The Official Publication Of The Florida Pharmacy Association JUNE 2015
Walking the Pharmacist’s Tightrope Balancing Patient Safety Against Pharmacy Performance Metrics
FLORIDA PHARMACY FOUNDATION
FUNDRAISER 2015 Honda Fit WHEN: WHERE: TIME: COST:
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June 27, 2015 Florida Pharmacy Association Annual Meeting Renaissance Resort at World Golf Village 500 Legacy Trail • St. Augustine, Florida 32092 7:00 PM - 10:00 PM $100.00 per ticket (You must be 18 years or older to purchase)
The proceeds will benefit the mission of the Florida Pharmacy Foundation, which provides scholarships and other resources to pharmacy students and pharmacists throughout the state.
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florida PHARMACY TODAY Departments
VOL. 78 | NO. 6 JUNE 2015 THE OFFICIAL PUBLICATION OF THE FLORIDA PHARMACY ASSOCIATION
Features
4 Calendar 4 Advertisers 5 President’s Viewpoint 7 Executive Insight 20 FPA News & Notes 28 Buyer’s Guide
11 18 19 22
Walking the Pharmacist’s Tightrope Dispose of Unneeded Medications Specialized Adherence Teams Clostridium Difficile Infection: A Review for Pharmacists
JUNE 2015
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Mission Statements:
FPA Calendar 2015
JUNE 24-28 125th Annual Meeting and Convention St. Augustine JULY 3
Independence Day Observed, FPA Office Closed
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FPA Governmental Affairs Committee Meeting Orlando AUGUST
2-5
32nd Annual Southeastern Education Gatherin’ Destin
14-16 45th Annual Southeastern Officers Conference Destin
SEPTEMBER 7
Labor Day, FPA Office Closed
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APhA Diabetes and Immunization Certificate Program
12-13 FPA Regulatory and Law Conference Ft. Lauderdale OCTOBER 10-14 NCPA Annual Meeting Washington, D.C. 17-18 FPA Mid-year Clinical Conference Orlando 17-18 FPA Nuclear Conference Orlando
22-23 FPA Committees, Councils and Board of Directors Meetings Orlando
For a complete calendar of events go to www.pharmview.com Events calendar subject to change CE CREDITS (CE cycle) The Florida Board of Pharmacy requires 10 hours’ LIVE Continuing Education as part of the required 30 hours’ general education needed every license renewal period. Pharmacists should have satisfied all continuing education requirements for this biennial period by September 30, 2015 or prior to licensure renewal. Consultant pharmacists and technicians will need to review their licenses and registrations by December 31, 2015. For Pharmacy Technician Certification Board Application, Exam Information and Study materials, please contact the FPA office. For more information on CE programs or events, please contact the Florida Pharmacy Association at (850) 222-2400 or visit our website at www.pharmview.com CONTACTS FPA — Michael Jackson (850) 222-2400 FSHP — Tamekia Bennett (850) 906-9333 U/F — Art Wharton (352) 273-6240 FAMU — Leola Cleveland (850) 599-3301 NSU — Carsten Evans (954) 262-1300
of the Florida Pharmacy Today Journal
The Florida Pharmacy Today Journal is a peer reviewed journal which serves as a medium through which the Florida Pharmacy Association can communicate with the profession on advances in the sciences of pharmacy, socio-economic issues bearing on pharmacy and newsworthy items of interest to the profession. As a self-supported journal, it solicits and accepts advertising congruent with its expressed mission.
of the Florida Pharmacy Today Board of Directors
The mission of the Florida Pharmacy Today Board of Directors is to serve in an advisory capacity to the managing editor and executive editor of the Florida Pharmacy Today Journal in the establishment and interpretation of the Journal’s policies and the management of the Journal’s fiscal responsibilities. The Board of Directors also serves to motivate the Florida Pharmacy Association members to secure appropriate advertising to assist the Journal in its goal of self-support.
Advertisers THE HEALTH LAW FIRM.............................. 21 HEARTLAND.................................................... 12 KAHAN HEIMBERG, PLC.............................. 10 PHARMACISTS MUTUAL............................. 16 PPSC.................................................................... 10
DISCLAIMER Articles in this publication are designed to provide accurate and authoritative information with respect to the subject matter covered. This information is provided with the understanding that neither Florida Pharmacy Today nor the Florida Pharmacy Association is engaged in rendering legal or other professional services through this publication. If expert assistance or legal advice is required, the services of a competent professional should be sought. The use of all medications or other pharmaceutical products should be used according to the recommendations of the manufacturers. Information provided by the maker of the product should always be consulted before use.
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E-MAIL YOUR SUGGESTIONS/IDEAS TO dave@fiorecommunications.com
The President’s Viewpoint SUZANNE KELLEY, FPA PRESIDENT
W
It’s Time to Engage with Profession of Pharmacy
hile Preston McDonald read the 2015 resolutions to our members at our May unit association, I sat in awe as I realized that most did not have a clue as to their importance. The two of us tried to explain how ultimately our profession could be affected. We solicited for delegates and got nowhere. Were they truly indifferent and not concerned by the direction pharmacy is going? I informed them about the upcoming Board of Pharmacy meeting and the topics for discussion. Again, most appeared apathetic. Where is their pharmacy passion, or have they not been successful in finding it? I would not be fair if I did not mention that a few showed interest, but the majority were really ready to get their CE certificate and go home. How can we instill the importance of being involved in local, state and national pharmacy initiatives? After our meeting, one pharmacist came up to me and said that he needed to get active. For simplicity, I am going to call him “Steve.” He confessed that it had been around 10 years since he had last attended our unit association’s meeting. Like all of us, Steve had been busy with work and had not taken the time to come. Steve said that he was going to the FPA 125th Annual Meeting and Convention in St. Augustine, but he could not be a delegate, since he had not renewed his membership in several years. With the very next breath, he said that he would renew his FPA membership so he could be a delegate. Steve did mention that he did not like how pharmacy had changed and the direction it was going in. He also mentioned that he should have helped by going to Tallahassee during the 2015
Legislative Days and Health Fair! Steve said that he should have been making calls to his legislators on topics such as MAC Pricing and Provider Status. Then, Steve surprised me by asking, “How can we encourage the students to become involved and then stay involved after graduating?”
So, how do we get pharmacists out of their comfort level to do something? Are we going to wait for someone else to do it for us? Unfortunately, if we wait for someone else to make it happen, we may not be happy with the results. Another question Steve asked was, “What can we do to get pharmacists out of their comfort level to visit their legislators, invite them to their practice, and donate to the FPA Florida Pharmacists Political Committee?” So, how do we get pharmacists out of their comfort level to do something? Are we going to wait for someone else to do it for us? Unfortunately, if we wait for someone else to make it happen, we may not be happy with the re-
Suzanne Kelley 2014-2015 FPA President
sults. Have you taken the time to read information on the other state pharmacy associations? Some of them have achieved much more than us! Now, please don’t get me wrong, THIS HAS BEEN A VERY SUCCESSFUL YEAR LEGISLATIVELY! Just this past May 11, Washington became the first state in the country to require that pharmacists be included in health insurance provider networks. Even though we have been successful in working with our medical association partners on many issues, we cannot seem to make headway on anything related to scope-of-practice. According to Michael Jackson, our medical friends here in Florida do not want to see any changes to our practice act that mirrors what physicians are doing now. On the other hand, our practice act must be changed in some ways to mirror the training that our pharmacy students are getting in school today. There are more than 29,000 licensed JUNE 2015
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2014 FPA Board of Directors The Florida Pharmacy Association gratefully acknowledges the hard work and dedication of the following members of the FPA leadership who work diligently all year long on behalf of our members:
Terry Gubbins.......................................................................... Chairman of the Board Suzanne Kelly...............................................................................................FPA President Tim Rogers...................................................................................................President-Elect Alexander Pytlarz................................................................................................Treasurer Bob Parrado................................................Speaker of the House of Delegates Jackie Donovan...........................Vice Speaker of the House of Delegates Jennifer Raquipo..............................................................Interim Director, Region 1 Michael Hebb........................................................................................ Director, Region 2 Stephen Grabowski........................................................................ Director, Region 3 Linda Lazuka........................................................................................ Director, Region 4 Jason Beattie...................................................................................... Director, Region 5 Luther Laite IV.................................................................................... Director, Region 6 Kimberly Jones................................................................Interim Director, Region 7 Humberto Martinez......................................................................... Director, Region 8 Mitchell Fingerhut......................................................... Interim Director, Region 9 Christine Gegeckas............................................................................. President FSHP Michael Jackson........................................Executive Vice President and CEO
Florida Pharmacy Today Journal Board Chair.............................................................. Carol Motycka, motycka@cop.ufl.edu Vice Chair...........................................Jennifer Pytlarz, jlc_rxdoc@hotmail.com Treasurer....................Stephen Grabowski, sgrabowski@seniormmc.com Secretary.............. Verender Gail Brown, brownvgrx4304@hotmail.com Member.................................................Joseph Koptowsky, docjik1215@aol.com Member.............................. Rebecca Poston, Rebecca.Poston@flhealth.gov Member........................................................Cristina Medina, cmmedina@cvs.com Member................................................................Norman Tomaka, FLRX9@aol.com Member........................................................................Stuart Ulrich, Stuarx@aol.com Member............................................................. Don Bergemann, don@bceinfo.com Executive Editor................Michael Jackson, mjackson@pharmview.com Managing Editor...................Dave Fiore, dave@fiorecommunications.com Journal Reviewer....................... Dr. Melissa Ruble, mruble@health.usf.edu Journal Reviewer....................................Dr. Angela Hill, ahill2@health.usf.edu
