TY - JOUR
AU1 - Zellmer, William, A.
AB - “Why don’t people’s hearts tell them to continue to follow their dreams?” the boy asked the alchemist. “Because that’s what makes a heart suffer most, and hearts don’t like to suffer.” —Paulo Coelho, The Alchemist This chapter is based on a dream for the future of pharmacy—a dream that pharmacy will become a profession that is dedicated to helping people make the best use of medicines and that this dedication will permeate the inner fiber of pharmacists and shape their interactions with patients and prescribers. This dream has been nurtured by the following four beliefs: People need a readily accessible and knowledgeable professional activist to help them make the best use of medicines. Pharmacists are better educated for this role than any other health worker. There is a profound gap between what pharmacists have been educated to do and how they typically behave in practice. It will be well worth the effort, from a broad societal perspective, to close this gap. There are two fundamental changes that must be made for pharmacists to become a more meaningful force in the rational use of medicines: Pharmacists must adopt professionalism as the dominant guide to their behavior. Pharmacy must rationalize the development and deployment of its work force. Not everyone associated with the field of pharmacy will agree with this vision or with this prescription for achieving the vision. For example, the marketers of pharmaceuticals will continue to promulgate the myth that prescription medicines are safe and effective for widespread use and pose no unreasonable risks in their consumption; by implication, a patient care role for pharmacists is unnecessary. Another example: The regulators of drug products will continue to pretend that perfect rules can be written and enforced to ensure patient safety in the use of medicines; the bureaucratic system in which they function blinds them to the results that could be achieved if pharmacists were engaged more deeply in the medication-use process. Pharmacists cannot look to the drug industry or government regulators to be their champions. They must be their own instruments of change. It is quite clear how that change could be achieved. It is not at all clear whether that change will be achieved. Pharmacists are well rewarded under their current method of practice, and there is ample reason to doubt that they will muster the desire and determination to transform their role in health care. Moreover, pharmacists are pegged with a well-entrenched stereotype that creates limited public expectations; it is easier to simply meet this low benchmark than create and fulfill a higher one. The profession of pharmacy For the purposes of this discourse, the writer is equating pharmacy practice with the profession of pharmacy. Pharmacy practice is conducted by individual pharmacists—individual pharmacy practitioners—not the corporate or institutional owners of pharmacy facilities, who have been called pharmacy providers. The pharmacy practitioner is the atom—the irreducible constituent—of the profession of pharmacy. If it were not for the personal health care service that individual pharmacists provide to individual clients, pharmacy would be merely an area of knowledge and an array of technical functions in the sequence of steps from drug discovery to drug consumption. It is pharmacy practitioners who have made personal commitments to attain and maintain the knowledge required to help people with their medication-related needs. It is pharmacy practitioners who have internalized the ethical standards of pharmacy. The core values of the profession, as well as the yearning for continued improvement of the profession, reside in the hearts of practitioners, not in the policies and procedures of providers.1 There is often confusion about what it means to be a pharmacy practitioner because individuals educated as pharmacists work in many sectors of society, inside and outside of health care. Such individuals are of great value to society, but, for the purposes of this discussion, they are not included as practitioners or as components of the profession of pharmacy. Others may make different distinctions, and it is their privilege to do so. This is not a question of right or wrong but simply a matter of communicating clearly. Preventable problems in medication use The array of problems associated with medication use has been well documented and will be discussed only briefly here. When reviewing such information, it is important to look for details about the extent to which the problems documented were preventable and to think about how pharmacists could have helped prevent those problems. Most medication use occurs among ambulatory patients, and significant medication-related morbidity and mortality occurs in this population. Based on a meta-analysis of various studies, it was estimated in 1994 that more than 1 million Americans were hospitalized because of adverse drug events (ADEs), which accounted