Law Exam 1

7 Lectures

Tip of the iceberg principle

Look at the big picture first and then investigate details

Simplified steps of answering a question

Receive, Research, Respond, Record

What information is being received

Background - helps to give effective response and find out what they are really looking for and pt. data

Demographics - helps determine mode of response given and its depth

Categorization - helps develop rational search strategy and what resources to use.

Is answering a question formulaic

No it involves communication and context

Background questions to consider when receiving

Patient-specific question, treatments already tried, resources already consulted

Failure to receive proper background information

Can result in the correct answer to the wrong question

What should you focus on receiving

Patient factors, disease state factors, medication factors

Steps to researching the question

Start with tertiary resources, then secondary, then primary. Evaluate quality of sources being used.

Parts of responding to a question

Analysis - critically assess evidence gathered and critique review

Synthesis - use logic and reasoning to form a coherent reply

1. Form opinions

2. Make judgements

3. Draw conclusions

4. Make Recommendations

Parts of a reply

Intro, body, conclusion, references, secondary questions

Why record after answering a question

Verify appropriateness, verify process used, and provide updates if new information becomes available

When do you do a DI consult

Whenever a complex question is asked that needs written documentation to answer

Who is the audience of a DI consult

Primary - the person who asked

Secondary - Nurse, RT, dietitians etc.

What is the purpose of a DI consult

To provide a solution, voice concern, relay findings, and convince your audience through analysis to use your recommendation

Critical parts to a DI consult

Obtaining background info, identifying the ultimate question, evaluating retrieved literature, relating information found to the question asked

Parts of a DI consult

Introduction/purpose, pt. assessment, literature review, analysis and synthesis, Conclusion, references

Introduction of DI consult

A brief and concise summary. Includes important background info such as PMH, FH, SH, and physical/objective findings. Includes the ultimate question.

DI pt. Assessment

Evaluation of the situation/patient. Can include medical records, patient interview, and lab data. Factual.

DI literature review

Summary of evidence. Requires interpretation of information found.

DI Analysis and Synthesis

Based on the evidence what conclusions can be drawn. Leads to development of your recommendation. Present treatment options for each problem assessed.

DI Conclusion

Contains no new information. Provides exact and specific recommendation.

What are P&T Committees

multidisciplinary bodies that evaluate and manage medication use to ensure safety, efficacy, and cost-effectiveness within healthcare organizations.

P&T Structure

Size is variable and consists of voting and non-voting members. Can have subcommittees. Basically medical staff.

Role of P&T

Formulary Criteria for use, policies/procedures, MUE/quality assurance, adverse drug reaction monitoring/reporting, educational initiatives, medication safety

What are some policies and procedures P&T develop

Therapeutic interchange, automatic stop dates, standard administration times, use of PRN orders, meds from home, investigational drugs.

What organizations use P&T committees

Institutional pharmacy, ambulatory care, insurance companies, Medicare/Medicaid, Manage care organizations, state/federal public institutions, long-term care facilities, employers.

What does P&T do in the PBM setting

Design, implement, administer outpatient drug benefits.

What is a formulary

It is a continually revised list of medications that are readily available for use within an institution or 3rd party that reflects the current clinical judgment of the medical staff or payer. Good for inventory control, cost effectiveness, and familiarity.

Open formulary

Everything is on it

Closed formulary

Limited

Positive formulary

Starts with nothing adds

Negative formulary

Starts with everything subtracts

Role of pharmacists on P&T

prepare agenda, prepare materials, present materials, answer questions, follow-up actions (prepare policies, education, safety reporting)

How do DI centers help P&T

Prepare materials, policies, and participate in other therapeutic policy activities (ADRs, MUEs).

Drug monograph/class reviews

Necessary for rational evaluation of medications. Drug monographs assist in the decision making process for P&T. Monograph is not the package insert.

Drug Regimen Review

DRR. Monthly review of drug regimens in managed care facilities. Mandated by CMS. Goal is to ensure proper drug therapy for each resident.

What do consultant pharmacists do

Perform DRRs. Help develop policies and procedures for facilities, they round with physicians.

Drug Utilization Review

An ongoing review of prescribing, dispensing, and use of medication. 3 Types: Prospective, Concurrent, Retrospective

Goal of DUR

Decrease fraud, decrease abuse, decrease inappropriate or unnecessary care

Drug use Evaluation

Retrospective evaluation of drug use. Concurrent evaluations of prescribing and outcomes.

Goal of DUEs

Provide feedback to clinicians and develop criteria/standards for medications.

Medication Use Evaluation

Focused effort to evaluate medication use processes or treatment response. Goal is to optimize patient outcomes (increase performance). Mandated by the joint commission. Examples include targeted drug and disease state management programs.

Purpose of MUEs

Evaluate effectiveness, improve patient safety, standardize therapy, optimize therapy, meet standards, minimize costs

How to perform MUE

Collaborative effort and responsibility. Guidelines are developed as part of formulary process. Should be focused on one specific goal.

Example Steps of MUE

1. Evaluate effectiveness of therapy

2. Follow-up response

3. Patient population management

4. Patient Satisfaction

Example Quality Improvement methods

1. Construct hypothesis

2. Test by experiment

3. Analyze data

4. Communicate results

Interventions, Education, Restriction, Process change, follow up and repeat

MUE analysis

Multidisciplinary group should oversee or review finding and discuss possible outcomes. Are standards to rigorous? Is performance lacking? Is there opportunity to improve?

Utilization management

Tools used by health plants to administer pharmaceutical benefits.

Examples of utilization management

Prior authorizations, step therapy, quantity limits, generic substitution

Medication Misadventure

Any hazard or incident associated with medications

Medication Error

A preventable event that has the potential to lead to inappropriate medication use or patient harm

Adverse Drug Event

Any injury caused by medicine

Adverse drug reaction

An unexpected or unintended excessive response to a medication

ADR severity Classification

Minor, Moderate, Severe, Lethal

ADR Classification by Mechanism

Idiosyncrasy, intolerance, drug interaction, pharmacologic, hypersensitivity

Naranjo algorithm

Only shows probable relationship between exposure to a medication and an ADR. Does not prove causality.

Reporting Mechanism for ADRs

FDA MedWatch, FDA Adverse Event Reporting System, Vaccine Adverse Event Reporting System

Key players for addressing ADRs

Healthcare agencies, professional organizations, practitioners, pharmacists

Common Types of Medication Errors

Wrong patient, time, dosage form, route, rate, duration

Patient Safety and Quality Improvement Act

Created Patient Safety organizations which help with monitoring safety

Factors that could lead to medication errors

Handwriting, abbreviations, prescription errors, look alike packaging, bedside mix up, order entry error

ISMP

Institute for Safe Medication Practices

3 Modes of Human Performance

Skill-based, Rules-based, Knowledge based

System Approach to Human Errors

Emphasize strategies that rely on system design.

Simplify and standardize, reduce memory reliance, improve information access, use constrains and forcing functions.

What is just culture a balance of

Institutions, systems employed, and behaviors of employees

Continuous Quality Improvement

Training and hiring practices. Evaluate distractions. Evaluate gaps.