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pharmacists in the state of Florida and fewer than 10 percent are members of the FPA. It is so sad that not all those in our pharmacy profession are active in the Florida Pharmacy Association. They should be supporting membership in a society that is fighting on their behalf. Just think of what all we could accomplish if all of these Florida licensed pharmacists became members. Now, add all of the Florida registered technicians to our organizations. Believe it or not, increasing our membership would help. Remember that it does cost money to get bills passed. We need your support to our advocacy fund. Not all of our members are involved in political advocacy and giving. Our political committee has raised more than $75,000 over the past two years. But it is sad to know that came from only about 214 FPA members. Unfortunately, the insurance industry and the medical associations spend millions of dollars on political activity. My next question is…what can we do to encourage more giving from more members? We need more members and we need more donations! What about donating the cost of a latte? You paid a lot of money for your education - isn’t it worth the cost of a membership in the Florida Pharmacy Association? Isn’t it worth a donation? Get active and make a difference! Find your pharmacy passion and help us to make the next legislative session the best ever! n
Executive Insight BY MICHAEL RPH MICHAEL JACKSON, B. PHARM, EVP & JACKSON, CEO, FLORIDA PHARMACY ASSOCIATION
Overcoming Today’s Practice Challenges
S
omething is happening in today’s pharmacy practice that is worthy of a discussion among stakeholders within our industry. I have an opportunity to visit with pharmacists in a variety of settings to talk about the FPA and professional issues. What I am finding is a trend of growing stress when caring for today’s patients. This behavior is not just limited to pharmacists nearing retirement, but rather it appears to be affecting practitioners midway through their careers and even recent graduates. This issue is likely not unique to pharmacy. The 2014 National Pharmacist Workforce Survey released by the Pharmacy Workforce Center and shared with the FPA members in the April 9, 2015 Stat News was interesting reading. That report, which surveyed pharmacists in various practice settings, appeared to authenticate what I have been seeing across our state. In the survey, there were a number of questions asked related to various types of stress-inducing events. Two glaring markers caught my attention. Those were responses to the questions dealing with adequate staffing and having so many tasks to complete that there is a feeling of not performing well. It is normal for people to want to perform admirably. Each day, when we walk into our pharmacies, our offices or other places of employment, our goal has always been to end the day having been as productive and fruitful as we can. We also want to know that our efforts have made a difference and have contributed to our nation’s economy. Pharmacists take pride in knowing that their interventions improved health, resolved problems and saved lives. This issue of growing and unresolved stress is very troublesome, and my greatest
fear is that unmanaged stress could have dire consequences for either the pharmacist or the patients being served by our industry.
Michael Jackson, B.Pharm
I listened to two presentations by Tallahassee clinical psychologist Dr. James G. Brown, who has considerable expertise on this issue. His remarks were quite profound and very relevant to what I have been seeing in this state. In Dr. Brown’s presentation, I learned that unmanaged stress can remove years from your life. Every week
95 million Americans suffer some kind of stress-related symptoms requiring medications.1 That is nearly 30 percent of America’s population. Another interesting comment by Dr. Brown was, “Think of a typical bottle of water that is half full, and let us see how that bottle is related to stress. With a half-full bottle of water we can control the liquid contents remaining in the container. We can chill it, freeze it, boil it or add coloring and flavoring. We can use that water to quench our thirst or even use the remaining water to wash off our soiled hands. Our stress begins when we are focused on the space in the bottle that has no water. We cannot freeze that space or boil it. That space cannot be used to clean our hands or quench our thirst. It is the lack of control over what we don’t have that may be contributing to this stress.”2 Let us review what is changing in the practice that is making the empty space in our water bottle larger and JUNE 2015 |
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FPA STAFF Executive Vice President/CEO Michael Jackson (850) 222-2400, ext. 200
Director of Continuing Education Tian Merren-Owens, ext. 120 Controller Wanda Hall, ext. 211
Educational Services Office Assistant Stacey Brooks, ext. 210 Coordinator of Membership Christopher Heil, ext. 110
why it is contributing to our stress. It is no secret that there is a lot of disruption going on within health care, and in particular the practice of pharmacy. We have made a number of significant changes in the practice allowing pharmacists to do more things and utilize their training at a higher level. At the same time, we struggle to shed the traditional tasks that pharmacists must perform or be accountable for. Changing technician ratios may help provide
ance advisor when you have no control over their benefit plan. You may have some limited ability to intervene and negotiate with their plan administrator or prescribing practitioner, but this effort creates disruption within your practice and compounds your stress. It is the water that is not in your bottle that you have to somehow add flavoring to on behalf of the patient. This steals valuable time away from the important tasks that you should be doing
FLORIDA PHARMACY TODAY BOARD Chair..................................... Carol Motycka, St. Augustine Vice Chair.........................Jennifer Pytlarz, Herndon, Va. Treasurer...............................Stephen Grabowski, Tampa Secretary.........................Verender Gail Brown, Orlando Member..................................... Joseph Koptowsky, Miami Member..............................Rebecca Poston, Tallahassee Member....................................Cristina Medina, Hollywood Member................................. Norman Tomaka, Melbourne Member..............................Stuart Ulrich, Boynton Beach Member.......................Don Bergemann, Tarpon Springs Executive Editor.........Michael Jackson, Tallahassee Managing Editor.........................Dave Fiore, Tallahassee
This is a peer reviewed publication. ©2015, FLORIDA PHARMACY JOURNAL, INC. ARTICLE ACCEPTANCE: The Florida Pharmacy Today is a publication that welcomes articles that have a direct pertinence to the current practice of pharmacy. All articles are subject to review by the Publication Review Committee, editors and other outside referees. Submitted articles are received with the understanding that they are not being considered by another publication. All articles become the property of the Florida Pharmacy Today and may not be published without written permission from both the author and the Florida Pharmacy Today. The Florida Pharmacy Association assumes no responsibility for the statements and opinions made by the authors to the Florida Pharmacy Today. The Journal of the Florida Pharmacy Association does not accept for publication articles or letters concerning religion, politics or any other subject the editors/ publishers deem unsuitable for the readership of this journal. In addition, The Journal does not accept advertising material from persons who are running for office in the association. The editors reserve the right to edit all materials submitted for publication. Letters and materials submitted for consideration for publication may be subject to review by the Editorial Review Board. FLORIDA PHARMACY TODAY, Annual subscription - United States and foreign, Individual $36; Institution $70/year; $5.00 single copies. Florida residents add 7% sales tax. FLORIDA PHARMACY ASSOCIATION
610 N. Adams St. • Tallahassee, FL 32301 850/222-2400 • FAX 850/561-6758 Web 8 Address: | F L O Rhttp://www.pharmview.com IDA PHARMACY TODAY
Metrics is a new term that I am only beginning to understand. It simply may be a type of measurement that is used to gauge performance of something or someone. For example, a traditional metric may be the profitability of a business, its sales, or cost of doing business. some relief, but simply doing that may not be enough. Pharmacists are still held liable for what technicians do and must continue to monitor their activity. Holding technicians accountable for what they do may help, but it may also create the need for different compensation and performance evaluation standards for these kinds of staffing positions. Only then would pharmacists be free to expand their practice reach. If you are the person who makes budget or operational decisions, then this may be the water in your half-full bottle that you can control and do something about. If not, you will have to find a way to fulfill your responsibilities as a pharmacist with only half the water you need. Managed care is creating a lot of rough seas within pharmacy. The space in this water bottle happens to be patients who are unfamiliar with their prescription drug benefit plan, and as pharmacists or pharmacy technicians, you have to be the one to explain their limits. This includes what medications are covered and why the patient’s cost share may change. In effect, you become their insur-
as a pharmacist or technician. Metrics is a new term that I am only beginning to understand. It simply may be a type of measurement that is used to gauge performance of something or someone. For example, a traditional metric may be the profitability of a business, its sales, or cost of doing business. With the use of technology, metrics is taking on a whole new meaning. Computer systems can now measure keystrokes, log activity and generate performance measures that, in years past, were unavailable. This creates another space in our half-empty water bottle, because some of these performance measures may not be in your direct control. In the FPA office, our staff takes pride in grabbing a phone that is ringing. On occasion, when there are multiple calls hitting our system at the same time and all staff may be helping our members with their issues, the phone may ring more than three times. If the system measures multiple missed calls, and as a manager, I use that data to evaluate performance, then I need to understand the data and why it is
showing anomalies. I can’t just come to a single conclusion that there simply is a staff performance issue. Such metrics to be used this way should include data on the call load during the period of missed calls and the number of hands on deck available to receive these calls. Such data can be used to make appropriate management decisions on staffing needs. In other words, the data should be used to help staff manage the water that they have control over, rather than holding them accountable for what is not in the bottle. So what is the answer to all this stress in our industry? How do we get our hands around it and control it? For one thing, our member (and non-member) stakeholders need to realize that you cannot manage stress alone. Associations were created for the purpose of helping an industry to thrive during times of adversity. Pharmacy is being disrupted from all sides. A Navy armada is needed to navigate these dangerous waters. You cannot get to
Pharmacy is being disrupted from all sides. A Navy armada is needed to navigate these dangerous waters. shore safely in a 12-foot fishing boat when the waves are over 30 feet. This is where networking within the FPA can help you rise to the crest of these huge waves and use that as a way to leap over shark-infested waters. Let us help you manage the water that is in your bottle. As you are reading this, we are preparing for our 125th Annual Meeting and Convention. If you are going to that meeting, I will be looking forward to seeing you there. If you will miss this adventure, then mark your calendar to be with us at our
next regional conference, or plan to be with us for the 126th Annual Meeting and Convention in Ft. Lauderdale at the Marriot Harbor Beach, June 29-July 3, 2016. n REFERENCES 1 Stress, Health and Longevity, James G. Brown, Ph.D., May 16, 2015, FPA Conference on Pharmacy Management of Mental Disorders, Jacksonville, Florida 2 2015 FAMU Clinical Symposium, February 20-22, 2015, College of Pharmacy and Pharmaceutical Sciences, Tallahassee, Florida
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FLORIDA PHARMACY ASSOCIATION 125TH ANNUAL MEETING AND CONVENTION Renaissance Resort at World Golf Village St. Augustine, Florida
SAVE THE DATE: June 24- 28, 2015 JUNE 2015
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Walking the Pharmacist’s Tightrope: Balancing Patient Safety Against Pharmacy Performance Metrics Joseph Scuro J.D., D.C., Pharm.D.
