Can't We All Just Get Along?

Recently, I received a letter from a colleague reaching out to ask a few questions about teamwork in the pharmacy.  This process of answering his questions got me thinking about how we interact with our peers on a daily basis.  Pharmacists and their technicians work in a fish bowl. It doesn’t matter if it is a retail or hospital setting; we are in a room, swimming around each other, sharing space, day after day after day.
I wanted to reach out to you about teamwork in the pharmacy. I’m currently in charge of Culture of Safety at my institution and one aspect involves increasing our teamwork here in the pharmacy. I read your article in Pharmacy Times about teamwork and completely agree with you that communication is paramount to successful pharmacy teamwork.

I was reaching out to see what approach you would take if teamwork was lacking in the pharmacy. In your years of experience, what methods have worked to bring co-workers together in order to increase teamwork?

In my opinion, quite often, corporate America sees that teamwork is lacking in a particular section or department and comes along with a mandate that everyone increase teamwork. Administrators often institute new policies, or even worse, require that everyone attend a "team building" exercise of some kind.  In my opinion, these exercises do little to change the intrinsic behavior of the individuals at work during the day.
Teamwork is an attitude of respect within the pharmacy. It's top down from administratiors, to the director of the pharmacy, to the pharmacy manager, to the staff pharmacists to the technicians. Administrators need to take the time to understand what their employees do, managers need to be available to sit in and help get the job done when there is a time crunch, staff pharmacists need to look out for each other and help each other get the work done. Also, staff pharmacists need to go out of their way to help their technicians any way they can. 
Technicians that see that their pharmacist is there to help them will step up and work harder to do their share. If a technician sees their pharmacists are not pulling a fair share of the workload, the technician will then slow down and slack. Importantly, pharmacists always need to be available for their technician if there is ever a rude or demanding customer at the window or on the phone (patient, nurse, doctor or outside customer). Technicians should feel comfortable handing something like this over to their pharmacist of the day.
Just like when we are parents, we need to model, from the top down, exactly the behavior we would like our children to have. If I yell at the kids, leave dirty dishes in the sink, and never make my bed, well, I can't get upset with my kids when they do the same. Similarly, if I take the time to write thank you cards for gifts and send them to people and teach my kids the same, when they grow up they will also write thank you cards and send them.
There is one tool I have used which is a good teamwork tool and I think it would benefit any situation where a problem needs input from an entire team. The point is the entire team (technicians, staff pharmacists, manager, and director) all need equal participation. The concept is simple and really easy to implement. Get everyone together, "huddle" style. Have a white board ready . Describe your concept of teamwork (respect, communication etc...) and why it is important (work flow, patient safety, etc...).  Everyone goes around the circle and lists 1 or 2 behaviors that model positive teamwork. List these on the white board. Then, go around and everyone list a couple behaviors that model poor teamwork. Have a short discussion about this, focusing on what it might look like in the pharmacy if everyone was able to model the positive behaviors. Ask for "buy in" from the team for a one-month time frame. Schedule a follow-up huddle in 30 days to evaluate how the process is going.  Revisit the process every 30 days until it seems to be improving all around.
Again, teamwork cannot be forced upon any group. This is a process that slowly develops over time as technicians come to see that they can always trust their staff pharmacists to be there for them as well as staff pharmacists coming to understand and see that their manager or pharmacy director will always be there to have-their-back in situations.
Here at my institution I’ve always been taught to “take control” over what I am doing in the pharmacy. From verification of medications, to checking fill sheets, to my projects; meaning, to make sure I finish what I start and not to ask for help. I understand why this was implemented because if I were to hand off an order to another pharmacist or they advise me one way and there ends up being a mistake, then who does that mistake land on? I agree that this doesn’t lead to great teamwork, but how can we rely on one another or have each other’s back when this is the atmosphere here in the pharmacy?

