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Resilience vs. Resistance: Winning the Battle Against Vancomycin-Resistant Infections

Learning Objectives

After completing this continuing education activity, pharmacists will be able to

•        EXPLAIN the common mechanisms of bacterial resistance and their impact on antibiotic efficacy
•        RECOGNIZE the importance of early and effective management of resistant bacterial infections.
•        IDENTIFY first- and second-line treatment options for VRE.

After completing this continuing education activity, pharmacy technicians will be able to

•        DESCRIBE proper storage, reconstitution, and other considerations for antibiotics used for resistant infections
•        IDENTIFY strategies to prevent dispensing errors when handling antibiotics and increase awareness of high-risk medications
•        RECOGNIZE common dosing of antibiotics used for resistant bacterial infections

Release Date:

Release Date:  June 5, 2025

Expiration Date: June 5, 2028

Course Fee

Pharmacists: $7

Pharmacy Technicians: $4

There is no grant funding for this CE activity

ACPE UANs

Pharmacist: 0009-9999-25-07-H01-P

Pharmacy Technician: 0009-9999-25-007-H01-T

Session Codes

Pharmacist: 25UC07-CBA96

Pharmacy Technician: 25UC07-BAC49

Accreditation Hours

0.5 hours of CE

Accreditation Statements

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-9999-25-007-H01-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

 

Disclosure of Discussions of Off-label and Investigational Drug Use

The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

Faculty

 

Dominic Biello, PharmD,
PGY-1 Resident
UConn Health Center
Farmington, CT

Gillian Kuszewski, PharmD, BCPS, FCPA,
Antimicrobial Stewardshhip Co-Chair
UConn Health Center
Farmington, CT

Jenny Zhao, PharmD,
PGY-1 Resident
UConn Health Center
Farmington, CT

Faculty Disclosure

In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

Drs. Biello, Kuszewski and Chan and  have no relationships with ineligible companies and therefore have nothing to disclose.

 

CONTENT

Content

Download PDF of Handouts

Pharmacist Post Test (for viewing only)

Pharmacist Learning Objectives:
1. Explain the common mechanisms of bacterial resistance and their impact on antibiotic efficacy
2. Recognize the importance of early and effective management of resistant bacterial infections
3. Identify first- and second-line treatment options for vancomycin resistant enterococci (VRE)

Pharmacist Questions:
1. How do enterococci develop resistance to vancomycin?
a. The terminus of the peptidoglycan cell wall changes
b. Production of enzymes inactivate vancomycin
c. Decreased outer membrane permeability

2. What prevention strategy involves early and effective therapy intervention?
a. Chlorhexidine bathing
b. Environmental cleaning
c. Antimicrobial Stewardship

3. Common enterococcal infection sites include the urinary tract, bloodstream, heart, and intra-abdominal space. What is the recommended first line agent for infective endocarditis?
a. High dose ampicillin
b. Linezolid
c. Tigecycline

4. Which prevention strategy can reduce the risk of VRE by addressing the risk factor of transmission through healthcare workers?
a. In vitro susceptibility testing
b. Hand hygiene
c. Active surveillance

5. The most common phenotype seen in VRE isolates is Van A. What mechanism of resistance is the VanA phenotype responsible for?
a. Increasing the efflux of antibiotics
b. Ribosomal protection
c. Changes in peptidoglycan cell wall

6. A provider calls the pharmacy asking for antibiotic recommendations for a bloodstream infection (bacteremia) growing gram positive cocci. The patient has a history of enterococcal bacteremia previously treated with antibiotics. What antibiotic should be recommended to the provider?
a. Ampicillin 2g every 4 hours
b. Daptomycin 8-12 mg/kg once daily
c. Nitrofurantoin 100mg twice daily

Pharmacy Technician Post Test (for viewing only)

Resilience vs Resistance:
Winning the Battle Against Vancomycin-Resistant Infections
Pharmacy Technician Learning Objectives:
1. Describe proper storage, reconstitution, and other considerations for antibiotics used for resistant infections
2. Identify strategies to prevent dispensing errors when handling antibiotics and increase awareness of high-risk medications
3. Recognize common dosing of antibiotics used for resistant bacterial infections

Pharmacy Technician Questions:
1. A patient is receiving daptomycin 400 mg IV every 24 hours. As a technician, you want to compound today’s dose as well as tomorrow’s dose. Is this appropriate?
a. Yes, reconstituted solutions of daptomycin are stable at room temperature for up to 48 hours
b. No, reconstituted solutions of daptomycin are stable at room temperature for up to 12 hours
c. No, reconstituted solutions of daptomycin are stable at room temperature for up to 5 hours

2. What is a potential strategy to prevent medication dispensing errors?
a. Build a culture that encourages error reporting
b. Reducing the number of medications dispensed daily
c. Require pharmacist double checks on every medication dispensed

3. You see a label print for oritavancin. What would be an appropriate dosing you would expect to see?
a. 1200 mg IV once
b. 1200 mg IV every 12 hours
c. 1200 mg IV every 24 hours

4. Linezolid is reconstituted in the morning for patient administration. The nurse is unable to administer the medication because the patient is in the OR. How, and for how long can linezolid be stored after reconstitution?
a. Store at room temperature 20ºC to 25ºC (68ºF to 77ºF) for up to 24 hours
b. Store at room temperature 20ºC to 25ºC (68ºF to 77ºF) for up to 12 hours
c. Store at room temperature 20ºC to 25ºC (68ºF to 77ºF) for up to 21 days

5. Which of the following describes the medication dispensing error prevention strategy, encouraging error reporting?
a. Calling a patient’s pharmacy to confirm dispense history
b. Scanning the vial or patient label before administration
c. Filling out safety incident paperwork

6. What is a reasonable renally adjusted dose for tedizolid?
a. Tedizolid does not need to be renally adjusted
b. 200 mg IV or PO every 48 hours
c. 100 mg IV or PO every 24 hours

Carbidopa-Levodopa: Revving Up Relief – Choose Your Formula!

Learning Objectives

After completing this continuing education activity, pharmacists will be able to

•      DESCRIBE the role of carbidopa-levodopa in Parkinson's disease and the use of different carbidopa-levodopa formulations
•      RECOGNIZE the differences between each carbidopa-levodopa formulation
•      DISCUSS the appropriate patient who may benefit from transitioning to a different formulation of carbidopa-levodopa

After completing this continuing education activity, pharmacy technicians will be able to

•        DESCRIBE the functions of the carbidopa-levodopa and how it aids in treatment for patients with Parkinson's disease
•        LIST different forms of carbidopa-levodopa
•        IDENTIFY when to refer patients with questions about Parkinson's disease to a pharmacist

Release Date:

Release Date:  June 13, 2025

Expiration Date: June 13, 2028

Course Fee

Pharmacists: $7

Pharmacy Technicians: $4

There is no grant funding for this CE activity

ACPE UANs

Pharmacist: 0009-9999-25-08-H01-P

Pharmacy Technician: 0009-9999-25-008-H01-T

Session Codes

Pharmacist: 25UC08-TXJ88

Pharmacy Technician: 25UC08-PJK42

Accreditation Hours

0.5 hours of CE

Accreditation Statements

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-9999-25-008-H01-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

 

Disclosure of Discussions of Off-label and Investigational Drug Use

The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

Faculty

 

Constance Chan, PharmD
PGY-2, Ambulatory Care Pharmacist
UConn Health Center
Farmington, CT

Kaitlyn Elliott, PharmD
Pharmacy Clinical Coordinator
UConn Health Center
Farmington, CT

Braylee Wardwell, PharmD
PGY-2, Ambulatory Care Pharmacist
UConn Health Center
Farmington, CT

Faculty Disclosure

In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

Drs. Chan, Elliott and Wardwell and  have no relationships with ineligible companies and therefore have nothing to disclose.

 

CONTENT

Content

Download PDF of Handouts

Pharmacist Post Test (for viewing only)

Carbidopa-Levodopa: Revving Up Relief – Choose Your Formula! Pharmacist Test
Learning Objectives: Pharmacists
• Describe the role of carbidopa-levodopa in Parkinson’s disease and the use of different carbidopa-levodopa formulations
• Recognize the differences between each carbidopa-levodopa formulation
• Discuss the appropriate patient who may benefit from transitioning to a different formulation of carbidopa-levodopa

Knowledge Questions
1. What is the primary role of carbidopa-levodopa in the management of Parkinson's disease?
a. Carbidopa and levodopa directly increase dopamine production in the brain
b. Levodopa converts to dopamine in the brain, and carbidopa prevents its breakdown
c. Carbidopa and levodopa work by inhibiting the breakdown of dopamine in the brain

2. Which of the following factors can lead to reduced efficacy of carbidopa-levodopa in treating Parkinson’s disease?
a. Decreased dopamine receptors in advanced disease stages
b. Increased carbidopa leading to less peripheral conversion of levodopa
c. Lowering the carbidopa-to-levodopa ratio to reduce side effects

3. How does the formulation of carbidopa-levodopa controlled-release differ from the immediate-release version?
a. It increases peak dopamine levels in the brain
b. It reduces the amount of carbidopa needed to enhance levodopa absorption
c. It provides a slower, more continuous release of levodopa

4. What is a key difference between carbidopa-levodopa IR and foscarbidopa-foslevodopa?
a. Carbidopa-levodopa IR causes peaks and troughs of levodopa, foscarbidopa-foslevodopa is formulated to give more consistent levodopa
b. Carbidopa-levodopa IR is dosed once daily, while foscarbidopa-foslevodopa is dosed multiple times daily
c. Carbidopa-levodopa IR is dosed using levodopa concentration levels, foscarbidopa-foslevodopa is dosed using carbidopa concentration levels

5. Which of the following is a reason why we should consider switching a patient’s carbidopa-levodopa IR to carbidopa-levodopa ER (Crexont)?
a. Patient is not experiencing “off” time
b. Patient is experiencing “off” time ≥2.5 hours
c. Patient is experiencing “on” time ≥2.5 hours

6. AL is a 55-year-old with Parkinson’s disease. He takes carbidopa-levodopa IR 25mg/100mg two tablets four times daily. He has a hard time with his current number of pills and breakthrough symptoms between doses. Which of the following alternative dose of carbidopa-levodopa would be appropriate for AL?
a. Carbidopa-levodopa ER (Crexont) 420mg three times daily
b. Carbidopa-levodopa ER (Rytary) 195mg twice daily
c. Foscarbidopa-foslevodopa (Vyalev) 0.27mg/hr

Pharmacy Technician Post Test (for viewing only)

Carbidopa-Levodopa: Revving Up Relief – Choose Your Formula! Technician Test

Learning Objectives: Technicians
• DESCRIBE the functions of the carbidopa-levodopa and how it aids in treatment for patients with Parkinson’s disease
• LIST different forms of carbidopa-levodopa
• IDENTIFY when to refer patients with questions about Parkinson’s disease to a pharmacist

Knowledge Questions
1. What is the primary role of carbidopa-levodopa in the management of Parkinson's disease?
a. Carbidopa and levodopa directly increase dopamine production in the brain
b. Levodopa converts to dopamine in the brain, and carbidopa prevents its breakdown
c. Carbidopa and levodopa work by inhibiting the breakdown of dopamine in the brain

2. Which of the following factors can lead to reduced efficacy of carbidopa-levodopa in treating Parkinson’s disease?
a. Decreased dopamine receptors in advanced disease stages
b. Increased carbidopa leading to less peripheral conversion of levodopa
c. Lowering the carbidopa-to-levodopa ratio to reduce side effects

3. How does the formulation of carbidopa-levodopa in Sinemet CR differ from the immediate-release version?
a. It increases peak dopamine levels in the brain
b. It reduces the amount of carbidopa needed to enhance levodopa absorption
c. It provides a slower, more continuous release of levodopa

4. Which of the following are approved dosage forms of carbidopa-levodopa?
a. Sublingual tablets and extended-release capsules
b. Intravenous infusion and immediate-release tablets
c. Extended-release capsules and subcutaneous infusion

5. Which of the following is a reason a patient may discuss with a pharmacist about switching from carbidopa-levodopa IR to carbidopa-levodopa ER (Crexont)?
a. Patient is not experiencing “off” time
b. Patient is experiencing “off” time >2.5 hours
c. Patient is experiencing “on” time >2.5 hours

6. Which of the following patients should be sent to pharmacist counsel window?
a. Patient with questions about drug interactions between CD-LD IR and antibiotics
b. Patient with questions about cost of CD-LD ER (Crexont) with their new insurance
c. Patients with questions about putting their PD medications on automatic refill

Patient Safety: Catch Me if You Can: Medication Errors and Their Impact

Learning Objectives

 

After completing this application-based continuing education activity, pharmacists will be able to

1.     Describe details of common medication errors in hospital and community pharmacies
2.     Differentiate between categories of medication errors
3.     Calculate medication error rates
4.     List approaches to learn from and prevent medication errors

After completing this application-based continuing education activity, pharmacy technicians will be able to

1.     Describe details of common medication errors in hospital and community pharmacies
2.     Differentiate between categories of medication errors
3.     Calculate medication error rates
4.     List approaches to learn from and prevent medication errors

A cartoon hand holding a cartoon figure with a circle head that contains a plus-sign in its center.

Release Date:

Release Date: June 15, 2025

Expiration Date: June 15, 2028

Course Fee

$7 Pharmacist

$4 Pharmacy Technician

ACPE UANs

Pharmacist: 0009-0000-25-035-H05-P

Pharmacy Technician: 0009-0000-25-035-H05-T

Session Codes

Pharmacist: 25YC35-JWN25

Pharmacy Technician: 25YC35-NWJ25

Accreditation Hours

2.0 hours of CE

Accreditation Statements

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-0000-25-035-H05-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

 

Disclosure of Discussions of Off-label and Investigational Drug Use

The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

Faculty

Mona El-Mouwfi, BS, PharmD Candidate 2026
UConn School of Pharmacy
Storrs, CT

Jeannette Y. Wick, RPh, MBA, FASCP
Director, Office of Pharmacy Professional Development
UConn School of Pharmacy
Storrs, CT

Faculty Disclosure

In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

Ms. Wick and Ms. El Mouwfi have no relationships with ineligible companies and therefore have nothing to disclose.

 

ABSTRACT

Statisticians and risk managers widely consider medication errors to be the most preventable and most common cause of patient injury. By understanding common error scenarios, implementing safety protocols, and leveraging technology, pharmacy professionals can actively reduce risks and enhance the quality of care. This continuing education activity is designed to empower pharmacy professionals with the knowledge and tools needed to understand, measure, and address medication errors effectively.

CONTENT

Content

INTRODUCTION

Ray and Kai are pharmacists that work together in a very busy outpatient clinic pharmacy. On a typical day, they fill around 800 prescriptions, and they usually have help from three technicians. Unfortunately, if anyone calls out sick or with an emergency, they don't have backup coverage.

 

Several times a week, patients return to the pharmacy and indicate that the prescriptions they received don't seem to be correct. Occasionally, Ray and Kai discover a medication error when patients indicate that their tablets or capsules don't look the same as a previous refill. Just yesterday, a mother returned to the pharmacy because her child’s liquid amoxicillin/clavulanate ran out before it should have. When Kai examined the label, she found a typographical error; it said, “take 5 mL three times a day” when it should have said, “take 2.5 mL three times a day.”

 

When staff members in this pharmacy identify medication errors, they usually discuss the problem quietly with the involved staff and make a mental note to implement corrective action or pay closer attention. Their pharmacy’s workload, staffing, error rate, and method of dealing with medication errors is not much different than many pharmacies across our nation. Throughout this continuing education activity, this example and others will help learners apply the lessons that experts have learned from analyzing medication errors.

 

Patient safety is a cornerstone of quality healthcare, and pharmacy professionals have an obligation to ensure patients receive safe and effective medications. Medication errors often stem from communication gaps, system complexities, or improper medication use. These errors not only compromise patient outcomes but also contribute to increased healthcare costs and increase risks of medication-related adverse effects.1

 

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) tallies and analyzes medication error reports from the National Medication Errors Reporting Program, which is administered by the Institute for Safe Medication Practices (ISMP). NCC MERP defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm.” Medication errors occur at various stages of the medication-use process, from prescribing and dispensing to administration and monitoring.2 Recognizing these errors and implementing prevention strategies are essential to improving patient safety and advancing pharmacy practice.

 

OVERVIEW OF MEDICATION ERRORS

To truly appreciate medication errors’ impact on patients, pharmacy team members must recognize common terms and types of errors.

 

Medication Error Terminology

Several medication errors can arise in clinical and retail settings. To actively prevent patient injury through medication errors, it is important to know what to look for in practice. Terms to be familiar with in all pharmacy practice settings include3,4:

  • Adverse drug event (ADE): An injury resulting from medical intervention related to a drug
  • Adverse drug reaction (ADR): An unintended reaction occurring at the intended drug dose
  • High-alert medications: Drugs that bear a heightened risk of causing significant patient harm when used in error
  • Look-alike/sound-alike (LASA) medications: Medications with similar-looking or similar-sounding names and/or shared features of products or packaging, leading to potential confusion
  • Medication reconciliation: The process of creating the most accurate list possible of all medications a patient is taking—including drug name, dosage, frequency, and route—and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points

 

PAUSE AND PONDER: When an error is identified, how does your pharmacy respond?

 

Defining and Classifying Medication Errors

Table 1 lists common medication errors that may occur throughout the stages of medication use.4

Table 1. Common Medication Errors4

Error Type Description Examples
Prescribing Errors occurring when ordering medication Wrong drug selection, incorrect dose/frequency, illegible handwriting, incomplete prescription, drug interactions
Dispensing Errors occurring during medication preparation and distribution Wrong medication, wrong strength, wrong dosage form, incorrect labeling, look-alike/sound-alike drug confusion
Administration Errors occurring during drug administration to the patient Wrong route, wrong dose, wrong rate, omission, administering to the wrong patient
Monitoring Errors occurring due to lack of proper patient monitoring Failure to monitor for adverse effects, inadequate lab test follow-up, failure to adjust dose for renal/hepatic function

 

Most medication errors are preventable and can also be classified by the severity of their impact on the affected patient. Leading organizations, such as NCC MERP, have developed taxonomies to classify medication errors in more detail, including nine categories labeled A through I. These categories range from circumstances that have the capacity to cause error (Category A) to errors that result in patient death (Category I). While categories E through I describe varying degrees of harm to the patient, categories A through D involve situations with no patient harm. These classifications help institutions analyze trends and implement targeted interventions.5

 

Figure 1 displays NCC MERP’s medication error classifications with severity levels increasing from top to bottom.5

 

Figure 1. Medication Error Classification5

 

A patient comes in to pick up a prescription at Ray and Kai’s pharmacy and the line is out the door. As Kai retrieves the medication, she quickly confirms the patient’s last name and date of birth. Ray knows the patient and greets him; “Hey Charlie, how are the kids?” Kai then realized the prescription in hand was meant for a different patient by the name of Billy and was in the same bin. The correct medication is retrieved, and the patient safely receives what was actually prescribed, resulting in a near miss, rather than a full medication error.

 

Later, Ray and Kai sit down to reflect on what could have happened if the mistake hadn’t been caught in time. If the pharmacy dispensed the wrong medication and the patient noticed and brought it back before taking it, this would be an error, no harm situation. However, if the patient took the incorrect medication and experienced harmful adverse effects, it would result in an error, harm situation. In a more severe scenario, if the patient took the wrong medication and had an allergic reaction or other fatal outcome, it would be considered error, death. After discussion, Ray and Kai decide to speak to the staff about the importance of verifying patient information in full at every encounter. They relay a PRO TIP: employees can place prescriptions for patients with similar names in separate bins to avoid confusion.

 

Even the smallest and most routine tasks, such as verifying a patient’s identity, carry immense responsibility. Every action performed in a pharmacy setting has a direct impact on patient health. A moment of inattention or a skipped step can be the difference between preventing harm and causing irreversible consequences. That’s why it is crucial to approach every task, no matter how routine, with full attention and diligence

 

Beyond preventing individual mistakes, classifying and analyzing medication errors is a key to improving patient care on a larger scale. Recognizing and labeling these errors—whether they are near misses, errors with no harm, or more serious mistakes—provides valuable insight into when and where they happen. By identifying patterns, pharmacies can implement targeted safety measures to minimize risks.4,5

 

ANALYSE, DOCUMENT, PREVENT

Medication Error Rates

To identify and reduce medication errors effectively, individuals and institutions must track their occurrences systemically. One of the most effective ways to achieve this is by calculating the medication error rate, which provides valuable insight into areas requiring improvement.6 The formula for calculating the medication error rate is as follows:

<<ADD IMAGE>>

 

The numerator represents the total number of medication errors recorded during a given period, with each error event counted as one. The denominator consists of all medication orders or doses that were dispensed and administered.6 This formula applies across all pharmacy settings, including both community and hospital environments.

