The Patient that Made the Difference

Her initials were the same as mine, and we greeted one another after a few phone conversations with "Hi, BB, it's BB." 

We had this connection. Two grown women. Both single and young. The big difference was that I was her home health pharmacist in charge of her pain pump and she had terminal cancer.

When you are halfway through your life (and maybe your career) there comes a time when you look back and remember the patients that change your life and maybe even validate the half-ass "I want to be a pharmacist" decision made by a young twenty-something with no idea how profound the decision would have on every aspect of your life. 

B wanted to go to Florida and be in the ocean one more time.  Her boyfriend was in Florida and since she knew her time was short, the ocean was on her bucket list... with the dilemma of a pain pump. That's where I fit into the story, finding a creative way to make it happen along with a couple home health nurses and some supplies. She was a nurse, too, and was a big part of her own end-of-life care.

It has been eleven years ago. B was 33 years old. I had been a pharmacist for only four years; a baby in the working world with little idea of how that year would change my life.

I had these biweekly chats with her concerning supplies she might need, including the intravenous pain medication itself but we often left the rigid discussion of how we were connected through pharmacist and patient to human conversation of "please do monthly self breast exams," to "live a full life and travel Beth!" to "who cares what people think about you, you certainly won't care when you are at the end of your life" and "I wish I could have been a mother." It was almost as if I had been granted insight into the world of a life ending way too soon and maybe learning my own lesson along the way. I sure did.

I finally went to meet her the last few days of her life. I waited much too long to meet my friend and that is my only regret. There is a professional line you have to keep in place with your patients, but sometimes that looks a little different patient to patient.  She squeezed my hand and had a picture of her vibrant former self before cancer ravaged her body sitting on her nightstand. "You are beautiful," I had said although wishing I had arrived months before.

Pharmacists and nurses along with other healthcare providers can make a difference. 

I witnessed the same thing with my father-in-law's nurse at the VA in Nashville caring for a man that had no family at bedside because of a lack of a relationship with his family. His nurse was amazing and was not only his nurse but his friend.  

I saw it again in Memphis on a hospice rotation where I saw different patients in different stages of terminal illness along with their families in different stages of grief. 

My life changed with each of these moments and patients who touched my life and maybe that young twenty-something college student knew more than I thought about selecting a career?

Alert Fatigue; Pop-up Fatigue and Drug Errors

It would be nearly impossible for me to meet the standard rate (number of entries per hour) of many hospital companies and properly investigate every single issue with a particular medication against disease state, interactions with other meds and allergies. We rely heavily on computer programs and screening programs to help facilitate this job. However, with the invention of alerts while we work is the issue of "alert fatigue."

The biggest problem I have encountered over the past several years is the sensitivity of alerts. I frequently not only get alerts for the things I NEED to know but the things that are not nearly as important. I receive an alert daily for Sodium Chloride 0.9% IV fluid and Potassium Chloride when entering the two.  The interaction is "chloride." Keep in mind, the potassium chloride is actually compounded into sodium chloride. This is mixed in with more important alerts like what the patient's potassium level really is. I also receive alerts about what is formulary and non formulary, what is in stock, what is on backorder, if I need to add an NDC to something for billing, if I need to pick another strength, if the med can only be ordered by one doctor and not another, and so on. This is all mixed in with the same level of importance as creatinine with metformin, INRs for warfarin, allergies entered, height and weight of the patient, and so on. With at least ten alerts per order and around fifty orders per hour, we are nearing 500 alerts per hour all the while answering phone calls, questions from the staff and people just walking into the room to chat and say hi. It's no wonder I feel so distracted.

The problem with this methodology is that we lose the real alerts that are important. Comparing an alert for someone with hyperkalemia with ordering potassium replacement vs letting me know that I need to change the potassium to another NDC vs that the med is on back-order is really changing the way the system was intended. Also, is anyone monitoring all the alerts that are bypassed daily? Is anyone noticing these and monitoring trends? 

Too many alerts turn into noise.

I know that if all facilities would start an initiative to reduce alerts, alerts would have more meaning and pharmacists would probably react more to the alert. 

And maybe... less errors. 

With the implementation of CPOE, this issue has risen to the forefront of what prescribers must wade through in selecting the best medication therapy for their patients. While the industry worries about prescribers becoming complacent to alerts due to overly sensitive drug-drug interactions or drug-allergy interactions, pharmacists have been battling this for years. Prescribers seemingly must worry about the meds and patients whilst pharmacists are wading through the leftover messages with safety along with pharmacoeconomic issues.