The Pharmacist’s Prayer “Today I will be pressured to fill more prescriptions faster than ever before, to provide extra services with less staffing hours, to operate with a less qualified staff, SO please don’t let me make any mistakes that could cause harm to a patient while meeting every pharmacy performance metric this day.” — Anonymous Pharmacist When pharmacists work exhausting hours under grueling pressure, mistakes happen. Thankfully, the majority of errors made are minor, but some have the potential to kill. It was typical Monday, one of the busiest days of the week, and the pharmacy by all accounts was understaffed. A mother picks up her child’s new prescription, which is written for Amoxicillin. Trusting her pharmacist she never questions the accuracy of the pills contained in the bottle and provides them to her daughter three times a day as her doctor prescribed. The pills inside the bottle were, in fact, a diabetes drug, at 16 times the adult dosage. After taking the medication, the little girl sank into a coma and suffered permanent brain damage. Investigators discovered that the pharmacist who made the mistake was at the end of a solo 10-hour shift, on a day when she filled more than 400 prescriptions; was working with fewer pharmacy staff, due to recent reductions; had received word that afternoon during a conference call that her store was underperforming on several key pharmacy performance metrics and, as a result she needed to be writtenup; had not eaten anything more than a soda and some chips all day; had not moved more than three feet in any direction outside of her one emergency bathroom break; had verified the child’s incorrect medication while being yelled at from across the counter by a customer upset and complaining to store management about how inconvenient it was to be asked to wait 30 minutes to get her Oxycodone prescription filled.
Pharmacies are reacting to the ever-growing demand for prescription drugs. Today the demand for prescription drugs is expected to exceed the 3 billion prescription mark, according to National Association of Chain Drug Stores (NACDS) estimates. No one involved in the pharmacy industry can deny that there’s a real crisis in our pharmacies today, and at the heart of it is overworked pharmacists. Recently, the use of pharmacy performance metrics has come under fire, as pharmacists are pushed to work beyond their individual breaking points. Today, the conditions at most pharmacies are often described as modern day sweat shops. So what is a Pharmacy Performance Metric? Defined generally as the deliberate measurement of the quantity and quality of a specific pharmacist task, it is a system or standard of measurement that quantifies results. Performance metrics quantify a pharmacist’s task completion rate. Business performance metrics quantify a business’ progress. They are commonly used by pharmacy management to set pharmacists’ performance goals and pharmacy performance expectations. Pharmacist performance metrics are used to define what is accepted performance in pharmacies such as: time allowed to fill a prescription, time and number of immunization shots given, time and number of daily patient phone calls attempted, time and number of provider calls at-
Could this have been you on any given Monday in your practice? Statistics suggest that this pharmacist is not alone. Pharmacists exhausted by the demands of burgeoning pharmacy service metrics are making a growing number of errors while filling prescriptions for customers, according to recent National Association of Boards of Pharmacy (NABP) reports. JUNE 2015 |
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tempted, time elapsed before answering the phone, customer satisfaction scores and many more on the daily pharmacist task list. Where did they come from? Business managers make the case that they are a result of business competition and the desire to please stockholders, which have driven pharmacists away from their primary task of “do no patient harm.” Instead, the focus seems to be on the number of prescriptions filled, how fast they can be filled and quarterly profit-sharing. Tracking and measuring meaningful metrics can provide insight into a pharmacy’s performance. However, the pharmacist is more likely to think in terms of health outcomes and medications safety than in terms of assets and sales. But pharmacists must acknowledge that pharmacies today are also in the retail business, and they need to think like retailers to survive in a competitive marketplace. Considering payroll and balance sheets with as much attention as patient outcomes can be the margin between growth and going out of business. It is important for pharmacists to at least appreciate the business side of the metrics discussion. Pharmacies must identify market trends and make changes to their operations and strategies in order to thrive. Under the new health law changes to pharmacy reimbursement, pharmacy practice has become a very restricted business. Therefore, pharmacies must adapt their practices to operate on thin margins.
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But pharmacists must acknowledge that pharmacies today are also in the retail business, and they need to think like retailers to survive in a competitive marketplace. However, when efficiency and productivity metrics are applied solely based on cost or number comparisons, without considering the associated quality outcome measures, the results may become meaningless.1 In a vast majority of opinion polls and published studies, an overwhelming majority of pharmacists have the strong perception that pharmacy performance metrics are employed simply to put pressure on the pharmacists to meet the ever-growing list of management demands and expectations, which inevitably results in less time available to accurately check prescriptions and counsel patients. Most recently, a growing number of wrongful termination and age discrimination legal actions have been brought by pharmacists alleging the use of pharmacy performance metric quotas as the foundation upon which the pharmacist was dismissed. The point to be made is that the performance metric itself is not the problem. The problem only arises when the performance metric promotes or is perceived by the pharmacist to promote an unreasonable standard or goal that the pharmacist can only achieve by cutting corners on patient safety. Maybe a sensible approach would be for business managers to partner with the pharmacists who actually provide the daily patient care to their customers and work to achieve a better application of the pharmacy performance metrics being employed. Working together may bring a balanced understanding of how and why each pharmacy performance metric is being utilized and how it will result in a positive patient outcome. The business managers must also acknowledge that one size never fits all applications. As pharmacists age with the years of knowledge and experience chiseled onto their forehead, there comes a natural slowing in production speed. They don’t read as fast as they once did, their ability to process input slows, a magnifying glass is now used to see the small pill imprinting, prescriptions are double- and sometimes triple-checked, and adapting to changes comes slower. Maybe, just maybe, pharmacy performance metric quotas should be flexible to leave room for the slower, but most experienced pharmacists in practice. I can’t ever image a circumstance when, upon needing open heart surgery, investing my life savings, or during the delivery of my child, that I would ever have chosen the young, new graduate with little to no experience, but who works real fast, over a slower, more experienced and proven professional who has performed the task
a thousand times over their career. Simple fact is, every pharmacist will someday be old, gray and yes, slower. So maybe a professional’s career should rely on more than meeting a pharmacy performance metric quota. Some states have attempted to address the issue. The North Carolina Board of Pharmacy had served notice that pharmacists shall not dispense, and permit-holders shall not allow a pharmacist to dispense, prescription drugs at such a rate per hour or per day as to pose a danger to the public health or safety; the statement mentions a threshold of 150 prescriptions per pharmacist per day. However, the document has been removed, according to meeting minutes, and it is unclear when or why the prescription volume limit is no longer implemented.2 The implementation of a similar rule by state Boards of Pharmacy would not remove a pharmacist’s freedom to verify large volumes of prescriptions they felt comfortable doing, or provide a cover for a pharmacist to become unproductive. But it would give the state Boards of Pharmacy the power to prevent employers from using pharmacy performance metrics to penalize and pressure pharmacists to perform in excess of their better judgment, by prohibiting the use of external metrics such as productivity or production quotas, to the extent that they interfere with the ability of pharmacists to practice safely. Medication errors have simply become a calculated cost of doing business. With the newly found over-abundance of pharmacists looking for work, a new, eager pharmacist replacement submits their resume every day, leaving those in practice with a fearful and often muted voice. But it’s a cost that concerns groups such as the National Association of Boards of Pharmacy. In 2013, pointing to research and polls showing that the use of metrics tend to increase errors, the NABP asked states to restrict, regulate or prohibit the use of pharmacy performance metrics:
Medication errors have simply become a calculated cost of doing business. With the newly found over-abundance of pharmacists looking for work, a new, eager pharmacist replacement submits their resume every day, leaving those in practice with a fearful and often muted voice.
