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.
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.
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.
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.
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.
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.
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:
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