1. Alerts should be tiered. Level 1, 2, 3, etc or color coded based on severity.  Never allow one sweeping override reason count for multiple alerts.

2. Alerts that have nothing to do with patient safety, formulary comments, billing issues should be reserved at another level not mixed in with potentially life-saving messages!

Adding financial notes with the already overburdened system of patient safety is a recipe for disaster both in patient safety and also for pharmacist job satisfaction. 

ISMP mentions this: "Protect against ALERT FATIGUE through fewer, more appropriate alerts that need consideration by pharmacists before filling the prescriptions.

Optimize the sensitivity of alert systems by carefully selecting alert severity levels and allowing only the most significant alerts to appear on the screen during data entry." 

3. Hard stops should be built for certain high risk interactions (even if the money doesn't exist to build). 

4. Someone in the department should be trending overrides. What are the trends? Can the system be improved without waiting for an event that causes injury?

5. Allow pharmacists who use the system daily to report alerts that are not needed.  

"Encourage the reporting of invalid or insignificant warnings so they can be altered or removed from the computer system." -ISMP

This is a great article on alert fatigue from our perspective. 

A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition

Click on image to order A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition (no paid link on this, just for your information)

            As a pharmacist and a clinician at my local hospital, there have been times where I am starting a new PN (total parenteral nutrition) and needed help beyond the usual formula or write-up that we use. In the information age, we have a diverse amount of information online at our fingertips; however sometimes this information can be from sources that are not legitimate. I can google PN and a disease state and hope for something relevant, or I can seek out material that is tried, true and tested.

            The A.S.P.E.N. Parenteral Nutrition Handbook, 2nd Edition is a pocket-sized handbook or quick reference that covers many parenteral nutrition topics with students in dietetics, nursing, medicine and pharmacy in mind. There are 10 fully revised chapters from the 2009 1st edition including: 

1.  Chapter 1: Nutrition Screening, Assessment, and Plan of Care

2.   Chapter 2:  Overview of Parenteral Nutrition

3.   Chapter 3:  Parenteral Nutrition Access Devices

4.   Chapter 4:  Parenteral Nutrition Formulations and Managing Component Shortages

5.   Chapter 5:  How to Prescribe Parenteral Nutrition Therapy

6.   Chapter 6:  Review and Verification of Parenteral Nutrition Orders, Preparing Parenteral Formulations, and Ordering

7.   Chapter 7:  Parenteral Nutrition Administration and Monitoring

8.  Chapter 8:  Complications of Parenteral Nutrition

9.  Chapter 9:  Medication-Related Interactions

10.  Chapter 10:  Home Parenteral Nutrition Support

These chapters cover many of the relevant topics for the patient receiving parenteral nutrition (PN) including some newer topics on order review, compounding, and drug shortage management. Also this handbook contains evidence-based guidelines from the A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations (JPEN, March 2014) and A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing (JPEN, March 2014).

I have taken the time to utilize this handbook while dosing PNs in the past few weeks and have found this reference accurate while covering many of the topics I needed.  I especially enjoyed the chapter on parenteral nutrition complications.  I found the topics succinct and spot-on for finding quick information on a couple of questions I had on a patient’s PN.

If you are looking for a guide with a broad range of topics related to PN that will help your student, resident or even new pharmacist managing PN, this guide will help you tremendously.

Pharmacists and Provider Status

What is provider status?  Why is it important to the profession to gain?

Pharmacists and pharmacists’ patient care services are not included in key sections of the Social Security Act (SSA), which determines eligibility for health care programs such as Medicare Part B. In the case of Medicare Part B, the omission of pharmacists as listed providers limits Medicare beneficiaries’ access to pharmacists’ services in the outpatient setting. Other health care professionals who are listed as providers in Part B of the SSA include physicians, physician’s assistants, certified nurse practitioners, qualified psychologists, clinical social workers, certified nurse midwives, and certified registered nurse anesthetists. In addition to providers, Part B provides the list of medical and other health services covered.

Many state and private health plans often cite the omission from Medicare Part B as a reason for lack of coverage for beneficiaries or lack of compensation of pharmacists for providing comprehensive, patient-centered care. Omission from Medicare Part B can also result in barriers to optimizing the use of pharmacists’ patient care services in emerging integrated care delivery models promoted by the Affordable Care Act (ACA), such as medical homes and accountable care organizations (ACOs), which are located in another section of the SSA.

