Monthly Archives: August 2011

Week 4: Distribution

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This week I mainly focused on verifying orders. Later on in the day, I discussed the activities performed during the day with my preceptor and asked any questions I had. I found some drug related problems and flagged them for the clinical pharmacist. I appreciated the way my preceptor stimulated learning by asking me more questions whenever I asked him questions vs. giving the answer away. I discovered that it is a logical process and involves linking different pieces of information acquired over the past 4 years to solve a problem. I definitely need more practice verifying orders and being systematic with the process I follow to assess the appropriateness of the order.
I also got the opportunity to shadow the oncology pharmacist and understand her role.

I completed 2 mini-projects for this rotation.
#1: Created a list of community pharmacies in the vicinity of Royal Columbian Hospital
#2: List of useful resources for pharmacists

Overall, it was a great learning experience! I will keep practising order verification. I am sure I will feel more comfortable doing it after doing some clinical rotations.

Week 3: Distribution

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Monday and Tuesday: At Abbotsford Hospital
On my first day I followed the technician taking care the narcotics. This was my first introduction to the Pyxis machine and its usefulness in the distribution setting. I got a chance to access the machine and use it to obtain drugs following the specific steps. I found it to be very secure and accurate. The second day I learnt about the steps followed every morning to distribute the drugs to different wards. Today I recieved more detailed knowledge about the system in terms of different drawer types. At the end of the day I was examined on the Pyxis system and Clinical Data categories. It was a good exercise as it gives me feedback on which parts I need to improve my knowledge and helps me reinforce my existing knowledge.

Wednesday: As we had academic half-day today, we had limited time to spend at SMH to learn about TPN. We gowned up and observed the technician setting up for the procedure. Later on, we entered some adult and TPN orders using test and real patients.

Thursday: ERH
It was interesting to learn about a different distribution sytem besides traditional dose packaging and automated dispensing system. ERH follows the unit dose system packaging. They recently transitioned from carfill system to cartless system. As compared to the other sites I have been to, ERH is a relatively smaller site. I got a brief tour of the site and observed technicians performing their different roles. I got a chance to enter my first order. I thought it would be difficult to get a hang of it, but because of a technician’s and my preceptor’s help I was able to grasp it well. It would take me time to learn about different commands, learn about wardstock and pharmacy items depending on the site and get used to doctor’s handwriting. And all this would come with more practice and training. It was interesting to learn about the nurses’ opinion on the new cartless system. I talked to two nurses and they like the switch to the new system as it is more systematic, convenient and time-saving for them.

Friday: PDDC
I am glad I got a second chance to learn about the procedures and systems followed at PDDC to prepare drugs for different sites in Fraser Health. We had a brief tour of the center during our first week of Residency but it was quick and I didn’t register everything.

There are no pharmacists as part of the distribution system, but there are pharmacists located in offices above the facility for advice and direction. The standardized procedures are based on a “tech-check-tech” system.
Activities performed:
CIVA: Observed the pharmacy technician setting up the hood for mixing and preparing IV medications for different sites.
Learnt about PacMed and Pentapack unit dose packaging machines
Practised mixing medications with expired products

Overall, it was an interesting week as I gained knowledge about different drug distribution systems used at different sites and their merits and shortcomings.

Distribution: Week 2

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Week 2: Distribution
Monday and Tuesday: Attended SES Conference
Wednesday: Verified orders, checked with the pharmacists if I had any questions.
Thursday: Discussed Site procedures, PDTM and TPN with Raymond.
Meeting with Dr. Loewen: Today was the first time during residency when I really felt that I am not applying my knowledge well. When I met up with Dr. Loewen, I told him everything was going fine and it has been a smooth transition, but if he had asked me few hours later it would have been a different answer. Later on in the afternoon, I discussed the orders that I had verified with my preceptor. After discussion, I realized I was not using the process of Necessary, Effective, Safe and Adherence when assessing orders. Although, I followed the process for renal failure patients I failed to think through it for all the patients. Initially, I paid attention to technical things (for example when an order of metronidazole was entered as 500 mg Q8H vs. Q12H), but as a pharmacist my role is to verify the order in terms of its requirement by the patient, safety and efficacy along with checking if it was entered correctly. I am glad we had this discussion as it would make me focus more on paying attention to clinical details. It is a learning process and I will get better and better.

