hospital, ambulatory clinic, outpatient pharmacy, home care pharmacy, and community pharmacy. 

Pain management is a significant expectation of the JCAHO in their year 2000 surveys. Expectations not only include established treatment pathways, but also documentation of outcomes and patient satisfaction. Pharmacists, whether in acute or home health care, community, or ambulatory settings should strive to become leaders in the area of pain management. 

The pharmacist communicates the elements of the plan to the patient and/or the patient s other healthcare providers). The pharmacist shares information with other healthcare providers as the setting for care changes, in order to help maintain continuity of care as the patient moves between the ambulatory, inpatient or long-term care environment... 

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