Integrating LGBTQIA+ Health Education into the Curricula of Professional Healthcare Students

by K. R. Fairley, Doctor of Pharmacy student, University of Mississippi School of Pharmacy

Summary and Analysis of: Kelley L, Chou CL, Dibble SL, and Robertson PA. A Critical Intervention in Lesbian, Gay, Bisexual, and Transgender Health: Knowledge and Attitude Outcomes Among Second-Year Medical Students, Teaching and Learning in Medicine 2008; 20:3: 248-253.

It is estimated that up to 4.5% of the U.S. population actively identifies themselves as a member of the LGBTQIA+ community.¹  When broken down, this equates to nearly 15 million Americans, being found across all major racial, ethnic, religious, and age-based groups.² Despite these staggering figures, however, the LGBTQIA+ community remains one of the most underserved populations in the United States when it comes to healthcare.³  The reasons for this disparity are multi-factorial, ranging from a lack of trust in providers due to previous discriminatory experiences in the healthcare system to issues with accessing insurance coverage based on name changes or sex and gender differences.  While not the only cause of these disparities, the lack of provider knowledge and competence to furnish the appropriate care to this diverse group of individuals is a contributing factor. 

As a third-year pharmacy student, the topic of LGBTQIA+ health has long been of importance to me.  I think that, over the course of this past year, that importance has only grown, especially after witnessing some of the disparities play out first-hand during my clinical rotations. The discrimination faced by members of the LGBTQIA+ community in the healthcare system, including pharmacies, is just as prevalent now as ever. I knew immediately when the topic of this essay was announced that I wanted to use this time and space to talk about a learning intervention for professional healthcare students to educate them about the needs of LGBTQIA+ patients, as well as to discuss why learning interventions such as this one are so important.

Image credit: Discoversociety. “Focus: Looking Critically at Gender and Sexuality.” Discover Society, 5 Dec. 2016, discoversociety.org/2016/12/06/focus-critical-perspectives-in-gender-and-sexuality/.

Originally published in 2008, the study by Leah Kelley and colleagues describes one of the very first interventions of its kind to incorporate LGBT health education into the curriculum.  This educational event was part of the second year Doctor of Medicine program at the University of California San Francisco.  The goals of the intervention were three-fold: (1) To increase the students’ awareness and address existing assumptions about LGBT people, (2) To highlight disparities in health care delivery to which LGBT patients, and (3) To underscore the important role that physicians can play in dispelling these disparities to optimize LGBT health care.³  In order to achieve these goals, the directors of the course developed a three-pronged intervention, consisting of a syllabus, a 1-hour patient panel, and a 1-hour small group session. The syllabus was distributed to the students prior to class and served as a brief introduction to the educational event, while also emphasizing basic definitions and health hazards associated with homophobia.  The 1-hour patient panel was organized based on prior studies that indicated direct contact between students and patients helped medical students form more positive impressions of marginalized populations. The panel consisted of three voluntary participants: an older gay man, a middle-aged lesbian, and a young transgender man.  Each participant gave a short presentation, which was then followed by an interactive Q+A session with the students.  The 1-hour small group sessions focused on working through three case studies designed to highlight several LGBT health issues.  Additionally, a pre-and post-class survey was created to assess if student attitudes had changed as a result of the intervention.

At the conclusion of the two-hour course, more than 90% of students agreed that the combination of the syllabus, patient panel, and small-group cases helped to educate them about relevant LGBT issues. The majority of student comments left on the surveys were overwhelmingly positive, with most of the students indicating that hearing about personal experiences of the LGBTQIA+ panel members was most helpful in terms of identifying and addressing unconscious biases toward the LGBT community.  The results of the pre- and post-class surveys indicated that the students experienced a significant increase in their general knowledge of the challenges that LGBT individuals face in the healthcare system. They also showed an increased level of awareness about sexual orientation, gender identity, and other related attributes relevant to clinical practice.¹