Friday: Verified orders, discussed TPN and orders I verified
Today was much better as I was more comfortable with verifying orders. For each order I followed the steps of assessing the prescription by focusing on if it was necessary, effective and safe.

What does “Commitment to the profession” mean personally to me?

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Before starting to answer this question, I gave it a lot of thought. It reminded me of the ‘White Coat Ceremony’ back in the first year of pharmacy. The ceremony marks our entrance into faculty and confirms our commitment to the profession of pharmacy. However, back then I did not really take it seriously perhaps because I didn’t really understand the deep meaning. I still had 4 years ahead of me and did not what the journey was going to be like. Conversely, today I believe in the pledge. Here is how and why:

After attending the Networking Night organized by the Canadian Society of Hospital Pharmacists, the amount of knowledge I had about hospital pharmacy and the practitioners working in this setting has expanded. Everyone is so different and has so much to contribute. The stories describing their journey to the world of pharmacy are different; some are here by chance, some wanted to pursue hospital pharmacy since the early days of their high school or post-secondary education but one thing that binds them together is their passion for patient care. They love what they are doing! And that is why they were at the educational sessions, travelled miles to listen to their colleagues, asked questions and engaged in discussions.

Patients come first. When I decided to pursue a career in pharmacy, I knew that there is no room for “9-5” attitude in this profession; I should be available for my patients whenever required. And yes, when I spoke to the practitioners present at the residency networking night, I felt like I didn’t know anything and wondered how I would ever get to that stage and what if I make a mistake. However, at the same time I have to remember that practice makes one perfect and these feelings are normal at the beginning. The more I ask questions to my preceptors, complete the assigned tasks and make the best of the opportunities provided to me, the easier it would be for me on the day when there is no one to watch me and when I will be fully responsible for taking care of my patients myself. In order to become a competent health professional and provide the best care to my patients, I will work hard.

There is no way I will retain everything or know everything about pharmacy but my focus is to make my best efforts to keep myself up to date with current and new knowledge. One of the reasons I decided to pursue pharmacy and then hospital pharmacy is because I enjoy challenges. Change excites me! Browsing through books or internet to find out an answer is what keeps me going! I remember when I was doing my 4th year rotation at Nanaimo Regional General Hospital, I was always looking up information; be it an abbreviation used by the doctor, a drug I had no clue about or any procedure mentioned in the discharge report or a patient’s chart. There were times when I got to the hospital at 7 am in the morning and left at 7 pm at my own will. Not because I was told to be there for so long, but because I enjoyed what I was doing! I have heard numerous stories about residency being intense and then you hit a point where your brain is full and you cannot take it any more. It might be the case with me at the end, however I am going to keep an open mind and try my best to learn as much as I can. I won’t know everything but my focus is to FOCUS ON THE CONTROLLABLES!

As I mentioned in my residency application, after residency I have future plans which will keep me in the student mode. Not sure when yet, but I am interested in doing a PharmD and in the future I would like to be a preceptor for undergraduate students and future Pharmacy Residents. This way I will get an opportunity to give back to the profession and make a difference.
After typing my response to this question, I decided to google what other people have to say about commitment to profession. I stumbled upon this book, Professional nursing: concepts & challenges by Kay Kittrell Chitty. Comparing profession with occupation, she states that professions consider their profession as an integral part of their life. They gain satisfaction from their work which surpasses their desire for money or other materialistic rewards. I remember back in first year when I shadowed a pharmacist at Surrey Memorial Hospital, he told me a similar story. He mentioned that even though his earnings would be higher as a community pharmacy, it is the job satisfaction that encouraged and inspired him to work in the hospital setting.
Therefore, I am looking forward to another year of being a student as a resident and hopefully more to come….

