Monthly Archives: June 2011

PEO: Pharmacotherapy Evaluation and Optimization


The past week I have been at Burnaby Hospital for my PEO (Pharmacotherapy Evaluation and Optimization) rotation with Dr. Aaron Tejani. It is mentioned as one of my elective rotation, however I did not pick this rotation as one of my electives. When I looked at my schedule, it just said ‘PEO’. I was not even aware what the abbreviation meant. But hopefully by the end of the rotation, I would be able to achieve all the objectives of the rotation. I am excited to learn something new and understate the roles of a Drug Use Evaluation Pharmacist. According to the description of the rotation posted on one 45, following are the goals of PEO rotation:

To understand and apply the concepts of drug use evaluation as a broad based systematic program that promotes and improves rational drug use in hospitals in Fraser Health. These concepts include:

1. Developing criteria for therapeutic appropriateness (reviewing and comparing evidence from clinical trials, assessing most appropriate indications for the drugs and evaluating their safety data)

2. Developing patterns of use of drugs, region wide or in individual institutions (overutilization, underutilization, incorrect dosage, inappropriate duration)

3. Pharmacoeconomic evaluation (cost utility, cost effectiveness, cost benefit, cost minimization, cost per quality adjusted life year gained)

One of my main objectives is to perform literature reviews and critically analyze the study design, methodology, bias, significance, and generalizability of results and conclusions of the trial and apply the acquired knowledge to my practice. Currently, I am assisting with the Directed Studies Project: Inappropriate use of IV PPIs in Fraser Health.
I read the past articles assessing the inappropriate use of IV PPIs and it was surprising to find out that over 60% of it is used inappropriately. We are in the process of writing the protocol which would be a very helpful when writing the protocol for my project.

I am also working on developing a survey to find out the reasons behind pharmacists not switching from IV to PO medications even though they have the authority to do so.

I am looking forward to the next three weeks and attaining the goals of this rotation. I am sure that the knowledge gained through this rotation would help me in becoming a competent pharmacist.

Administration: Final week


The past week I got the opportunity to shadow Bruce Millin and understand the roles of an Executive Director and a pharmacy leader. Bruce is a busy man with LMPS Pharmacy Services, Financial Monitoring, Policies & procedures, staff development, performance planning and human resource planning under his portfolio at RCH, ERH, PAH and DAH. The entire week was a great learning experience. We attended two teleconferences and few in person meetings. We (Greg and myself) worked as a team on our budget assignment and our mini-project: Developing an Interview tool for the position of a grade two pharmacist. I prefer working as a team as Greg shared his wisdom and experience which helped me understand key concepts and complete assignments. Shadowing Bruce helped me develop an understanding of the principles and roles of management & leadership and the role of the department within the Fraser Health Authority.

We discussed pharmacy technician regulation at a great length and it’s impact on pharmacy staff recruitment.
Other key concepts discussed during evaluation: Leaders ensure people are doing the right thing and managers make sure people are doing it right. A manager manages tasks vs. a leader who leads people and creates vision. A manager controls processes and helps in implementation of the vision.
Another lesson I learnt is that learning is a life long process and as a health care professional I am committed to self-improvement. Life-long learning is more than just completing a CE course and much more than what I learn in pharmacy.

During one of the meetings, we were exposed to a real-life situation where communication played a big role in the cause and management of an issue. The take home message from the incident is that as a health care professional you need to communicate effectively with patients, fellow-workers, administrative staff and other health care workers. Email is one of the least effective means of communication in resolving a conflict or discussing a problem as it is difficult to comprehend the other person’s tone and facial expressions. There are times when we are in a rage and send out emails that could be perceived differently from what our intent was. Therefore, it might be a good idea to wait for a day before you send out an angry email and think over.

We finished the week with Academic Half-Day session with Dr. Loewen presenting on project research on Friday. The session exposed us to steps we need to take to finish our project and the do’s and don’ts to be followed during the entire process. The session was very helpful. I also attended the Medication Safety session in the afternoon. I am glad I attended the session even though we had a lecture with Mark Collins on the same topic because I was exposed to more real life incidents relevant to medication safety. It also helped in reinforcing the concepts I learnt on my first day of administration rotation.

Oh I finally have a drop box account!