I totally agree. I remember when I first started at my hospital, I was working with a seasoned pharmacist one weekend morning and a major issue came over from the neonatal intensive care unit. I had a question about how to proceed and this pharmacist pointed me in the right direction. Then I had another question and he said, "look, you stepped in it, it's yours." I took that to heart.  Yes, modeling teamwork means taking what you have stepped in, as well as your routine duties and following them through to completion, no loose ends, always.
Respectful teamwork comes in to play a couple of ways with this.  
First, we have all had situations where the pharmacist working the shift prior to us did something one way that we may have done another way. The nurse calls down and talks with us about the issue. How do we respond?  Do we agree that it should be changed, put out a general apology, fix the situation and move on; or, do we tell the nurse that so-and-so was working earlier and they did it wrong and I will now fix it?  Respectful teamwork will never throw your peer under the bus. Respectful teamwork will simply acknowledge that yes, this is a problem, and what can we do to fix it? Then, later, you have a conversation with that particular team member just to let them know what happened.
Second, if you, for example, are on a project day and you walk into the pharmacy and see your peer deeply involved in a short term urgent situation. Having there back would mean jumping in for 5-10 minutes to check the counter, answer the phone or help out in any way possible to cover your partner while they get through the urgent situation.  
Importantly, in my opinion, both of these behaviors need to be modeled by our managers and supervisors.  When a call comes down from another department with a complaint about something that pharmacy did, the manager needs to acknowledge the problem, while at the same time standing up for their employee. Later, the manager may have a serious private discussion with their pharmacist about the situation and carry out any actions that may be necessary.  As well, if a manager walks into an urgent and busy pharmacy, there should be no problem with them stepping up and checking the bench or processing a couple orders if necessary to help get caught up.
We’re all in this together!


Opiate Warnings

I believe it is our duty as pharmacists to educate patients about their medications.  Furthermore, according to the Omnibus Budget Reconciliation Act of 1990 (OBRA ’90), among other items, pharmacists must counsel patients on the proper use, warnings, and common side effects of their medications.
Yes, outpatient pharmacies are busy and regularly we are pressured into meeting pharmacy metrics, which may limit time at the pharmacy counter. We constantly weigh the importance of discussing medication with patients at the counseling counter against completing our ever increasing workload before our shift is complete.
To fit it all in, we need to have a clear understanding of the salient counseling points for the top 300 medications ready to go at a moment’s notice. When called to the counseling counter, following a brief introduction, we quickly review the patient’s prescriptions and any notes we have made, and then launch into our session.
Of course, we all have our own way and order of addressing the prescription counseling points as well as our personal way of engaging with our patients. Among other items, of course, we will never let a patient leave the counter without at least a brief discussion of the important black box warnings associated with each specific prescription dispensed.
These are the most important warnings as designated by the FDA. When a medication is listed as having a black box warning it means that an adverse reaction or inappropriate use may lead to serious injury or death. Discussing with a patient the cautions about these warnings may save theirs or a family member’s life.
Long-acting opioid medications, such as oxymorphone er, oxycodone er, and morphine er, have between 7 or 8 black box warnings associated with them. Before you review the list below, take a moment and see if you can list them.
  1. Extended release opiates are only for moderate to severe pain when around-the-clock pain control is needed and other pain medications are not working. 
  2. If these medications are used on a patient not used to taking narcotics, they may stop breathing.  Serious or fatal cases have happened even with the regular dose. Swallow the tablet whole, do not crush or chew the tablet.
  3. These medications have an increased risk of abuse, addiction and theft. Tell your doctor know if you or anyone in your family has a history of substance abuse. Store these medications in a safe place to prevent theft.
  4.  If a child accidently takes even one tablet, they may stop breathing and die.
  5.  Do not consume alcohol while taking these medications. Combining alcohol and extended release opioids may be fatal.
  6.  When pregnant mothers use these medications, the unborn child is at risk.  The newborn may need prolonged withdrawal treatment.
  7.  These medications may interact with other specific medications and cause serious side effects including death.  Tell your doctor and pharmacist all of your other medications before starting extended release opiates.
  8.  Be aware, combining these medications with anxiety medications, such as diazepam or alprazolam, may cause extreme sleepiness, significant breathing difficulties, and death.
Keep these warnings in mind the next time you approach the counter to talk with a patient about their long acting opioid pain medication. 


Disrupt Patient Education at MedStartr Momentum 2016

Visit the MedStartr home page to see how Your Institution may participate in a TRIAL or PILOT with AudibleRx.

In the United States, 36% of adults (approximately 115 million) lack the required health literacy to read or act on prescription labels, patient handouts, understand pharmacist counseling, or to convey their needs to the pharmacist.  Low health literacy is associated with poorer health outcomes and higher hospitalization and mortality rates, as well as an increased risk of adverse medication events.