 

 

For example, a hospital pharmacy dispenses 100,000 doses in a month and identifies 50 medication errors in that month. What is the medication error rate?

 

Once calculated, error rates are a crucial tool for identifying trends and implementing targeted interventions. By analyzing the data, healthcare teams can pinpoint high-risk areas, set measurable goals, and put corrective measures into action to minimize errors. This proactive approach not only enhances patient safety; it also optimizes pharmacy workflow and overall efficiency.

 

The pharmacy where Ray and Kai work is accredited. During an accreditation audit, one of the surveyors asks Ray about their medication error rate. Ray is unable to answer. The surveyor pushes a little and asks Ray to provide copies of all incident reports regarding medication errors. Ray finds two or three in which the medication error was serious enough to attract attention from the clinical staff or the clinic's risk manager. When the surveyor explains how to calculate a medication error rate, Ray listens carefully. Needless to say, the surveyor noted the lack of documentation about medication errors as a deficit in the survey and indicated that she did not believe that they only had three medication errors in the past year. When Ray and Kai meet to plan corrective action, they realize that without good documentation, they cannot make this calculation.

 

To ensure accuracy and reliability, all pharmacy and healthcare organizations must foster a culture of transparency and promote non-punitive error reporting.6,7 Management must encourage staff to report errors without fear of retribution, allowing institutions to collect comprehensive data and develop effective mitigation strategies. Hospitals and community pharmacies can gain valuable insight into their performance by benchmarking their calculated error rates against institutions of similar size and complexity. Comparing rates with national standards or similar organizations helps ensure adherence to best practices and provides insight into additional potential interventions.7

 

Documenting Medication Errors

Pharmacists and technicians should know how to document and report incidents that occur in their pharmacy properly, usually following policies or procedures put in place by their institution and legal regulations. Unusual incident reports (UIRs) are a formal mechanism for documenting clinically significant medication errors and near misses.

 

Following identification of an incident and corrective patient measures, all relevant personnel should be notified and asked to record their recall of events. These reports should include key details such as who was involved, when and where the incident occurred, type of error, contributing factors, and corrective actions taken.8 To prevent recurrence of an incident or find a systemic issue leading to incidents, errors should regularly be recorded regardless of severity or whether it reached the patient or not. A PRO TIP is to maintain a list of errors that should be documented and keep unused UIRs in an accessible place (e.g., pinned on all desktops or stored in designated folders), encouraging staff to fill them out. These forms should be completed in full and a PRO TIP is to include instructions on what steps to take following the incident (i.e., read over and include any forgotten details, ensure all relevant staff is notified). Investigative staff should thoroughly gather data pertaining to the incident, including records, UIRs, patient notes, and physical items used in the event.9 Staff should establish a clear chronology of events to determine the root cause and prevent future occurrences.

 

Pharmacists and technicians should be well-versed in properly documenting and reporting incidents in their pharmacy, usually following institutional policies and legal regulations. UIRs serve as a formal mechanism for recording clinically significant errors and near misses. The following steps are necessary for proper documentation and reporting8-10:

  1. Identify and respond to the incident
    • When an error or near miss occurs, prioritize patient safety by taking corrective actions and notify all relevant personnel, including leadership.
  2. Thoroughly document the incident
    • UIRs should capture key details such as
      1. who was involved
      2. when and where the incident occurred
      3. type of error and contributing factors
      4. corrective actions taken and follow-up measures
    • All involved personnel should document their recollection of events promptly to ensure accuracy.
  3.  Encourage consistent reporting
    • To prevent recurrences and identify systemic issues, all errors—regardless of patient impact severity—should be recorded.
    • PROTIP: Maintain a list of errors that must be documented and keep unused UIRs easily accessible (i.e., pinned on desktops or stored in a designated folder) to encourage completion.
    • Forms should be fully completed, and staff should review their entries for accuracy before submission.
  4.  Investigate and analyze the incident
    • Investigative staff should collect all relevant data, including UIRs, records, forms, and any physical items used in the event.
    • Establish a clear chronology of events to determine the root cause and prevent future occurrences.

           

          UIRs are considered Quality Improvement data in healthcare organizations, making them confidential and generally protected from disclosure under laws like the Patient Safety and Quality Improvement Act.11 Organizations use these reports internally to enhance patient safety and do not share them with patients or lawyers. However, protection can vary based on state laws and institutional policies, so a PRO TIP for organizations would be to highlight their specific policies and require additional training and separate filings to ensure proper procedures to maintain confidentiality.

           

          Individuals must report serious medication errors resulting in patients harm or regulatory violations to state boards of pharmacy and should also report them to accreditation agencies (e.g., Joint Commission) and the FDA through the MedWatch program.8 Pharmacy personnel is expected to know how and when to use institution-specific forms and to revise these to simplify and encourage the error reporting process.

           

          Ray and Kai are motivated to track medication errors better. When they dust off their stack of unused UIR forms, they realize that their forms are skeletal and their organization would benefit from a better tool. One of their technicians, Tara, volunteers to look at a number of different forms and identifies four. The staff chooses to “pilot” two, meaning they will document all medication errors that occur over the next three weeks on both forms, and then analyze the results. At the end of the pilot, they choose one form but realize that they need to tailor it to their practice. Tara also notes that they could automate the form and include a picture of the dosage forms that were involved.

           

          Within three months, Ray and Kai realize from the pictures that a full 25% of their errors involve tablets that are white. Ray and Kai can share a PRO TIP with other organizations now. They create a whiteboard that lists most of their white tablets and the tablet markings. The technicians who handle inventory update the whiteboard when they change generics. Additionally, whenever Ray or Kai visually verify a prescription for a white tablet, they note the tablet marking on the prescription. In this way, they eliminate a good number of errors.

           

          Institutions may have different methods for documenting unusual incidents, so it is essential that pharmacy staff know how to access and properly complete these forms. Keeping UIR forms up to date ensures they remain effective and relevant. Attached are three different incident report forms; review them carefully and identify their similarities and differences (see Appendix).12-14

           

          Accurate medication error reporting is the underpinning of identifying risks and improving patient safety. However, traditional error-reporting systems often capture only a portion of actual incidents and do not usually account for adverse effects. This could be attributed to limitations in error-reporting, including but not limited to underreporting due to fear of punishment, time-consuming processes, and a lack of feedback and follow-up.15 Research suggests that the use of observation, when appropriate and feasible, could lead to more accurate detection of medication errors in practice.16,17 When applicable, institutions can use observation in combination with tracking error reports and greatly reduce the frequency of medication errors.

           

          A strong culture of safety in pharmacy practice encourages transparent error reporting and non-punitive responses. Employees should feel comfortable reporting mistakes without fear of disciplinary action, as this fosters a learning environment rather than a blame culture. Encouraging reporting allows institutions to7,18

          • identify error trends and implement preventative measures
          • provide additional training where needed
          • improve medication safety policies and procedures

           

          All people in positions of authority should encourage pharmacy personnel to report medication errors to their institutions and to the FDA, ISMP, or NCC MERP if appropriate.19

           

          System-Based Prevention Approaches

          Healthcare institutions implement structured systems to enhance workflow efficiency and minimize medication errors. These systems provide standardized protocols, technological advancements, and communications strategies that help pharmacy personnel ensure safe and accurate medication dispensing and administration.

           

          With advancements in technology, healthcare professionals frequently rely on automated systems to assist with medication safety. While these tools greatly reduce the potential for human error, they should be used to complement, not replace, pharmacist and technician expertise. Proper training and implementation of these tools are essential to their effectiveness. Key technologies that reduce medication errors include the following18,20,21:

          • Barcode scanning as an additional verification step in the dispensing and administration process ensures that the correct drug, dose, and patient matches the prescription and manufacturer specifications.
          • Computerized provider order entry (CPOE) and e-prescribing reduce errors by eliminating the risk of misinterpreting handwritten prescriptions. CPOE also alerts prescribers about potential drug interactions, allergies, and dosing errors before orders are processed.
          • Automated dispensing cabinets, commonly used in hospitals, help regulate medication storage, access, and tracking to prevent unauthorized or incorrect dispensing.

           

          To maximize these systems’ effectiveness, pharmacy staff must remain vigilant, ensuring that they do not blindly trust automation. As recommended by the ISMP, conducting manual double-checks judiciously, selective to certain high-risk tasks or medications, can further enhance patient safety.22

           

          Familiarizing all staff with institutional standard operating procedures (SOPs) is essential for ensuring consistent and safe practice. These guidelines outline step-by-step procedures for specific pharmacy operations, reducing deviations that could lead to medication errors.23 When adhered to properly, SOPs standardize processes (minimizing variability and human error), provide clear instructions for handling high-alert medications, and outline best practices for prescription verification, dispensing, and patient counseling.21,23 For example, a hospital SOP may require two licensed healthcare professionals to verify chemotherapy doses independently before administration. In a community pharmacy, an SOP may require mandatory counseling for first-time prescriptions of high-risk medications, such as opioids or anticoagulants. Having SOPs and checklists readily accessible ensures that pharmacy personnel can reference best practices quickly when dealing with complex or high-risk situations.

           

          SIDEBAR: A Word About CHECKLISTS

          When checklists are numerous in quantity and poor in design, pharmacy staff may experience a sense of checklist fatigue, becoming overwhelmed and disengaged with completing them. This could lead to rushed or skipped steps, negatively impacting performance and patient safety. The following lists some strategies to avoid feeling desensitized to the repetitive nature of checklists22,24,25:

          • Use checklists selectively by focusing on the most important or highest-risk tasks
          • Improve the design to be clear, concise, and easy to follow
          • Avoid unnecessary or redundant steps
          • Regularly ensure the checklists are up-to-date and effective
          • Address fatigue with staff and provide training and feedback on the importance of each step

           

          PAUSE AND PONDER: When reviewing a prescription, what red flags should prompt you to double check with a prescriber, pharmacist, or colleague?

           

          PHARMACY PRACTICE CONSIDERATIONS

          Each pharmacy practice type has its own unique concerns and considerations with regard to medication error reporting.

           

          Community Pharmacy

          In a retail or clinic pharmacy setting, like the one in which Ray and Kai work, pharmacists and pharmacy technicians must exercise caution throughout the prescription filling process to prevent errors. These errors can be minor and initially go unnoticed, but can lead to serious adverse events, hospitalizations, or even fatalities if not promptly identified and addressed.26

           

          The first stage of medication processing—receiving a prescription—creates a significant risk for errors. Whether prescriptions are transmitted electronically, by phone, or handwritten, pharmacy personnel may misread, misinterpret, or fail to recognize important details.27 Especially in high-volume settings, healthcare professionals should prioritize accuracy by seeking prescriber clarification when needed, rather than making assumptions or rushing through interpretation.  Errors can also originate from prescribers, and pharmacy personnel should have a high index of suspicion that every prescription is incorrect. Calling to clarify questionable doses or frequencies ensures patient safety and may also prompt prescribers to recognize and correct unintended mistakes.26 All three errors that Ray and Kai documented had been serious enough to result in an ADE or ADR. When they looked back at these errors, they realized that for two of them, if they had questioned the patients or called the prescribers, the errors may have been avoided entirely.

           

          Common errors that pharmacists and technicians should be vigilant about in community pharmacy include1,3,27,28

          • Misinterpreting abbreviations and symbols: Sloppy abbreviations and symbols can lead to dangerous dosing errors. Table 2 summarizes the Joint Commission’s “DO NOT USE” list of abbreviations that should be displayed in pharmacies.
          • LASA medications: Medications with similar names can be easily confused if not carefully verified.
          • Incorrect dosing and strength selection: Errors can occur by selecting the wrong strength of a medication or miscalculating pediatric or weight-based doses.

           

          Table 2. The Joint Commission’s “DO NOT USE” List28

          Do Not Use Potential Problem Use Instead
          U, u Mistaken for “0” (zero), the number “4” (four) or “cc” Write “unit
          IU Mistaken for IV (intravenous) or the number 10 (ten) Write “International Unit”
          Q.D., QD, q.d., qd

           

          Q.O.D., QOD, q.o.d., qod

          Mistaken for each other

           

          Period after the Q mistaken for “I” and the “O” mistaken for “I”

          Write “daily”

           

          Write “every other day”

          Trailing zero (X.0 mg) *

          Lack of leading zero (.X mg)

          Decimal point is missed Write X mg

          Write 0.X mg

          MS

           

          MSO4 and MgSO4

          Can mean morphine sulfate or magnesium sulfate

           

          Confused for one another

          Write “morphine sulfate”

           

          Write “magnesium sulfate”

          *Exception: A trailing zero is only allowed when necessary to indicate the exact level of precision, such as in laboratory results, imaging studies that report lesion sizes, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

           

          Maintaining readily accessible reference lists can help pharmacy personnel cross-check potential medication errors before contacting prescribers. The ISMP has identified numerous LASA pairs that contribute to medication errors and has created lists of commonly confused abbreviations and symbols.29 Additionally, using TALL Man lettering (e.g., capitalizing part of a drug's name in upper case letters to differentiate similar drug names like hydrALAzine vs hydrOXYzine) when documenting or labeling LASA medications can minimize confusion.29

           

          In the hypothetical pharmacy, Ray notes that one of the technicians consistently fills prescriptions for dipyridamole with diphenhydramine. He has pointed this problem out to the technician several times and asked the technician to find the correct medication, but the problem continues. After learning about TALL Man lettering, he realizes that their computer system does not use this simple but useful intervention. He contacts the programmers and asks if they can make the changes, providing the ISMP's list of drugs for which this intervention could prevent many errors. A PRO TIP here is to ask the technician to use a highlighter to highlight the part of the drug name that follows "DIP-" on all drugs that begin with these three letters before filling prescriptions.

           

          Errors often arise during the later stages of prescription processing, including data entry, assembly, and pharmacist verification. Pharmacy personnel may rely too heavily on the auto-populated fields in electronic prescribing systems (e.g., McKesson, PioneerRx), assuming the information is correct without double-checking key details. This could lead to incorrect medication strengths, frequency, or refill quantities, ultimately causing billing issues or improper medication dispensing.27,20

           

          Dispensing the wrong formulation can occur if pharmacy staff select similar-looking bottles. Barcode scanning technology can help reduce assembly errors by ensuring use of the correct product. Pharmacists must physically inspect medications rather than relying solely on electronic systems. Pharmacy staff should attach medication guides, auxiliary labels, and other patient education materials as necessary. Pharmacy professionals must recognize that technology is a tool, not a replacement for human oversight. Systems may have glitches or auto-fill errors, and staff should remain vigilant to manually verify accuracy when needed. 20

           

          Over the few weeks after the accreditation survey, Ray and Kai see a number of minor medication errors in the pharmacy. During a counseling session, Kai learns that one patient has been taking a diuretic but has not been increasing the amount of potassium in her diet. The patient reports cramping and nausea. Kai realizes that the pharmacy staff stopped using colorful auxiliary labels, assuming that the key counseling points are covered in the multi-page handout that the computer prints with each prescription. Unfortunately, many patients simply throw that multi-page handout into the recycle bin (as did this patient). Kai realizes that using auxiliary labels is an opportunity to improve counseling and to increase the likelihood that patients will take medications correctly.

           

          The final step in the prescription process—dispensing the medication to the patient—requires uninterrupted attention to detail. Staff often overlook or rush this step in busy retail pharmacies, especially under pressure from patients who may be in a hurry. Patients who are eager to leave or have pressing time constraints may create an environment where staff feel rushed to complete the transaction quickly, potentially compromising safety. The Joint Commission requires two patient identifiers before dispensing a medication (e.g., full name and date of birth) to prevent mix-ups.26 Failing to confirm the patient’s identity may result in a patient receiving the wrong prescription, leading to serious consequences.

           

          While not all patients will ask for counseling, it is the pharmacy staff’s responsibility to offer counseling proactively, especially in critical situations. Pharmacy staff must remain alert to identify potential medication errors and recognize when pharmacist intervention is necessary. Pharmacy technicians are essential to this process. In our hypothetical pharmacy, Ray and Kai realize that the way that they've been dealing with medication errors isn't conducive to ideal teamwork. Further, they realize that they need to engage their technician support team so the pharmacist becomes involved in the process earlier when technicians see red flags.

           

          Common errors that require technician awareness and referral to the pharmacist include2,4,20

          • misuse or incorrect administration
          • first-time prescriptions, dose changes, or class switches
          • high-risk medications or drug interactions
          • duplicate therapy or overlapping prescriptions

           

          By actively engaging in patient education and ensuring clear communication at the point of dispensing, pharmacy professionals can significantly reduce medication errors and enhance patient safety. A PRO TIP comes from the Indian Health Service where pharmacy staff take a few minutes to remove medication from the bag, read the drug name, open the bottle, shake a few dosage units into the cap, and show it to the patient. Patients may identify medications that look different than they remember, which may signal a change in generic supplier or may identify an error. Although this process sounds time consuming, it actually takes just a few seconds for each bottle, and it prevents adverse outcomes in many cases.

           

          Hospital Pharmacy

          Hospital pharmacists and pharmacy technicians have serious responsibilities in ensuring safe medication use among high-risk patient populations. Like patients seen in the community, hospitalized patients often have complex conditions, multiple comorbidities, and require high-alert medications. But any event that precipitates hospitalization increases vulnerability to medication-related adverse events.21 Learners should note that many of these interventions apply in community centers as well.

           

          Similar to retail or clinic pharmacy, miscommunication between prescribers and pharmacy personnel remains a leading cause of medication errors in hospitals. Healthcare providers can reduce errors through effective communication, verification, and collaboration. Regularly confirming prescription details and clarifying discrepancies helps prevent errors before they reach patients. Pharmacy staff need to establish trust and employ open communication with prescribers to ensure patient safety in hospitals. A breakdown in interprofessional relationships can lead to medication errors, such as18,21

          • incorrect medication selection due to misinterpreted verbal or written orders
          • dosing errors, particularly in pediatric or renally impaired patients, when key patient information is not communicated
          • failure to adjust medications in response to changing renal or hepatic function, leading to toxicity or subtherapeutic dosing
          • missed allergy documentation, resulting in patients receiving medications that trigger adverse reactions

          By fostering a culture of open dialogue and verification, hospital pharmacy teams can minimize preventable errors and ensure optimal patient care.

           

          Consider a hospital pharmacy that employs nine pharmacists on three shifts, with a staffing ratio of one pharmacist to two technicians throughout the entire 24 hours. This pharmacy does a better job of documenting medication errors on unusual incident reports, but considerable room for improvement remains. Lisa is the pharmacist who works closely with the Performance and Quality Improvement (QPI) Department. Her liaison in QPI notifies Lisa that of the 46 medication errors reported in the last quarter, eight were associated with orders from a hospitalist, Dr. Backoff, who rotates shifts. The underlying cause seems to be miscommunication. Dr. Backoff is well known for his offensive behaviors; he humiliates people who ask questions, intimidates coworkers using insults or repeatedly bringing up past errors, excludes staff from opportunities to participate, and is generally so critical that people avoid him.30

           

          When staff call Dr. Backoff, he often fails to return the call. Over time, the situation has escalated to the point where staff are afraid to pick up the phone and call him when problems occur. As Lisa works with her QPI liaison, they realize that their workplace has no comprehensive policies and procedures targeting workplace bullying. Without clear guidelines and protocols, people who are targeted by bullies may feel powerless and unwilling to work with their bully.31 A PRO TIP is that this organization needs to develop training to address bullying, and Lisa and the QPI liaison need to speak to Dr. Backoff's supervisor immediately. The supervisor can refer Dr. Backoff to employee assistance program or implement corrective and disciplinary action.