The American Pharmacists Association has a full page of the hows and whys.

The American Society of Health-System Pharmacists is on board as well.

California has passed legislation and just like most bills starting in CA, it will sweep the country.

Here's a summary of what was passed in California last year:

Pharmacist Provider Status Legislation SB 493 (Hernandez) Summary

Now that the pharmacist provider status bill has been signed by the Governor, many pharmacists are asking: “what does this bill do for me?” SB 493 grants all pharmacists certain authorities in all practice settings that had previously been limited to inpatient settings or integrated systems. The bill also establishes a new “Advanced Practice Pharmacist” recognition. This recognition can be granted when specified experience and/or certification requirements are met. The Advanced Practice Pharmacist recognition is not mandatory, but it does allow pharmacists to provide additional services. Below is a summary of SB 493’s changes, which take effect January 1, 2014, though some provisions require regulations by the Board of Pharmacy and will not take effect until those regulations are approved.

• Declares pharmacists as healthcare providers who have the authority to provide health care services.
• Authorizes all licensed pharmacists to:
• Administer drugs and biologics when ordered by a prescriber. Previously, this was limited to oral and topical administration. SB 493 allows pharmacists to administer drugs via other methods, including by injection. 
• Provide consultation, training, and education about drug therapy, disease management and disease prevention. 
• Participate in multidisciplinary review of patient progress, including appropriate access to medical records. 
• Furnish self-administered hormonal contraceptives (the pill, the patch, and the ring) pursuant to a statewide protocol. This authority is similar to the existing emergency contraception protocol. Once a statewide protocol is adopted by the Board of Pharmacy, it will automatically apply to all pharmacists. 
• Furnish travel medications recommended by the CDC not requiring a diagnosis. 
• Furnish prescription nicotine replacement products for smoking cessation pursuant to a statewide protocol if certain training, certification, recordkeeping, and notification requirements are met. Once a statewide protocol is adopted by the Board of Pharmacy, it will automatically apply to all pharmacists. 
• Independently initiate and administer immunizations to patients three years of age and older if certain training, certification, recordkeeping, and reporting requirements are met. A physician protocol is still required to administer immunizations on children younger than three years of age. 
• Order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies, in coordination with the patient’s primary care provider or diagnosing prescriber. 
• Establishes an Advanced Practice Pharmacist (APP) recognition, and authorizes APPs to:  

1. Perform patient assessments
2. Order and interpret drug therapy-related tests in coordination with the patient’s primary care provider or diagnosing prescriber. 
3. Refer patients to other healthcare providers. 
4. Initiate, adjust, and discontinue drug therapy pursuant to an order by a patient’s treating prescriber and in accordance with established protocols. 
5. Participate in the evaluation and management of diseases and health conditions in collaboration with other healthcare providers. 
6. Requires pharmacists seeking recognition as APPs to complete any two of the following three criteria: Earn certification in a relevant area of practice, such as ambulatory care, critical care, oncology pharmacy or pharmacotherapy. Complete a postgraduate residency program. Have provided clinical services to patients for one year under a collaborative practice agreement or protocol with a physician, APP pharmacist, CDTM pharmacist, or health system.

I want recognition for the value brought to patients and the health care team.

Pharmacists are an integral part of the healthcare team.  I hope to see this sweep across the country in the next few years and that board certification propels us into a whole new recognized role.

10 Rules of Email Etiquette at Work

One of the most frustrating things about pharmacy jobs today, for me at least, is the lack of email etiquette at work.  I know it sounds crazy to even bring this up, but I have been pondering this post for years.  You see, I have been guilty of not being the best at email, but over the years it is becoming crystal clear the errors people make every single day that not only make the sender look badly, but can actually fracture a team.  Without further ado, the email changes I would like to see in the pharmacy and hospital world with a disclaimer that since I have been practicing for almost 15 years, these examples go way back in time. 1.  REFRAIN FROM REACTIVE EMOTIONAL EMAILS.  If you find yourself getting worked up over what you are reading, do your best to avoid pressing reply and firing off a response.  Avoid sending emails when you’re feeling any type of negative emotion. These types of emails will ALWAYS make you look unprofessional and maybe even unstable.  Before you send off that email rant or reply to an email that angers you, try cooling off overnight.  Or, write an uncensored draft that you never actually send. Remember that all emails are forwardable.  If you don't want your whole department to read it, do not send it.