for nearly 5% of hospital admissions.2 One study showed that 17% of outpatients reported a problem with prescribed medications.3 In a study of ambulatory Medicare patients, the annual rate of ADEs was 5%.4 There is abundant evidence that pharmacists who are appropriately engaged with ambulatory patients can help them improve the outcomes of their medication therapy.5 Some medical researchers have become believers in the value of pharmacists in improving patient outcomes. Consider, for example, a study involving four medical practices in Boston in which 25% of patients who had one or more prescriptions had ADEs.6 Of these ADEs, 28% were ameliorable and 11% were preventable, suggesting that assertive community pharmacists could have made a significant difference in the well-being of many patients. In fact, the authors of this study stated that “increasing patients’ access to outpatient pharmacists (to discuss medications and side effects)” would be a good strategy to improve patient outcomes.6 There have been many studies of preventable ADEs in hospitals. To cite one example, the rate of ADEs was 6.5 per 100 nonobstetrical admissions at two tertiary care hospitals, with an extrapolated mean of approximately 1900 ADEs per hospital; 28% of the ADEs were preventable.7 Studies of patients in intensive care units and general medical units of hospitals have demonstrated that pharmacists attending rounds reduced preventable ADEs by more than 70%.8,9 Based on the available evidence, an Institute of Medicine report listed the following 2 strategies among 14 ideas for improving medication safety10: Ensure the availability of pharmaceutical decision support (i.e., the availability of pharmacists to consult with prescribers) and Include a pharmacist during rounds of patient care units. The National Quality Forum, which is developing and implementing a national strategy for health care quality measurement and reporting, has included the following point in its list of 30 “practices that have been demonstrated to be effective in reducing the occurrence of adverse health care events”: Pharmacists should actively participate [in all acute care settings] in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications, and administration and monitoring of medications.11 In summary, preventable ADEs are a serious public health problem, there is solid evidence that pharmacists can significantly reduce the severity of this problem, and health care leaders are calling on practicing pharmacists to address this issue. Current deployment of pharmacists Let us conduct a mind experiment. Think about all of the pharmacy practitioners in the various sectors of health care delivery in the United States. Now imagine a linear scale that could be used to differentiate among pharmacists on the basis of their primary roles, irrespective of practice site. At the left end of the scale is a classification for those who engage in only technical, impersonal functions related to order fulfillment in the dispensing process. At the right end is a classification for those who spend essentially all of their time interacting with patients, caregivers, and prescribers in giving advice or making decisions about appropriate medication use. Impersonal, technical services on the left; personal, high-judgment services on the right; mixed roles in between. It is in the best interest of society for the profession of pharmacy to seek the optimal distribution of pharmacists along this imaginary scale. The need for services is certainly great at both ends of the scale, but where does society achieve the maximum benefit from its investment in developing the knowledge, skills, and abilities of the pharmacist? Currently, the distribution of pharmacists is clustered around the left end of the scale. However, given the immense societal needs related to achieving the best use of medicines, pharmacy should encourage a mass migration of practitioners toward the right. The majority of pharmacists practice in community pharmacies, and most of them are extremely insular. They are preoccupied by the mechanics and rudiments of their work. They define their role in production-line terms: processing all the prescriptions that come in as quickly as possible without compromising accuracy. This is a valuable service; no consumer should expect anything less. But the expertise of the pharmacist is misapplied in the performance of this service. Other valuable services that should be provided in tandem with transferring a powerful medicine from the pharmacy’s shelves to the patient are not being performed because the pharmacist is immersed in the mechanics of dispensing. For example, does the pharmacist concern herself or himself with whether the medication regimen is appropriate for the patient’s condition and health-related behavior? Does the pharmacist care whether the patient understands how to use the medicine? Does the pharmacist want to know if the patient has any questions or concerns about the medicine? It is utterly