           

          Certain medications require heightened safety precautions due to their potential for severe patient harm if misused. The ISMP has a list of high-alert medications that require extra safeguards in hospital settings. An example of these are anticoagulants; even small dosing mistakes could lead to severe bleeding or thrombosis (clotting).32 Due to the serious risks associated with high-alert medications, pharmacy staff pharmacists and pharmacy technicians should double-check and arrange independent verification consistently.21

           

          Medication errors frequently occur during transitions of care, including hospital admission, transfers to other facilities (e.g., long-term care, rehabilitation), and discharge to home. These errors can result in unintentional medication discontinuation, dose and frequency errors, or discharge medication miscommunication, significantly increasing patients’ risk of harm.33  One of the most significant risks during transitions of care is unintentional medication discontinuation (mistakenly stopping an essential chronic medication). Dose and frequency discrepancies and miscommunications about discharge medications further increase the risk of ADEs post-hospitalization.34

           

          To prevent these errors proactively, hospital pharmacists and pharmacy technicians should21,33

          • conduct a thorough medication reconciliation at the time of admission, ensuring all home medications are accurately documented
          • maintain clear, updated medication lists through each stage of hospitalization
          • collaborate to ensure patients and caregivers receive comprehensive discharge counseling, with the technician reminding or prompting pharmacists if this step is missed, and reinforcing medication changes adherence instructions

           

          Lisa’s hospital has a structured transitions of care program. They hire pharmacy students to conduct medication reconciliation under a pharmacist’s supervision. Before pharmacy students can conduct medication reconciliation, they complete a comprehensive training program. Regardless, errors on the medication list still slip through.

           

          Lisa's hospital is not alone with this problem. Many hospitals find that errors occur even after medication reconciliation. A 2024 study of the medication reconciliation process and related medication errors indicates that these processes are “very heterogeneous,” meaning that in some areas, medication reconciliation was very good and in others, not so much.35 They found that error rates were unexpectedly high in some areas. This study looked at 929 prescriptions written for 182 patients. In 91% of cases, the reconciler had not specified the drug form. About 72% of medication administration errors pursuant to a faulty medication reconciliation exercise resulted in patients receiving the wrong release dose formulation (i.e., immediate release as opposed to extended release). The researchers indicated that medication error rates did not improve significantly over the period before they conducted routine medication reconciliation.35

           

          Lisa has heard coworkers talk about medication reconciliation as a useless process and seeing them roll their eyes when they look at a medication reconciliation report that has obvious errors. In the past, pharmacy staff did not consider a mistake on a medication reconciliation list to be a medication error. However, when a serious error slips through, Lisa’s QPI liaison suggests that they began tracking such errors on unusual incident reports. A PRO TIP here is to track errors in medication reconciliation and try to identify the areas where errors are most likely to occur in the medication reconciliation process. At this hospital, Lisa and the QPI liaison were able to confirm that they also had a problem with identification of the correct formulation. Over the following months, they were able to improve by using additional training and revising their medication reconciliation form to force technicians to ask about the formulation or to see the bottle.

           

          PAUSE AND PONDER: Can you think of any processes or policies in your workplace that can be improved to enhance patient safety?

           

          Pharmacist and Technician Responsibilities

          Pharmacy professionals have a responsibility to actively communicate with their colleagues and other healthcare providers to prevent errors. Effective collaboration within the healthcare team ensures safe medication practices by18

          • clarifying unclear or incomplete prescriptions before dispensing
          • confirming appropriate dosing adjustments for renal or hepatic impairment
          • coordinating medication reconciliation during transitions of care to prevent omissions or duplications

           

          Management needs to empower pharmacists and pharmacy technicians to voice concerns regarding potential medication errors. Addressing these concerns professionally and respectfully fosters a culture of teamwork and patient safety.

           

          A key responsibility of pharmacy professionals is to provide clear, understandable medication counseling to patients. However, it is unrealistic to expect that staff can counsel all patients on every detail of their prescription. Instead, pharmacists should prioritize the most critical points, especially on new prescriptions, including36

          • dosing instructions and adherence importance
          • common and serious adverse effects
          • drug interactions and contraindications
          • proper storage and administration techniques

           

          One effective counseling strategy is the teach-back method, where patients repeat the pharmacist’s instructions back in their own words. This ensures patients fully understand how to use their medication correctly. For example, when dispensing doxycycline, instead of simply stating “Take this with a full glass of water,” a pharmacist using the teach-back method would ask one simple question after explaining how to take the doxycycline: “Can you explain to me how you will take this medication to avoid stomach irritation? I need to be sure I covered everything.”18,21,26 

           

          When a serious medication error occurs, it is crucial to investigate the underlying causes to prevent future occurrences. Root-cause analysis (RCA) is a structured problem-solving method used to analyze errors after they have happened—including what, how, and why it happened—and can help determine what lessons could be learned and how to reduce the risk of recurrence and make care safer.3,21 For example, if a retail pharmacy dispenses the wrong insulin type and a patient is subsequently hospitalized, an RCA might reveal that the error stemmed from look-alike packaging and a lack of independent verification.

           

          Failure mode and effects analysis (FMEA) is a proactive approach to medication safety, identifying potential failures before they occur. By evaluating processes and pinpointing high-risk areas, institutions can implement safeguards to prevent errors before they reach patients.21 For instance, before introducing a new automated dispensing cabinet, an FMEA could help identify potential failure points, such as medication selection due to user interface design, allowing for preventive modifications.

           

          CONCLUSION

          Patient safety is a fundamental pillar in pharmacy practice, and reducing medication errors requires a proactive, systematic approach. Errors can occur at any stage of the medication use process, from receiving and interpreting prescriptions to dispensing and patient counseling. Recognizing common errors—such as abbreviations, LASA drugs, incorrect dosing, and transcription mistakes—helps pharmacy professionals to implement safeguards that prevent harm.

           

           

           

           

           

           

          Appendices 1-3

           

           

          Pharmacist Post Test (for viewing only)

          Patient Safety: Catch Me if You Can: Medication Errors and Their Impact

          Pharmacist Post-test

          After completing this continuing education activity, pharmacy technicians will be able to
          • Describe details of common medication errors in hospital and community pharmacies
          • Differentiate between categories of medication errors
          • Calculate medication errors rates
          • List approaches to learn from and prevent medication errors

          1. Which of the following examples of medication errors is correctly matched with its error type/stage of prescription processing?
          A. Wrong route of administration – Prescribing
          B. A prescription written with illegible handwriting – Dispensing
          C. Failure to adjust dose for renal/hepatic function – Monitoring

          2. Which of the following is an example of a high-alert medication that requires extra caution?
          A. Normal saline
          B. Loratadine
          C. Warfarin

          3. You need to calculate your pharmacy’s medication error rate for the past calendar week before the staff meeting. There have been eight errors and 6,400 medication orders that were dispensed for this week. What is the medication error rate?
          A. 0.13%
          B. 0.08%
          C. 8.13%

          4. Which of the following is a key benefit of encouraging incident reporting systems in pharmacies?
          A. Identifying trends to implement system-wide improvements
          B. Finding who is responsible and firing them immediately
          C. Reducing the daily workload for pharmacy staff

          5. Which of the following is an example of why it is important to maintain good relationships with other health professionals?
          A. It ensures that pharmacists thoroughly document allergies
          B. It facilitates clear communication, reducing risk of errors
          C. It allows pharmacy staff to bypass unnecessary verification steps

          6. Which of the following best differentiates a prescribing error from a dispensing error?
          A. A prescribing error occurs during medication order entry, while a dispensing error occurs during medication preparation or distribution
          B. Prescribing errors only occur in hospitals, while dispensing errors only occur in community or outpatient clinic pharmacies
          C. A prescribing error is always detected by the pharmacy technician, while a dispensing error is only noticed by the pharmacist

          7. A patient started thyroid medication 6 months ago and has been taking the same dose without any follow-up bloodwork. What type of medication error is this?
          A. Monitoring error
          B. Transition-of-care error
          C. Prescribing error

          8. Which of the following is the best strategy to prevent look-alike/sound-alike medication errors?
          A. Using only brand names during the prescription filling process
          B. Using TALL Man lettering and routine barcode scanning
          C. Storing similar-sounding medications together for easy access

          9. How can you use the medication error rate to identify areas for improvement and enhance patient safety?
          A. Analyzing error rate trends to pinpoint problem areas
          B. Creating predictive models that estimate future potential error rates
          C. Benchmarking error rates against comparable institutions

          10. In your very busy pharmacy, you identify that most medication errors are occurring at the point of prescription entry. What is an appropriate response?
          A. Provide additional training on prescription verification
          B. Add a verification call to the prescriber for all written prescriptions
          C. Stop accepting handwritten prescriptions in your pharmacy

          Pharmacy Technician Post Test (for viewing only)

          Patient Safety: Catch Me if You Can: Medication Errors and Their Impact

          Pharmacy Technician Post-test

          After completing this continuing education activity, pharmacy technicians will be able to
          • Describe details of common medication errors in hospital and community pharmacies
          • Differentiate between categories of medication errors
          • Calculate medication errors rates
          • List approaches to learn from and prevent medication errors

          1. Which of the following medication errors is correctly matched with its error type/stage of prescription processing?
          A. Wrong route – Monitoring
          B. Illegible handwriting – Dispensing
          C. Wrong drug selection – Prescribing

          2. When would you classify a medication error as a near miss?
          A. An error occurred, but did not reach the patient
          B. A potential error was identified, intercepted, and avoided
          C. An error occurred and reached patient, but the patient is fine

          3. The pharmacist you work with wants to calculate the percentage of prescription orders that were errors in the past calendar week. They ask you to calculate this number, telling you that there have been five errors out of 7,000 medication orders dispensed this week. What is the medication error rate?
          A. 0.07%
          B. 0.05%
          C. 1.40%

          4. How can you use the medication error rate to identify areas for improvement and enhance patient safety?
          A. Analyzing error rate trends to pinpoint problem areas
          B. Creating predictive models that estimate future potential error rates
          C. Benchmarking error rates against comparable institutions

          5. Which of the following is a common cause of medication errors in community pharmacy?
          A. Using auxiliary labels on all medications without reviewing their necessity
          B. Providing medication counseling for patients even when they are rushed
          C. Misinterpreting prescriptions due to abbreviations or unclear handwriting

          6. Which of the following scenarios would prompt you to refer a patient to the pharmacist to prevent a medication error?
          A. A patient picking up medication refill for her spouse
          B. A patient requesting an early refill on a maintenance medication
          C. A patient using new insurance information on a prescription refill

          7. Where can you find lists of high-alert medications and look-alike/sound-alike medications?
          A. American Pharmacist Association (APhA) practice guidelines
          B. Standards of operations forms
          C. Institute of Safe Medication Practices

          8. Which strategy can help prevent accidental medication discontinuation during transition of care?
          A. Medication reconciliation
          B. Automatic therapeutic substitution
          C. Discharging the patient as fast as possible

          9. Which strategy can help prevent medication errors in all pharmacy settings?
          A. Using auto-population options on electronic systems as often as possible
          B. Encouraging a double-check system for high-risk medications
          C. Relying solely on bar-code scanning as the final verification step

          10. In a hospital setting, when is there a high chance of medication errors occurring?
          A. During surgery
          B. During discharge
          C. During visitation hours

          References

          Full List of References

          References

             

            1. Hodkinson A, Tyler N, Ashcroft DM, et al. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Med. 2020;18(1):313. doi:10.1186/s12916-020-01774-9
            2. National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors. Accessed February 2, 2025. https://www.nccmerp.org/about-medication-errors
            3. Agency for Healthcare Research and Quality. Glossary. Patient Safety Network. Accessed February 2, 2025. https://psnet.ahrq.gov/glossary-0
            4. Technical Series on Safer Primary Care: Medication Errors. World Health Organization. December 13, 2016. Accessed February 2, 2025. https://www.who.int/publications/i/item/9789241511643
            5. National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP Index for Categorizing Medication Errors. Updated October 2022. Accessed February 2, 2025. https://www.nccmerp.org/sites/default/files/index-color-2021-draft-change-10-2022.pdf
            6. Allan BL. Calculating medication error rates. Am J Hosp Pharm. 1987;44(5):1044-1046.
            7. Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); April 2008.Accessed February 4, 2025. https://pubmed.ncbi.nlm.nih.gov/21328752/
            8. Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: Achieving a New Standard for Care. Washington (DC): National Academies Press (US); 2004.Accessed March 21, 2025. https://nap.nationalacademies.org/catalog/10863/patient-safety-achieving-a-new-standard-for-care
            9. Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf. 2012;21(5):369-380. doi:10.1136/bmjqs-2011-000443
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            11. U.S. Department of Health and Human Services. Understanding patient safety confidentiality. October 22, 2024. Accessed March 25, 2025. https://www.hhs.gov/hipaa/for-professionals/patient-safety/index.html
            12. Clinical incident report sample PDF form. FormsPal. Accessed March 27, 2025. https://formspal.com/pdf-forms/other/clinical-incident-report-sample/
            13. 7 Essential Elements of an Incident Report, and a Free Guide. Safety Evolution Blog. August 24, 2022. Accessed March 27, 2025. https://www.safetyevolution.com/blog/7-essential-elements-of-an-incident-report-and-a-free-guide
            14. Tariq A, Georgiou A, Westbrook J. Medication incident reporting in residential aged care facilities: limitations and risks to residents' safety. BMC Geriatr. 2012;12:67. Published 2012 Nov 2. doi:10.1186/1471-2318-12-67
            15. Flink E, Chevalier CL, Ruperto A, et al. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US); February 2005.Accessed March 22, 2025. https://www.ncbi.nlm.nih.gov/books/NBK20547/
            16. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002;59(5):436-446. doi:10.1093/ajhp/59.5.436
            17. Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541-548. doi:10.1016/s1070-3241(16)30180-8
            18. Alhur A, Alhur AA, Al-Rowais D, et al. Enhancing Patient Safety Through Effective Interprofessional Communication: A Focus on Medication Error Prevention. Cureus. 2024;16(4):e57991. doi:10.7759/cureus.57991
            19. Mutair AA, Alhumaid S, Shamsan A, et al. The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines (Basel). 2021;8(9):46. doi:10.3390/medicines8090046
            20. Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014;83(6):427-437. doi:10.1016/j.ijmedinf.2014.02.004
            21. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50(2):305-314.
            22. Independent double checks: Worth the effort if used judiciously and properly. ISMP. June 6, 2019. Accessed March 25, 2025. https://home.ecri.org/blogs/ismp-alerts-and-articles-library/independent-double-checks-worth-the-effort-if-used-judiciously-and-properly?utm
            23. Caetano BDL. SOP management in the pharmaceutical industry. SimplerQMS. Updated January 24, 2025. Accessed February 3, 2025. https://simplerqms.com/pharmaceutical-sop-management/
            24. Chance EA, Florence D, Sardi Abdoul I. The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing medical errors in hospital settings: A narrative review. Int J Nurs Sci. 2024;11(3):387-398. Published 2024 Jun 8. doi:10.1016/j.ijnss.2024.06.003
            25. Grigg E. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg. 2015;121(2):570-573. doi:10.1213/ANE.0000000000000352
            26. Hong K, Hong YD, Cooke CE. Medication errors in community pharmacies: The need for commitment, transparency, and research. Res Social Adm Pharm. 2019;15(7):823-826. doi:10.1016/j.sapharm.2018.11.014
            27. Pervanas HC, Revell N, Alotaibi AF. Evaluation of Medication Errors in Community Pharmacy Settings: A Retrospective Report. J Pharm Technol. 2016;32(2):71-74. doi:10.1177/8755122515617199
            28. The Joint Commission. Official “do not use” list. September 2018. Accessed March 21, 2025. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/patient-safety/do_not_use_list_9_14_18
            29. Institute for Safe Medication Practices. FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man (Mixed Case) Letters. 2023. Accessed April 25, 2025. https://online.ecri.org/hubfs/ISMP/Resources/ISMP_Look-Alike_Tallman_Letters.pdf
            30. Knapp K, Shane P, Sasaki-Hill D, Yoshizuka K, Chan P, Vo T. Bullying in the clinical training of pharmacy students. Am J Pharm Educ. 2014;78(6):117. doi:10.5688/ajpe786117
            31. Customer Harassment, Bullying Affecting Pharmacists’ Ability to Do Their Jobs. US Pharmacist. February 2, 2022. Accessed March 11, 2025. https://www.uspharmacist.com/article/customer-harassment-bullying-affecting-pharmacists-ability-to-do-their-jobs
            32. Institute for Safe Medication Practices. ISMP list of high-alert medications. 2018. Accessed February 4, 2025. https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf
            33. Donaldson L, Ricciardi W, Sheridan S, Tartaglia R, eds. Textbook of Patient Safety and Clinical Risk Management. Cham (CH): Springer; 2021.Accessed February 4, 2025. https://pubmed.ncbi.nlm.nih.gov/36315660/
            34. Park J, Kim AJ, Cho EJ, et al. Unintentional medication discrepancies at care transitions: prevalence and their impact on post-discharge emergency visits in critically ill older adults. BMC Geriatr. 2024;24(1):1000. doi:10.1186/s12877-024-05517-w
            35. Schuster J, Saddawi A, Frisch A, et al. A comprehensive study of prescribing, administering and drug handling medication errors in ten wards of a university hospital after implementation of electronic prescribing, clinical pharmacists or medication reconciliation. Pharmazie. 2024;79(1):11-16. doi:10.1691/ph.2024.3579
            36. Center for Medicare & Medicaid Services. Drug diversion toolkit: Patient counseling—a pharmacist’s responsibility to ensure compliance. November 2014. Accessed February 4, 2025. https://www.cms.gov/files/document/patientcounselingbooklet111414pdf

            So Much STI Data: Information to help you stay current and informed – RECORDED WEBINAR

            The Arthur E. Schwarting Symposium is an educational conference focused on pharmacy practice for pharmacists in many settings.

            This year's symposium had an overall topic of Information Overload.

            Learning Objectives

            • Describe updated screening recommendations and epidemiological trends of sexually transmitted infections (STIs).
            • Review the Centers for Disease Control and Prevention’s STIs recommendations.
            • Explain the latest evidence-based STI updates.
            ·       Given medication shortages, outline the pharmacist's role in delivering targeted patient education and implementing strategies for responsible medication stewardship for STIs

            Activity Release Dates

            Released:  April 24, 2025
            Expires:  April 24, 2028

            Course Fee

            $17 Pharmacist

            ACPE UAN Codes

             0009-0000-25-030-H01-P

            Session Code

            25RS30-KVX29

            Accreditation Hours

            1.0 hours of CE

            Accreditation Statement

            The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

            Pharmacists and Pharmacy Technicians are eligible to participate in this application-based activity and will receive 1.0 CE Hour  for completing the activity  (ACPE UAN 0009-0000-25-030-H01-P), passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

            Grant Funding

            There is no grant funding for this activity.

            Faculty

            Jennifer Girotto, PharmD, BCPPS, BCIDP
            Associate Clinical Professor
            UConn School of Pharmacy
            Storrs, CT

                

            Faculty Disclosure

            • Dr. Girotto doesn't have any relationships with ineligible companies.

             

            Disclaimer

            The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

            Content

            Post Test Pharmacist

            1.) A 19-year-old female is at the clinic. She had recent unprotected sexual intercourse with her partner. She has not had any previous STI screenings. Which STIs are indicated for screening at this time?
            a. HIV, gonorrhea, and chlamydia
            b. Gonorrhea, chlamydia, and syphilis
            c. Chlamydia, syphilis, and HPV

            2.) Which of the following STIs have shown a continued increase in incidence based on 2023 data?
            a. Congenital syphilis
            b. Gonorrhea in the population
            c. Chlamydia cases in men

            3.) After completing gonorrhea treatment, when should a clinician re-screen the patient?
            a. 1 month after completing treatment
            b. 3 months after completing treatment
            c. 1 year after completing treatment

            4.) What is the guideline-based treatment recommendation for a 200 lb male patient with a confirmed gonorrhea and chlamydia co-infection?
            a. Ceftriaxone 500 mg IM x 1 and azithromycin 1000 mg PO x 1
            b. Ceftriaxone 250 mg IM x 1 and doxycycline 100 mg PO BID x 7 days
            c. Ceftriaxone 500 mg IM x 1 and doxycycline 100 mg PO BID x 7 days

            5.) Which population should receive seven days of treatment with metronidazole for trichomoniasis?
            a. Young males 15 – 24 years old
            b. Males 25 – 45 years old
            c. Females of any age

            6.) A pregnant patient is positive for primary syphilis. What is the guideline recommended treatment for her?
            a. 2.4 million units benzathine penicillin G IM x 1
            b. 2.4 million units benzathine penicillin G IM x 3 weekly doses
            c. 100 mg PO doxycycline 2 time daily doses for 28 days
            7.) Which of the following is a newly approved type of product that will increase patient access?
            a. OTC bacterial Pre-Exposure Prophylaxis
            b. OTC home screening tests for STIs
            c. OTC HIV Post Exposure Prophylaxis

            8.) What should pharmacists warn healthcare providers about regarding possible alternatives during a shortage of Bicillin LA for syphilis?
            a. Impact of HIV cases
            b. Adverse effects from the frequent use of the medication
            c. Antimicrobial resistance

            9.) You are working with emergency department physicians to manage a shortage of ceftriaxone. One concern is the treatment of gonorrhea. Which of the following would be a stewardship principle applied to this STI management choice?
            a. Use the most recent antibiotic approved for the indication
            b. Use alternative based on narrowest effect spectrum and incorporating local resistance data, if known
            c. Choose an alternative that will also cover other STIs just in case

            Patient Safety: Anticoagulation Stewardship: Identifying Key Data, Avoiding Errors, and Enhancing Safety – RECORDED WEBINAR

            The Arthur E. Schwarting Symposium is an educational conference focused on pharmacy practice for pharmacists in many settings.