A couple of the strengths of this study included (1) the integration of three different but cohesive teaching interventions to achieve the stated goal and (2) the inclusion of face-to-face contact between the medical students and members of the LGBTQIA+ community.  A few limitations were: (1) the short-term follow-up period, (2) the ability to measure a change of attitude as an outcome, and (3) the limited definitions of sexual orientation, attraction, and identity when describing the LGBTQIA+ population.  The authors in this paper continually made references to the LGBT community as “homosexual”, which is not true for every self-identified LGBTQIA+ individual.  I think the study could have been more comprehensive/ inclusive had the researchers also addressed the problems of transphobia and biphobia, as well as some of the more common issues faced by non-binary and asexual individuals in the healthcare system.  In terms of the outcome measures for this study, I believe that the investigators measured them in the best way available, given that a change in attitude is difficult to measure and prone to social desirability bias. I would have liked to have seen a longer follow-up period to this study to evaluate just how much the intervention affected the students during clinical rotations and, ultimately, their practice habits as healthcare providers.

Regardless of its limitations, this study truly has made waves in the medical education community since it was first published. I found over 200 articles citing this paper as well as two books. I believe that educators should take this study as an outline when developing courses to educate healthcare students about the challenges faced by minority groups, including but not limited to the LGBTQIA+ community.  Integrating a working knowledge about the causes and consequences of health disparities, discrimination, and unconscious bias into the professional curriculum can help increase access to healthcare and trust in providers.⁴ 

The authors state:  “It is essential for students to understand that a common causative factor in these health risks is not necessarily in merely being lesbian, gay, bisexual, or transgender: it is living as a LGBT person in a homophobic society.”³ Or, more generally, in a LGBTQ-phobic society.  This remark, I think, is the central message that educators should take away from this paper and it states clearly why educational interventions are so crucial.  More schools (including schools of medicine, pharmacy, and nursing) should consider adding similar interventions to their curriculums.

References

1. Newport F. In U.S., Estimate of LGBT Population Rises to 4.5%. com, Gallup, 29 Oct. 2020,  Accessed November 5, 2020.
2. Macapagel K, Bhatia R, Greene GJ. Differences in Healthcare Access, Use and Experiences Within a Community Sample of Racially Diverse Lesbian, Gay, Bisexual, Transgender and Questioning Emerging Adults, LGBT Health 2016; 3 (6): 434-442.
3. Kelley l , Chou CL, Dibble SL, and Robertson PA. A Critical Intervention in Lesbian, Gay, Bisexual, and Transgender Health: Knowledge and Attitude Outcomes Among Second-Year Medical Students, Teaching and Learning in Medicine 2008; 20 (3): 248-253.
4. Rowe d, Ng YC, O’Keefe L, Crawford D. Providers’ Attitudes and Knowledge of Lesbian, Gay, Bisexual and Transgender Health, Federal Practitioner 2007; 34(11): 28–34.

Mental Health First Aid Training for Student Pharmacists

by Taylor Williams, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy 

Summary and Analysis of:  El-Den S, Chen TF, Moles RJ, O’Reilly C. Assessing Mental Health First Aid Skills Using Simulated Patients. Am J Pharm Educ 2018; 82 (2): Article 622.

One in six people in the United States uses psychotropic medications and psychotropic medications representing 13% of the top 300 most frequently prescribed medications in the United States.¹  In a 2012 survey designed to characterize the relationship between individuals with mental health conditions and community pharmacists, approximately 80% of individuals and family caregivers indicated they received their medications for mental health conditions from a community pharmacy.²  Given that community pharmacists see patients with psychiatric illnesses every day, it is imperative that student pharmacists know how to skillfully interact with these patients. Many prescriptions have refills for up to three months, so these patients may see their pharmacist more than any other healthcare provider. This is why it is essential that student pharmacists have adequate training on how to interact with people who suffer from mental illness.

However, a survey of pharmacy schools reported that only 9.5% of the didactic course content was dedicated to psychiatric topics.³  Furthermore, a survey of North Carolina pharmacists, concluded that despite the volume of prescriptions with mental health-related medications every day, a significant portion of licensed pharmacists indicated that the emphasis on mental health in their training was inadequate.⁴  These results suggest that pharmacy programs are not providing student pharmacists with enough training to become mental health first aid responders. So how are we preparing our future pharmacists to serve patients with mental illness? While being knowledgeable about psychiatric medications is essential, many student pharmacists have not been trained to manage a mental health crisis.  The methods and criteria used to ensure students have mastered these skills before graduating do not appear to be adequate.