Resolution No: 109-7-13 Title: Performance Metrics and Quotas in the Practice of Pharmacy Action: PASS WHEREAS, a survey conducted by the Institute for Safe Medication Practices (ISMP) of 673 pharmacists revealed that 83 percent believed that distractions due to performance metrics or measured wait times contributed to dispensing errors, and that 49 percent felt specific time measurements were a significant contributing factor; and WHEREAS, performance metrics, which measure the speed and efficiency of prescription workflow by such parameters as prescription wait times, percentage of prescriptions filled within a specified time period, number of prescriptions verified and number of immunizations given per pharmacist shift, may distract pharmacists and impair professional judgment; and WHEREAS, the practice of applying performance metrics or quotas to pharmacists in the practice of pharmacy may cause distractions that could potentially decrease pharmacists’ ability to perform drug utilization review, interact with patients and maintain attention to detail, which could ultimately lead to unsafe conditions in the pharmacy; THEREFORE BE IT RESOLVED that the National Association of Boards of Pharmacy (NABP) assist the state boards of pharmacy to regulate, restrict, or prohibit the use in pharmacies of performance metrics or quotas that are proven to cause distractions and unsafe environments for pharmacists and technicians; and BE IT FURTHER RESOLVED that NABP review and propose amendments to the Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy to address the regulation, restriction or prohibition of the application of performance metrics and quotas that are proven to cause distractions and unsafe environments for pharmacists and technicians. (Resolution passed at the NABP 109th Annual Meeting in St Louis, MO)(3) So is the use of pharmacy performance metrics to blame for the errors occurring? Based upon anecdotal and empirical evidence, the strong suggestion supports simple intuition that pharmacists who are rushed and distracted because of imposed pharmacy performance metrics are surely more prone to making mistakes than when adequate time is allowed to review prescriptions, dosages, patient profiles and when patient consulting is provided. The evidence includes the following studies: Study: Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug-drug interactions (DDIs). Conclusion: This study found that pharmacist workload, as determined by the number of prescriptions dispensed per pharmacist work hour, was significantly associated with the rates of dispensed potential DDIs. Other pharmacy characteristics, such as total pharmacy staffing levels and automation, JUNE 2015
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were also significant predictors of potential DDIs. The findings are intuitive because pharmacies attempt to become efficient in order to process higher prescription volume often exceed capacity. Unfortunately, implementation of automation and other pharmacy staffing may not sufficiently compensate for the increased pharmacist workload, leading to increased errors.4 Study: Workload and its impact on community pharmacists’ job satisfaction and stress: a review of the literature. Conclusion: A significant majority of studies cited suggested that community pharmacists generally perceived that increased workload contributed to increasing prescription errors, job-related stress and decreasing job satisfaction.5 However, pharmacy performance metrics alone may not be the only suspect to be blamed for the pharmacy errors. The reality is that the average retail pharmacist is expected to
The ability of pharmacists to multi-task in busy settings has not been well studied. It may be in part that it is simply intuitive that in any profession, constant interruptions will result in increasing the risk of errors being made. It is a wellcited general principle that frequent interruptions can have a significant effect on memory; interruptions result in loss of concentration, leading to medical errors.7 Every prescription that passes through a pharmacist’s hands can improve a patient’s life or bring death! Think about this staggering reality – every pharmacist every day in every pharmacy has the chance to kill any one of the hundreds of people whose lives they will touch that day. The next time you ask your pharmacist to do anything other than focus on each prescription with their undivided attention, do so as if your life depended upon it. Because one day, it just might!
Pharmacists must take the time to speak with their patients; an informed patient is still the best defense against pharmacy errors. Pharmacists need to encourage patients to read the literature provided, ask questions and make sure their medication makes sense. perform their job under circumstances that few other medical professionals would tolerate. The enormous number of distractions faced by the pharmacist in an average day can be simply overwhelming. Far too often, the pharmacist’s job responsibilities verge on the customer service absurd. When a customer comes up to the prescription counter and asks a pharmacist where they can find dog food, the pharmacists in some practice sites report that they are required to stop what they’re doing and lead the customer to the product. Pharmacists are expected to interrupt their prescription checking process for any and all customer issues, they must stop to answer the constantly ringing phone, retrieve doctor voice mails within minutes of arrival and devote however much time is needed to resolving every customer issue, no matter how unreasonable. The pharmacist is expected to absorb all the vulgar verbal abuse and threats a customer wishes to deliver, without raising their voice, raising their blood pressure or breaking their concentration. Such distractions are more than a mere annoyance for the pharmacist. Pharmacist distractions and interruptions have an unquestionable effect on the number of prescription mistakes made.6 Would any of us expect that, while performing surgery, our doctor would be multi-tasking; making patient follow-up calls, answering patient phone calls, giving immunization shots, providing medication counseling, running the customer complaint window and giving tours of the hospital, all while holding our future in her hands? 14
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Conclusions Based upon the conclusions of the vast number of pharmacist performance studies, pharmacy performance metrics, as they are frequently being used in pharmacy today, are a unilateral mistake. They are a poor substitute for true leadership, mentorship and a vision for excellence. Quotas cannot replace quality. Pharmacists must take the time to speak with their patients; an informed patient is still the best defense against pharmacy errors. Pharmacists need to encourage patients to read the literature provided, ask questions and make sure their medication makes sense. Amazingly, when a pharmacist takes the time to talk with a customer about their prescriptions, especially the first time filling a prescription, it has been estimated that nearly 80 percent of potential dispensing errors can be caught at that point. But I hear the cries! Where does the pharmacist get the time to counsel patients? Remember that the pharmacist production speedometer on the dashboard is always running and recording the failure of the pharmacist to complete the prescription fill in the time allowed by the performance metric. As a result, taking the time to counsel the patient is reduced to a registrar clerk asking if the patient has any questions for the pharmacist. The opportunity to correct the medication error before it walks out of the pharmacy – or maybe the opportunity to save a life – is lost. But the pharmacy performance speedometer on the dashboard will end the day in the green. And by all quantifiable performance metrics, it will demonstrate that
We hear all the time from pharmacy spokespeople that patient safety is the primary responsibility of the pharmacy. These comments are certainly aspirational, but arguably, are rarely echoed by the pharmacist. you were a great pharmacist today. We hear all the time from pharmacy spokespeople that patient safety is the primary responsibility of the pharmacy. These comments are certainly aspirational, but arguably, are rarely echoed by the pharmacist. What can pharmacists do? ■■ Work with your state pharmacy association and Board of Pharmacy to develop an honest and complete prescription error reporting system that provides clear liability relief for the reporting pharmacist and pharmacies. Currently, prescription error reporting is not mandatory, resulting in very little voluntary reporting. Collecting this data is important because we need to develop a clear and concise understanding of where and what factors are driving the pharmacy errors before the growing trend can be reversed. ■■ Work with your state pharmacy association and Board of Pharmacy to develop, draft and adopt the NABP suggested model act recommendations, setting forth the regulation, restriction or prohibition of the application of performance metrics and quotas that are proven to cause distractions and unsafe environments for pharmacists and technicians. Doing such will give the state Boards of Pharmacy the power to prevent employers from using pharmacy performance metrics to penalize and pressure pharmacists to fill prescriptions in excess against their better judgment.
viding pharma-legal education, research and consultation in the areas of pharmacy compliance, regulation, quality improvement, and errors. He is a graduate of the Whittier School of Law, North-western Health Sciences University and Lloyd L. Gregory School of Pharmacy. References
1. Kaplan RS. When benchmarks don’t work hbswk.hbs.edu/ tools; 2006. 2. North Carolina Board of Pharmacy. Board Statement on Pharmacist Workload. March 26, 1997. 3. Performance Metrics and Quotas in the P ractice of Pharmacy (Resolution 109-7-13) June 5, 2013, 12:05 PM Topics: Resolutions. 4. Malone DC, Abarca J, Skrepnek GH, et al. Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug-drug interactions. Med Care. 2007; 45: 456-62. 5. Lea, V.M., Corlett, S.A., & Rodgers, R.M. (2012). Workload and its impact on community pharmacists’ job satisfaction and stress: a review of the literature. 6. International Journal of Pharmacy Practice, 20(4), 259-271.6. Murphy JE, Forrey RA, Desiraju U. Community pharmacists’ responses to drug-drug interaction alert. Am.! Health Sy.l Pharm. 2004;61:1484-’-1487. 7. Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians multitasking? Acad Emerg Med. 2000;7:1239-1243.