            This year's sympoisum had an overall topic of information overload.

            Learning Objectives

            Differentiate high-priority, practice-changing information from less relevant or conflicting data after reviewing the anticoagulation guidelines, literature and clinical updates.
            Recognize common anticoagulation-related errors in pharmacy practice and implement strategies to minimize patient safety risks
            Identify red flag situations in anticoagulation management that pose patient safety risks.
            Determine the appropriate guidelines or evidence-based resources to guide clinical decision-making and referrals

            Activity Release Dates

            Released:  April 24, 2025
            Expires:  April 24, 2028

            Course Fee

            $17 Pharmacist

            ACPE UAN Codes

            0009-0000-25-029-H05-P

            Session Code

            25RS29-CBA96

            Accreditation Hours

            1.0 hours of CE

            Accreditation Statement

            The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

            Pharmacists and Pharmacy Technicians are eligible to participate in this application-based activity and will receive 1.0 CE Hour  for completing the activity  (ACPE UAN 0009-0000-25-029-H05-P), passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

            Grant Funding

            There is no grant funding for this activity.

            Faculty

             Youseff Besada, PharmD, BCPS, BCPP
            Assistant Clinical Professor
            UConn School of Pharmacy
            Storrs, CT

            Faculty Disclosure

            • Youssef Bessada doesn't have any relationships with ineligible companies.

             

            Disclaimer

            The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

            Content

            Post Test Pharmacist

            1. Which of the following BEST represents a high-priority takeaway from current guideline recommendations for DOAC use in atrial fibrillation?
            a) DOACs are preferred over warfarin in all patients with AF
            b) Apixaban is the only DOAC that does not require renal dosing adjustments
            c) DOACs should not be used in patients with mechanical heart valves

            2. A 68-year-old male with nonvalvular atrial fibrillation (weight 60 kg, age 78) and SCr 1.4 mg/dL is started on apixaban. Which of the following would be considered a dosing error?
            a) apixaban 5 mg BID
            b) apixaban 2.5 mg BID
            c) warfarin with a target INR of 2–3

            3. A 55-year-old female patient with atrial fibrillation (weight 75 kg, SCr 1.6 mg/dL) and recent MI has been taking apixaban 5 mg BID, clopidogrel 75 mg daily, aspirin 81 mg daily, and pantoprazole 40 mg for the past 7 months. Which of the following should be considered a red flag that would prompt pharmacist stewardship at this point?
            a) Use of aspirin in combination with DAPT
            b) Use of clopidogrel in a patient with CAD
            c) Use of apixaban for stroke prevention at the incorrect dose

            4. You are managing a patient with cirrhosis (Child-Pugh Class B) who requires anticoagulation for VTE. Which of the following is the most appropriate course of action?
            a) Prescribe rivaroxaban using its complete prescribing information recommendation
            b) Refer to hepatology/hematology to discuss bleeding risk and treatment alternatives
            c) Use warfarin because it’s always the safest anticoagulant in liver disease

            5. A patient newly started on warfarin reports they “just stopped eating leafy greens” to be safe. What is the best pharmacist action?
            a) Encourage the patient to continue avoiding all vitamin K-containing foods
            b) Educate that consistent vitamin K intake is more important than avoiding it
            c) Schedule weekly INR checks and adjust the warfarin dose aggressively

            Information overload in Chronic Coronary Disease – RECORDED WEBINAR

            The Arthur E. Schwarting Symposium is an educational conference focused on pharmacy practice for pharmacists in many settings.

            This year's symposium had an overall topic of Information Overload.

            Learning Objectives

            • Determine if a patient has chronic cardiac disease (CCD).
            • Identify lifestyle modifications that can reduce the risk of CCD.
            • Identify therapies that can reduce final health outcomes for specific CCD patient types to design successful drug regimens.
            • Describe how the steps in the PPCP process can be applied when reviewing a cardiac patient.

            Activity Release Dates

            Released:  April 24, 2025
            Expires:  April 24, 2028

            Course Fee

            $17 Pharmacist

            ACPE UAN Codes

             0009-0000-25-028-H01-P

            Session Code

            25RS28-TXJ88

            Accreditation Hours

            1.0 hours of CE

            Accreditation Statement

            The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

            Pharmacists and Pharmacy Technicians are eligible to participate in this application-based activity and will receive 1.0 CE Hour  for completing the activity  (ACPE UAN 0009-0000-25-028-H01-P), passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

            Grant Funding

            There is no grant funding for this activity.

            Faculty

            C. Michael White, PharmD, FCCP, FCP
            BOT Distinguished Professor and Chair of Pharmacy Practice
            University of Connecticut School of Pharmacy
            Storrs, CT

                

            Faculty Disclosure

            • Dr. White doesn't have any relationships with ineligible companies.

             

            Disclaimer

            The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

            Content

            Post Test Pharmacist

            1. A female patient is interested in lifestyle modification. Which of the following would you recommend?
            a. Switch from EVOO to coconut oil
            b. Switch from smoking weed to “doing” crystal methamphetamine
            c. Limit alcohol to a maximum of 1 drink a day

            2. A patient with CCD is determined to have “high risk” of experiencing an ASCVD event. The patient cannot receive high- or even moderate-intensity statins due to a history of significant rises in liver enzymes 8-10 weeks after initiation on two occasions. Which is true of the patient’s recommended lipid regimen?
            a. The patient needs high-intensity statin regardless of the liver issues and ezetimibe should be added if the LDL on the statin is over 70mg/dL
            b. The patient could receive a low intensity statin + a PCSK9 inhibitor and if the LDL remains over 70mg/dL, ezetimibe can be added
            c. The patient could receive a PCSK9 inhibitor and if the LDL remains over 70mg/dL, ezetimibe can be added

            3. Why can’t metoprolol tartrate be used to terminate a new onset angina pectoris event?
            a. Because the onset of action is 30 minutes, and the maximum effect is felt 2 hours after ingestion
            b. Because I am a pharmacist and I said so, that’s why
            c. Because metoprolol does not work on the coronary arteries and only coronary dilators can be used for acute angina pectoris events

            4. A student is explaining the PPCP process to you. Which of the following statements would you question and ask the student to research?
            a. The PPCP process helps structure an assessment to be sure that important drug related problems are all included
            b. Major pharmacy organizations agreed upon this process to show regulators, clinicians, patients, payers and insurers our unique patient services
            c. “PPCP” is an old term; major professional organizations have replaced it with the subjective-objective-assessment-plan process

            5. When would it be useful to recommend nitroglycerin spray instead of sublingual nitroglycerin?
            a. In a patient taking an anticholinergic
            b. In a patient taking an SSRI
            c. In a patient taking benzodiazepines

            6. JP is a patient who has rheumatoid arthritis and chronic coronary disease. He has an hsCRP test taken and the level is 7.2 mg/dL. Would this patient be a candidate for colchicine therapy according to the AHA/ACC Guideline and why or why not?
            a. Yes, colchicine should be used in all people with elevated hsCRP
            b. Yes, colchicine should be used in all patients regardless of hsCRP
            c. No, specific disease modifying antirheumatic drug are used in patients with RA

            7. AT is a patient with heart failure with reduced ejection fraction, who also has chronic coronary disease. Would an SGLT2 inhibitor or a GLP-1 agonist be preferred for the treatment of this patient?
            a. Neither drug should be used at all
            b. The SGLT-2 inhibitor would be preferred
            c. The GLP-1 agonist would be preferred

            8. WC is a patient who just had a PCI procedure but also has atrial fibrillation and is treated with rivaroxaban. What is the proper regimen to prevent stent occlusion?
            a. Clopidogrel + aspirin + rivaroxaban for one month, then clopidogrel + rivaroxaban for 5 months, then just rivaroxaban alone thereafter
            b. Clopidogrel + aspirin + rivaroxaban for six months, then clopidogrel + rivaroxaban for 6 months, then just rivaroxaban alone thereafter
            c. Clopidogrel + aspirin + rivaroxaban for 12 months, then rivaroxaban + clopidogrel then rivaroxaban for 6 months, then rivaroxaban alone

            Information overload to action: Decoding academic concepts for pharmacy preceptors- RECORDED WEBINAR

            The Arthur E. Schwarting Symposium is an educational conference focused on pharmacy practice for pharmacists in many settings.

            This year's symposium had an overall topic of Information Overload.

            Learning Objectives

            • Discuss how ACPE standards, the NAPLEX blueprint, and Entrustable Professional Activities (EPAs) guide the development of clinical competence in students, specifically in the context of patient care.
            • Describe the Pharmacist Patient Care Process (PPCP) and its key components.
            • Explain how the PPCP framework is applied in experiential education and clinical rotations.

            Activity Release Dates

            Released:  April 24, 2025
            Expires:  April 24, 2028

            Course Fee

            $17 Pharmacist

            ACPE UAN Codes

             0009-0000-25-026-H04-P

            Session Code

            25RS26-ABC28

            Accreditation Hours

            1.0 hours of CE

            Accreditation Statement

            The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

            Pharmacists and Pharmacy Technicians are eligible to participate in this application-based activity and will receive 1.0 CE Hour  for completing the activity  (ACPE UAN 0009-0000-25-026-H04-P), passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

            Grant Funding

            There is no grant funding for this activity.

            Faculty

            Jennifer Luciano, PharmD
            Director Office of Experiential Education
            University of Connecticut School of Pharmacy
            Storrs, CT

                

            Faculty Disclosure

            • Dr. Luciano doesn't have any relationships with ineligible companies.

             

            Disclaimer

            The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

            Content

            Post Test Pharmacist

            1. Joey is an IPPE student under your supervision this month. He observes as you meet with a patient who has a question about various options to treat psoriasis. You tell the patient you will get back to him about medications covered by his plan, out of pocket costs, the time burden associated with treatment, and potential adverse effects. Joey wants to help. What can Joey do?
            A. Collect information, asking for help if or when he needs it
            B. Observe how you collect information but assess independently
            C. Collect information only under direct and proactive supervision

            2. Phoebe is an APPE student in her first clinical rotation. She aspires to obtain an industry fellowship and hopes to receive the best grade possible on this rotation with the least work. She says, "I don't plan to work in a clinical position, so this is not a priority for me. What is the BEST answer?
            A. The PPCP is not just applicable to clinical situations. It structures processes for all kinds of projects, not just clinical challenges.
            B. Most students who aspire to work in industry do not get fellowships, and you need to know the PPCP if you land in an actual pharmacy.
            C. Say nothing. Allow Phoebe to do minimal work.

            3. Rachel is on her last APPE rotation before graduation. YAY! She works up a patient who has a cardiac issue. She collects a lot of appropriate information, and her assessment is almost perfect. She makes one statement that seems "off" to you. She recommends using a medication that is no longer first-line treatment. What is the MOST LIKELY cause for her omission?
            A. She relied on only one guideline for evidence
            B. She collects too much information and is confused
            C. She is hyper-focused on cost, not effectiveness

            4. Joey is now an APPE student on a general medicine rotation. You assign him a patient to review for your discussion this afternoon. When Joey joins you, he provides background information on the patient, reports on the physical notes, pertinent laboratory values and his conversation with the patient. What step of the Pharmacist Patient Care Process is Joey demonstrating?
            A. Collect
            B. Assess
            C. Plan

            5. Ross, an APPE student on your ambulatory care rotation, is writing up a SMART goal for his patient with diabetes. The goal reads “Reduce the patient’s blood glucose within six months. Patient will start metformin XL 500mg PO daily and follow up with the pharmacy team for titration every seven days. Reduction in the patient’s A1c will lead to better health outcomes and reduce the severity of complications from his diabetes.” What part of the SMART goal is Ross missing?
            A. Specific
            B. Measurable
            C. Realistic

            6. What is the performance goal for a “practice ready” APPE student in terms of level of entrustability on each of the entrustable professional activities (EPAs)?
            A. Direct supervision
            B. Reactive supervision
            C. General Direction

            Law: Understanding Disabled Pharmacy Patients’ Right to Nondiscrimination-RECORDED WEBINAR

            The Arthur E. Schwarting Symposium is an educational conference focused on pharmacy practice for pharmacists in many settings.

            This year's symposium had an overall topic of Information Overload.

            Learning Objectives

            • Describe the federal and state laws that protect patients with disabilities
            • Recognize situations in which accommodations should be provided to disabled patients
            • Recall examples of common modifications for patients with disabilities

            Activity Release Dates

            Released:  April 24, 2025
            Expires:  April 24, 2028

            Course Fee

            $17 Pharmacist

            ACPE UAN Codes

             0009-0000-25-027-H03-P

            Session Code

            25RS27-VXK92

            Accreditation Hours

            1.0 hours of CE

            Accreditation Statement

            The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

            Pharmacists and Pharmacy Technicians are eligible to participate in this application-based activity and will receive 1.0 CE Hour  for completing the activity  (ACPE UAN 0009-0000-25-027-H03-P), passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

            Grant Funding

            There is no grant funding for this activity.

            Faculty

            Caroline Wick, JD, MSPH, BA
            Practitioner-in-Residence and Acting Director of the Disability Rights Law Clinic
            American University Washington College of Law
            Washington DC

                

            Faculty Disclosure

            • Caroline Wick doesn't have any relationships with ineligible companies.

             

            Disclaimer

            The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

            Content

            Post Test Pharmacist

            1. What was Congress’ purpose when it wrote the definition of “individual with a disability”:
            A. To make it easier for people with disabilities to be covered by federal law
            B. To restrict coverage to people with certain medical diagnoses
            C. To only cover people with physical impairments

            2. When may a pharmacist refuse to administer the flu shot to a person with HIV?
            A. If the patient is in a rehabilitation program for using illegal drugs.
            B. If the patient hasn’t made an appointment ahead of time and all patients must make appointments ahead of time.
            C. If special gloves are not available for administering shots to people with communicable diseases.

            3. A patient enters the pharmacy with a dog, and you are not sure if it’s a service animal or not. Which of the following questions may you ask the patient?
            A. What is the nature and extent of your disability?
            B. Do you need the dog to be present because of a physical, sensory, psychiatric, intellectual or other mental disability?
            C. Is the dog required because of a disability?

            4. A patient enters the pharmacy with a dog. When you ask what tasks the dog has been trained to perform, the patient says that it is a comfort animal and has undergone no training. Can you ask the patient to leave and come back without the comfort animal?
            A. No, because comfort animals are considered service animals under federal law.
            B. Yes, because comfort animals are not protected by federal law.
            C. No, because that would be discrimination.

            5. A patient enters the pharmacy with a bulldog. When you ask if the patient needs the bulldog because of a disability, the patient says yes. Can you exclude the bulldog?
            A. No, because a service animal cannot be excluded based solely on its breed.
            B. Yes, because bulldogs are known to be aggressive.
            C. Yes, because the patient has not disclosed their specific disability in response to your question.

            6. If a patient enters the pharmacy using a mobility device, a pharmacist is permitted to inquire about which of the following?

            A. The nature and extent of the patient’s disability.
            B. What paperwork the patient has with them to prove that the mobility device has been serviced recently.
            C. Whether the mobility device is needed because of the patient’s disability.

            THYROID DISEASE: The Basics and the Latest

            Learning Objectives

             

            After completing this application-based continuing education activity, pharmacists will be able to

            1. Discuss Thyroid Disease and the typical medications used to treat it
            2. Explain drug-induced hypo/hyperthyroidism, drug interactions, and proper administration of thyroid medications
            3. Explain the lab work and the frequency of monitoring needed for patients treated with levothyroxine
            4. Differentiate hypothyroid disease from subclinical hypothyroid disease and their respective treatment approaches

            After completing this application-based continuing education activity, pharmacy technicians will be able to

            1. Recall and list the common symptoms of thyroid disease
            2. Identify typical medications used to treat thyroid disease
            3. Recognize when to refer patients to the pharmacist for further consultation

            Release Date:

            Release Date: May 20, 2025

            Expiration Date: May 20, 2028

            Course Fee

            Pharmacist:  $5

            Pharmacy Technician: $2

            ACPE UANs

            Pharmacist: 0009-0000-25-034-H01-P

            Pharmacy Technician: 0009-0000-25-034-H01-T

            Session Codes

            Pharmacist: 22YC25-XYZ35

            Pharmacy Technician: 22YC25-FXT27

            Accreditation Hours

            2.0 hours of CE

            Accreditation Statements

            The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-0000-25-034-H01-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

             

            Disclosure of Discussions of Off-label and Investigational Drug Use

            The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

            Faculty

            Kathryn M. Colucci, RPh
            Medical Writer
            Newtown, CT

            Faculty Disclosure

            In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

            Kathryn Colucci, RPh has no relationship with an ineligible company and therefore has nothing to disclose.

            ABSTRACT

            Thyroid hormones, produced by the tiny thyroid gland, influence almost every organ in the body. They control the body’s energy production and metabolic rate; imbalances can have profound health consequences. Thyroid disease is classified as hypothyroidism or hyperthyroidism. In the United States, an estimated 20 million people have thyroid disease. Hashimoto’s thyroiditis, an autoimmune disease resulting in hypothyroidism, accounts for most thyroid disease in the U.S. Prescribers treat it with levothyroxine, which is among the most frequently dispensed medications. Many patients have subclinical hypothyroidism and the decision to treat with levothyroxine is based on a patient’s individual circumstances. Hyperthyroid disorders are less common, and most cases are Graves’ disease, an autoimmune disorder. The 2020 approval of teprotumumab marked a major advancement in the treatment of thyroid eye disease. Pharmacologic treatment of thyroid disease is largely safe and effective with proper management. A knowledgeable pharmacy team can have a positive impact on patient care.

            CONTENT

            Content

            INTRODUCTION

            Did the Mona Lisa have hypothyroidism? Discussions around the Mona Lisa’s enigmatic smile have fascinated art lovers for centuries but now some endocrinologists have started a new line of debate. They describe telltale signs, like swollen hands, thinning hair, and a lump in the neck, that point to the famous Mona Lisa exhibiting hypothyroidism. They even suggest that the disease contributed to her mysterious smile. Amusing! When you view the painting do you see the same signs?

             

            Theodor Kocher, a Swiss physician who was award the Nobel Prize in 1909 for his work on the thyroid gland, described the first case of hypothyroidism in the mid-19th century.1 Effective treatment emerged about 100 years ago, so if the 16th century Mona Lisa had hypothyroidism, she might have suffered without knowing the cause. Patients with undiagnosed or inadequately treated hypothyroidism are at risk for cardiovascular problems, osteoporosis, and infertility.2

             

            The thyroid gland’s main hormones are responsible for controlling the body’s energy production and metabolic rate and they affect nearly every organ system in the body. Having too little or too much of these hormones can have profound consequences on health.

             

            Millions of Americans are affected by thyroid disease with most cases classified as hypothyroidism or underactive thyroid. Children, whose cognitive and physical development depends on normal thyroid function, can also be affected.3 Levothyroxine is used to treat hypothyroidism and is consistently among the most frequently prescribed medications in the United States (U.S.).4 Although less common, hyperthyroid disease is a serious endocrine disorder with profound health consequences if not properly treated.