An educational program implemented at The University of Sydney explored different teaching strategies to train student pharmacists to become mental health first aid (MHFA) responders.⁵ One hundred and sixty-three fourth-year bachelors of pharmacy students in their final semester before earning their degree completed MFHA training, with 88% of the students completing the post-training confidence level evaluations following the simulations.⁵ Postnatal depression (PND) and suicide vignettes were randomly assigned to 36 students and their simulation performances and MHFA training were compared to their self-evaluations.⁵ The study compared the teacher feedback with post-training self-evaluations. The trainers developed an assessment rubric based on the Mental Health First Aid Action Plan. This rubric was completed by the simulated patients to assess students’ MHFA skills during the roleplays.  The encounters were audio recorded in order to facilitate performance feedback and to give students an opportunity to self-assess their own performance.⁵ The study authors concluded that after receiving MHFA training most students overestimated or underestimated their ability to appropriately respond in a mental health first aid crisis. While these results show there is much work to be done, it also gives insight into how we can better educate students.

 

Learning is an active process. We learn by doing. 

Only knowledge that is used sticks in your mind. 

– Duke Corregie

 

The key to this educational program and others is the realization that “knowing” is different than “knowing how”.⁵  In other words, while students may know what to do in a mental health crisis, they may not know how to respond when confronted with a patient in crisis. Indeed, over 95% of pharmacy students who participated in this study agreed or strongly agreed that they were confident after participating in the suicide vignette. Moreover, only 50% of students took the appropriate actions, which involved both referring the patient to an appropriate health care professional and not leaving the simulated patient alone.⁵  This suggests the best way to assess pharmacy students is to not depend solely on written or verbal evaluations of their knowledge, but we must evaluate their actions when placed in real-life scenarios. This study had notable limitations, one being that the sample was only from one university.  Further, there were only two types of mental health crisis scenarios evaluated. Thus, the results might not be generalizable to students attending other schools or when addressing other mental health problems. However, despite these limitations, the study hypothesized the reason the student’s scores did not align with their self-assessment may be due students felt uncomfortable providing help to suicidal persons. None-the-less, MHFA training with the addition of simulation proved to be an effective teaching method.

There are many benefits to role-playing/simulation training. The Northern Illinois University Center of Teaching and Learning explained some advantages of using role-play.⁶ Some of the benefits include motivating and engaging students, enhancing current teaching strategies, providing real-world scenarios to help students learn, and providing opportunities for critical observations of peers.⁶  Simulation training gives students the opportunity to receive positive and constructive feedback from their teachers.

In a recent study that surveyed mentally ill patients, they found that 75% of respondents reported they seldom or never receive assistance from their pharmacist regarding their medication when they pick up their prescription at a community pharmacy, and 40% of participants felt that they did not have a strong relationship with their pharmacist.¹  As future pharmacists, we should work to eliminate barriers to care. I feel the best way to do so is to actively engage students through role-playing/ simulation scenarios paired with training while in school similar to the MHFA developed by the University of Sydney.

This study reinforces the effectiveness of using simulation training as a teaching tool. Simulation training allows pharmacy students to practice in a setting similar to where they will be practicing. During simulation training, students are given feedback on their performance and have an opportunity to correct problems. Becoming a mental health first responder takes both knowledge and experience. By implementing simulation training into the core curriculum in pharmacy school, students will be better prepared for their future roles.

References

 

1. Moore CH, Powell BD , and Kyle JA. The Role of the Community Pharmacist in Mental Healt U.S. Pharmacist 2018; 43 (11): 13-20. Accessed October 14,2020 
2. Carley CF and Stimmel GL. Characterizing the Relationships Between Individuals with Mental Health Conditions and Community Pharmacy . CPNP Foundation, December 2012. Accessed October 14, 2020
3. Cates ME, Monk-Tutor MR, and Drummond SO. Mental Health and Psychiatric Pharmacy Instructions in US Colleges and Schools of Pharmacy Am J Pharm Educ 2007; 71 (1): Article 04 Accessed November 1,2020
4. Goodman CS, Smith TJ. and LaMotte JM. A Survey of Pharmacists’ Perceptions of The Adequacy of Their Training For Addressing Mental Health-Related Medication Issues. The Mental Health Clinician 2017; 7(2): 69-73. Accessed November 1,2020
5. El-Den S, Chen TF, Moles RJ, and O’Reilly C. Assessing Mental Health First Aid Skills Using Simulated Patients Am J Pharm Educ 2018; 82 (2): Article 6222. Accessed October 14,2020
6. Role Playing. Northern Illinois University Center for Innovative Teaching and earning. 2012. Accessed October 14,2020