astounding that in the vast majority of settings in which prescription medicines are dispensed, the answer to all these questions is no. In institutional practice, too many pharmacy staffs restrict their sights to the activities within the confines of their departments. The expertise and oversight of the pharmacist are needed in the entire medication-use process, the major steps of which are prescribing, transcribing, dispensing, administering, and monitoring. Just as this process transcends professional and departmental boundaries, so must the pharmacist transcend her or his department and ensure that safe systems and appropriate expertise are applied to all the steps of medication use. Weak pulse of professionalism In too many practice settings, the pulse of pharmacist professionalism is weak or nonexistent. Resuscitation is urgently needed. Unless that revival occurs, there is no assurance that pharmacists will continue to be required in the prescription-dispensing process. A major characteristic of a profession is the compact that exists between the discipline and society. In exchange for an exclusive franchise to practice a profession, the individuals in the discipline promise to use their knowledge and expertise to help members of society and put their clients’ interests and welfare above their own. These ideas about professionalism have been captured in a code of ethics for pharmacists.12 The code’s principles convey some sense of what it means to be guided by professionalism as a pharmacist; the first five of these principles focus on responsibilities related to serving individual patients: A pharmacist respects the covenantal relationship between the patient and the pharmacist. (This is the exchange mentioned above—in return for the gift of trust from society, the pharmacist promises to help people achieve the best use of medications.) A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. A pharmacist respects the autonomy and dignity of each patient. A pharmacist acts with honesty and integrity in professional relationships. A pharmacist maintains professional competence. Pharmacy educators have devoted significant attention to explaining the importance of professionalism and have recommended how to foster the behavioral attributes of professional health care workers among pharmacy students and new pharmacy practitioners.13 Why do so many pharmacists who are blessed with an outstanding professional education regress to technicians when they enter practice? Among the components of an answer to this complex question may be the following points: Most pharmacists do not control the policies and procedures of their practice setting. Current practice procedures are so firmly entrenched that many pharmacists with leadership skills self-select for roles in other sectors of pharmacy. Years of neglecting the obvious have conditioned everyone to expect no more. This problem cannot be corrected overnight. However, it can be corrected over time with sufficient forethought and will. Here are a few of the things that could be done14: Encourage ambulatory patients to select a personal pharmacist. Not a pharmacy, but a pharmacist. Teach pharmacists how to recognize and resist corporate edicts, both blatant and subtle, that undermine their ability to care for patients. Recognize and honor pharmacists who have demonstrated an authentic professional commitment to patients. We need more heroes in the frontline ranks of pharmacy. Increase efforts to develop and enrich the work of frontline pharmacists in all practice settings. Let us remember that the true nature of pharmacy is defined in the everyday interface between pharmacists and patients. Limit entry to colleges of pharmacy to students who have already demonstrated their capacity for compassion and caring. The field of pharmacy, which includes the employers of pharmacists, is in the process of adjusting the need for pharmacists in the mechanics of dispensing, as evidenced, for example, by the growth of mail-service pharmacies and the immense investments hospitals are making in automated dispensing technology. So far there is no evidence that these changes are resulting in any greater contact between patients and pharmacists. The profession of pharmacy needs to be more fully engaged in this process, and it must assertively ensure that the public’s interests are protected as these changes occur. Optimum use of pharmacists Some sense of what the optimum distribution of pharmacists would look like may be gained by reviewing the work of an important conference conducted in 2001.15 This program occurred at a time when there was a lot of worry and talk about the shortage of pharmacists. The solution-seeking discussions were generally based on the current roles of pharmacists. This led the conference organizers to ask, What would the projections of future need for pharmacists look like if we assumed that pharmacists will be performing the roles for which they have been educated? The conferees examined the current use