             

            THYROID GLAND AND FUNCTION

            The thyroid gland is a small bow tie shaped endocrine gland that sits at the base of the neck. It produces two main hormones: tetraiodothyronine called thyroxine (T4), and triiodothyronine (T3). T4 and T3 control energy production and metabolic rate and influence nearly every organ system in the body including the brain, bowels, and skin. They regulate protein, carbohydrate, and fat metabolism by stimulating protein production and increasing oxygen needs at the cellular level. They are essential for proper fetal and neonatal development. Thyroid hormones influence body temperature, heart rate, appetite, mood, and digestion.2

             

            Iodine is a constituent of T4 and T3 and sufficient dietary intake of iodine and its adequate uptake by the thyroid gland is necessary for proper thyroid function. The thyroid gland produces mostly inactive hormone in the form of thyroxine, called T4 because it has four iodine atoms. T4 is highly protein bound for transport to the liver where it undergoes deiodination (the removal of one iodine atom) resulting in T3. T3, like T4, is highly protein bound and must be released from its binding protein to be active. Equilibrium is maintained between bound and free T3; as the body demands more biologically active hormone more T3 is released from the binding protein. Free T3 is the main biologically active form of thyroid hormone.2

             

            Hypothalamic-Pituitary-Thyroid Axis

            The hypothalamic-pituitary-thyroid axis governs thyroid hormone production by regulating the synthesis and secretion of thyroid stimulating hormone (TSH), also called thyrotropin. The hypothalamus is the part of the brain responsible for monitoring thyroid hormone levels in the body. When the hypothalamus detects low levels of thyroid hormone in the body, it releases a hormone called thyrotropin-releasing hormone (TRH). TRH stimulates the pituitary gland, the small pea-size gland sitting at the base of the brain, to secrete TSH. TSH, in turn, instructs the thyroid gland to produce more T4 and T3. High levels of T4 in the body inhibit TSH secretion while low levels of T4 stimulate TSH secretion. Disease affecting any part of the hypothalamic-pituitary-thyroid axis can result in thyroid hormone imbalances and disease.2

             

            THYROID DISEASE AND ETIOLOGY

            Thyroid disease is an endocrine disorder. Primary thyroid disease refers to disease of the thyroid gland. Secondary thyroid disease is far less common and refers to disease affecting the hypothalamus or pituitary gland resulting in thyroid dysfunction. Thyroid disease is classified as either hypothyroidism or hyperthyroidism.

             

            Hypothyroid Disease

            Hypothyroid disease occurs when inadequate thyroid hormone is available to the body. It is often referred to as an underactive thyroid and it is the most common form of thyroid disease. Hypothyroid disorders are categorized as either primary hypothyroidism or secondary hypothyroidism. The vast majority of cases are primary hypothyroidism.2

             

            Hashimoto’s Thyroiditis

            Hashimoto’s thyroiditis (HT) is the most common cause of primary hypothyroidism in the U.S. Japanese physician Hakaru Hashimoto first described the disease in 1912. It wasn’t until decades later that it was recognized as an autoimmune disorder and it is now considered the most prevalent autoimmune disease.5 Many patients do not realize that their hypothyroid condition is caused by this autoimmune disorder.

             

            HT is characterized by infiltration and destruction of thyroid cells by leukocytes (white blood cells). A chronic autoimmune inflammation ensues resulting in atrophy and fibrosis of the thyroid gland that leads to hypothyroidism. Circulating thyroid autoantibodies, anti-thyroperoxidase antibody (anti-TPO Ab), and anti-thyroglobulin antibody (anti-Tg Ab) can be detected but clinicians usually don’t measure them since all treatment of hypothyroidism is similar.6

             

            Women are more likely to develop HT and often have a family history, implicating a genetic component. The presence of other autoimmune disorders is common and prevalence is higher among those with chromosomal disorders like Down syndrome.2

             

            Patients may present with thyroiditis (inflammation of the thyroid gland) and symptoms of hypothyroidism, like weight gain and fatigue, but not always. Symptoms can develop gradually and go unnoticed. Laboratory assessment of thyroid function (discussed below) confirms the diagnosis. Individuals diagnosed with HT require lifelong treatment with the thyroid replacement hormone levothyroxine.6

             

            HT’s complications can manifest particularly in untreated or undertreated individuals including2:

            • Lipid disorders (elevated total cholesterol, LDL, and triglycerides)
            • Anemia
            • Menstrual abnormalities
            • Infertility
            • Hyponatremia
            • Thyroid associated orbitopathy
            • Increased risk for papillary thyroid carcinoma

             

            Lipid disorders are of particular concern because they can contribute to coronary artery disease. Anemia is observed in 30% to 40% of patients. Recent research has suggested greater risk for recurrent pregnancy loss in patients with HT and an additional autoimmune disorder, but more research is needed to fully understand the link.7

             

            Most complications of HT are rare but prescribers must monitor and treat complications as they arise to optimize patient management.8

             

            Researchers have also noted vitamin D deficiency in HT. A randomized, double blind, clinical trial observed that supplementation with vitamin D reduced circulating thyroid autoantibodies.5 The researchers suggest a possible role for vitamin D in the alleviation of disease activity but acknowledge the need for further studies before introducing this intervention to clinical practice. Despite the need for additional research, treating vitamin D deficiency in patients with HT may be warranted.

             

            Gut microbiota are considered intrinsic regulators of thyroid autoimmunity. Scientists have studied the composition of the microbiota in patients with thyroid autoimmunity and have found it to be altered in HT.9 Clinical implications of this research are not fully understood, but further research may determine the role these findings may have in HT management.

             

            With early diagnosis, prompt treatment, proper follow-up care, and attention to associated complications, HT’s prognosis is excellent, and patients lead a normal life.10

             

            Iodine Deficiency Hypothyroidism

            Although uncommon in America, iodine deficiency is the leading cause of hypothyroidism worldwide. Adequate iodine intake is necessary for the thyroid gland to function properly, and it is critical for normal fetal and neonatal development. The recommended daily allowance (RDA) for adults is 150 mcg and it increases to 250 mcg in pregnancy and to 290 mcg during lactation. Goiter (an abnormal enlargement of the thyroid gland) is common as the thyroid gland enlarges in an attempt to sequester iodine to make thyroid hormone.11,63

             

            Universal salt iodization programs have dramatically reduced iodine deficiency-related thyroid disease.12 Historically, iodine deficient areas in the U.S. included the mountainous regions and the so called “goiter belt” around the Great Lakes. Most Americans now consume adequate amounts of iodine in their diets by using iodized salt and by eating dairy products, eggs, and seafood. However, certain populations may still be at risk, including vegans, pregnant women, and people who don’t use iodized salt.11 Most alternative milk products are low in iodine and processed foods like canned soup and specialty salts–including kosher, Himalayan, and sea salt–rarely provide iodine.13 Healthcare practitioners must be aware of iodine deficiency’s consequences, especially during pregnancy.11,63

             

            Thyroid diets have gained interest among patients and circulate widely on the Internet. These diets promote avoiding particular foods to achieve optimal thyroid function. Certain foods including broccoli, Brussels sprouts, cabbage, cauliflower, and soy contain goitrogens, which are substances that interfere with iodine uptake by the thyroid. For most people in the U.S. who consume adequate amounts of iodine, eating foods containing goitrogens is not a concern. People with iodine deficiency who eat an abundance of these foods may have trouble consuming enough iodine.13,63

             

            Thyroidectomy and Cancer Treatment Resulting in Hypothyroidism

            Thyroidectomy, the surgical removal of the thyroid gland, is sometimes indicated in cancer treatment and in some cases of hyperthyroidism. Thyroidectomy results in hypothyroidism and patients require life-long thyroid hormone replacement with levothyroxine.14

             

            Most thyroid cancers respond well to treatment, but a small percentage can be very aggressive. Treatment of thyroid cancer often results in hypothyroidism and patients require lifelong treatment with thyroid replacement hormone.14

             

            Medication-Induced Hypothyroidism

            The pharmacy team must be aware that certain medications can affect thyroid function. Table 1 lists common medications that can cause hypothyroidism and hyperthyroidism. The medications that cause hypothyroidism decrease synthesis of T4/T3, inhibit T4/T3 secretion, and/or cause thyroiditis.15

             

            Table 1. Medications that May Lead to Thyroid Dysfunction

             

            Drug class/medications  Hypothyroidism Hyperthyroidism
            Antidysrhythmic:

             

             Amiodarone X X
            Bipolar Disorder Medication:

             

             Lithium X X
            Thyroid Medications:

             

             PTU X
             Methimazole X
             Radioactive Iodine X
            Cancer Medications:

             

             Biological response modifiers:
             Interferon X
             Interleukin-2 X
             Tyrosine kinase inhibitors:
               Sunitinib X
               Sorafenib X
             Checkpoint inhibitors:
               Nivolumab X X
               Pembrolizumab X X
               Ipilimumab X X
            Multiple Sclerosis Medication:

             

               Alemtuzumab X

             

            Medications that cause thyroid disorders are important treatments and, in most cases, they cannot be discontinued; any drug-induced hypothyroidism requires levothyroxine.

             

            Amiodarone structurally resembles thyroid hormone and is often implicated in thyroid dysfunction, mostly hypothyroidism.16 It is comprised of 37% iodine, so a 200 mg dose provides 75 mg of organic iodide, which is 100 times more than required. Researchers estimate thyroid abnormalities occur in 14% to 18% of patients taking long-term amiodarone but a meta-analysis found that with low doses, the incidence is lower (3.7%).17 Lithium can inhibit thyroid hormone release resulting in hypothyroidism; it usually occurs in younger women within the first two years of therapy. Antineoplastic agents may cause thyroid dysfunction in 20% to 50% of patients.18 Pharmacists must educate patients about the need for routine thyroid function assessment when receiving these medications.

             

            Hyperthyroid Disease

            Hyperthyroidism is characterized by excessive metabolism and secretion of thyroid hormones. It is less common than hypothyroid disease. Graves’ disease, thyroiditis, multi-nodular goiter, and toxic nodular goiter (benign growths on the thyroid gland that produce thyroid hormone in excess) can also cause hyperthyroid disease. Ingestion of too much external thyroid hormone is another possible cause of hyperthyroidism.19

             

            Graves’ Disease

            Graves’ disease (GD) accounts for most cases of hyperthyroidism. GD is an autoimmune disorder caused by a stimulatory autoantibody against the thyroid receptor for TSH. Most autoantibodies are inhibitory; in GD, the autoantibody is stimulatory. Overstimulation of the thyroid gland results in the overproduction of T4 and T3 leading to hyperthyroidism.12

             

            Graves’ disease, like HT, appears to have a genetic link and is often comorbid with other autoimmune disorders. Risk factors for GD include smoking and iodine deficiency. In the case of iodine deficiency, multifocal autonomous growth of the thyroid gland can occur and result in thyrotoxicosis (excess levels of thyroid hormone in the body).20 Women are affected at a higher rate and children can also be affected. GD’s clinical presentation may be dramatic or subtle and goiter may or may not be present. Laboratory assessment of thyroid function is used to help diagnose GD.

             

            Researchers have studied the composition of gut microbiota in patients with GD and similar to findings in HT, have found it to be altered. The researchers suggest the findings from this randomized controlled trial may offer an alternative noninvasive diagnostic methodology for GD.21 Further research is needed to elucidate the role microbiota may play in thyroid autoimmunity.

             

            Thyroid Eye Disease

            Thyroid eye disease is a progressive, potentially sight threatening ocular disease that is reported in almost half of patients who have GD. It arises from a separate autoimmune process involving autoantibodies that activate an insulin-like growth factor-1 receptor (IGF-1R) mediated signaling complex on cells within the eye orbit. The most common clinical feature is proptosis (bulging eyes) with edema and erythema of the surrounding eye tissue, but patients may also experience a skin manifestation called thyroid dermopathy (a nodular diffuse thickening of the skin on the legs). Patients with thyroid eye disease often complain of dry and gritty ocular sensation, photophobia, excessive tearing, double vision, and pressure sensation behind the eyes. Severe disease occurs in 3% to 5% of patients causing intense eye pain and inflammation, and threatening sight.22

             

            Recently, the Food and Drug Administration (FDA) approved the monoclonal antibody teprotumumab for treatment of adults with thyroid eye disease, marking a significant advancement in treatment. Prior to this approval, treatment options only included steroids or surgery.23

             

            Medication Induced Hyperthyroidism

            Like medication that can cause hypothyroidism, some medication can cause hyperthyroidism. The pharmacy team must be knowledgeable of the medications that can cause hyperthyroidism that warrant close monitoring of thyroid function (See Table 1). Patients should understand the importance of routine thyroid function assessment when taking medications that can affect thyroid function.

             

            Amiodarone-associated hyperthyroidism is less common than amiodarone-associated hypothyroidism; still, it is estimated to occur in 3% of patients. Onset of amiodarone-induced thyrotoxicosis (elevated levels of free thyroid hormone) can be sudden and require rapid assessment and treatment.16 Pharmacists must educate their patients about the symptoms of hyperthyroidism and instruct them to report them immediately if encountered.

             

            PAUSE AND PONDER: How many of your patients take medications that might cause thyroid dysfunction? Why is it important to tell these patients that some of their medications might influence the thyroid gland?

             

            PREVALENCE

            As many as 20 million Americans are affected by thyroid disease. Clinicians diagnose hypothyroidism in nearly five of 100 Americans aged 12 years and older.24 Thyroid disease affects men, women, and children. Women are disproportionately affected at a 10 to 15 times higher rate, and it’s estimated one in eight women will develop some form of thyroid disease in their lifetime.24

             

            HT is most often diagnosed between the ages of 40 to 60 years. Prevalence increases with age.8 Twenty percent of adults older than 75, most of them women, have insufficient levels of thyroid hormone.24 The Colorado Thyroid Disease Prevalence Study, a cross-sectional study conducted more than 20 years ago, reported the prevalence of hypothyroid disease in symptomatic and asymptomatic adults at 9.5%.25 In people not taking thyroid hormone, prevalence was 8.5% and 0.4% for subclinical and overt disease, respectively.10

             

            Hyperthyroidism is much less common than hypothyroidism. Prevalence of hyperthyroidism in the U.S. is estimated at 1.3%. GD is the most common cause of hyperthyroidism followed by toxic nodular goiter. GD is estimated to affect 1% of the population, mainly women of childbearing age. Incidence increases with age, and it is observed more frequently in Caucasians compared to other races. Mild hyperthyroidism occurs at a higher rate in iodine deficient geographic areas.12

             

            SYMPTOMS

            Because thyroid hormones affect nearly every organ system in the body thyroid disease’s symptoms are wide ranging and numerous. Symptoms vary depending on the type of thyroid disease and patients may experience few or many symptoms.26 Clinicians should routinely monitor patients for symptoms of thyroid disease, especially those at risk for thyroid disease including elderly women (See Table 2).27

             

            Table 2. Thyroid Disease’s Common Symptoms
            Hypothyroidism Hyperthyroidism
            Whole body Fatigue, lethargy, cold sensitivity Hunger, fatigue, weakness, sweating, increased appetite, heat intolerance, insomnia
            Mood/behavioral Depression, irritability, sluggish, brain fog Nervousness, restlessness, hyperactivity, panic attacks
            Cardiac Bradycardia, elevated cholesterol Tachycardia, palpitations
            Weight Weight gain Weight loss
            Hair, skin, nails Hair loss, dry skin/hair, brittle nails Hair loss, warm skin
            Eyes/face Periorbital edema, puffy face Proptosis (abnormal protrusion of eyes)
            Gastrointestinal Constipation Frequent bowel movements
            Menstruation/fertility Heavy or irregular menstrual periods, fertility problems Amenorrhea, lighter or irregular menstrual periods, fertility problems
            Musculoskeletal Joint/muscle pain Osteoporosis
            Thyroid presentation May be enlarged May be enlarged

             

            Weight gain is a common and often first symptom of hypothyroidism. Up to 82% of women with HT have excess body weight and a third suffer from obesity.28 Despite achieving euthyroidism (normal thyroid function) with levothyroxine treatment, many women continue to struggle to lose weight. Caloric reducing diets are often unsuccessful and excess body weight increases risk for comorbidities.29

             

            Food sensitivity and the effects of elimination diets on autoimmune disease have gained interest. An interventional/observational study evaluated the effect of an elimination diet in obese women diagnosed with HT. The researchers observed that women eliminating sensitive foods (foods that may cause an IgG antibody reaction) in addition to caloric reduction had a greater decrease in body mass index (BMI) when compared to women only reducing caloric intake.30 Improvement in thyroid function laboratory parameters was also observed in the group eliminating sensitive foods.31

             

            LABS TO ASSESS THYROID FUNCTION

            Thyroid function is assessed mainly through readily available laboratory blood tests. Results of basic thyroid function laboratory tests largely differentiate and diagnose thyroid disease (See Table 3).

             

            Table 3. Thyroid Function Tests in Hypothyroidism and Hyperthyroidism32

            TSH (Thyrotropin) FT4 (Thyroxine) T3
            Lab reference range*  

            0.5-4.8 mIU/L

             

            0.7-1.8 ng/dL

             

            80-220 ng/dL

            Hypothyroidism
            Primary, untreated High Low Low or normal
            Secondary to pituitary disease Low or Normal Low Low or normal
            Hyperthyroidism
            Untreated Low High High
            T3 toxicosis Low Normal High

            *Reference ranges may vary among laboratories.

             

            TSH is the best measurement to assess thyroid function. A normal TSH essentially rules out thyroid disease, except in the less common cases of disease affecting the hypothalamus or pituitary gland. The American Thyroid Association (ATA) recommends routine screening of TSH in adults beginning at age 35 and repeating the test every five years.27

             

            T4 is the primary thyroid hormone circulating in the blood. T4 is found in the body in two forms: free T4 and bound T4. More than 99% of T4 is bound. Because T4 is converted into T3, free T4 (FT4) is the more important hormone to measure. Any changes show up in T4 first; therefore, FT4 reflects thyroid gland function more accurately.33 Assessment of T3 is primarily used to diagnose and manage hyperthyroidism. It is rarely assessed in hypothyroidism since it’s the last test to become abnormal.34

             

            Patients with thyroid autoimmunity disease develop thyroid autoantibodies. Measurement of autoantibodies may help diagnosis, but clinicians need not monitor them routinely for disease management. Physicians typically order TSH with reflex to FT4 to assess thyroid function in disease management. Reflex testing allows the laboratory to automatically add the FT4 test to the blood sample based on an abnormal TSH result.35

             

            Clinicians sometime use radioactive iodine uptake (a non-blood test) to assess thyroid function. Because iodine is a necessary component of thyroid hormone, administering radioactive iodine and calculating its uptake by the thyroid can determine if the gland is functioning properly. Very high uptake is associated with hyperthyroidism while low iodine uptake indicates hypothyroidism.34

             

            TREATMENT APPROACHES

            Levothyroxine

            Levothyroxine sodium tablets (Synthroid and many generics) are synthetic T4 and indicated as replacement therapy in all hypothyroidism, regardless of the cause. Thyroid replacement hormone has a narrow therapeutic index and prescribers must individualize each patient’s levothyroxine dose. It is available in 12 different strengths, making it possible for prescribers to titrate doses carefully and avoid under- or over-treatment. Tablets are color-coded and are available from many manufacturers. (See Table 4.)

             

            Table 4. Various Strengths and Colors of Levothyroxine Tablets

            Strength Color
            25 mcg Orange
            50 mcg White
            75 mcg Violet
            88 mcg Mint green
            100 mcg Yellow
            112 mcg Rose
            125 mcg Brown
            137 mcg Deep blue
            150 mcg Light blue
            175 mcg Lilac
            200 mcg Pink
            300 mcg Green

             

            Variability in levothyroxine absorption may exist across manufacturers. A cohort study in the Netherlands evaluated a forced switch of levothyroxine brand. The researchers concluded that a dose-equivalent levothyroxine brand switch might necessitate a dose adjustment.36 The ATA recommends using a consistent manufacturer. If a brand switch is made, the pharmacy team must inform prescribers; it may necessitate a dose adjustment.37

             

            Sidebar: Tech Tasks for Thyroid Medications

             

            • Inform patients about the importance of using a consistent brand of levothyroxine.
            • Note brand of levothyroxine on each patient’s profile.
            • Review levothyroxine shipments when restocking to assure consistent brand use.
            • Tag all bags and inform the patient if a brand switch is made.