Improving Scientific Reasoning Levels through Active Learning Strategies

by Hannah Schmoock, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Marušić M and Dragojević A. Assessing Pharmacy Students' Scientific Reasoning After Completing a Physics Course Taught Using Active-Learning Methods. [Internet] American journal of pharmaceutical education, 2020: 84(8): Article 7610

This article piqued my interest because it aimed to show how implementing active learning methods into physics courses could improve scientific reasoning.¹ Active learning is a widely used instructional method in our pharmacy curriculum at the University of Mississippi and I find active learning techniques useful in helping to deepen my understanding of the topics we discuss. As future pharmacists, we are expected to be able to think critically when it comes to devising solutions to complex patient cases and medication regimens. Using active learning in pharmacy curricula, students build their scientific reasoning skills which will be very important throughout their careers. This study aimed to compare two groups, an active-learning group, and a traditional-learning group. The active-learning group received a traditional 60-minute lecture followed by 30 minutes of active learning activities during each class meeting. The traditional-learning group received a traditional 90-minute lecture-style class.

This study took place from 2013 to 2018 in a Physics for Pharmacists course taught by the Faculty of Chemistry and Technology at the University of Split in the Republic of Croatia. A total of 150 first-year pharmacy students participated in the course over the five years. In the first 3 years of the study, the active learning method was used. During the active learning activity, the instructors described an experiment to the students and had them predict all of the possible outcomes that might result from performing the experiment. The experiment was then be performed by the instructor. After the experiment, the students were allowed to repeat the experiment themselves and ask questions. During the 2017 and 2018 academic years, the traditional lecture style was used. This meant that no time was allotted to the active learning activity. Over the 5 years during which this study was conducted, the same professor was responsible for all instruction, and the same course syllabus was used. Each year the students were assessed before and after completing the physics course using Lawson's Classroom Test of Scientific Reasoning. This assessment consists of 12 two-tiered multiple-choice questions where students are awarded points for correctly answering the question and also correctly identifying the reason for that answer.¹ This test helped differentiate how the different teaching methods affected the students' scientific reasoning skills. Based on the results of the test, students were classified as either a concrete, transitional, or formal learner, with formal being the highest level of learning.² A formal thinker is defined as being able to understand different variables within a problem as well as explain how these variables relate to each other.

The results of this study revealed that the active learning group had a significant improvement in a students’ level of scientific reasoning and also the ability of students to transition to a higher level of scientific thinking.² The percentage of formal thinkers in the active learning group increased from a baseline of 14.4% to 33.3%. In the traditional instructional group, the percentage of formal thinkers remained stagnant at 13.3%. When comparing the active learning group to the traditional group, performance in the physics course was significantly improved, with the mean grade point average of 4.0 on a 5.0 scale in the active learning group versus 2.8 in the traditional learning group.

The strengths of this study include the use of a control to compare the results of the two teaching approaches as well as the use of a pre- and post-assessment to assess each students’ scientific reasoning level. The LCTSR is a validated and widely used tool to assess scientific reasoning. Some of the weaknesses of the study include the fact that the control and intervention cohorts were concurrently conducted during the same academic year. It’s possible that the two groups had very different experiences in other course work that might explain the different outcomes.  By having both comparison groups happen simultaneously, students would have experienced the same course curriculum and instructors. 

A similar study by Styers was conducted in 2018; however, the investigators used Critical Thinking Assessment Test (CAT) to assess critical thinking rather than the LCTSR.³  While the findings were similar, the Styers study did not use a control group.³ A third study by Latif and Mumtaz looked at implementing active learning using a debate type approach.⁴ This study also showed positive outcomes, but this was only on the basis of how the student’s perceived the growth in their critical thinking skills. No test to objectively measure critical thinking was administered. 

I believe this study provides strong evidence that implementing active learning activities can help improve scientific reasoning. From my own experiences, I personally found active learning activities in my physics courses and other science-based courses helped me to be more successful because it made me think more about the topic. The goal of initiating active learning is to stimulate thinking and allow students to make mistakes. Every educator should strive to include active learning activities in their instruction to help mold future scientific thinkers. 