of pharmacists in four areas: Outpatient prescription dispensing and inpatient drug order fulfillment, Patient care services in primary care settings, Patient care services in secondary and tertiary care settings, and Non-patient-care functions that require pharmacists. The conference participants assumed that the public and the profession of pharmacy want the services of pharmacists to contribute to medication use that is safe, effective, patient centered, timely, efficient, and equitable. (These are attributes that the Institute of Medicine has said should characterize the entire health care system.16) Based on this assumption, the conferees forecasted the need for pharmacists in the year 2020. The remarkable conclusions are summarized in Table 11. Table 1. Estimates of Current Deployment of and Projected Need for Pharmacists (Full-time Equivalents)15 Function Deployment of Pharmacists in 2001 Need for Pharmacists in 2020 Order fulfillment 136,400 100,000 Primary care services 30,000 165,000 Secondary/tertiary care services 18,000 130,000 Indirect/other services 12,300 22,000     Total 196,700 417,000     Total estimated supply (based on currently known plans for school of pharmacy capacity) … 260,000     Shortfall … 157,000 Function Deployment of Pharmacists in 2001 Need for Pharmacists in 2020 Order fulfillment 136,400 100,000 Primary care services 30,000 165,000 Secondary/tertiary care services 18,000 130,000 Indirect/other services 12,300 22,000     Total 196,700 417,000     Total estimated supply (based on currently known plans for school of pharmacy capacity) … 260,000     Shortfall … 157,000 Open in new tab Table 1. Estimates of Current Deployment of and Projected Need for Pharmacists (Full-time Equivalents)15 Function Deployment of Pharmacists in 2001 Need for Pharmacists in 2020 Order fulfillment 136,400 100,000 Primary care services 30,000 165,000 Secondary/tertiary care services 18,000 130,000 Indirect/other services 12,300 22,000     Total 196,700 417,000     Total estimated supply (based on currently known plans for school of pharmacy capacity) … 260,000     Shortfall … 157,000 Function Deployment of Pharmacists in 2001 Need for Pharmacists in 2020 Order fulfillment 136,400 100,000 Primary care services 30,000 165,000 Secondary/tertiary care services 18,000 130,000 Indirect/other services 12,300 22,000     Total 196,700 417,000     Total estimated supply (based on currently known plans for school of pharmacy capacity) … 260,000     Shortfall … 157,000 Open in new tab These projections, of course, are very rough estimates based on a particular set of assumptions and should not be taken as the last word on pharmacist needs two decades hence. Nevertheless, several important points are revealed. First, the need for pharmacists in patient care probably cannot be met fully by simply redeploying pharmacists from order fulfillment; if the profession is to meet the needs that patients, caregivers, and health professionals have relating to the best use of medicines, the output of new pharmacists over the next 20 years must accelerate significantly. Currently, it is estimated that 69% of practicing pharmacists are engaged in order fulfillment; the comparable figure in the 2020 projection is 38% (based on an estimated supply of 260,000 pharmacists). Given the legal requirements imposed on the order-fulfillment process, the demands in this area of practice may take precedence over the demands in patient care. Hence, if nothing is done to expand the output of pharmacists, only about 140,000 practitioners will be available for patient care services in 2020 (54% of pharmacists in practice, compared with 24% today). Based on conference projections, at least twice that many pharmacists will be needed in primary, secondary, and tertiary patient care. It may take far longer than 20 years for the profession to satisfy completely the need for pharmacists in patient care. Many questions are raised by the above discussion. Will other health workers step in to fill the void in medication-related patient care? If traditional pharmacies (and the pharmacists they employ) continue to be perceived as conveying only a commodity, not a professional service, will the rate of evolution of alternative sources of that commodity accelerate? (An example is the use of technology to deliver the medicine for the initial course of therapy before the patient leaves the doctor’s office, with the remaining supply delivered by mail.) Will Pharm.D.-educated pharmacists migrate to patient care positions, regardless of opposing salary incentives, leaving the pickings scarce for those who are hiring pharmacists for order fulfillment? Would such a migration, especially in the face of the retirement of B.S.