2.  RESIST THE REPLY ALL BUTTON.  This is the one that literally will make my entire head explode at work.  I have seen coworker after coworker make this mistake and it is not pretty.  This can make you look totally clueless all the way up the chain.  Coworkers don't let coworkers reply all.  In fact, I would love to see the day when reply all is no longer an option in Outlook, Gmail, or any other email client.  Why?  Because it creates mindless replies when all of the discussion could be tabled and then ONE single email sent out to a team.  Time after time in all of my jobs have seen emails go out - an official type declaration of what we are going to be doing - and someone else will reply all and jump in with something else essentially calling out critically all the things wrong with the initial.  Take the time to call the person that sent the email and give them the professional courtesy to make any corrections.  Don't shoot the messenger!

3.  UNDERSTAND WHAT CC AND BCC MEAN.  The recipients listed in the To field are the direct addressees of your email. These are the people to whom you are writing directly.  CC, which stands for “carbon copy” or even “courtesy copy,” is for anyone you want to keep in the loop but are not addressing directly in the email. The person(s) in the CC field is being sent a copy of your email as an FYI. Commonly, people CC their supervisors to let them know an email has been sent/an action has been taken or to provide a record of communications. The general rule of thumb is that recipients in the To field are expected to reply or follow up to the email, while those in the CC field do not.  So many times I see the ones in the CC field adding in their two-cents and then the whole thing becomes a reply-all festival.

4. IF YOU ADD SOMEONE IN THE CC OR TO FIELD, LET THE OTHERS KNOW.  Guess what?  There are times when people are added willy-nilly for no good reason and you look back and notice it a couple of emails later.  Let people know.  Professional courtesy and politeness go a long way.

5.  BCC IS GOOD FOR ONE THING ONLY.  Let's say that only half in your department contributed to the annual walk fund.  Rather than sending out an email to all those that contribute in the TO field where each of them can see who did contribute and who did not, put your own name in the TO and the rest in the BCC.  That way, gossip about who gives and doesn't is stopped before it can even begin.  Don't use the BCC field to add someone random to eavesdrop on the email.

6.  PICK UP THE PHONE.  If you notice that you are going back and forth on an email and getting nowhere, the phone still works.  Guess what?  Voices can convey so much more than words and rarely are misinterpreted as much as typed words.  I remember an email I saw that was sent for the third time.  The second time it was heavily highlighted with quotes from the manager's email weeks before.  The third send apologized for resending the email yet again but someone was not doing it correctly.  Because of the sender's frustration, more time was wasted from the entire department reading about some small piece in the whole operation, and worse, half of the department had nothing to do with the infraction.

7.  DON'T PUT A QUOTE IN YOUR SIGNATURE.  There is no reason for it.  From The Wordsmith:

******Avoid quotes, witty sayings and colors in the signature.

8.  DON'T ASSUME EVERYONE READS THEIR EMAIL IMMEDIATELY.  If something is important and needs to be communicated quickly, pick up the phone.

9.  DO NOT FORWARD AN EMAIL UNTIL YOU ASK PERMISSION.  This is just plain common professional sense.

10.  DO NOT USE UNPROFESSIONAL FONTS OR BACKGROUND PAPERS.  They only distract.  This means NO comic sans.

Hope that helps.  And, by the way, I do mess up on some of these myself.

Ativan Drips and Precipitation

If you happen to run short of the lorazepam 2 mg/mL vials to compound your ativan drips, be mindful of the possibility of precipitation when using the lorazepam 4 mg/mL vials.  AHFS Drug Info states:

Precipitation-- The choice of commercial lorazepam concentration to use in the preparation of dilutions is a critical factor in the physical stability of the dilutions. Both the 2- and 4-mg/mL concentrations utilize the same concentrations of solubilizing solvents. On admixture, the solvents that keep the aqueous insoluble lorazepam in solution are diluted twice as much using the 4-mg/mL concentration than if the 2- mg/mL were used, resulting in different precipitation potentials for the same concentration of lorazepam. Care should be taken to ensure that the compounding procedure that is to be used for lorazepam admixtures has been demonstrated to result in solutions in which the lorazepam remains soluble.

Lorazepam concentrations up to 0.08 mg/mL have been reported to be physically stable, while occasional precipitate formation in admixtures of lorazepam 0.1 to 0.2 mg/mL has been reported. The precipitate has been observed in both containers and in administration set tubing.

In one case, a visible precipitate formed in a lorazepam 0.5-mg/mL admixture in sodium chloride 0.9% in a glass bottle.  However, a 0.5-mg/mL concentration may remain in solution longer if prepared from the 2-mg/mL concentration, yielding a higher concentration of organic solvents in the final admixture.