             

            Peak therapeutic effect of levothyroxine is seen in four to six weeks. Prescribers often start levothyroxine at low doses and titrate in small increments of 12.5 to 25 mcg every four to six weeks based on TSH testing until achieving euthyroidism.38 Average full replacement dose is 1.6 mcg/kg/day. Current ATA guidelines recommend adjusting the levothyroxine dose to resolve symptoms of hypothyroidism and to keep the TSH level within the range of 0.4 to 4 mIU/L.29 Clinicians should assess thyroid function in patients on stable doses of levothyroxine every six to 12 months and within six to eight weeks of any dose change. Ongoing assessment helps avoid under- or over-replacement.38

             

            Adverse reactions associated with levothyroxine therapy are primarily those of hyperthyroidism and include the following37:

            • Anxiety
            • Diarrhea
            • Fatigue
            • Hair loss
            • Heat intolerance, excessive sweating
            • Increased appetite
            • Increased heart rate
            • Muscle weakness
            • Nervousness
            • Palpitations
            • Weight loss

             

            Over-replacement with levothyroxine can lead to serious consequences and can put elderly patients at risk for cardiac arrhythmias, especially atrial fibrillation.10 Complications of over-replacement include

            • Accelerated bone loss
            • Increased cardiac contractility
            • Increased cardiac wall thickness
            • Increased heart rate
            • Osteoporosis
            • Reduction in bone mineral density

             

            Medications, supplements, food, coffee, and even orange juice can decrease levothyroxine’s absorption.10 Levothyroxine is taken with water one hour before breakfast and any other prescription medications. Calcium, iron, antacids, cholestyramine, and sucralfate can inhibit its absorption and must be separated by at least four hours.37 Individuals with celiac disease or gastric bypass surgery may absorb medication inadequately.40,41

             

            Bedtime dosing of levothyroxine offers an alternative to morning dosing. Randomized controlled trials have found patients taking the medication in the evening had improved thyroid hormone status control.38,42 Patients struggling with morning dosing may find evening dosing easier. The ATA recommends that if levothyroxine is taken at bedtime that it be separated by three hours from the evening meal.43

             

            Because levothyroxine is usually administered for life, dose adjustment is often necessary to optimize therapy throughout a patient’s lifetime.44 Situations that necessitate possible dose adjustment of levothyroxine include

            • Aging (age older than 65)
            • Diagnosis of new medical conditions
            • Pregnancy
            • Start of new medications
            • Weight changes

             

            The Colorado Thyroid Disease Prevalence study assessed thyroid function, symptoms, and corresponding lipid levels in more than 25,000 participants. Among patients taking thyroid medication, only 60% were within the normal range of TSH. Modest TSH elevations corresponded to changes in lipid levels that may affect cardiovascular health.25 Optimization of levothyroxine therapy requires that the healthcare team recognize the need for dose adjustments throughout a patient’s life.

             

            PAUSE AND PONDER: Among your patients being treated for hypothyroidism, how many also take calcium supplements? How many of these patients know to separate them from levothyroxine by four hours?

             

            Liothyronine

            Liothyronine (Cytomel) is synthetic T3. It is not recommended, either alone or in combination with levothyroxine, as first line treatment for hypothyroidism. Combination therapy hopes to mimic thyroid hormone physiology more closely; however, current guidelines do not suggest routine use of this approach.10 A 2016 randomized, double blind, crossover study evaluated combination therapy in 32 patients and found no clear clinical benefit and observed increased heart rate in patients receiving it.45A trial, however, may be indicated in a small group of patients who remain symptomatic despite adequate levothyroxine monotherapy.46

             

            Iodine

            Patients with iodine deficient hypothyroidism are treated with iodine supplements to correct the deficiency while levothyroxine is used to achieve euthyroidism. When the iodine level has been restored and goiter size has decreased, levothyroxine may be interrupted. Prescribers should reassess thyroid function in four to six weeks.11

             

            Consumption of too much iodine can have a negative impact on thyroid health. The safe upper limit of iodine for adults is 1.1 mg/day.63 Iodine toxicity may lead to thyroiditis, hypothyroidism, hyperthyroidism, and thyroid papillary cancer.47 Pharmacists should be aware that drug interactions with potassium iodine exist. It can interact with antithyroid drugs and when potassium iodide is taken with ACE inhibitors or potassium sparing diuretics, serum potassium can increase.13

             

            Selenium

            Selenium is an important micronutrient in the diet and increases active thyroid hormone production. The RDA for selenium is 55 mcg/day. Selenium supplements are used to treat or prevent selenium deficiency. Doses exceeding 400 mcg/day can be toxic. Signs of toxicity include brittle hair and nails, diarrhea, irritability, and nausea. Extremely high intakes of selenium can cause severe problems, including difficulty breathing, tremors, kidney failure, heart attacks, and heart failure. Most people consume adequate selenium through the diet, which is preferred. Consuming two Brazil nuts daily can provide adequate selenium intake; each nut contains 68 to 91 mcg of selenium, so people should not consume too many. Selenium is also found in oysters, tuna, whole-wheat bread, sunflower seeds, meat, mushrooms, and rye.48

             

            Subclinical Hypothyroid Disease

            Subclinical hypothyroidism is a common condition occurring in about 15% of older women and 10% of older men.2 It is a persistent condition in which TSH levels are elevated but free T4 levels remain normal. Treating subclinical hypothyroidism with levothyroxine results in an improved quality of life for many while others show no benefit and continue to complain of symptoms despite treatment.

             

            The decision to treat subclinical hypothyroidism is being reevaluated after a large European study found no clear benefit with treatment.3 Published in the New England Journal of Medicine in 2017, this double-blind, randomized, placebo-controlled, parallel-group trial concluded levothyroxine provided no apparent benefits in older people with subclinical hypothyroidism.49 Investigators are conducting more research to evaluate the effect of discontinuing levothyroxine in subclinical hypothyroidism.50 They hope to determine if discontinuing levothyroxine in patients with subclinical hypothyroidism is safe or will reduce quality of life.

             

            For now, prescribers should follow current clinical practice guidelines, which state that they should tailor the decision to treat subclinical hypothyroidism to the individual patient when the serum TSH is less than 10 mIU/L. Prescribers should consider the presence of symptoms and how likely the patient will progress to overt hypothyroidism when making the decision to treat.24

             

            Antithyroid Drugs

            The treatment goal for hyperthyroid disease is to lower excessive thyroid hormone levels and achieve euthyroidism. The two antithyroid drugs (ATD) available in the U.S. for the treatment of hyperthyroidism are methimazole (Tapazole) and propylthiouracil (PTU). Hepatotoxicity has been reported with both medications but methimazole has been associated with far fewer cases. Therefore, methimazole is used as first line therapy, except in pregnancy.51

             

            ATDs inhibit T4 and T3 synthesis by blocking oxidation of iodine in the thyroid gland. PTU also partially blocks peripheral conversion of T4 to T3. Beta-blockers can provide symptomatic relief in patients with hyperthyroidism.

             

            Methimazole is available in 5 mg and 10 mg tablets. The starting dose is 5 mg to 20 mg orally every eight hours. Prescribers must titrate the dose over time to the lowest dose needed to maintain euthyroidism. Maintenance doses range from 5 mg to 30 mg/day administered once daily. Once euthyroidism is achieved, patients usually continue the ATD for another 12 to 18 months. The prescriber should check thyroid function four to six weeks after therapy initiation and then every two to three months once the patient is euthyroid.12

             

            PTU’s labeling carries a boxed warning for acute liver failure, and it is reserved for use in those who cannot tolerate other treatments such as methimazole, radioactive iodine, or surgery.52 It is also recommended for use in the first trimester of pregnancy because birth defects have been associated with methimazole. PTU is available as a 50 mg tablet. The initial starting dose is 50 mg to 150 mg orally every eight hours and the maintenance dose is usually 50 mg every 8 to 12 hours.53

             

            Minor side effects occur in about 5% of patients receiving an ATD. Side effects include53

            • Agranulocytosis (severe drop in white blood cells)
            • Arthralgia
            • Gastrointestinal distress
            • Hepatotoxicity
            • Pruritus
            • Vasculitis (dangerous inflammation of blood vessels)

             

            Serious side effects are less common at lower doses; patients should be maintained at the lowest possible dose needed to achieve euthyroidism. Although rare, hepatotoxicity and agranulocytosis can be life threatening. Pharmacists should educate patients to report signs of agranulocytosis, such as sudden fever, sore throat, or chills, to their prescribers immediately. Prescribers should obtain a baseline serum liver profile and white blood cell count before starting an ATD. Most side effects occur within the first 90 days of therapy. Vasculitis is more common with longer duration of therapy.

             

            A drawback of ATD therapy is the high relapse rate. A longitudinal cohort study concluded that patients initially treated with an ATD had about a 50% relapse rate and 25% felt they had not fully recovered in six to 10 years.54

             

            Recent studies have shown that longer treatment time with an ATD can achieve higher remission rates. A randomized, parallel-group study compared relapse rates in patients receiving longer-term versus conventional-length methimazole therapy in GD. The authors concluded that low-dose methimazole treatment for 60 to 120 months was safe and effective and had a higher remission rate compared to conventional treatment for 18 to 24 months.55

             

            Long-term methimazole therapy was also evaluated in juvenile GD in a randomized parallel trial. Patients receiving short-term methimazole therapy were almost three times more likely to relapse than those on long-term therapy. The researchers found long-term methimazole treatment of 96 to 120 months to be safe and effective with a significantly higher four-year cure rate.56

             

            Teprotumumab

            The FDA’s approval of teprotumumab (TEPEZZA) in January 2020 was the most significant advance in treating thyroid eye disease in decades. Teprotumumab binds to IGF-1R and blocks its activation and signaling. It was shown to improve the course of thyroid eye disease in patients in two separate clinical trials, leading to this monoclonal antibody’s approval.23,57 Proptosis and diplopia improved, as did eye pain, redness and swelling, and quality of life. Serious adverse events were uncommon. The most common adverse reactions observed were

            • alopecia
            • altered sense of taste
            • diarrhea
            • dry skin
            • fatigue
            • headache
            • hearing loss
            • hyperglycemia
            • muscle spasm
            • nausea

             

            The FDA approved teprotumumab to be given as an infusion every three weeks for a total of eight doses. Patients completing the course of therapy showed significant improvement in symptoms associated with thyroid eye disease. Infusion reactions are reported in about 4% of patients. Dose is based on weight. The first dose is 10 mg/kg, and then the dose is increased to 20 mg/kg for the remaining seven infusions. Teprotumumab is contraindicated in pregnancy. Women of childbearing age must be counseled on pregnancy prevention during treatment and for six months following the last dose.58

             

            PAUSE AND PONDER: Which patients with thyroid disease in your practice might benefit from teprotumumab? What is important to tell them about this new biologic?

             

            Surgery

            Thyroidectomy is not used as a first line approach for treating hyperthyroidism. It is reserved for patients who refuse radioactive iodine after relapsing on an ATD, patients who cannot tolerate an ATD, or patients with very large goiter, multinodular goiter, or toxic adenoma. Thyroidectomy destroys the thyroid gland and if indicated, patients require lifelong levothyroxine therapy.

             

            Radioactive Iodine

            In the U.S., radioactive iodine is the most common treatment for hyperthyroidism. Radioiodine therapy, like surgery, destroys the thyroid gland requiring patients to be on lifelong levothyroxine therapy.

             

            In the last 20 years, radioiodine has been used less frequently.19 Many patients report a lower quality of life after receiving radioactive iodine than patients receiving ATD or surgical treatment.59 A randomized parallel group trial found that long-term methimazole, when compared to radioiodine, was safe, effective, and not inferior to radioiodine further supporting the use of ATD over radioiodine.60

             

            Pregnancy

            Undiagnosed or inadequately treated hypothyroidism during pregnancy can lead to miscarriage, preterm delivery, or developmental disorders in children. Levothyroxine is safe in pregnancy, but pregnant patients may require a 30% increase in levothyroxine dose to maintain euthyroidism. During pregnancy, attending healthcare providers should titrate levothyroxine doses against TSH, which has trimester-specific ranges. Postpartum TSH levels are similar to preconception levels, so the dose of levothyroxine should return to the preconception dose following delivery.61

             

            Iodine is a critical mineral for proper fetal development and iodine needs increase by at least 50% in pregnancy and lactation. Pregnant women should receive a prenatal vitamin containing 150 mcg of iodine during pregnancy and lactation. Unfortunately, prenatal vitamins contain variable and inconsistent amounts of iodine. Close to 40% of marketed prenatal vitamins in the U.S. contain no iodine and when measured, the actual iodine content varied between 33 and 610 mcg.11 Healthcare practitioners must be vigilant in assuring that iodine requirements are met during pregnancy and lactation when iodine requirements increase. The ATA recommends that women receive 150 mcg of supplemental iodine daily during pregnancy and lactation and that all prenatal vitamin/mineral preparations contain 150 mcg of iodine.11

             

            Hyperthyroidism in pregnancy requires special consideration. Care givers must stabilize women undergoing treatment for GD who intend to become pregnant prior to conception. Prescribers should advise women to delay attempts at conception until they achieve a stable euthyroid state, whenever possible.62 Additionally they should treat hyperthyroidism during pregnancy with the lowest possible dose of PTU because methimazole has been associated with cases of congenital malformation.

             

            The majority of patients with thyroid eye disease are women of childbearing age. Physicians must explain treatment limitations to patients who are contemplating pregnancy. Teprotumumab is contraindicated in pregnancy. Caregivers must provide contraceptive counseling to women of childbearing age with thyroid eye disease treated with teprotumumab during treatment and for the six months following therapy.23

             

            Pharmacy Team’s Role

            The pharmacy team can have a positive impact on the successful management of patients with thyroid disease by educating and screening patients regarding

            • Adverse effects associated with their thyroid medications
            • Importance of medication adherence
            • Laboratory assessment of thyroid function
            • Screening for drug interactions
            • Signs and symptoms of hyperthyroidism and hypothyroidism

             

            CONCLUSION

            Thyroid disease affects millions in the U.S. and most cases are well controlled with pharmacological management. Adherence to thyroid disease medications is important. A knowledgeable pharmacy team can promote good practices and provide patient education, having a positive impact on patient care. Proper management allows most patients to have an excellent prognosis and quality of life.

             

            With your newly gained knowledge, take another look at the Mona Lisa. Did Leonardo da Vinci, a man before his time, notice a thyroid disorder that he captured in his famous painting and did it intentionally contribute to her enigmatic smile?

             

             

             

            Pharmacist Post Test (for viewing only)

            This test is for viewing purposes only. If you would like to submit the test, go to the blue button at the top of the page or  Test/Evaluation Site.

             

               
              Pharmacist Post-test
              1. Which of the following statement accurately describes hypothyroid disorders?
              A) They are all of autoimmune etiology
              B) They require treatment with levothyroxine, regardless of cause
              C) They are caused only from disease directly affecting the thyroid gland

              2. A woman of childbearing age who follows a strict vegan diet and only uses sea salt is contemplating pregnancy. Which of the following is a risk?
              A) Selenium deficiency
              B) Vitamin D deficiency
              C) Iodine deficiency

              3. What is the best laboratory assessment of thyroid function?
              A) TSH
              B) T3
              C) Total T4

              4. How often should patients on stable doses of levothyroxine have lab assessment of thyroid function?
              A) every 6-12 months
              B) every 3-6 months
              C) every 24 months

              5) A patient newly diagnosed with Hashimoto’s Thyroiditis (HT) is very concerned with her new diagnosis. What statement MOST ACCURATELY describes HT?
              A) It is an autoimmune disease that has an excellent prognosis and is treated with lifelong levothyroxine therapy.
              B) It is an autoimmune disease that has an excellent prognosis and is treated with liothyronine and levothyroxine.
              C) It is subclinical hypothyroidism and she may not need treatment with levothyroxine.

              6) A patient stable on methimazole for Graves’ disease remarks that she is considering having a child. Why would you encourage her to speak to her primary care provider?
              A) Pregnancy is contraindicated
              B) Methimazole is contraindicated and she should be switched to PTU
              C) Methimazole is contraindicated and she should be switched to teprotumumab

              7) Which medication carries a boxed warning in its labeling for acute liver failure, requiring baseline liver function assessment prior to its start?
              A) Methimazole
              B) Propylthiouracil
              C) Teprotumumab

              8) A patient starting methimazole for Graves’ disease asks about symptoms that are common to the condition. Which statement MOST ACCURATELY describes possible symptoms of GD?
              A) Symptoms of hyperthyroidism may include rapid heart rate, weight loss, nervousness, hunger, fatigue, and hair loss.
              B) Symptoms of hyperthyroidism may include hair loss, fatigue, swelling, puffiness, and depression.
              C) Symptoms of hyperthyroidism may include proptosis, anxiety, difficulty breathing, and weight gain.

              9) Which statement MOST ACCURATELY reflects symptoms of hypothyroidism?
              A) Patients may exhibit many or few symptoms, including fatigue, weight loss, depression, constipation, and hair loss
              B) Patients may exhibit many or few symptoms, including fatigue, weight gain, depression, constipation, and hair loss
              C) Patients may exhibit many or few symptoms, including insomnia, weight gain, depression, constipation, and hair loss

              10) What statement MOST ACCURATELY describes subclinical hypothyroidism?
              A) It is a common persistent condition in which TSH levels are elevated and free T4 is high.
              B) It is a common persistent condition in which TSH levels are elevated and free T4 is low.
              C) It is a common, persistent condition in which TSH levels are elevated and free T4 is normal.

              Pharmacy Technician Post Test (for viewing only)

              This test is for viewing purposes only. If you would like to submit the test, go to the blue button at the top of the page or  Test/Evaluation Site.

               

                 
                Pharmacy Technician Post-test

                1. What are common symptoms of hypothyroid disease?
                A) Hair loss, proptosis, hunger, fatigue
                B) Hair loss, depression, weight gain, fatigue
                C) Hair loss, heat intolerance, weight loss, fatigue

                2. A patient who started on levothyroxine a year ago is picking up her refill; she remarks that she continues to feel sluggish, fatigue and is still overweight. The patient asks why she is still feeling unwell. What do you tell her?
                A) Refer this patient to the pharmacist
                B) Assure the patient nothing is wrong
                C) Suggest she take a dietary supplement

                3. Which medication is used to treat hyperthyroidism?
                A) Liothyronine
                B) Levothyroxine
                C) Methimazole

                4. Which medication is used to treat hypothyroidism?
                A) Propylthiouracil (PTU)
                B) Levothyroxine
                C) Methimazole

                5. What are common symptoms of hyperthyroid disease?
                A) Hunger, weight loss, nervousness, palpitations, frequent bowel movements
                B) Weight gain, heat intolerance, excessive sweating, increased heart rate
                C) Fatigue, depression, decreased heart rate, cold sensitivity, constipation

                6. What are the available dosage strengths for levothyroxine?
                A) 12 different tablet strengths ranging in dose from 25-300 mcg in 12.5-25 mcg increments.
                B) 8 different tablet strengths ranging in dose from 50-300 mcg in 25-50 mcg increments
                C)16 different tablet strengths ranging in dose from 100-300 mcg in 25-50 mcg increments

                7. A patient who recently started methimazole calls the pharmacy complaining that suddenly she is feeling feverish with sore throat and chills. What next steps should a pharmacy technician take?
                A) Indicate that she probably has a cold
                B) Refer her to the pharmacist
                C) Tell her to call back if she isn’t better in two days

                8. Which mineral is important for thyroid health?
                A) Calcium
                B) Iron
                C) Selenium

                9. What medication was recently approved for thyroid eye disease marking a significant advancement in treatment?
                A) Propylthiouracil
                B) Methimazole
                C) Teprotumumab

                10. A patient is picking up her levothyroxine refill and was told by her physician that she is anemic. She is purchasing iron supplements too. What is important to communicate to the patient?
                A) Iron supplements must be separated by four hours from levothyroxine
                B) Iron supplements should not be used with levothyroxine
                C) Iron supplements may cause upset stomach and dark stools

                References

                Full List of References

                1. The Nobel Prize in Physiology and Medicine, Theodore Kocher. The Nobel Prize. Accessed October 17, 2021. https://www.nobelprize.org/prizes/medicine/1909/kocher/biographical/
                2. Porter RS, ed. Merck Manual. 20th ed. Rahway, NJ: Merck Publishing; 2018.
                https://www.merckmanuals.com/professional/endocrine-and-metabolic disorders/thyroid-disorders/overview-of-thyroid function?query=Overview%20of%20the%20Thyroid%20Gland.
                3. Brody J. The Subtle Signs of a Thyroid Disorder. The New York Times. July 24, 2017. Accessed August 11, 2021.