References

1. Khoirina M, Cari C, Sukarmin. Identify Students’ Scientific Reasoning Ability at Senior High School [Internet]. Journal of Physics: Conference Series 2018; 1097: 012024.
2. Marušić M and Dragojević A. Assessing Pharmacy Students' Scientific Reasoning After Completing a Physics Course Taught Using Active-Learning Methods. [Internet] Am J Pharm Educ 2020: 84(8): Article 7610.
3. Styers ML. Active Learning in Flipped Life Science Courses Promotes Development of Critical Thinking Skills [Internet]. CBE-Life Sciences Education. 2018; 17 (3): [cited 2020Oct16]. https://doi.org/10.1187/cbe.16-11-0332
4. Latif R and Mumtaz S. Learning through debate during problem-based learning: an active learning strategy [Internet]. Adv Physiol Educ 2017; 41: 390-394.

Student Pharmacists as Pediatric Asthma Educators

by Caroline Adrian, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Review and Summary of: Elliott JP, Marcotullio N, Skoner DP, et al. Impact of student pharmacist-delivered asthma education on child and caregiver knowledge. Am J Pharm Educ. 2014 Dec 15;78(10):188.

 As a student pharmacist, I recognize the importance of medication adherence in the management of chronic conditions. However, when I was diagnosed with asthma as a child, I did not understand the concept of maintenance therapy. I didn't understand that I needed to use my inhaled corticosteroid every day to prevent exacerbations. Frankly, I didn't even know what that inhaler was for, so I frequently missed doses. Looking back, I wish someone had taken the time to educate me about asthma and the medications I needed to use so I might have had better symptom control. I recently discovered a study¹ that looked at the impact of student pharmacists as asthma educators to both children and their caregivers. I was eager to learn more.

This cross-sectional study enrolled children and caregivers who attended at least 1 of 6 For Your Good Health, LLC asthma camps at Duquesne University over a two year period. The asthma camp series was developed to teach children, ages 5-17 years, and their caregivers asthma self-management skills. The camps were directed by an interdisciplinary team of physicians and pharmacists and staffed by student pharmacists and university athletes. Camps were held on Saturdays from 9:00 am to 2:00 pm, with asthma screenings and education being conducted during the morning session. The primary objective was to evaluate the impact of student pharmacist-delivered asthma education on child and caregiver knowledge about asthma. The secondary objective was to assess child and caregiver baseline asthma knowledge and its correlation with asthma control.

The hands-on educational activities implemented at each asthma camp were developed by sixth-year Doctor of Pharmacy students under the guidance of two faculty members. The activities focused on the 4 key components of effective asthma management: avoidance of triggers, medication compliance, proper inhaler technique, and the importance of an asthma action plan. Some of the activities included interactive skits to teach proper inhaler technique, game shows highlighting the differences between controller and reliever medication, and a memory game of asthma triggers. One group of students built a large cardboard house that contained common asthma triggers for their activity. They worked with the children to make the house more "asthma-friendly," discussing how to limit exposure to each of the triggers. Caregivers were not required but strongly encouraged to attend with their children.  The participants rotated through 4 stations of activities that lasted up to 15 minutes each. 

An asthma knowledge questionnaire was administered separately to the children and to the caregivers at the beginning and end of each asthma camp to assess the effectiveness of the educational program. Of the 87 children enrolled in the study, 76 completed both the pre- and post-intervention questionnaires. Only 45 caregivers participated in the educational intervention with 42 completing the pre- and post-intervention questionnaires. Statistical analyses compared the pre and post-intervention scores. 

The study found that the asthma education program was effective in increasing asthma knowledge among children. However, the student pharmacist-delivered education was not effective in increasing asthma knowledge among caregivers. Many of the caregivers who participated did not have children with asthma and the investigators also noted that many caregivers opted to socialize amongst themselves rather than participate in the educational components of the For Your Good Life camp. It was unclear to me whether the investigators designed the educational intervention with the caregivers in mind, or if they designed the intervention to focus on the children alone with hopes that the caregivers would be willing to participate. It seems the educational intervention was engaging for the children but perhaps not of great interest to adults. However, the investigators found a strong association between caregiver pre-intervention scores and asthma control in their children, suggesting that caregiver knowledge of asthma plays a role in asthma control.