E-Tips for Practice Education

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What? The modules were a great learning tool in terms of getting exposure to how to become an effective preceptor. I have always been blessed with great preceptors who have been very encouraging and supportive. In my application to the residency program, I had expressed my desire to become a preceptor in the near future. I hope I can be a role model for someone and make a difference!

So What?

Pre-Course Reflection Form (Available on E-Tips website: http://www.practiceeducation.ca/courses/file.php/2/Printable_Docs/PREcourse_Reflection_Forms_ETIPS.pdf).

Post-Course Reflection Form (Available on E-Tips website: http://www.practiceeducation.ca/courses/file.php/2/Printable_Docs/POSTcourse_Reflection_Form_ETIPS.pdf)

These forms could not be saved and uploaded after filling them in, so I have typed my responses to the questions in the word document. It contains both pre and post course reflection:
Reflection Form

Now What? Outcome of the event, what changes if any do you intent to make in my role as a practice educator as a result of this program?

A conflict may interfere with the effectiveness of learning and teaching. There are different sources of conflict and sometimes is inevitable. Since high school, I have never taken a course which discussed conflict resolution skills until E-Tips. These tips would be handy in work setting as well as in personal life when a conflict arises.

Resolving a conflict:
I found the following the strategy described in the module on how to communicate assertively helpful:
D: Describe the situation rationally and briefly
E: Express your feelings about the situation
S: Specify desired changes
O: Outcome or results that may occur

Key Message: Be as clear as you can about your expectations and check your student’s understanding of your expectations.

Conflict Management Styles
Collaboration is the best style as it is a win-win for both the parties

It is important to:
• Stay ‘cool’ Manage Yourself
• Be clear about your own intentions. What do you want to accomplish?
• Focus on intended outcomes
• Watch yourself (be an observer) and notice your own internal and external language
• Don’t vent. Describe your feelings without judging or blaming
• Take a break if you feel yourself losing clarity

Discuss the conflict in a positive way
Try to look at conflict as a learning opportunity and don’t let it go unresolved.

Reflecting upon myself as a teacher is very important as well. I will make sure that I ask the student for feedback on regular basis as well and understand how he/she would like me to assist.

Distribution Rotation: Week 1

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As I haven’t had any experience working in the community or hospital setting besides my pharmacy rotations, the distribution rotation is my first ‘real’ exposure to hospital pharmacy. My SPEP rotation was mainly clinical and I only spend couple of hours in the dispensary. Almost everyone in the dispensary has asked me about my previous pharmacy experience. I am trying to ask as many questions as I can and the pharmacists and assistants have been very helpful so far. So far I have performed the following activities:

Orientation
Observed pharmacy assistants filling out the orders and checking the end product, filled out some orders (this was helpful as I got to different dosage systems)
Observed and performed ward stock check
Observed delivery narcotic medications to different wards
Observed aseptic preparation of CIVA products
Discussion with preceptor regarding Fraser health policies and procedures e.g. Non-formulary drugs, Formulary drugs, Excluded drugs, Restricted drugs and Patient’s own medications
Discussion with preceptor regarding CIVA: advantages and disadvantages
Academic Half Day on Distribution at Vancouver General Hospital
Spent time in dispensary and checked some orders with the help of the pharmacist

Second week: I will be at the SES conference on Monday and Tuesday. On Wednesday we will discuss CIVA, PDTM (Parentral Drug Therapy Manual), TPN and site procedures in detail.
Thursday: Clinical Trial, Oncology, Pediatrics, NICU.
During my third week, I will be off site at different hospitals in Fraser Health gaining knowledge about different technology used for distributing medications.

I have been assigned two projects by my preceptor Raymond Lee so far:
1. Compile a list of pharmacies close to the hospital
2. Add links to useful pharmacy resources in addition to ones already available on the Fraser Health website
3. I will be doing a presentation in the last week: TBA

My goals for the rotation:

1. Be comfortable with assessing prescription order’s appropriateness in terms of necessity, effectiveness, safety.
2. Become more proficient at identifying and resolving Drug related problems.
3. Learn how to enter orders
4. Learn how to navigate the Meditech system