If these action steps are things you are ready to support, then reach out at RxLawDoc@gmail.com, so that we can continue the conversation on how to keep improving pharmacy practice. This article discusses general principles of law and risk management. This discussion is not intended to represent legal advice. Specific legal questions should be referred to local legal counsel. Opinions expressed reflect those of the presenter and should be confirmed within your pharmacy jurisdiction. Joseph Scuro, is president of HealthForce Consultant Group proJUNE 2015
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FPA Officer and Director Nominations Although we have just finished the election for a President-Elect and Directors for the odd-numbered regions to be installed at the 2015 annual meeting, it is time to start thinking about nominees for the 2016 election, since the nomination deadline is September 1 of this year (9/1/15). As the form below indicates, this year we will need candidates for President-Elect, Treasurer and Directors for the even-numbered regions. Please note that you may nominate yourself. CALL FOR FPA OFFICER AND DIRECTOR NOMINATIONS for 2016 Elections The FPA bylaws specify that any subdivision or any member in good standing may nominate one person for the office of President-Elect and one person for the office of Treasurer. A President-Elect shall be elected every year and shall assume the duties of the President on the last day of the annual meeting of the year following election as President-Elect. The Treasurer shall serve a two-year term and may succeed to one consecutive term of office in that capacity. Nominees must be Florida registered pharmacists in good standing with the Florida Pharmacy Association and the Florida Board of Pharmacy. Nominees for President-Elect should have a good understanding of how the Association functions and should be current on the issues impacting pharmacy. Nominees for Treasurer should have good analytical skills and experience and ability in financial management and budget preparation. There are nine regional Board Directors who shall serve two year terms. Nominees must be a Florida registered pharmacist in good standing with the Florida Pharmacy Association and the Florida Board of Pharmacy. Additionally, Board Directors must be a member of at least one the FPA Unit Associations within their region. Board Directors terms are staggered such that even numbered regions shall be elected in even numbered years and odd numbered regions shall be elected in odd numbered years. All newly elected Board of Directors Regional Directors shall take office on the last day of the annual meeting, and shall continue in office until the last day of annual meeting of the second ensuing year.
FPA CANDIDATE NOMINATION FORM I AM PLEASED TO SUBMIT THE FOLLOWING NOMINATION: NAME: ADDRESS:
FOR THE FOLLOWING OFFICE:
(Nomination Deadline September 1, 2015)
q President-Elect q Treasurer q Board Director Region 2 Region 4 Region 6 Region 8 NOMINATED BY: NAME: DATE SUBMITTED: SIGNATURE:
MAIL NOMINATIONS TO: Election Nominations, Florida Pharmacy Association, 610 N. Adams St., Tallahassee, FL 32301 (850) 222-2400 FAX (850) 561-6758 DEADLINE FOR NOMINATIONS IS SEPTEMBER 1, 2015
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Dispose of Unneeded Medications Kristen Jones, Pharm.D., Risk Management Consultant
Prescription drug abuse has reached epidemic proportions across the country. In 2011, more than 6 million people aged 12 or older abused prescription drugs, according to the Substance Abuse and Mental Health Services Administration, a government agency that conducts a national survey on related topics each year. The same survey showed that more than 50 percent of people abusing these drugs got them from friends or family for free. Often, those who abuse drugs, including teens, take them right out of the medicine cabinet. Ridding the home of unused, expired, or unneeded medications helps to prevent the drugs from falling into the wrong hands. Cities and counties across the country provide permanent medication disposal programs. Recently, the Drug Enforcement Administration has allowed pharmacies to register as disposal sites for both controlled and non-controlled medications. Other programs are run by hazardous waste disposal agencies or other entities that cannot accept controlled substance medications, but can take all other unused drugs for
In particular, you should securely store controlled substance prescription drugs, such as certain pain medications and ADHD medications. 18
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safe disposal. AWARxE’s online locator tool on its Drug Disposal Sites page allows users to search for local disposal programs. If there are no drug disposal sites near you, there are options for disposing of drugs at home. The information that comes with your prescription may provide instructions on home disposal. Only some medications should be flushed down the toilet, and the US Food and Drug Administration has a list of these drugs on its website. If there are no instructions for disposal, you can throw the drugs in your home garbage. But first, take them out of the container and mix them with an undesirable substance like coffee grounds or cat litter. Seal the mixture in a sealable bag, empty can, or other container that can be disposed of in the garbage. Parents should securely store all medications in the household. For example, you may want to lock your medications in a secure cabinet or a medicine safe. In particular, you should securely store controlled substance prescription drugs, such as certain pain medications and ADHD medications. You may also wish to keep track of the number of pills left in the bottle. Remember that sometimes prescription drugs are taken out of medicine cabinets by visitors to the home. More details about drug disposal programs are available on the Find Disposal Information page of the AWARxE website.
Specialized Adherence Teams
By Christopher Daly In today’s evolving cost conscious health care system there have been increasing talks centering on accountable care organizations (ACOs), medical homes, and multidisciplinary teams. Where do these buzz words belong in improving patient outcomes in your pharmacy by expanding your current medication adherence program? The answer is quite simply to create a specialized medication adherence team for your patients. Who would be on this team? Candidates must be able to help facilitate behavioral change when it comes to medication adherence. Some of the top candidates for this adherence team are doctors, the busy “sandwich” generation caregivers, and the pharmacist. This team can be assembled to synergistically be that ‘other’ voice in the patient’s ears about medication adherence. Targeting and marketing to doctors can be as simple as sending a brochure explaining the benefits of your adherence program. Highlight the increased efficiency that would result from fewer calls for uncoordinated refills, therapeutic medication review opportunities, and identifying overall adherence issues. This will allow prescribers to identify their own medication adherence problem patients and begin to make referrals to your program. The physician knows that it is not enough to just trust their own patients to carry out the execution of the medication regimen. Make the doctor aware by enlisting a patient to an adherence program overlooked by a pharmacist will lead to better health outcomes. The patient ultimately benefits in the end. Many times caregivers are behind a patient’s complex medication regimen. They are the liaisons
and health care proxies who communicate to the health care professionals. These frazzled, busy individuals many times are juggling professional lifestyles and would benefit from the simplification of a medication regimen from an adherence program. Taking the time to pull these individuals aside to explain the benefit of your adherence programs can make all the difference. Some of the many benefits include fewer trips to the pharmacy, reduced number of phone calls to the physician for refill requests, and an increased understanding of their medication regimen. This little investment of time can help patients realize their adherence goals. Marketing to doctors and caregivers about your adherence program is only the beginning. This program, like any other marketable niches, can service many local groups like long‐term care and group homes. When you survey the needs of the community the possibilities and applications are endless. Lastly, the buck stops with you, the pharmacist. You have the ability to identify the barriers while providing expertise, positive reinforcement, encouragement, and support to improve your patient’s medication adherence. To target certain individuals and officially make them aware and participate in your adherence program, you also invite them onto the patient’s medication adherence team. In the end, incorporating this program into your service mix can help you manage these patients more efficiently and thoroughly. Do you have an adherence tip to share with colleagues? Email us at adherence@ncpanet.org Reprinted with permission from National Community Pharmacists Association in the December 2011 issue of America’s Pharmacist. For more information about NCPA, visit www.ncpanet.org.
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FPA News & Notes e-Prescribing of Controlled Substances Over the years there has been growth in the electronic prescribing of medications. This includes the e-prescribing of controlled substances which is now permitted for class II through V medications. A number of health systems will be on-boarding their services to connect with approved e-prescribing networks that have passed the necessary encryption required by the DEA. Pharmacies will need to be prepared to receive these prescriptions. If you wish to view a list of pharmacy and prescriber software that is compliant visit this link. The FPA has received notice that major health systems will be converting to electronic prescribing platforms. If your pharmacy is not enabled to receive these prescriptions you may run into difficulty getting these patients served in your pharmacy. According to the Florida Electronic Prescribing Annual Report for 2014 from AHCA, the average number of electronic prescriptions transmitted per month has increased from 372,085 in 2008 to 6,316,242. The number of e-prescribing physicians has increased from 4,492 in 2008 to over 34,000 in 2014. The Board of Pharmacy has discussed electronic prescribing of controlled drugs and has determined that this is permissible for class II through V. (See March 29, 2014 Stat News). Continue Provider Status Advocacy Keep finding your passion for pharmacy provider status. The work continues on this issue and your messaging is helping. As you receive this, there are 144 cosponsors who have signed onto H.R. 592 and 17 Senate sponsors who have signed onto S314. Both of these bills recognize pharmacists as health care providers. Florida’s two Senators have not signed onto this bill yet. There are six members of the Florida delegation serving in the Congressional House that are publically supporting this legislation. They are Representatives Alcee Hastings, David Jolly, Dennis Ross, Patrick Murphy, Gus Bilirakis and Carlos Curbelo. If you live in those Congressional districts thank you for your hard work. If your Congressman is not on this list, it’s time to get involved and contact them asking for their support. Consider where Florida stands on the list of states with the most cosponsors.
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■■ ■■ ■■ ■■ ■■ ■■
California (20) Illinois (14) New York (9) Ohio (7) Pennsylvania (8) Florida, North Carolina and Texas (6 each)
Go into our advocacy center and send a message and ask for your Congressman to support H.R. 592. Reach out to Senator Nelson and Senator Rubio and encourage their support of S314. This web site will tell you how to do that. After you send this message make a phone call to follow up on your message. Repeat contacts are likely to get better results. If you are waiting for Somebody Else to make the call be reminded that Somebody moved to Ohio and will not be doing anything for you! Congressman Carter to Visit FPA Convention The FPA is pleased to announce that Congressman Buddy Carter will be visiting with us at the 125th Annual Meeting and Convention in St. Augustine, Florida. Congressman Carter will make brief remarks during the Awards Banquet on Saturday, June 27, 2015. Buddy Carter A committed public servant, Buddy previously served as the Mayor of Pooler, Georgia, and in the Georgia General Assembly where he used his business experience to make government more efficient and responsive to the people. Buddy is serving his first term in the United States House of Representatives and is a member of the Education and the Workforce Committee as well as the Committees on Homeland Security and Oversight and Government Reform. As the only pharmacist serving in Congress, Buddy is the co-chair of the Community Pharmacy Caucus and is dedicated to working toward a healthcare system that provides more choices, less costs and better services.