Abbreviations I get confused about:
RFP: Request for proposal and ROP: Required Organizational practices

Day 5


Human Resource Planning and Collective Agreement: This topic was completely new to me. Terms like FTE, HEU and HSA are new additions to my memory bank. I had no clue about the process employed by health authorities during the hiring process. For example in case of HEU (Pharmacy Technicians) the determining factors are efficiency (1/3rd), required qualifications including initiative (1/3rd) and then seniority (1/3rd); there is no tie-breaker. However, for HSA (Pharmacists) capability, performance, qualifications and then seniority (tie-breaker) is taken into account. I need to review this topic again. In order to accomplish this I would go over Dr. Millin’s notes again when they are sent out.

Community Programs: Dr. Priti Flanagan reviewed community pharmacy programs structure and discussed planning, designing and implementing chronic disease management programs in Fraser Health. She exposed us to the Medication Management Program run by Fraser Health and its impact on reducing costs incurred by the health system. The medication management program consists of home visits by pharmacists where a patient’s medications are reviewed, outdated and unneeded medications are removed, aid options (e.g. blister packs) are introduced as needed, and recommendations are given to the patient and the family physician.

I found this information from Fraser Health’s website: “Seniors taking more than 6 medications, at risk of drug interaction, with kidney or liver failure, or with dementia or confusion are typically referred to the program. In addition, pharmacists involved in home visits are automatically alerted of individuals over the age of 65 who have been recently discharged from the hospital and who are taking six or more medications. Additionally, there is a medications return program which enables the safe disposal of expired or unused medications.”

Drug Distribution Systems and Pharmacy Drug Distribution Center: This session was led by Tessa Valg and Bal Dhillon. We discussed the drug distribution system plan for Fraser Health and reviewed the structure, function and staffing of the PDDC. The PDDC provides 4 main services: bulk CIVA select products, CIVA patient specific services bulk, purchasing services and bulk unit dose packaging services. We were told that we would spend a whole day at PDDC during our Distribution rotation and then we would be tested. I did not grasp everything that was explained to us in the half an hour tour of PDDC. Therefore, I am going to make sure I take good notes during my next visit and also go over the slides that would be sent out by Bal Dhillon next week. It was surprising to know that the whole center operates without a pharmacist.

Day 4


New concepts learnt:
Open (provide anything that anyone wants) vs. closed (selective list) formulary.
Other categories:
Formulary unrestricted, Non-formulary, Excluded category and formulary restricted

Hospital authorities need to keep factors like storage, cost, waste reduction in mind. Pharmacare (name changed to Pharmaceutical Services Division) doesn’t need to worry about inventory control. Their focus is simply funding and to provide drugs that are safe, effective and are most cost effective.

Hospital Act: Hospitals should provide whatever is clinical necessary for the patient. But if we are obliged to provide everything, then we need open formulary but there are issues with having a open formulary. Striking a balance is difficult. As the average length of stay in hospital is only 5 days, providing medications to patients as compared to using their own like advair and tiotropium results in cost incurrence. Other issues related to sending medications home include no records on pharmanet, cost issues for the patient after discharge, absence of labeling on the canister.

BC Health Authority Pharmacy & Therapeutics Committee and the associated medication formulary alignment initiative: It is hard to include everyone in order to make a decision. We discussed issues surrounding consolidation of the health authorities in lower mainland. P & T committee is responsible for making additions and deletions to the formulary. The rest of the session has been summarized by Herb Wong really well and I referred to the following link: I went on the Ministry of Health Services website and found more information about Drug Review Process and Drug Benefit Council. It was interesting to know that some of our faculty members are part of DBC and Drug Review Resource Committee. As suggested by Dr. Tejani I also looked at the drugs that are going to be reviewed: hydromorphone, febuxostat, paliperidone palmitate and lacosamide. I was unaware of the fact that elgibile BC residents can provide input for consideration by the Drug Benefit Council using online questionnaire or a printed questionnaire. I also explored some links to CDR review of the drugs posted on the website. Overall, this session was very informative and I look forward to my PEO rotation with Dr. Tejani.

Later on the afternoon, we had a session with Pharmacy Technician Supervisor, Harinder Takhar and she helped us understand the role of the Technician Supervisors and potential innovative technician roles in pharmacy department. I was unaware of some roles played by pharmacy technicians for example, clinical pharmacy support technician, Drug use evaluation technician and STAT delivery service Technician.