-educated pharmacists, force the chain drugstores and state regulators to invent a new model for the safe dispensing of prescriptions to outpatients, empowering lower-trained personnel to assume most of the work? Can the nation’s capacity for postgraduate pharmacy residency training be expanded sufficiently to prepare an adequate number of practitioners for patient care? Credentialing patient care pharmacists Ambulatory patients who use medicines need pharmacists for two broad types of patient care services. The first type of service relates to oversight and communication at the time the prescription is dispensed. Many pharmacists have been well educated to provide this service. The second type of service relates to the management of a patient’s drug therapy in collaboration with the prescriber. This type of advanced practice is especially valuable to patients taking multiple medicines or medicines that are particularly risky to use. It is one thing to call for the profession to become more engaged in collaborative drug therapy management, but it is quite a different proposition for the public to understand and support such a shift. This issue often comes to the fore in the public policy arena when pharmacist organizations advocate for an expanded scope of pharmacist practice and for payment of pharmacists for services such as collaborative drug therapy management. The typical initial reaction to such advocacy from a legislator or government bureaucrat is “What?! Tell me again what you want to be authorized to do and to be paid for? Isn’t that what the doctor is supposed to do? Is the pharmacist I see behind the counter in my pharmacy even interested in doing what you say you want to be paid for?” The profession should face up to its well-entrenched dispensing stereotype and public skepticism about an advanced role for pharmacists. The most powerful way to bust out of its monolithic image would be for the profession to create a specific category of licensed pharmacists who have demonstrated their qualifications for collaborative drug therapy management. Optometry has developed a system of licensure and certification that may be a model for pharmacy. Basic licensure of the optometrist empowers the practitioner for traditional roles related to eye examination and the prescription of corrective lenses. In addition, the optometrist can become certified by the state board of optometry, through examination, for advanced practice that entails the use of diagnostic and therapeutic pharmaceutical agents.17 Pharmacy should develop a similar system to distinguish between practitioners who are qualified only for traditional practice roles versus those who have demonstrated the knowledge, skills, and abilities for advanced practice, such as collaborative drug therapy management. This system would assure the public that pharmacy has a mechanism to verify the competence of individual practitioners for advanced roles and provide a framework for compensation for such services. Continuing the development of pharmacy technicians The shortage of pharmacists and the escalation in pharmacists’ salaries have stimulated sharp growth in the employment of pharmacy technicians. This has been particularly notable in recent years among chain drugstore corporations (hospitals have used pharmacy technicians for decades), many of which, since the late 1990s, have encouraged their technicians to become certified by the Pharmacy Technician Certification Board (PTCB). The creation of the PTCB in 1995 and its certification of more than 190,000 technicians (as of 2004) have been important milestones in pharmacy’s development of a technical corps of workers to perform routine tasks and allow the pharmacist to engage in higher-order functions. In many states, pharmacists are allowed to delegate more tasks to technicians who are certified compared with noncertified technicians. However, this aspect of rationalizing the pharmacy work force is not yet complete. Pharmacy should now move assertively to establish appropriate standards for the education and training of technicians. Let us consider this issue from the layperson’s perspective. Walk into almost any community pharmacy today and take a careful look at the personnel in the prescription department. A common model is for a sales clerk to be positioned for primary contact with the customer. Behind the sales clerk is typically a short wall of shelves filled with merchandise and bags of dispensed prescriptions. Behind that wall, sometimes on a raised platform, is the dispensing area, populated with a number of workers. There is rarely any distinction in garb between pharmacists and technicians, so consumers are unable to tell exactly what type of worker is in the dispensing area, although they may assume that everyone there is a pharmacist. Now examine this picture from a public health perspective. The pharmacist is required to be licensed by the state. Nationwide, the minimum qualifications for pharmacist licensure include graduation from an accredited school of pharmacy. This is in line with general public expectations about governmental oversight of health professionals. But what about the certified technician? There are no education and training requirements for certification. All that are necessary are high school