This study found that the educational program was beneficial to the children who participated as well as the student pharmacists. The student pharmacists were able to practice their role as future educators by developing and implementing novel educational activities. A weakness of this study was that the investigators used different student pharmacists at the camps and this may have led to differences in how the educational activities were conducted. A limitation of this type of educational intervention is that the development and implementation of such a camp requires a significant amount of time and resources.

This was the first study to assess the effectiveness of student pharmacists as asthma educators in a pediatric population. Other studies have shown student pharmacists can effectively educate adults with chronic illness.^2,3 Other studies have found that asthma education of children and caregivers can lead to better symptom management and fewer acute exacerbations,⁴ and educational programs for asthma self-management in children alone can also lead to improved lung function and fewer trips to the emergency department.⁵

This is a great way for educators to engage student pharmacists to conduct hands-on learning experiences teaching children about asthma. Similarly, structured learning activities may be beneficial in teaching children about other disease states as well. Diabetes and epilepsy are also common chronic conditions in children where student pharmacists can assist in delivering fun educational programs to kids. 

References:

1. Elliott JP, Marcotullio N, Skoner DP, et al. Impact of student pharmacist-delivered asthma education on child and caregiver knowledge. Am J Pharm Educ. 2014 Dec 15;78(10):188.
2. Letassy N, Dennis V, Lyons TJ, et al. Know your diabetes risk project: Student pharmacists educating adults about diabetes risk in a community pharmacy setting. J Am Pharm Assoc (2003). 2010 Mar-Apr 1;50(2):188-94.
3. Shrader S, Kavanagh K, Thompson A. A diabetes self-management education class taught by pharmacy students. Am J Pharm Educ. 2012 Feb 10;76(1):13.
4. Agusala V, Vij P, Agusala V, et al. Can interactive parental education impact health care utilization in pediatric asthma: A study in rural Texas. J Int Med Res. 2018 Aug;46(8):3172-3182.
5. Guevara JP, Wolf FM, Grum CM, et al. Effects of educational interventions for self-management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003 Jun 14;326(7402):1308-9.

Continuing Education and Performance Evaluation: Essential Elements of Community Pharmacy Success

by Dewansia Sutton, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Grant M, Remines J, Nadpara P, Goode J. Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting. Innov Pharm. 2020;11(3): Article 11. https://doi.org/10.24926/iip.v11i3.3291

The Academy of Managed Care Pharmacy reports that medication errors affect at least 1.5 million people every year resulting in direct medical costs of at least $3.5 billion and result in significant morbidity and mortality.¹ I know that medication errors are a widespread problem, so I chose this study² because I was curious about the influence of training programs on the practice and whether they would be a beneficial addition to my future practice as a community pharmacist. This study assessed the benefit of live interactive training and also analyzed the impact of pharmacy prescription volume and the ratio of pharmacists to pharmacy technicians on the incidence of medication errors.

The study analyzed the incidence of medication errors at several Kroger pharmacies in one district before and after a live training program that addressed the most common types of medication errors reported in the previous six months. These errors occurred at reception, product dispensing, and during the final verification step. The topics of physical and mental fatigue, workplace cohesiveness, ways in which medication errors occur, strategies for mitigating errors, best practices for pharmacy workflow, and company policies and procedures were also addressed during a series of mini (8-minute) lectures. Following the lectures, teams of four consisting of both pharmacists and pharmacy technicians discussed examples of how they could improve their practice to reduce the occurrence of medication errors. These sessions were led by the same team of pharmacists on six occasions. Eighty pharmacists and 150 technicians from 20 different Kroger pharmacies completed the program. The pharmacies were classified as low, medium, or high volume based on their average number of prescriptions filled per week.

Comparisons of medication error occurrences before and after training and differences between the pharmacy categories were made. The ratios of pharmacists to certified pharmacy technicians and other demographic information was recorded. The results of the study are summarized in the tables below. There was a decrease in the number of errors overall and between the pharmacy classifications from pre and post-training but these differences were not statistically significant. The number of pharmacists and technicians based on pharmacy volume (low, medium, or high volume) was significantly different.  The authors concluded that the implementation of these live training programs helped streamline best practices and reiterate patient safety by focusing on medication error reduction.