FPA Member Believes in Political Donations Much of what we do as pharmacists and pharmacy technicians is driven by current and new policies shaped by those in elected offices. Input in legislative decision-making comes from those who are elected into public service. The Florida Pharmacist Political ComSteve Pressman mittee campaign fund account has been growing thanks to the many members who make volunteer contributions to support their mission. The Florida Pharmacist Political Committee would like to thank FPA member Steve Pressman and Pillbox Pharmacy for their major contribution to the FPPC fundraising campaign. Steve’s contribution is one of the largest received. Pillbox Pharmacy and Medical recently celebrated 30 years of service in the Pembroke Pines community. Pillbox Pharmacy received a proclamation from Mayor Frank C. Ortis ack nowledg i ng t he services provided in that community. Congratulations Steve from the FPA. Are you interested in supporting the FPPC? Visit this web site link for more information and FIND YOU R PA SSION FOR PHARMACY. Pembroke Pines Mayor Frank Ortis reads
Pharmacy Organizations Comment on USP Chapter 800 The USP Convention is considering the adoption of Chapter 800 as a standard. The purpose of Chapter 800 is to describe practice and quality standards for handling hazardous drugs to promote patient safety, worker safety, and environmental protection. Each year, approximately 8 million U.S. healthcare workers are potentially exposed to hazardous drugs. The new proposed general chapter defines processes intended to minimize the exposure to hazardous drugs in healthcare settings. Some of the concerns in the new chapter by USP include but are not limited to duplicative requirements currently in state and federal regulations and the effect on patient access. A comment letter has been filed by national pharmacy organizations including the National Alliance of State Pharmacy Associations of which the FPA is a member of.
Representing Health Care Professionals
Proclamation for Pillbox Pharmacy
Track and Trace Requirements for Pharmacies Late in 2013, the Drug Supply Chain Security Act (DSCSA) was approved by Congress and signed into law by President Obama. This legislation implemented some track and trace requirements for prescription drugs that are being wholesaled and dispensed. Many of you are familiar with Florida’s pedigree program which for now appears to be in limbo given these new federal requirements. At this time we do not have clear direction from the Bureau of Pharmacy Services in the Florida Department of Business and Professional Regulations (DBPR). DBPR regulates prescription drug wholesaling in this state. Members need to be aware that the federal DSCSA has requirements taking affect that may require some modifications to your wholesaler agreements.
• DOH Investigations • Licensure Discipline • Medicare/Medicaid Defense • Administrative Hearings • Contract Litigation George F. Indest III, J.D., M.P.A., LL.M.
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Clostridium Difficile Infection: A Review for Pharmacists K. Ashley Jones, Pharm.D., Lori Dupree, Pharm.D., BCPS
Epidemiology During 2011, Clostridium difficile infected almost half a million people in the United States, resulting in approximately 29,000 deaths within 30 days of initial diagnosis.1,2 With the large number of infections and resulting deaths, C. difficile infections (CDI) are one of the most concerning threats in health care and account for 15 percent to 25 percent of all cases of antibiotic-associated diarrhea. These findings highlight the importance of pharmacists’ ability to understand the infection, treatments and methods for prevention in order to effectively treat and counsel patients. Pharmacists can also play a role in recognizing patients at risk for CDI, based on antimicrobial usage.3 Pathogenesis C. difficile is a spore forming, grampositive anaerobic bacillus that produces two types of exotoxins (toxin A and B).4 The presence of C. difficile does not always result in an infection. Some patients are colonized with C. difficile, meaning they test positive for C. difficile toxin but do not exhibit any clinical symptoms associated with CDI, such as diarrhea, fever and nausea.4,5 An estimated 3 percent to 8 percent of healthy adults are colonized with C. difficile; whereas, approximately 20 percent of hospitalized patients are colonized with C. difficile.4 In order for a patient to develop an infection from C. difficile, mucosal injury and inflammation must occur. Injury and inflammation occurs after the normal gut flora is disrupted, often by antibiotics or antineoplastic agents that have antibacterial activity. When this disruption occurs in conjunction with colonization of C. difficile, it results in toxin-mediated cytoskeletal derangement of target cells. Finally, injury and 22
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inflammation of the mucosa cause the patient to experience the clinical symptoms of CDI.4 On the other hand, patients do not have to be a pre-existing carrier of C. difficile in order to experience a symptomatic infection. Most cases of CDI occur from exogenous sources in which C. difficile is spread via fecal-oral transmission, usually in the hospital setting.5
Clinical Manifestations The major pathologic feature of CDI is the formation of a pseudomembrane, referred to as pseudomembranous colitis. C. difficile was detected in at least 90 percent of patients with pseudomembranous colitis. In patients with pseudomembranous colitis, the mucosa can be visualized with endoscopy as having raised, white or yellowish plaques with or without the presence of inflamma-
Table 1. Antibiotics Associated with CDI
Highest Risk of CDI4
Lowest Risk of CDI4
•
• • • • •
• • •
Cephalosporins (especially second and third generation agents) Clindamycin Penicillins Trimethoprim-sulfamethoxazole
Metronidazole Rifampin Aminoglycosides Amphotericin B Ticarcillin-clavulanate
tion and mucous. These plaques start off small and difficult to detect. As the infection progresses, the plaques can grow and coalesce.4 Diarrhea may begin the first day or even as late as 10 weeks after antibiotic therapy. The symptoms can range from mild, brief diarrhea to fulminant and sometimes fatal colitis. Other than diarrhea, the most common symptoms include fever (30 percent to 50 percent), leukocytosis (50 percent to 60 percent), and abdominal pain and cramping (20 percent to 33 percent). White blood cells are often extremely elevated in CDI, with 25 percent of patients experiencing white blood cell counts greater than 35,000 cells/ÂľL. CDI can also manifest as toxic megacolon, which is identified as acute dilatation of the colon to a diameter greater than 6 cm, systemic toxicity, and the absence of mechanical obstruction. Toxic megacolon carries a 64 percent mortality rate, as reported by one case series (n=11).4 As the most accessible health care professionals, pharmacists are often approached by patients complaining of symptoms consistent with CDI, highlighting the need for pharmacists to recognize a possible CDI presentation. When patients develop an infection from C. difficile, the onset is usually five to 10 days following treatment with antibiotics. While almost all antibiotics have been known to cause CDI, some antibiotics are more frequently associated with CDI than others. Table 1 categorizes antibiotics according their risk of CDI based on findings from large case series.4 Treatment The 2010 Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) guidelines recommend CDI treatments based on the severity and number of previous infections. A severe infection is classified by either a white blood cell count greater than 15,000 cells/ÂľL or a serum creatinine of 1.5 mg/dL or more times higher than baseline. An initial severe infection should be treated with oral vancomycin (125 mg orally four times daily), and an initial mild to moderate infection should
be treated with oral metronidazole (500 mg orally three times daily). CDI is classified as severe complicated if the patient exhibits hypotension, shock, ileus, or toxic megacolon. Severe complicated infections require treatment with both oral vancomycin (500 mg orally four times daily) and intravenous metronidazole (500 mg orally three times daily). The SHEA/IDSA guidelines recommend treating CDI for 10 to 14 days. For the first recurrence, the same treatment as the initial treatment is recommended. For the second recurrence, a tapering or pulsed dose regimen of oral vancomycin is recommended. Dosing and duration of vancomycin taper varies, but may be given as 125 mg orally four times daily for 10 to 14 days, then 125 mg orally twice daily for a week, and then 125 mg orally every two or three days for two to eight weeks.6 Fidaxomicin is a macrolide antibiotic and an alternative to the aforementioned treatments. In two large randomized, multicenter, double-blind clinical trials, fidaxomicin was shown to be noninferior to oral vancomycin for the treatment of CDI. However, the trials showed superiority over oral vancomycin for recurrences of non-North American Pulsed Field type 1 strains.7 Due to the high cost of fidaxomicin, it
The 2014 European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines recommend oral fidaxomicin as an option for initial nonsevere, severe, complicated or recurrent episodes;9 however, the SHEA/IDSA guidelines do not make a recommendation regarding fidaxomicin’s role in treating CDI.6 In patients without oral access, intravenous metronidazole or vancomycin retention enemas have been successful. Some patients may even benefit from surgery and direct instillation of vancomycin or metronidazole through the stoma.4 The ESCMID guidelines recommend IV metronidazole plus enteral vancomycin or IV tigecycline, a tetracycline antibiotic, for a severe episode.9 Probiotics are theorized to be effective in the prevention and treatment of CDI by maintaining the normal gut flora, secreting antimicrobial molecules, and inhibiting colonization via adhesion sites. Saccharomyces boulardi increases host antitoxin A IgA and proteases that break down C. difficile toxins. Despite the theoretical benefits of probiotics, large trials have failed to show a benefit for the treatment or prevention of CDI; however, small trials and metaanalyses have demonstrated a benefit.10 Of concern, probiotics have been shown
Inpatient pharmacists can ensure patients diagnosed with CDI are placed on appropriate antibiotic therapy for the severity of the CDI, placed on contact isolation, and that all health care personnel use proper hand hygiene to prevent the spread of C. difficile. should be reserved for patients at high risk for recurrence, such as elderly patients and/or those with a previous history of recurrence. Fidaxomicin offers several advantages over oral vancomycin such as twice-daily dosing and less impact on the gut flora, due to its narrow spectrum. Because of its limited activity against gram-positive bacteria, it is potentially less likely to cause vancomycin-resistant enterococcus and the development of candida infections.8