graduation or equivalency and satisfactory completion of the PTCB examination. About half the states require some type of on-the-job training for technicians, but there are no uniform standards for such training. For the most part, the quality of the education and training of pharmacy technicians is left to the employer. Imagine a muckraking television journalist reporting this situation: “When you take a prescription to your local pharmacy, you trust that you will be getting the right medicine and that it will be labeled correctly. Is your trust warranted? How much do you know about the people who are dispensing your medicine? Can you be assured that they have the necessary qualifications for interpreting your doctor’s order correctly, for choosing the right medication, and for labeling it properly? The answer may surprise you. “While pharmacists are required to have five or six years of college education and pass a nationally standardized licensure exam, there is no standard for the education and training of the nonpharmacists who assist them. Some of the assistants—called pharmacy technicians—may have passed a test of their knowledge to receive national certification, but there is no requirement that only certified individuals be hired. Further, there is no educational requirement for certified technicians, other than high school graduation. As many as three technicians are allowed to work with each pharmacist. Individual pharmacies and drugstore corporations have their own methods for training technicians, but there is no national standard for the content and quality of that training. With a national shortage of pharmacists and with more new medications coming on the market every year, the number of prescriptions dispensed by the nation’s pharmacies is mushrooming. With this growth come more opportunities for mistakes. A report in the Boston Globe in 1999 said that in Massachusetts alone there are 2.4 million prescriptions filled improperly every year; 86% of these errors involved the consumer getting the wrong medicine or the wrong strength. “Why do pharmacies permit such a notable gap in the education and training of personnel who handle your prescription medicines? We have nationwide educational standards for most occupations in the health field; why is an exception made for pharmacy technicians? Will your health be put at risk the next time you have a prescription filled?” Uniform national standards for the education and training of pharmacy technicians should be developed and enforced because anything less poses a tremendous risk to public confidence in pharmacy. The current lack of standards for technician education and training inhibits the extent to which pharmacists are willing to delegate tasks to technicians. Identification of appropriate standards for the education and training of technicians can be done more effectively and efficiently nationwide by a body such as the Accreditation Council for Pharmacy Education, which performs a similar function for pharmacist education, than by the thousands of individual employers of technicians. An alternative scenario What if, the dreams of dreamers notwithstanding, it turns out to be impossible to professionalize front-line pharmacy dispensing practice? If such a hypothetical reality were to become widely accepted inside and outside of pharmacy, what type of rational system could be devised to ensure public safety when prescription medicines are dispensed? Among the action steps that could be contemplated to make this scenario acceptable are the following: Standardize the ambulatory-care prescription dispensing process in all pharmacies, such that a worker moving from pharmacy A in town X to pharmacy B in town Y would be stepping into the same process. Imbue the process with advanced, computer-driven quality-assurance techniques with appropriate checks and balances to avoid essentially all dispensing errors. Require ongoing documentation of the safety of the process that is available for inspection at any time by the state board of pharmacy. Based on an objective task analysis, outline the minimum knowledge, skills, and abilities that a worker in this system must have to ensure patient safety. Establish national standards for the education and training of workers in the minimum requirements. Test workers on the mastery of the minimum knowledge, skills, and abilities and certify those who pass. Require retesting based on updated requirements every few years. Train personnel thoroughly in the dispensing process. Verify competency in the process often. Require that the prescriber enter the prescription in an electronic system, which transmits the order automatically to the pharmacy, to avoid the problem of illegibility. Require that a licensed pharmacist be available at a central call center to consult with onsite pharmacy workers on any unusual situations that arise and to broker any adjustments in therapy with the prescriber. Under such a system, the vast majority of pharmacists would be available