Day 3


Rajwant Minhas Residency Competency Self-Assessment-BASELINE

Today we learnt about parenteral drug therapy manual. It was a great learning experience as I had no prior knowledge of how drug manuals are put together and how much effort goes into preparing each one.  We learnt about the differences between drug manuals of different health authorities. The next step for me is to explore Fraser Health’s consolidated drug manual on my own and understand how to use it.

The next session was about Clinical Practice Leaders and we were given insight into how a clinical pharmacist differs from clinical pharmacist specialist and a pharmacist. Before this lecture, I was unaware of terms like clinical pharmacist specialist and clinical pharmacy leaders.

Gregory and me stayed behind yesterday to work on our budget assignment. In order to understand the organizational levels we referred to the LMPS organization chart under Director Bruce Millin, who is also our mentor for Administration rotation. The chart helped us understand the hierarchy better and gain more understanding of our assignment. Budgeting is a definitely a hard task and requires a deep understanding of a hospital’s needs such that patient care is not jeopardized and finances are kept under control.

Day 2

Day 2: The day started off with Mark Collins showing us a video about drug safety. It was an eye opener as I didn’t know how many patients die because of medication errors during their stay in the hospital. Even the best pharmacist, physician or a nurse can make a error given the right circumstances. I was moved by the grief experienced by families of the patient and feeling of guilt a health care professional has to overcome. We learnt that on average only about 10% of the errors are reported. Therefore, we need to get better at reporting errors as this would help us in improving the system and preventing these errors from occurring. We should not blame the person, but should strive towards fixing the system.
The overall message of the session was to become an active participant, know our ROPs () and take action. Dr. Collins shared an example of fentanyl overdose at a hospital in BC where the pharmacist followed the guidelines listed in the product monograph due to unfamiliarity with the dosing guidelines used by the hospital (where the recommended dose was much lower). This resulted in respiratory depression in the patient and action was taken to notify the manufacturer and change their recommended dose. I also learnt that constraints and restricting the concentration and amount of medication on the ward is the most effective strategy to prevent medication errors versus educating the staff.
Dr. Collins ended the session with a great message, “You don’t know what you don’t know, you have to experience it. Learn from others, check in with others, let them guide you.
High alert drugs: Check it 3 times. Don’t give in to peer pressure, take your time. Take individual responsibility.
Dr. Virani’s part: We learnt how fraser health is organized as an organization. We also gained some insight into how much money goes into running the pharmacy department.



As we start our first rotation tomorrow, one of my biggest goal is to be organized. There have been times in the past when I realized that if only I was a little more organized, I would saved a lot of time. I plan to accomplish this by making good use of my agenda, checking emails on time, setting deadlines for myself at least a day before the actual deadline and by making sure I get all my questions answered on time. Our ‘Survival Guide’ ends with

YOU WANT WHAT? Everyone in the department is very busy. You will be given the opportunity to learn a little about some of the various responsibilities that many of the individuals in the department may have; thereby appreciating their busy schedule. This has a number of ramifications for the resident. Although, you will find that all LMPS-FH Pod (especially the pharmacy) staff are generally very friendly & willing to help: DO NOT AUTOMATICALLY ASSUME THAT THE PHARMACY DEPARTMENT REVOLVES AROUND YOU. You will need to develop some foresight & planning/organizational skills during your residency year. When you have that paper to type; data to collate; PowerPoint to produce; handout to format; poster to develop; room to book; drug information matter to discuss…. Etc…. Do not assume that individuals may be able to drop everything & assist you. They may also be in a panic situation & unable to help. Then, they may be going on holidays for a long time to recover. You will need to plan for such an occurrence. When everyone concerned is aware of what you may need, well in advance, you are much more likely to achieve success in your endeavours.

This paragraph caught my eye and is a kind of a wake up call. I need to stay on top of things during these next twelve intense months. Everything has a set schedule and not finishing a task on time would disrupt the rest of the schedule. Also, Dr. Dillon reiterated this during the orientation session that if things are started well in advance, it is much easier to sort out problems. He gave us an example of a past resident where his chosen residency project didn’t commence due to communication issues. Therefore, I am going to try my best to make sure I have an open communication with my preceptor in terms of his expectations, my goals and objectives and my responsibilities. I plan to do this by asking my preceptor questions in the first couple of days i.e. regarding what does he expect me to do, receive verbal feedback from him regularly (Check point Friday or more often if possible). This would assure that we are on the same page and I accomplish goals in time.