                4. The 50 most commonly prescribed drugs in America and their average price. Drugreport. Accessed June 1, 2021. https://www.drugreport.com/50-commonly-prescribed-drugs-in-america/.
                5. Chahardoli R, Saboor-Yaraghi AA, Amouzegar A, Khalili D, Vakili AZ, Azizi F. Can supplementation with vitamin D modify thyroid autoantibodies (anti-TPO Ab, anti-Tg Ab) and thyroid profile (T3, T4, TSH) in Hashimoto's thyroiditis? a double blind, randomized clinical trial. Horm Metab Res. 2019;51(5):296-301. doi:10.1055/a-0856-1044.
                6. Hashimoto’s thyroiditis: the strange-sounding condition you can have without realizing it. Cleveland Clinic. https://health.clevelandclinic.org/hashimotos-thyroiditis-thyroid-disease-condition/ Accessed June 2, 2022.
                7. Cellini M, Santaguida MG, Stramazzo I, et al. Recurrent pregnancy loss in women with Hashimoto's thyroiditis with concurrent non-endocrine autoimmune disorders. Thyroid. 2020;30(3):457-462. doi:10.1089/thy.2019.0456.
                8. Caturegli P, De Remigis A, Rose NR. Hashimoto thyroiditis: clinical and diagnostic criteria. Autoimmun Rev. 2014;13(4-5):391-397. doi:10.1016/j.autrev.2014.01.007.
                9. Zhao F, Feng J, Li J, et al. Alterations of the gut microbiota in Hashimoto's thyroiditis patients. Thyroid. 2018;28(2):175-186. doi:10.1089/thy.2017.0395.
                10. What is the Incidence of Hashimoto Thyroiditis in the US? Medscape. Accessed August 11, 2021.https://www.medscape.com/answers/120937-122448/what-is-the-incidence-of-hashimoto-thyroiditis-in-the-us.
                11. Niwattisaiwong S, Burman KD, Li-Ng M. Iodine deficiency: clinical implications. Cleve Clin J Med. 2017;84(3):236-244. doi:10.3949/ccjm.84a.15053.
                12. De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016;388(10047):906-918. doi:10.1016/S0140-6736(16)00278-6.
                13. Iodine Fact Sheet for Consumers. National Institutes of Health Office of Dietary. Accessed August 11, 2021. Supplements. https://ods.od.nih.gov/factsheets/Iodine-Consumer/
                14. Merk Manual Professional Version. Thyroid Cancers. Accessed October 17, 2021. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/thyroid-disorders/thyroid-cancers
                15. Haugen BR. Drugs that suppress TSH or cause central hypothyroidism. Best Pract Res Clin Endocrinol Metab. 2009;23(6):793-800. doi:10.1016/j.beem.2009.08.003.
                16. Tsang W, Houlden RL. Amiodarone-induced thyrotoxicosis: a review. Can J Cardiol. 2009;25(7):421-424. doi:10.1016/s0828-282x(09)70512-4.
                17. Trohman RG, Sharma PS, McAninch EA, Bianco AC. Amiodarone and thyroid physiology, pathophysiology, diagnosis and management. Trends Cardiovasc Med. 2019;29(5):285-295. doi:10.1016/j.tcm.2018.09.005
                18. Hamnvik OP, Larsen PR, Marqusee E. Thyroid dysfunction from antineoplastic agents. J Natl Cancer Inst. 2011;103(21):1572-1587. doi:10.1093/jnci/djr373.
                19. Clinical thyroidology for the public. American Thyroid Association. Accessed August 11, 2021. https://www.thyroid.org/patient-thyroid-information/ct-for-patients/november-2016/vol-9-issue-11-p-3-7
                20. Chung HR. Iodine and thyroid function. Ann Pediatr Endocrinol Metab. 2014;19(1):8-12. doi:10.6065/apem.2014.19.1.8
                21. Jiang W, Yu X, Kosik RO, et al. Gut microbiota may play a significant role in the pathogenesis of Graves' disease. Thyroid. 2021;31(5):810-820. doi:10.1089/thy.2020.0193.
                22. Bahn RS. Graves' ophthalmopathy. N Engl J Med. 2010;362(8):726-738. doi:10.1056/NEJMra0905750.
                23. Douglas RS, Kahaly GJ, Patel A, et al. Teprotumumab for the treatment of active thyroid eye disease. N Engl J Med. 2020;382(4):341-352. doi:10.1056/NEJMoa1910434.
                24. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association [published correction appears in Endocr Pract. 2013 Jan-Feb;19(1):175]. Endocr Pract. 2012;18(6):988-1028. doi:10.4158/EP12280.GL.
                25. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000;160(4):526-534. doi:10.1001/archinte.160.4.526.
                26. Hypothyroidism (Underactive Thyroid). National institute of diabetes and digestive and kidney diseases. Accessed August 11, 2021. https://www.niddk.nih.gov/health-information/endocrine-diseases/hypothyroidism.
                27. Ladenson PW, Singer PA, Ain KB, et al. American Thyroid Association guidelines for detection of thyroid dysfunction [published correction appears in Arch Intern Med 2001 Jan 22;161(2):284]. Arch Intern Med. 2000;160(11):1573-1575. doi:10.1001/archinte.160.11.1573.
                28. Song RH, Wang B, Yao QM, Li Q, Jia X, Zhang JA. The impact of obesity on thyroid autoimmunity and dysfunction: a systematic review and meta-analysis. Front Immunol. 2019;10:2349. doi:10.3389/fimmu.2019.02349.
                29. Khaodhiar L, McCowen KC, Blackburn GL. Obesity and its comorbid conditions. Clin Cornerstone. 1999;2(3):17-31. doi:10.1016/s1098-3597(99)90002-9.
                30. Gocki J, Bartuzi Z. Role of immunoglobulin G antibodies in diagnosis of food allergy. Postepy Dermatol Alergol. 2016;33(4):253-256. doi:10.5114/ada.2016.61600.
                31. Ostrowska L, Gier D, Zyśk B. The influence of reducing diets on changes in thyroid parameters in women suffering from obesity and Hashimoto's disease. Nutrients. 2021;13(3):862. doi:10.3390/nu13030862.
                32. What are Normal Thyroid Hormone Levels? UCLA Health. Accessed August 11, 2021.https://www.uclahealth.org/endocrine-center/normal-thyroid-hormone-levels
                33. Free and Bound T4. University of Rochester. Accessed October 17, 2021. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=t4_free_and_bound_blood.
                34. Thyroid Function Tests. American Thyroid Association. Accessed August 11, 2021. http://www.thyroid.org/thyroid-function-tests/.
                35. Henze M, Brown SJ, Hadlow NC, Walsh JP. Rationalizing thyroid function testing: which TSH cutoffs are optimal for testing free T4?. J Clin Endocrinol Metab. 2017;102(11):4235-4241. doi:10.1210/jc.2017-01322.
                36. Flinterman LE, Kuiper JG, Korevaar JC, et al. Impact of a forced dose-equivalent levothyroxine brand switch on plasma thyrotropin: a cohort study. Thyroid. 2020;30(6):821-828. doi:10.1089/thy.2019.0414.
                37. Levothyroxine sodium tablets [package insert]. Lloyd, Inc.; 2019.
                38. Srivastava S, Sharma G, Rathore M, et al. A crossover study evaluating effect of timing of levothyroxine on thyroid hormone status in patients of hypothyroidism. J Assoc Physicians India. 2018;66(9):37-40.
                39. Thayakaran R, Adderley NJ, Sainsbury C, et al. Thyroid replacement therapy, thyroid stimulating hormone concentrations, and long term health outcomes in patients with hypothyroidism: longitudinal study. BMJ. 2019;366:l4892. doi:10.1136/bmj.l4892.
                40. Skelin M, Lucijanić T, Amidžić Klarić D, et al. Factors affecting gastrointestinal absorption of levothyroxine: a review. Clin Ther. 2017;39(2):378-403. doi:10.1016/j.clinthera.2017.01.005.
                41. Gadiraju S, Lee CJ, Cooper DS. Levothyroxine dosing following bariatric surgery. Obes Surg. 2016;26(10):2538-2542. doi:10.1007/s11695-016-2314-x.
                42. Bolk N, Visser TJ, Nijman J, Jongste IJ, Tijssen JG, Berghout A. Effects of evening vs morning levothyroxine intake: a randomized double-blind crossover trial. Arch Intern Med. 2010;170(22):1996-2003. doi:10.1001/archinternmed.2010.436.
                43. Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association task force on thyroid hormone replacement. Thyroid. 2014;24(12):1670-1751. doi:10.1089/thy.2014.0028
                44. Duntas LH, Jonklaas J. Levothyroxine dose adjustment to optimise therapy throughout a patient's lifetime. Adv Ther. 2019;36(Suppl 2):30-46. doi:10.1007/s12325-019-01078-2.
                45. Kaminski J, Miasaki FY, Paz-Filho G, Graf H, Carvalho GA. Treatment of hypothyroidism with levothyroxine plus liothyronine: a randomized, double-blind, crossover study. Arch Endocrinol Metab. 2016;60(6):562-572. doi:10.1590/2359-3997000000192.
                46. Dayan C, Panicker V. Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance. Thyroid Res. 2018;11:1. Published 2018 Jan 17. doi:10.1186/s13044-018-0045-x.
                47. Southern AP, Jwayyed S. Iodine Toxicity. [Updated 2021 Apr 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Jan. 2021 Accessed August 11, 2021.https://www.ncbi.nlm.nih.gov/books/NBK560770/.
                48. Schomburg L. Dietary selenium and human health. Nutrients. 2016;9(1):22. doi:10.3390/nu9010022.
                49. Stott DJ, Rodondi N, Kearney PM, et al. Thyroid hormone therapy for older adults with subclinical hypothyroidism. N Engl J Med. 2017;376(26):2534-2544. doi:10.1056/NEJMoa160382.
                50. Discontinuation of levothyroxine therapy for patients with subclinical hypothyroidism. U.S. National Library of Medicine. Accessed August 11, 2021. https://clinicaltrials.gov/ct2/show/NCT04288115?term=underactive+thyroid&recrs=a&cond=hypothyroidism&fund=01&draw=2&rank=1
                51. Kahaly GJ. Management of Graves Thyroidal and Extrathyroidal Disease: An Update. J Clin Endocrinol Metab. 2020;105(12):3704-3720. doi:10.1210/clinem/dgaa646.
                52. U.S. Food and Drug Administration. FDA Drug Safety Communication: New Boxed Warning on severe liver injury with propylthiouracil. Accessed October 17, 2021. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fda-drug-safety-communication-new-boxed-warning-severe-liver-injury-propylthiouracil.
                53. Propylthiouracil tablets [package insert]. Chartwell Pharmaceuticals; 2015
                54. Sjölin G, Holmberg M, Törring O, et al. The long-term outcome of treatment for Graves' hyperthyroidism. Thyroid. 2019;29(11):1545-1557. doi:10.1089/thy.2019.0085.
                55. Azizi F, Amouzegar A, Tohidi M, et al. Increased remission rates after long-term methimazole therapy in patients with Graves' disease: results of a randomized clinical trial. Thyroid. 2019;29(9):1192-1200. doi:10.1089/thy.2019.0180.
                56. Azizi F, Takyar M, Madreseh E, Amouzegar A. Long-term methimazole therapy in juvenile Graves' disease: a randomized trial. Pediatrics. 2019;143(5):e20183034. doi:10.1542/peds.2018-3034.
                57. Smith TJ, Kahaly GJ, Ezra DG, et al. Teprotumumab for thyroid-associated ophthalmopathy. N Engl J Med. 2017;376(18):1748-1761. doi:10.1056/NEJMoa1614949.
                58. Tepezza (toprotumumab-trbw) [package insert]. Horizon Therapeutics;2021.
                59. Törring O, Watt T, Sjölin G, et al. Impaired quality of life after radioiodine therapy compared to antithyroid drugs or surgical treatment for Graves' hyperthyroidism: a long-term follow-up with the thyroid-related patient-reported outcome questionnaire and 36-item short form health status survey. Thyroid. 2019;29(3):322-331. doi:10.1089/thy.2018.0315.
                60. Azizi F, Takyar M, Madreseh E, Amouzegar A. Treatment of toxic multinodular goiter: comparison of radioiodine and long-term methimazole treatment [published correction appears in Thyroid. 2019 Dec;29(12):1871]. Thyroid. 2019;29(5):625-630. doi:10.1089/thy.2018.0397.
                61. Li SW, Chan SY. Management of overt hypothyroidism during pregnancy. Best Pract Res Clin Endocrinol Metab. 2020;34(4):101439. doi:10.1016/j.beem.2020.101439.
                62. Managing Graves' disease during pregnancy: risks and benefits. Endocrineweb. Accessed August 11, 2021.
                https://www.endocrineweb.com/conditions/graves-disease/managing-graves-disease-during-pregnancy-risks-benefits.
                63. Iodine Fact Sheet for Professionals. National Institutes of Health Office of Dietary Supplements. Accessed August 19, 2021. https://ods.od.nih.gov/factsheets/Iodine-HealthProfessional/.

                AI: A New Way to Help Pharmacy Thrive!

                Learning Objectives

                 

                After completing this knowledge-based continuing education activity, pharmacists and technicians will be able to

                1. Recognize artificial intelligence (AI) and the models underlying these technologies
                2. Describe the implications of AI within the healthcare and pharmacy fields
                3. List the opportunities and challenges that AI introduces to healthcare and pharmacy services
                4. Recognize AI’s impact on the pharmacy workforce and its implications in shaping the future of pharmacy practice

                  Two robotic hands surrounding a box labeled with the letters "AI."

                  Release Date:

                  Release Date: May 15, 2025

                  Expiration Date: May 15, 2028

                  Course Fee

                  Pharmacist:  $7

                  Pharmacy Technician: $4

                  ACPE UANs

                  Pharmacist: 0009-0000-25-032-H04-P

                  Pharmacy Technician: 0009-0000-25-032-H04-T

                  Session Codes

                  Pharmacist: 25YC32-KFT44

                  Pharmacy Technician: 25YC32-FTK68

                  Accreditation Hours

                  2.0 hours of CE

                  Accreditation Statements

                  The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-0000-25-032-H04-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

                   

                  Disclosure of Discussions of Off-label and Investigational Drug Use

                  The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

                  Faculty

                  Kortney J. Knudsen, PharmD
                  PGY-1 Resident
                  Westchester Medical Center
                  Valhalla, NY

                  Jeannette Y. Wick, RPh, MBA, FASCP
                  Director of the Office of Pharmacy Professional Development
                  UConn School of Pharmacy
                  Storrs, CT

                  Faculty Disclosure

                  In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

                  Jeannette Y. Wick, RPh and Kortney Knudsen, PharmD have no relationships with ineligible companies and therefore have nothing to disclose.

                  ABSTRACT

                  The global adoption of artificial intelligence (AI) continues to expand, with AI systems providing essential functions in prediction, recommendation, and decision-making based on their underlying algorithms. Healthcare institutions are exploring how these resources may enhance workflows, improve patient outcomes, and allow clinicians to focus more time on direct patient care. Researchers are exploring AI implementation in numerous areas, including diabetes and heart failure management, medical imaging evaluation, acute kidney injury detection, medication adherence, and electronic health record integration. While AI holds immense potential for transforming healthcare, its implementation faces several challenges. Barriers to AI integration include resource allocation, legal consideration, and securing healthcare provider acceptance. Healthcare professionals must address these barriers for the successful application of AI into daily clinical practice.

                  CONTENT

                  Content

                  INTRODUCTION

                  Dolly is a pharmacist in an independent pharmacy working 9 to 5 (what a way to make a living!). Her technician, Miley, calls her to the front to talk with Carol, a 60-year-old woman who consistently wears her smartwatch. Miley tells Dolly, “You have to hear this!” Carol reports that while walking her dog, she tripped and landed face down on the pavement. Carol says her smartwatch called out, “It looks like you’ve taken a hard fall,” and asked if it should call 911. Carol didn’t need emergency services, but she was grateful that the watch detected her fall and could help if necessary. If Carol had been unresponsive, the watch would have called 911 automatically. When Carol left, Miley said, “You know Dolly, I am really concerned that artificial intelligence (AI) is going to replace me.” Dolly nodded and said, “I know. I have some concerns, too. It's enough to drive you crazy if you let it.” Dolly realizes she needs to look into AI and its possibilities.

                   

                  AI is a technology that learns, reasons, and performs tasks to mimic humans.1 A 2022 Pew Institute survey of 11,004 Americans found that while 55% use AI frequently, awareness of its presence and capabilities varies.2 Only 30% of participants demonstrated high AI awareness, with factors such as education level, income, and Internet use influencing their familiarity.2 Despite growing adoption, public engagement is mixed, with concerns about AI’s impact fueling debate.

                   

                  Recently, many media outlets have published articles about AI, and many of those pieces have generated public debate and concern.3-5 Public engagement in ethical debates about AI’s use and limitations is only reasonable and well advised if individuals understand its strengths and limitations. Despite the widespread adoption of AI technologies among Americans, another Pew Research Center survey reported that only 15% express more excitement than concern about its increased use in daily life, 38% express more concern than excitement, and 46% are mixed, containing both excitement and concern.6 Nonetheless, AI’s adoption and market value increases annually. Researchers estimated the AI market size at $40 billion in 2022 and expect it to grow to $1.3 trillion by 2032.7

                   

                  Americans rely on AI in their everyday lives for web searches, task automation, and more—often without even realizing it. Engineers have seamlessly integrated AI into technologies like Siri, Alexa, and Google Home, making everyday tasks more convenient. With almost limitless possibilities, AI continues to evolve and grow, including in the healthcare field.

                   

                  PAUSE AND PONDER: Take a moment and look at this list. Which of the following are AI powered? You can find the answers at the end of this activity (after the CONCLUSION).

                  • Air conditioners
                  • Automatic washing machines
                  • Basic calculators
                  • Customer service chatboxes
                  • Email services
                  • Facial recognition technology
                  • Media/playlist recommendations
                  • Purchase recommendations
                  • Refrigerators
                  • Social media
                  • Television remote controls
                  • Voice assistants
                  • Wearable fitness trackers

                   

                  Defining AI

                  AI systems predict, recommend, and make decisions using machine-based algorithms. Programmers design these systems with a set of rules and human-defined objectives to accomplish a variety of tasks.8,9 As Table 1 implies, no single definition fully captures AI’s complexity, and its applications are broad.1

                   

                  Table 1. Definitions and Possibilities Associated with AI1
                  An artificial system…
                  ·         performs tasks in predictable and unpredictable conditions with minimal human oversight
                  ·         learns and improves its performance from experience and data set exposure
                  ·         is developed in software or hardware
                  ·         works to complete tasks requiring human-like action, cognition, communication, learning, perception, or planning
                  ·         is developed to mimic human cognition and neural networks
                  ·         is made with techniques for approximating a cognitive task
                  ·         is designed to act rationally

                   

                  AI Models

                  AI system designs vary based on the AI model used. Common algorithms include machine learning, neural network, deep learning, natural language processing, and rule-based expert systems. Neural network and deep learning fall under the broader category of machine learning. Table 2 describes how developers tailor each model to accomplish specific tasks in unique ways.10 It also captures common AI models used in healthcare with examples for their application.