Table 1: Pharmacy Characteristics

*Differences between groups p <0.01

Table 2:  Medication Error Rates at Baseline vs. Post-Training

This study is valuable because it highlights the fact that even in the most structured pharmacy practice systems, there is always room for improvement. It is also valuable because it shows the potential benefit of continuing education and analyzing medication error trends. I think more pharmacies should design programs similar to this one where pharmacists educate pharmacy technicians and other pharmacists on methods to decrease workplace fatigue and increase cohesiveness to decrease medication errors. The mean number of full-time pharmacists to certified technicians was 2:1 in low volume pharmacies and 2:2 in medium volume pharmacies. The mean number of errors in the medium volume pharmacies pre-live training was just over double the mean number of errors in the low volume pharmacies pre-training.  These results were interesting to me because they show that the number of pharmacists relative to pharmacy technicians may be an important factor in mitigating medication errors. It would be beneficial to employees and patients if the work environment was less stressful and had a smooth, structured workflow with a balanced workload. It is also valuable because it shows what difference can be made when the focus is put towards fixing systematic problems in the pharmacy instead of placing blame on individual employees.

A limitation of this study is the fact that it relied on the pharmacies to self-report the number of medication errors. Recall bias and underreporting of medication by pharmacies could give false confidence that the pharmacy made fewer errors after the training. It also failed to report a breakdown of the number of reported errors in each category before and after the training. This data would have been helpful to determine if the training is effective in minimizing a specific type of medication error. Another limitation is the fact that the pharmacies included in the study were all Kroger pharmacies and have similar policies and procedures.  Moreover, the pharmacists and technicians may not have had the freedom to make significant changes in the workflow or environment if it violated corporate policies. A sample including multiple chains and independent pharmacies would have provided a more accurate assessment of whether this training program leads to a reduction in medication errors and which kinds of practices benefit the most. A larger sample may have produced statistically significant results and more generalizable data. A longer observation period for data collection before and after the training would have increased the amount of data available to analyze and perhaps draw more precise conclusions. 

A similar study analyzed the impact of pharmacist-led training on the incidence of medication errors in an intensive care unit and post-surgical care unit.³ The educators in that program included a clinical pharmacist and a nurse.  The incidence of medication errors before and after the program, which included a lecture and ward-based hands-on instruction, remained high.  But the authors concluded that the program was effective because it changed the work environment to promote a safety culture. Another study published in the Journal of Pharmacy Technology evaluated the incidence of medication errors in the community pharmacy setting but collected data retrospectively.⁴ It attributed the number of reported medication errors to high prescription volumes and lack of adequate pharmacist coverage.  The authors concluded that increasing the number of pharmacists to accommodate the workload may help to minimize errors. The results of this study lead to a revision of pharmacy technician training requirements and certification in the state of New Hampshire. The results of these studies suggest that more work is needed to minimize medication errors and well-constructed training programs may be part of the solution.

Medication errors are expensive, harmful, and potentially deadly.  Live interactive training programs are a great method for delivering information.  I believe people are more likely to remember things when given the opportunity to interact with other participants and the instructor compared to when participants only hear or read about the material. More studies regarding the impact of live interactive training in community pharmacy are needed but the available data suggests they can make a difference in medication errors in pharmacy. Trial and error will be needed to figure out what elements are needed in the training sessions and whether periodic follow-up training should be implemented. Training sessions will also need to be adapted to fit different types and sizes of community pharmacies. Pharmacists should be aware of this study and similar studies so they can make informed decisions about employee training and different approaches to reduce medication errors. 

References:

1. Medication Errors. AMCP.org. https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors. Published 2019.
2. Grant M, Remines J, Nadpara P, Goode J. Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting. Innov Pharm. 2020;11(3):11. doi:10.24926/iip.v11i3.3291
3. Nguyen H, Pham H, Vo D et al. The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study. BMJ Qual Saf. 2013;23(4):319-324. doi:10.1136/bmjqs-2013-002357
4. Pervanas H, Revell N, Alotaibi A. Evaluation of Medication Errors in Community Pharmacy Settings. Journal of Pharmacy Technology. 2015;32(2):71-74. doi:10.1177/8755122515617199