to increase the risk of bacteremia, fungemia, and endocarditis. Because of the poor evidence and risks associated with probiotics, the SHEA/IDSA guidelines recommend against the use of probiotics for the treatment or prevention of CDI.6 Emerging treatments for CDI include fecal transplant or Fecal Microbiota Transplant (FMT). Transplantation of fecal matter requires a human to donate feces that are then blended into a liquid JUNE 2015
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slurry and inserted into the receiving patient’s gastrointestinal tract through either a duodenal tube, rectal tube, colonoscopy, or fecal tablets enclosed in a shell. At this time, FMT is used as a last resort for patients who have failed or experienced recurrence on pharmacological therapy.11 The mainstay of treatment for CDI is discontinuation of the offending agent. Other supportive care measures may be warranted, such as fluid and electrolyte replacement. Pharmacists caring for patients with CDI should counsel patients about avoiding the use of antiperistaltic agents (e.g., loperamide and diphenoxylate with atropine) and identifying any patients purchasing these agents who are being treated for CDI. Other than verifying the appropriate agent and dosing of CDI therapy, pharmacists can impact CDI rates by thoroughly counseling patients about the importance of compliance and completing the full course of therapy to potentially avoid the risk of recurrence, sepsis and need for surgery.4 Prevention Another important way pharmacists can reduce the rates and impact of CDI is through prevention. Inpatient pharmacists can ensure patients diagnosed with CDI are placed on appropriate antibiotic therapy for the severity of the CDI, placed on contact isolation, and that all health care personnel use proper hand hygiene to prevent the spread of C. difficile. Because C. difficile is a spore-forming bacteria, it is resistant to decontamination with alcohol, and requires soap and water to remove. Community pharmacists can also be a valuable source of information for prevention of CDI in patients continuing treatment in the outpatient setting.4 Pharmacists are uniquely trained to recognize adverse effects of drugs and to weigh the risks and benefits of each agent; therefore, pharmacists play a key role in understanding which antimicrobial agents pose the highest risk for developing CDI. For certain high-risk patients, pharmacists can recommend alternative antimicrobial therapies to decrease the risk of CDI. Moreover, restriction of antimicrobials associated 24
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with a high risk of CDI has been shown to reduce the occurrence of CDI.4 Conclusion In summary, pharmacists serve an essential role in reducing the complications and preventing the spread of CDI, whether in the inpatient or outpatient setting. Pharmacists are equipped to educate both patients and healthcare professionals about reducing risk through infection control and antimicrobial stewardship initiatives. Furthermore, pharmacists have the training to weigh the risks and benefits of treatment options while reducing overall cost. References 1. Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile Infection in the United States. N Engl J Med. 2015;372:825-34. 2. Healthcare-associated Infections. Clostridium difficile Infection. Centers for Disease Control and Prevention. [Internet]. [updated 2015 Feb 25; cited 2015 Mar 30]. Available from: http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html 3. Healthcare-associated Infections. Tracking Clostridium difficile Infection. Centers for Disease Control and Prevention. [Internet]. [updated 2015 Feb 24; cited 2015 Mar 30]. Available from: http://www.cdc. gov/hai/organisms/cdiff/trackingCdiff.html 4. Thielman NM, Wilson KH. Antibiotic-Associated Colitis. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. Elsevier, Inc. 2005; 96:1375-84. 5. Healthcare-associated Infections. Frequently Asked Questions about Clostridium difficile for Healthcare Providers. Centers for Disease Control and Prevention. [Internet]. [updated 2012 Mar 6; cited 2015 Mar 30]. Available from: http://www.cdc. gov/HAI/organisms/cdiff/Cdiff_ faqs_HCP.html 6. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of
America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31:431-455. 7. Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus Vancomycin for Clostridium difficile Infection. N Engl J Med. 2011;364:422-431. 8. Chaparro-Rojas F, Mullane KM. Emerging therapies for Clostridium difficile infection – focus on fidaxomicin. Infection and Drug Resistance. 2013;6:41-53. 9. Debast SB, Bauer MP, Kuijper EJ; ESCMID. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014;20(suppl 2):126. 10. Varughese CA, Vakil NH, Phillips KM. Antibiotic-associated diarrhea: a refresher on causes and possible prevention with probiotics. J Pharm Pract.2013;26:476-482. 11. C Difficile. Tracking the rise of a superbug. [Internet]. [cited 2015 Mar 30]. Available from: http://www. cdifficile.org/what-is-the-c-diff-fecal-transplant-therapy/ About The Authors Lori H. Dupree received her Pharm.D. from the McWhorter School of Pharmacy at Samford University. Her postdoctoral training includes Pharmacy Practice and Internal Medicine residencies. Dr. Dupree began her affiliation with the University of Florida in 2004 as a Courtesy Clinical Assistant Professor and rotation preceptor. She accepted a full time faculty appointment in July 2013. K. Ashley Jones, Pharm.D., is a first-year UF pharmacy resident at Auburn University.
S AV E
T H E D AT E — J U N E
24-28, 2015
125th Annual Meeting and Convention of the Florida Pharmacy Association Renaissance World Golf Village Resort
500 South Legacy Trail St. Augustine, Florida 32092 For room reservations call (800) 468-3571
JUNE 24-28, 2015 Florida Pharmacy Association 610 North Adams Street Tallahassee, Florida 32301
Phone: (850) 222-2400 Fax: (561) 6758 www.pharmview.com
NETWORK WITH COLLEAGUES
The Florida Pharmacy Association (FPA) is accredited by the Accreditation Council of Pharmacy Education as a provider of continuing education. The FPA is also a Florida Department of Health approved provider of continuing education and reports to CEBroker
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Florida Pharmacy Association’s 125 ANNUAL MEETING AND CONVENTION Renaissance World Golf Village Resort, St. Augustine, FL June 24-28, 2015 th
Room Rates: $129 single/double occupancy for standard deluxe room. The room reservation deadline is Monday, June 1, 2015 or when room block is full. Thereafter, reservations may be taken on a space available or rate available basis. Please be sure to ask for the Florida Pharmacy Association group rate. All reservations must be accompanied by a first night room deposit or guaranteed with a major credit card. A deposit is refundable only if Hotel receives cancellation at least 72 hours prior to arrival. The check-in time is 4:00pm and the checkout time is 11:00 am. Room reservations can be made by calling (800) 266-9432. Guest self parking is complimentary. Valet parking is $10 per day/night.
Keynote Speaker:
JOHN H. ARMSTRONG, MD, FACS, was appointed by Governor Rick Scott as Surgeon General and Secretary of Health for the State of Florida on April 27, 2012. A graduate of Princeton University, the University of Virginia School of Medicine and the US Army Command and General Staff College, Dr. Armstrong believes that education and training are drivers for change. Dr. Armstrong came to the Florida Department of Health having previously served as the Chief Medical Officer of the USF Health Center for Advanced Medical Learning and Simulation in Tampa, where he worked to bring health care professionals together through hands-on team training. General Education Track Thursday - Sunday The general education track will offer courses designed to educate pharmacists on a wide variety of important topics pertaining to the profession of pharmacy practice. Specific courses being offered are Reducing Medication Errors, HIV/AIDS, and the always-popular offering of Florida Legislative Update. There will also be a New Drug Update course which focuses on the most recently FDA approved drugs introduced into the market. Consultant Education Track Thursday- Saturday The consultant education track will provide pharmacists with the most current information available on various topics that pharmacists encounter in the profession of pharmacy. The specific topics being offered include Nutrition, Pain Management and Autoimmune Disorders. There are 15 hours available for consultant pharmacists. Student and Technician Track Thursday – Sunday Students and Technicians will benefit from interacting with practicing pharmacists and attending student and technician focused continuing education programs. The technician track offers several hours of continuing education on a variety of topics, including the required courses for Florida registration and PTCB renewal: Medication Errors, Pharmacy Law and HIV/AIDS for initial renewal. The student track consists of several hours of fun and exciting continuing education, such as The Career Forum and the NASPA/NMA Game Show. Students will also have an opportunity to participate in the Patient Counseling Competition and showcase their Poster Presentations. Pre-Convention Education Wednesday Only Our traditional Wednesday program will focus on Pulmonary Disorders. Pulmonary disease affects all age groups. Pharmacists play a vital role in the management and patient education of pulmonary disorders. The hands on program will focus on the most current information evolving in the area of pulmonary disorders. The program will offer 7 hours of live continuing education credit. Register for this outstanding program and walk away with valuable knowledge for you and your patients with pulmonary disorders. A separate registration fee is required for the pre-convention program. Special Events Exhibits: Participate in our grand opening reception in the exhibit hall! Poster Presentations: Browse submissions from pharmacy students. Contact the FPA office for more information if you would like to submit a poster presentation. Awards Ceremony Reception: Honor outstanding practitioners during the awards presentation. President’s Breakfast: Attend the Sunday morning installation of new officers. Receptions: Enjoy catching up with your colleagues as the Universities entertain their alumni and friends, and as the FPA Foundation host its Speedway Tailgater. House of Delegates: Be a delegate or observer and see how important member participation is to the direction of the Association. Student Events: Participate in the Adopt-A-Student Mentor Social and Volleyball Tournament. Students will benefit from interacting with practicing pharmacists, attending student focused continuing education programs and learning first hand about the FPA and how involvement can improve their chosen profession. Call the FPA office and offer to mentor or sponsor a student. FPPC Reception: Attend this reception to support your Political Action Committee. 5K FUN RUN/WALK: Exercise is good for the soul. Incorporate health and fitness while at the FPA convention. FPA Golf Event: Join us Friday for the FPA Golf Event. Please register early to reserve your space.