Concentrations of 1 and 2 mg/mL have been reported to be physically stable for up to 24 hours as well as concentrations below 0.08 mg/mL.

Concentrations in the middle range of 0.8 to 1 mg/mL may be problematic.  In one report, use of lorazepam 2 mg/mL to prepare lorazepam 1-mg/mL admixtures in dextrose 5% or sodium chloride 0.9% was acceptable but use of the lorazepam 4-mg/mL concentration to prepare the same solutions resulted in almost immediate precipitation.

Lorazepam solubility in common infusion solutions has been reported. Its solubility in sodium chloride 0.9% is approximately half that found in the other tested solutions. This result was attributed to the pH of the sodium chloride 0.9% (pH 6.3) being essentially the same as the isoelectric point of lorazepam (pH 6.4), where aqueous solubility would be the lowest. Dextrose 5% was the best diluent for lorazepam.

If you are a hospital or facility that mixes the middle range of 0.8mg to 1 mg/mL you have to be more mindful of other factors.  This is the reason I had no idea of this problem since other facilities where I have worked we mixed a much less concentrated solution.  I found out the validity of this information and wasn't too pleased.

The bottom line is that it would be nearly impossible for a pharmacist to know every single intricacies of different hospitals and compounding practices.  If knowledge like this is indeed something we should all 100%  know, then someone somewhere dropped the ball on training and/or education.  I am mostly wondering, how does your facility compound ativan drips?  What scenarios caused precipitation?

For more about this issue read here.

New Year's Resolutions for the Pharmacist

Most of the time, the New Year ushers in thoughts of dropping 15-20 lbs and signing up for a few road races.  No, not to race, but just to finish.  This year, I have been much more introspective thinking about life and career and all the above.  Maybe some of these pharmacy related resolutions will be similar to yours.

1. Begin studying for another certification.  I am heavily learning toward the BCNSP.  I am in no hurry because quite honestly, there is no reason professionally to obtain.  I would just accomplish something that has interested me in the past.  I used to work for a home infusion company and there was a pharmacist (JB) who was quite fabulous.  I am sure he still is today, but I noticed he has this designation and is probably running circles around most in the area when it comes to nutrition.  It is quite an in-depth topic from enteral to parenteral nutrition, and I am predicting another 1-2 year study.  I have purchased the material and have started though not nearly as much gusto as the BCPS so far.  If you are not certified, consider it.  IT MATTERS.
2. Stop worrying about what other pharmacists think about you.  You cannot live your professional life trying to beat out or outsmart the guy/gal next to you.  Yes, you may be in fact more qualified and more experienced, but you cannot control how a company decides to utilize your experience or knowledge.  Perhaps a position in a different area will open up and any type of learning on the side you have pursued will open doors!?  Sometimes it is just timing and sometimes just sheer luck.  In the meantime, focus on being a better pharmacist.  Focus on remaining competitive and the go-to person for all things current.  If you keep up with the current practice and move forward, the people who win are your patients.
3. Look to the future.  Prepare for the future so that when it happens, you will be ready to step right into the role without any problems.

Those are my resolutions for pharmacy this year.  I hope 2014 holds many wonderful things for you in your career whether it is pursuing a board certification or attending an update to begin the process to do more for your patients than last year.

Cheers!

Why Should You Become Board Certified?

I enjoy brainstorming with other pharmacists and asking them their opinions on becoming board certified.  I remember back in 1998-1999, the assistant dean of my alma mater, University of Tennessee at Memphis stressed how important it was for us to consider residency and board certification.  At the time, I was a 25-26 year old making decisions that would impact me for life.  You see, I decided back then to decline that path.  I only saw the dollars that were before me and the student loan debt piling up.  I quipped, "Why would I want to work for half-pay or less for a whole year?" Why?  Hindsight is 20/20.  Fast forward to a 40 year-old in the profession for over 14 years experiencing all sorts of different experiences, and after trying most, I have a couple of regrets as far as my tenure in pharmacy school.  I regret not doing a rotation overseas.  I regret not doing an residency.  I regret that I dismissed more learning inferior to money.

I know not everyone feels like me, and that is understandable.  Perhaps I am just a different sort who becomes stir-crazy when bored.  Whatever the reason, I decided to pursue BCPS last year.  I missed it barely the first time and immediately jumped back up and started studying again.  I work in a small community setting in a smaller city and though it is nothing like Memphis was in terms of clinical opportunities, these opportunities can be found with a little thought.  Passing the test was probably up there with other accomplishments in life - like the time I finished my first marathon (26.2 mile run) in 2002.  Victory!