Furthermore, patients receive prescriptions in the mail or pick up prescriptions from busy pharmacy counters on a daily basis. Current barriers to effective medication counseling do not regularly allow time for the pharmacist to sit with the patient and discuss their medications for 10-15 minutes at the counter.  Pharmacists are under tremendous pressure to meet their performance metrics and will regularly cover the counseling points of three or four medications in fewer than two minutes. The patient is then sent home with stacks of medication leaflets that may be difficult to read. 

DELIVER Consumer Medication Information (CMI), through accessible patient portals, bridging the medication education gap that exists between patients and their healthcare providers.

ACCESSIBLE and USEFUL education, with the intent of helping patients and their caregivers understand what they do and don’t know about their medication so they may take educated questions back to their own health care provider.

DESIGN CMI content with specific Federal Health Literacy guidelines in mind. Create a document that is more pleasing to the reader and easy to read, while also meeting all the necessary requirements listed in the FDA Useful Consumer Medication Information guidance document.

FORMAT CMI to allow consumers to read-along with an audible presentation of the CMI accessed seamlessly through their computer or mobile device.

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Do You Stand All Day?

I started my first hospital pharmacy job during the winter of 1988. It was a great learning experience, as my supervisor at the time helped me understand all the intricacies of running a hospital pharmacy.
My shift was usually from 12:30 PM to 9 PM, which freed up my mornings. Being young and full of energy, I took a morning job 2 to 4 days a week helping out a 77-year-old pharmacist named Fred who still ran his own successful independent store. I’d show up at 9 AM and work until noon, and then I’d drive across town and present at the hospital for my 12:30 shift.

Fred had varicose veins and it hurt him to stand for any length of time. His normal process was to sit in his chair with his leg up on a stool and verify the work his technicians and clerks did for him. He’d tell me stories about the 50+ years he spent standing behind the counter, paying no attention to the oncoming pain in his legs until it was too late.

At 24 years old, this was my first exposure to varicose veins. I’m sure we discussed it in pharmacy school, but it certainly didn’t stick as something important to remember. At the time, 77 years old seemed like a lifetime away, and I didn’t think anything like that would ever happen to me.

Ten years later, I was sitting in an orientation session for my new job at an outpatient pharmacy at the local community hospital. Sitting next to me was a gentleman named Howard, a retired pharmacist who owned his own store in town for many years. He’d recently sold his store to one of the chain entities that made him an offer he couldn’t refuse, and now he was working relief in the hospital outpatient pharmacy.

Over the next 7 years or so, I had the privilege of working with Howard at least 1 or 2 days each month. He was one of the most respected and knowledgeable pharmacists I’d ever met. There were many occasions when a patient came to the store when Howard was working and asked a question about a device or product. Howard would go into great depth answering the patient’s question, while at the same time gaining another customer for our pharmacy. 

At 70+ years old, Howard had been standing on the job for well over 50 years. At one point, for some reason or other, he said he wanted to show me something. He bent over and pulled up his pant leg, lowered his sock, and showed me the dark blue, swollen knots all around his calf. 
Howard’s legs hurt all the time. He needed to take regular breaks to put his feet up. He said he wished someone had warned him about it when he was a young pharmacist. I hadn’t listened to Fred, but I was definitely listening to Howard. 

I was about 35 years old when Howard showed me his varicose veins. Now, I’m nearly 53 and have worn support socks to work just about every day since that discussion.
How Varicose Veins Form
Blood circulates through the arteries, providing oxygen to all of the tissues. The unoxygenated blood then needs to be returned to the heart through the veins. Over time, gravitational forces begin to fight against all the blood returning from the bottom of the leg all the way back up to the heart. 
When a vein becomes weakened in one particular location, or one of its tiny valves isn’t working well, the unoxygenated blood will accumulate, leading to a small, blue bulge. Over time, more blue bulges will form. They’ll become larger and begin to compress the surrounding nerve endings, making them difficult to ignore.

Varicose veins may form because we’re overweight or our veins have become weak over time. For Howard and Fred, however, they formed because they’d been standing all day, every day. That constant gravitational pressure over the course of 50+ years made it very likely for varicose veins to develop. Therefore, those standing all day long at work need to pay special attention to the health of their legs.

A Simple Fix
Support socks are made from strong, elasticized material that help our veins push the unoxygenated blood back up to the heart. If you start wearing these socks before you need them, chances are you’ll never develop varicose veins. 
If you stand all day for your job, do yourself a favor: buy some support socks.

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