FPA 125h ANNUAL MEETING & CONVENTION June 24-28, 2015 INFO (850) 222-2400 26
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FPA 125th Annual Meeting and Convention June 24-28, 2015 St. Augustine, FL
1
5 Pre Convention -
Participant Participant Information Information
Name: _____________________________________________________ Name: _______________________________________________ Mailing Address: _____________________________________ Badge Name: _______________________________________________ City, State, Zip: _______________________________________ Mailing Address: ____________________________________________ Phone: (W)Zip: _____________________________________________ __(H)___________________ City, State, Email: _____________________________________________ (H)_______________________ Phone: (W) License: PS______________ PU _____________RPT_________ Fax: ______________________________________________________ NABP License:e-profile#____________________ PS________________ PU_________DOB Other(MM/DD)_______ State___________
Full____________________________________________________ Package Registration—Excludes Box 5 2Email: Full package registration includes Educational Programs (ThursExhibit Hall, Awards Reception and President’s Breakfast. 2 Sun), Handbooks are not included in full package registration.
Handouts will be available on our website, www.pharmview.com, the week of June 22, 2015. Before May 29 After May 29 Amount_ $_______
Wednesday, June 24, 2015
PULMONARY DISORDERS
Before May 29 � FPA Member with Full Registration $75 � FPA Member $140 � Non Member with Full Registration $100 � Non Member $190
After May 29 $95 $160 $120 $210
Pulmonary disease affects all age groups. Pharmacists play a vital role in the management and patient education of pulmonary disorders. The hands on program will focus on the most current information evolving in the area of pulmonary disorders. Total Amount: $__________
6
Special Events Registration
The events listed below must be purchased individually and are not included in any other registration packages.
House of Delegates
(Non-convention registrants)
Quantity
Price
Amount
_________
@ $25
$_______
Reception _________ Special Events Registration 6FPPC (Complimentary event, indicate if attending)
@ N/C
FPA Member
$320
$405
Non Member
$500
$585
$_______
The events listed below must be purchased individually and are not Golf Event in any other registration _________ $_______ included packages. @ $150
Pharmacist BEST Value
$515
$600
$_______
Christian RPh Breakfast
Quantity _________
Price @ $40
Amount $_______
Member Technician
$145
$180
$_______
PharmPACCE Luncheon Student Luncheon
_________
@@$60 $45
$_______ $_______
Non Member Technician
$165
$200
$_______
Technician BEST Value
$175
$210
$_______
Student
$135
$135
$_______
Guest (no CE)
$150
$150
$_______
$40
N/A
$_______
Guest Name: Handbooks
3(BEST Value includes Registration & Membership) indicate below which functions you will attend. These 3 Please functions are included in the Full Package. If no boxes are
selected, we will assume you will not attend any of the events listed below. Full registration package includes one ticket to each of these events. Please see box 7 for additional tickets.
House of Delegates (Thursday)
Exhibit Hall (Friday and/or Saturday)
4
#
Awards Reception (Saturday)
#_______
Before After President’s Breakfast (Sunday) June 27 June 27 I will not attend any of these functions. FPA Member $140 $150
# Amount
Non MemberEducation Daily
$_______
4
$195 $225 Registration
________
7
Total Amount: $
_____
Additional Tickets
The following events ARE included in the Full Registration Package. However, you must purchase additional tickets for guests who are NOT registered. Quantity Price Amount
Additional Tickets 7Exhibit Hall
@ $30 $_______ The following events ARE included in the Full Registration Package. Awards Ceremony @for $80 However, you must purchase additional tickets guests who$_______ are NOT registered.Breakfast President’s @ $50 $_______ Quantity Price A_______ Total Amount: $_______ _____
8
Contributions (Make
Foundation).
check payable to FL Pharmacy
Adopt-A-Student Program
Foundation
8 9
$_______
Daily registration include admittance$60 to functions or Member Technician does not $40 $_______ handbooks. Handouts will be posted on our website June 22. Non Member Technician $55 $75 $_______ Before After May 29 May 29 Amount Handouts $30 N/A $_______ Please select the day(s) you will attend: FPA Member $165 $185 $_______ Thursday Friday Saturday Sunday Non Member $220 $240 $_______
___________
Amount: $_______ Total Amount: $
Convention Polo Shirt (Deadline is May 29, 2015) Quantity
Yes
Price
______ @ $35
Payment Payment Check (To: FPA)
9
Amount: $_______
Discover
M/F
______
Size
______
Amount $_______
Total Enclosed: $______ Enclosed:$Visa Total MasterCard
Check#(To: FPA) MasterCard Visa AMEX Discover Account _______________________________________________ Account # ________________________________________________ Security Code _________________ Expiration Date ______________
Member Technician
$85
$105
$_______
SecurityAddress Code _________________ Expiration Date _______________ Billing ___________________________________________
Non Member Technician
$100
$120
$_______
Billing Address _____________________________________________ Signature _______________________________________________
Handbooks
$40
N/A
$_______
Please select the day(s) you will attend: Friday Saturday Thursday
Sunday
Four Ways to Register
Mail: FPA, 610 North Adams Street, Tallahassee, FL 32301 Phone: 850-222-2400 Fax: 850-561-6758 Web: www.pharmview.com JUNE 2015
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florida BUYER’S GUIDE PHARMACY TODAY
ADVERTISERS: This is a special section designed to give your company more exposure and to act as an easy reference for the pharmacist.
PHARMACY RESOURCES Abbott Diabetes Care Hernan Castellon (305) 220-0414 PPSC Retail Pharmacy Purchasing Program (888) 778-9909
LEGAL ASSISTANCE Kahan ◆ Heimberg, PLC Brian A. Kahan, R.Ph., Attorney at Law (561) 392-9000 Fried Law Office, P.A. Dennis A. Fried, M.D., J.D. (407) 476-1427 The Health Law Firm George F. Indest III, J.D., M.P.A., LL.M. (407) 331-6620
PHARMACEUTICAL WHOLESALER
PHARMACY CONSULTANTS HCC Pharmacy Business Solutions Bob Miller, BPharm, CPH (800) 642-1652 Empire Pharmacy Consultants Michael Chen PharmD., CPH President (855) 374-1029
TEMPORARY PHARMACISTS – STAFFING HealthCare Consultants Pharmacy Staffing Bob Miller (800) 642-1652 Empire Pharmacy Consultants Michael Chen PharmD., CPH President (855) 374-1029 Rx Relief (800) RXRELIEF
McKesson Drug Company Jim Springer (800) 804-4590 (863) 616-2953 (fax)
Advertising in Florida Pharmacy Today Display Advertising: please call (850) 264-5111 for a media kit and rate sheet. Buyers’ Guide: A signed insertion of at least 3X per year, 1/3 page or larger display ad, earns a placement in the Buyers’ Guide. A screened ad is furnished at additional cost to the advertiser. Professional Referral Ads: FPA Members: $50 per 50 words; Non‑members: $100 per 50 words; No discounts for advertising agencies. All Professional Referral ads must be paid in advance, at the time of ad receipt. 28
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FREQUENTLY CALLED NUMBERS AHCA MEDICAID PHARMACY SERVICES 2727 Mahan Drive Tallahassee, FL 32308 (850) 412-4166 www.fdhc.state.fl.us/medicaid/ pharmacy AMERICAN PHARMACISTS ASSOCIATION (APhA) Washington, D.C. (800) 237-2742 www.pharmacist.com AMERICAN SOCIETY OF HEALTH SYSTEM PHARMACISTS Bethesda, MD (301) 657-3000 www.ashp.com/main.htm DRUG INFORMATION CENTER Palm Beach Atlantic University (561) 803-2728 druginfocenter@pba.edu FLORIDA BOARD OF PHARMACY 4052 Bald Cypress Way Bin #C04 Tallahassee, FL 32399-3254 (850) 245-4292 www.doh.state.fl.us/mqa FLORIDA POISON INFORMATION CENTER NETWORK (800) 222-1222 www.fpicn.org NATIONAL COMMUNITY PHARMACISTS ASSOCIATION 100 Daingerfield Road Alexandria, VA 22314 (703) 683.8200 (703) 683.3619 (fax) info@ncpanet.org RECOVERING PHARMACISTS NETWORK OF FLORIDA (407) 257-6606 “Pharmacists Helping Pharmacists”