for patient care roles in medical offices, clinics, hospitals, nursing homes, other health care settings, and private clinical pharmacy practices. All hope and pretense of making community pharmacies anything other than retail outlets would be removed. (This may be what pharmacists in prescription departments, through their insularity and reticence, are signaling they want.) Although this alternative scenario is not one the author favors, the marketplace, in fact, will decide if pharmacy moves in this direction over the course of time. Among the forces at play in the marketplace are the vision and motivation of pharmacists, the decisions of chain drugstore executives, and consumer beliefs about the safety and value of medicines. The first factor—the vision and motivation of pharmacists—is both a source of despair and a source of hope; despair in the sense that so few contemporary pharmacy practice leaders are speaking and living the language of professionalism, and hope in that if enough pharmacists are true to their hearts, an unstoppable force for change will be unleashed. Conclusion People need a readily accessible and knowledgeable professional activist to help them make the best use of medicines. Pharmacists have an opportunity to fulfill this vital public health role. Profound changes in the attitude and orientation of practitioners will be required for this to happen on a large scale, and it may take generations before those changes become instilled into pharmacy practice. The profession should make its work force development and deployment more rational. Pharmacists should migrate from routine technical functions in dispensing to patient care functions that produce better value for society’s investment in the education of pharmacists. Two specific work force changes needed are the development of a system of credentialing pharmacists who are qualified to collaborate with prescribers in managing drug therapy and the establishment of minimum standards for the education and training of pharmacy technicians. These are the big unresolved issues in pharmacy. They are not new issues. It is not too late to face them head-on. References 1 Zellmer WA. Distinguishing between pharmacy practitioners and providers. Am J Hosp Pharm. 1994 ; 51 : 2314 . Editorial. 2 Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA . 1998 ; 279 : 1200 –5. Crossref Search ADS PubMed 3 Gandhi TK, Burstin HR, Cook EF et al. Drug complications in outpatients. J Gen Intern Med . 2000 ; 15 : 149 –54. Crossref Search ADS PubMed 4 Gurwitz JH, Field TS, Harrold LR et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA . 2003 ; 289 : 1107 –16. Crossref Search ADS PubMed 5 Posey LM. Proving that pharmaceutical care makes a difference in community pharmacy. J Am Pharm Assoc . 2003 ; 43 : 136 –9. 6 Gandhi TK, Weingart SN, Borus J et al. Adverse drug events in ambulatory care. N Engl J Med . 2003 ; 348 : 1556 –64. Crossref Search ADS PubMed 7 Bates DW, Cullen DJ, Laird NM et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA . 1995 ; 274 : 29 –34. Crossref Search ADS PubMed 8 Leape LL, Cullen DJ, Clapp MD et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA . 1999 ; 282 : 267 –70. Crossref Search ADS PubMed 9 Kucukarslan SN, Peters M, Mlynarek M et al. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med . 2003 ; 163 : 2014 –8. Crossref Search ADS PubMed 10 Kohn LT, Corrigan JM, Donaldson MS, eds. Institute of Medicine Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999 .158. 11 Safe practices for better healthcare. Washington, DC: National Quality Forum; 2003 .7. 12 American Society of Health-System Pharmacists. Code of ethics for pharmacists. www.ashp.org/bestpractices/ethics/Ethics_End_Code.pdf (accessed 2003 Apr 1). 13 Hammer DP, Berger BA, Beardsley RS et al. Student professionalism. www.ajpe.org/aj6703/aj670396/aj670396.pdf (accessed 2003 Oct 1). 14 Zellmer WA. Searching for the soul of pharmacy. Am J Health-Syst Pharm . 1996 ; 53 : 1911 –6. Crossref Search ADS PubMed 15 Knapp DA. Professionally determined need for pharmacy services in 2020 .mdash;report of a conference sponsored by the Pharmacy Manpower Project Inc. www.aacp.org/Docs/MainNavigation/Resources/4634_needsconferencefinalreport.pdf (accessed 2003 Oct 1). 16 Committee on Quality of Health Care in America. Crossing the quality chasm—a new health system for the 21st century. Washington, DC: National Academy Press; 2001 . 17 Optometry license requirements. www.op.nysed.gov/optom.htm (accessed 2003 Oct 1). Author notes Written as a chapter for the forthcoming book: Smith M, Wertheimer A, Fincham J, eds. Pharmacy and the U.S. healthcare system. 3rd ed. Binghamton, NY: Haworth; 2005. Copyright © 2005, American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Unresolved issues in pharmacy
JF - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/62.3.259
DA - 2005-02-01
UR - https://www.deepdyve.com/lp/oxford-university-press/unresolved-issues-in-pharmacy-Er2CSLcXBR
SP - 259
VL - 62
IS - 3
DP - DeepDyve
ER -