Why should you become board certified?

1. BPS website quotes:  "From patient to provider, the value of the BPS-certified practitioner registers throughout the health care continuum. For pharmacy professionals, documentation of specialized experience and skills yields the additional benefits of personal satisfaction, financial rewards and career advancement."  I definitely agree with most of this though most I have talked with did not receive a raise unless they changed jobs.  In the past where BCPS maybe helped with landing a clinical job, today it may be the thing to separate you from a PharmD without BCPS.
2. If you have been out of school for over four to five years, you can be sure you have already forgotten some of what you have learned and have not learned new material being presented to new graduates.  You can depend on your local hospitals' computer system to remind you of every little thing (trusting those that program such systems) OR you can take charge of what you know and remain committed to being the best you can be.  Think of it like this, if you work in a hospital and you are commanding larger salaries than new graduates with fresher knowledge, there comes a point where you are replaceable.  Be your best to remain competitive in your field.  This means utilizing continuing education to really learn something and not last-minute cramming to renew your state license.  (Guilty, by the way).
3. A paper wrote in 2006 (seven years ago) states that "Future Clinical Pharmacy Practitioners Should Be Board-Certified Specialists."  In the past clinical pharmacists have not made board certification a priority, but this is changing rapidly with not only clinical positions but in staff positions.  Clinical faculty and preceptors MUST be board certified, I believe.  As pharmacists move toward the direction of becoming reimbursed professionals for optimizing medications, there will be a trend toward licensing agencies requiring board certification in certain scenarios.  Sure, it is not TODAY, but if you would have asked me in 2000 if I thought the market would be in the shape it is with oversaturation, I would have done things VERY differently in 1999-2002.  Direct patient care IS coming.
4. The PharmD curriculum is not enough to be able to interact in sync with other healthcare professionals.  Experience in dealing with physicians and their assistance along with board certification will take you to the next level in recommending appropriate treatment.  Placing a new graduate in a clinical position without experience and expecting them to build relationships with clinicians is not the best case scenario for the patient.  Requiring a board certification ensures a higher level of expertise and should be a requirement of all hospitals (in my opinion).  I know, I know.  Not something anyone wants to enforce, but wow!  The benefits in just preparing and studying for the test are immense.
5. Last, but not least, you should become board certified to give your patients the best care possible.  This was my number one reason.  I remember the day I sat at my desk years ago and realized I had no idea about new guidelines (and even some not-so-new) and that centralized order entry had essentially turned me into a robot at a computer verifying at will, I realized it was time to make some personal changes that would cost me both dollar and more importantly time but result in amazing benefits for my patients.  BCPS.

I hope that you will consider these reasons.  For the most part most people are reluctant because no one wants to fail, much less fail twice.  Yes, it is humbling to fail once, but it is euphoric to pass (even the second time).  Especially for someone like me, I prove you can teach an old dog new tricks.  I hope to inspire more of you to seek to be your best in our profession, stop worrying about your coworkers and if you fail, and realize that any amount of learning that happens will significantly change how you practice pharmacy.

In the future, I am thinking about tackling another certification.  I hope you will, too!

I Passed BCPS!

The weight was lifted off my shoulders when I saw the results last Friday. I am thrilled this one is in the past and thinking about taking another one.

CV Risk Calculator - American Heart Association and American College of Cardiology's Changes

Guidelines change, and recently new material was released concerning cardiovascular risk.   The spreadsheet enables health care providers and patients to estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD), defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke, based on the Pooled Cohort Equations and the work of Lloyd-Jones, et al., respectively. The information required to estimate ASCVD risk includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status. However, the more I play with different patients' numbers, even my own mother's, the more it is very obvious the calculator overestimates risk fairly significantly.  We can expect, I guess, statin snack machines to pop up everywhere since most will now be candidates to be on a statin.

Read more about this in a fabulous NY Times article that really goes in-depth concerning the embarrassment and application in the future.

The controversy set off turmoil at the annual meeting of the American Heart Association, which started this weekend in Dallas. After an emergency session on Saturday night, the two organizations that published the guidelines — the American Heart Association and the American College of Cardiology — said that while the calculator was not perfect, it was a major step forward, and that the guidelines already say patients and doctors should discuss treatment options rather than blindly follow a calculator.