                   

                  Table 2. Explanations and Examples of AI Model Applications10-15
                  Model Explanation Example(s)
                  Machine Learning ·         Fits models to data

                  ·         Trains models with data sets

                  ·         Encompasses neural network and deep learning models

                  ·         Precision medicine: uses information about a person’s genes and lifestyle to prevent, diagnose, or treat disease

                  ·         A breast cancer prediction algorithm: interpreted 38,444 mammograms from 9,611 women to predict biopsy malignancy and distinguish between normal and abnormal screenings

                  Neural Network ·         Inspired by and mimics the human brain

                  ·         Uses nodes that mimic human neurons to process and learn from data

                  ·         Considers inputs, outputs, and weights of variables

                  ·         Google Photos: uses a neural network to categorize images based on face or object recognition
                  Deep Learning ·         Complex model building off the neural network

                  ·         Uses features and variables used to predict an outcome

                  ·         Facial recognition: uses deep learning for security purposes like unlocking smartphones or for tagging people on social media

                  ·         Enables the identification of individuals as the same person, even with changes to physical appearance, lighting, or visual obstructions

                  Rule-Based Expert Systems ·         If-then format for decision-making processes

                  ·         Constructs rules in a knowledge domain

                  ·         Medical diagnosis: if the patient has a fever and a sore throat, then consider the possibility of strep throat

                   

                  After some research, Dolly was ready to determine the model AI uses to detect falls. She found that smartwatches rely on machine learning models, including deep learning, to identify falls. Specifically, the technology uses accelerometer (an instrument that detects and measures speed and directional vibrations) and gyroscope (an instrument that detects and measures angular momentum) data from the watch to detect abrupt movements and shifts in motion that could signal a fall.16

                   

                  PAUSE AND PONDER: How can healthcare professionals and leaders integrate AI models into healthcare?

                   

                  AI IN DISEASE MANAGEMENT

                  Integrating AI into healthcare can transform patient care and streamline workflows.10 A recent survey reported that 80% to 90% of forecast panelists believe that AI will improve care, simplify patient referrals, and facilitate prior authorizations.8 Also, 63% of participants indicated that it is very or highly likely for health systems to adopt AI for pharmacist documentation. AI can specifically help document patient information in electronic health records (EHR).8 Some physicians and advanced practice providers are already using AI to improve patient documentation.8

                   

                  Generative AI uses machine models to analyze data patterns and create content like images and text. In healthcare, it enhances patient care and supports whole-person health.8 This technology can assist with medical image interpretation, inform disease diagnosis, identify care gaps, personalize treatment plans, enable remote patient monitoring, and support early intervention and preventive care.8,17 In her research, Dolly found a number of applications that could improve patient care.

                   

                  Diabetes Management

                  By 2050, statisticians expect that 1.31 billion Americans will have diabetes.18 Diabetes management requires frequent follow-up and comprehensive examinations to monitor blood glucose levels and detect complications.19 Medical resources are unevenly distributed across the United States (U.S.). Physicians are often concentrated in wealthier and suburban areas, leaving rural regions with limited access to primary and specialty care. Yet, rural populations have a 16% higher prevalence of type 2 diabetes (T2DM) and a 20% higher T2DM-related hospital mortality rate compared to urban populations.20

                   

                  Effective diabetes management requires a collaborative approach involving endocrinology, nutrition, nephrology, ophthalmology, pharmacy, and podiatry. Since primary care alone is insufficient to handle this complex condition, rural areas face significant challenges in diabetes management.19 By 2034, researchers estimate a shortage of 124,000 doctors in the U.S., with the majority of loss in primary care.21 If this prediction is accurate, individuals in rural areas will face growing challenges accessing healthcare. Given the uneven distribution of healthcare resources across various regions, AI advancements may enhance efficiency in diabetes care while diminishing overall health expenditures.10,19

                   

                  To achieve better care for all people, clinicians may use predictive models to assess disease progression in T2DM, forecast blood glucose levels, and detect diabetic retinopathy.22

                   

                  AI technology may prevent diabetes onset in high-risk patients by ensuring early medical intervention.19 AI technologies may use non-invasive, cost-effective methods capable of early identification and classification of diabetes.

                   

                  An emerging theory is that machine learning using facial texture features and tongue color analysis could predict diabetes onset and identify those at high risk. In patients with diabetes, skin manifestations are common.23 These manifestations range from acanthosis nigricans (demarcated plaques with grey to brown pigmentation), to dermopathy (spots on the front of lower legs), to skin thickening.23 The pathophysiology of these conditions is not entirely understood. However, aging and diabetes causes increased collagen interlinking. Consequentially, skin changes like thickening and hardening may occur.23

                   

                  In Chinese Medicine, practitioners believe face regions reflect the health of internal organs.24 Asian researchers postulated that tongue discoloration, such as a yellow coating, is linked to diabetes, with studies showing a connection between tongue features and glucose metabolism.25,26 In 2017, researchers conducted a study to determine which model analyzes facial texture and color to detect diabetes most accurately.24 They took facial images, divided them into regions, characterized regions by textures, and analyzed them using eight different models.24 In 2019, Chinese researchers collected tongue images from 570 patients and analyzed their color and texture using AI models. The results demonstrated that these models may effectively associate tongue images with diabetes, but these studies remain preliminary.25

                   

                  In 2024, 8.7 million Americans or 3.4% of all U.S. adults met laboratory criteria for diabetes but were not aware that they had this condition.27 Delayed diagnosis is a common concern in diabetes, with about 45% of adults worldwide undiagnosed.18 Current diabetes diagnostic tests include hemoglobin A1C, fasting plasma glucose, 2-hour plasma glucose, and oral glucose tolerance test (OGTT). These four tests are invasive as they require venipuncture.24 Non-invasive diagnostic methods, such as analyzing facial images and tongue color, could help identify diabetic patients who are unaware of their condition.

                   

                  Dolly is fascinated by this information, but aware that these findings are very preliminary. Recently, one of her favorite patients, Lily, had gained weight rapidly in the early trimesters of pregnancy. Her obstetrician ordered an OGTT. Before the test, Lily fasted, then drank a sugary solution and had her blood sugar levels measured at specific intervals. This process was challenging for Lily, as the sight of blood and having her blood drawn nauseates her. Dolly wishes that non-invasive methods were currently available.

                   

                  In primary care, AI technologies may create personalized diet and exercise plans for people with diabetes. These plans could align with clinician recommendations and contribute to effective diabetes management.18

                   

                  Despite the promise of AI technology in diabetes management, predicting blood glucose levels remains challenging because food and subcutaneously administered insulin absorption rates vary. AI technologies are increasingly embedded into continuous glucose monitoring (CGM) systems to predict blood glucose levels. CGMs track patients’ blood glucose levels in real time and eliminate frequent finger pricks. CGMs provide regular and accurate blood glucose data, offering greater convenience than traditional finger sticks. Regardless, errors may still occur. CGM may report blood glucose levels that differ from actual values by roughly 9%. Differences in actual blood glucose level measurements may be an important consideration for individuals with diabetes and their healthcare providers. Soon, it’s likely that AI will also measure ketone levels; some systems will be integrated into CGMs.29

                   

                  Another obstacle is when clinicians’ recommendations differ from those generated using AI, as both may be correct. To resolve discrepancies, AI may serve as a tool to support human decision-making. Last, AI technology is designed based on the data it receives. Data quality is important for accurately predicting and managing diabetes.19,22

                   

                  Cardiac Care

                  Like diabetes, heart failure (HF)—the inability of an individual’s heart muscle to pump enough blood—is becoming more prevalent. Common symptoms include shortness of breath, fatigue, and swelling of the legs, ankles, or abdomen.30 Worldwide, approximately 60 million individuals live with HF.31 Managing HF requires accurate diagnoses and treatments tailored to individual patients. AI technologies may help diagnose, predict outcomes, classify, and optimize treatment strategies in HF.32

                   

                  Researchers have published much information on HF, and information on the use of machine learning to analyze this data is increasing. AI algorithms address challenges like data noise (large amounts of unwanted data that make analysis difficult), false correlations (no relationship between two variables), and statistical power issues (a study’s inability to detect accurate results or effects). By streamlining data analysis, AI complements traditional statistical methods to gather insights into HF.32

                   

                  Researchers have created an AI-based diagnostic algorithm for HF. The study enrolled 600 patients with and without HF. The results demonstrated a diagnostic accuracy of 98% and surpassed non-specialist clinicians, who had an accuracy of 76%. In regions with limited access to HF specialists, these AI technologies could be beneficial.32,33

                   

                  Patients with HF also face high 30-day readmission rates. Decreasing HF hospital admissions and readmissions is important considering the financial penalties that the Centers for Medicare and Medicaid Services (CMS) impose. CMS reduces hospital payments by a percentage following unplanned 30-day readmissions for patients with HF.34 The hospitalization rate has improved from about 367 hospitalizations per 100,000 adults in 2016 to 350 hospitalizations in 2020. However, Healthy People 2030’s target is 330 per 100,000, meaning more improvement is needed.35

                   

                  Deep learning AI models may help lower hospital readmissions for patients with HF. In a 900-patient cohort study, these technologies outperformed traditional techniques in predicting readmission rates. This AI algorithm used heart sounds, respiratory rate, tidal volume (the amount of air that moves in and out of the lungs during a normal breath), heart rate, and patient activity to make predictions.32

                   

                  The rising use of remote monitoring and wearable devices is likely to expand AI’s effectiveness in managing HF. AI-powered smartwatches programmed with electrocardiography features demonstrate acceptable accuracy in detecting HF with reduced ejection fraction. These technologies allow continuous data streams, better prediction in hospital readmission rates, and earlier HF identification.31,32

                   

                  Dolly finds that smartwatches can also be useful for patients who have or are at risk for atrial fibrillation (AFib). Carol, the patient whose smartwatch detected a fall, has been worried that she might develop AFib, which causes irregular heartbeats. Last week, the watch detected an episode of AFib. When Carol visited her provider, she brought the printed electrocardiogram showing the episode. This enabled the provider to make informed decisions about next steps, supported by AI technologies.

                   

                  Sepsis Identification

                  Globally, sepsis—a life-threatening response to an infection—is a leading cause of illness and death.36 Patients with sepsis present with varying degrees of severity, ranging from mild sepsis to septic shock. It can lead to tissue damage, organ failure, and death. Sepsis’s variable presentation makes early detection challenging. However, prompt recognition of sepsis is critical, as every hour without treatment increases the risk of death.36

                   

                  AI technologies may predict sepsis hours before its onset. Through machine learning and predictive algorithms, AI improves the accuracy of sepsis detection in a clinical setting.36-38 Researchers conducted a prospective, multi-center study of 590,736 patients across five hospitals, with 6,877 included in the analysis.38 During the study, researchers used the Targeted Real-time Early Warning System (TREWS) as a sepsis alert system for providers.38 TREWS is a machine learning-based algorithm that notifies providers when a patient is at high risk for sepsis.

                   

                  TREWS integration enabled early intervention from providers and reduced the hospital mortality rate by 5.1% when providers responded to the alert within three hours.38 The TREWS intervention group also saw a 4.5% decrease in overall mortality compared to patients whose providers did not respond within three hours. Patients flagged as high risk also experienced reductions in organ failure severity.38 A critical point is provider response time. It is possible that providers who responded more quickly simply had better resources or teams at their disposal.39

                   

                  This study’s major limitation was the predetermined alert settings, which may have influenced the alerts and their associations with clinical outcomes.38 TREWS notified providers when patients exhibited significant findings related to sepsis. This constraint limits the study’s generalizability, as variations in alert settings may lead to significant differences in the timing of alerts and, potentially, patient outcomes. Future implementation may adopt a less restrictive model, allowing earlier warnings by identifying patients with fewer sepsis-related criteria.38

                   

                  Alert fatigue—healthcare provider desensitization to safety alerts—may also limit this study’s applicability to clinical practice.38 Alert fatigue often causes individuals to not respond properly to safety alerts and warnings.40 TREWS integration may contribute to the alert fatigue phenomenon that plagues the healthcare industry.

                   

                  Despite this study’s promising results, few large, randomized controlled trials (RCTs) have evaluated AI-based alerts for patients with sepsis.37

                   

                  Acute Kidney Injury Alert

                  Acute kidney injury (AKI; a decline in the kidney filtrate rate) impacts approximately 18% of inpatients and greater than 50% of patients in intensive care units.41 Like managing HF and diabetes, early detection is critical.41,42 Two studies have examined AI in AKI.

                   

                  Chinese researchers led a double-blind RCT to evaluate the impact of electronic alerts on adults with AKI.41 They randomized more than 2,000 hospitalized patients to determine whether an AKI alert combined with management strategies improves care and clinical outcomes. The data showed that alerts did not improve kidney function or overall patient outcomes. However, the alerts influenced treatment approaches. Patients in the alerts group received more intravenous fluids (82.6% vs 61.8%), fewer nonsteroidal anti-inflammatory drugs (5% vs 11%), and more AKI documentation at discharge (49.9% vs 27.3%).41

                   

                  Another double-blinded, multicenter RCT enrolled more than 6,000 patients. Researchers concluded that the AKI alerts did not reduce the risk of AKI progression, dialysis initiation, or death within 14 days of randomization.42

                   

                  Both studies found that integrating their specific AKI alert algorithms into EHR did not improve patient outcomes.41-43 However, pairing these alerts with management strategies influenced providers’ treatment decisions. These findings suggest that while changes in treatment strategies may not directly benefit patients, they may help avoid medications that can contribute to AKI.41,42

                   

                  Image Interpretation

                  Beyond its use in facial recognition for social media and security, AI also has the proven potential to analyze medical images. Specifically, AI technologies show promise in oncology for identifying and categorizing cancers, and in managing diabetic retinopathy.

                   

                  Oncology

                  Researchers are developing AI models for cancer imaging, aiming to improve tumor detection, characterization, and monitoring.10,44 These tools identify various cancers and predict patient outcomes very accurately.45 They can help minimize oversights and serve as an initial screen to reduce omission errors.

                   

                  AI tumor characterization involves tumor segmentation (outlining and identifying boundaries of the tumor in images), diagnosis, and staging. AI-driven automated segmentation has the potential to enhance the efficiency, reproducibility, and quality of tumor measurements.44 It may also improve the ability to monitor changes in tumors over time. Despite these promising advancements, challenges remain in ensuring accurate detection, characterization, and monitoring.44

                   

                  Diabetic Retinopathy

                  AI models can detect diabetic retinopathy, a complication of diabetes that progressively impairs vision over time. AI identification of diabetic retinopathy is facilitated through retinal fundus imaging, which has demonstrated high sensitivity and selectivity, as defined in the SIDEBAR.22,46,47

                   

                  SIDEBAR: Differentiating Sensitivity and Specificity47
                  Sensitivity Specificity
                  ·         A test’s ability to determine whether an individual with the disease is positive

                  ·         High sensitivity: limited false negative results—few cases where the disease is missed

                  ·         A test’s ability to determine if an individual who does not have the disease is negative

                  ·         High specificity: limited false positive results

                  ·         Using a test with low specificity causes many people without the disease to screen as positive and receive treatment

                   

                  In 2017, researchers enrolled 521 participants across 10 U.S. centers. Each patient underwent a dilated ophthalmoscopy (an eye exam). The AI algorithm accurately identified 36 of 37 positive cases (97% sensitivity) and 162 of 184 negative cases (88% specificity).46 The researchers concluded that the AI system detects mild diabetic retinopathy more effectively than general ophthalmologists or retina specialists. This tool may offer a low-cost solution for diabetic retinopathy screening and help reduce the burden of diabetic eye screenings.46


                  Electronic Health Records

                  Approximately 80% of clinically relevant healthcare information is unstructured data.48 Applying a natural language processing (NLP)-based algorithm to the EHR may help hospitals identify patients who need a clinical pharmacist’s review. NLP models possess the ability to engage in speech recognition, text analysis, and translation, with goals centered around language processing. One example of its use is transcribing patient interactions, which may be helpful for medication reconciliation. Similarly, NLP-based systems can prepare reports, such as patient notes within the EHR, and analyze these notes.10 By analyzing notes, the system can also identify patients requiring extensive medication interventions and categorize them as high risk. This classification enables pharmacists to dedicate their efforts to patients most likely to benefit, ultimately enhancing their impact on patient care.48

                   

                  AI models may also detect and alert providers when an ordered medication deviates from its typical use pattern. AI captures information on standard dosages and indications, aiding drug selection, dose recommendations, drug-drug interaction detection, and order entry.49 This tool supports pharmacists and other healthcare providers in clinical decision-making to minimize medication-related errors and improve patient outcomes.49

                   

                  Generative AI models may streamline providers’ documentation processes. Clinicians spend approximately 35% of their time documenting patient data and notes.50 AI technologies may reduce this workload, allowing providers to focus more on patient care. However, before integrating AI into documentation, leaders must set clear guidelines. For effective use, these guidelines must address concerns such as data security, accuracy, reliability, ethical considerations, and the need for ongoing evaluation of AI programs to ensure regular maintenance and optimization.51

                   

                  The possibilities for AI integration in EHR are endless. With proper use, these resources help streamline workflow and increase time providers spend on direct patient care.

                   

                  PAUSE AND PONDER: What are the opportunities and challenges for AI integration into healthcare?

                   

                  AI CHALLENGES

                  A major challenge is AI’s inability to explain how it arrives at its conclusions, referred to as model transparency. Predictive modeling and deep learning procedures are difficult to adopt in clinical environments. The algorithms behind these models often lack transparency and experimental context.8,22

                   

                  For clinicians to accept AI, they must understand how models generate recommendations. By detailing internal decisions, behaviors, and actions, AI’s developers can build trust among healthcare providers. Developers must equip clinicians with sufficient information to understand each event’s causes. Subsequently, providers can determine how to incorporate AI recommendations into their clinical decision-making processes.8,22

                   

                  Another barrier arises from EHRs’ limitations. Since EHR data is not publicly available, AI technologies may struggle to generate comprehensive recommendations. Also, healthcare organizations often restrict data access to internal use, leaving predictive modeling without sufficient information.22 To address this challenge, some experts propose federated learning. This allows institutions to contribute to a global model while keeping sensitive data within their respective systems.10 However, as AI processes large volumes of data, the risk of data breaches and unauthorized access increases. Protecting databases from security threats remains a challenge.8

                   

                  Bias presents another obstacle. If data used in AI models is homogenous, the results may be skewed. Developers must ensure that training datasets include a wide range of patient demographics and conditions to prevent biased outcomes.8

                   

                  Cost inhibits widespread adoption of AI. Institutions allocate resources for AI differently. Smaller, rural hospitals may struggle to implement these technologies due to financial constraints.8 Also, demonstrating a clear return on investment for AI integration is difficult. The limited cost avoidance data per intervention and impact on patient outcomes makes it challenging for hospital executives to justify AI investments.8

                   

                  Legal and ethical considerations further complicate AI acceptance. Mistakes are inevitable with AI technologies. Who will be held accountable for errors, especially when they impact patient outcomes? Healthcare providers may be reluctant to adopt AI technologies if responsibility for potential AI errors is unclear.8,10 This also calls into question regulatory compliance. If AI becomes the standard of care, providers who choose not to use these tools may face legal and regulatory consequences.8,10

                   

                  Before implementing AI in clinical practice, healthcare institutions must thoroughly test and validate each model. A designated committee containing diverse healthcare professionals should lead the approval process to ensure safe and effective implementation of AI models. This approval process and integration into daily practice may take years.10

                   

                  After looking at how AI is used currently, the research underway, and AI’s challenges, Dolly feels confident that she can discuss changes in the workplace and pharmacy processes with Miley.

                   

                  TAILORING AI TO PHARMACY PRACTICE

                  Many healthcare providers already recognize the implications of AI integration in healthcare. A recent survey asked pharmacists, “How likely is it the following will occur by the year 2029 in the geographic region where you work?”8 Table 3 displays the findings on AI integration in pharmacists’ documentation and medication histories.8

                   

                  Table 3. Forecast Panelists’ Survey Responses to AI Integration in 20298
                  Response Percent of Responders
                  Statement 1: 50% of health systems will adopt technology in the EHR for pharmacist documentation to be completed by generative AI.
                  Very Unlikely 4%
                  Somewhat Unlikely 33%
                  Somewhat Likely 44%
                  Very Likely 19%
                  Statement 2: 25% of health systems will use a Chatbot to obtain medication histories.
                  Very Unlikely 10%
                  Somewhat Unlikely 33%
                  Somewhat Likely 43%
                  Very Likely 14%
                  AI, artificial intelligence; EHR, electronic health record.

                   

                  As healthcare professionals acknowledge AI’s expanding function, they must develop a strong understanding of these technologies. Pharmacists and pharmacy technicians, in particular, need a basic knowledge of AI.48 With this foundation, pharmacists can assess AI models’ strengths and limitations and determine when and how to use them effectively.

                   

                  To establish a baseline understanding of AI technologies, institutions must integrate education and didactic experiences into training for pharmacy technicians, pharmacy students, and pharmacists.52,53 This will equip healthcare providers with the basic skills needed to evaluate AI models and understand its responsibility in improving patient care.

                   

                  AI and the Pharmacy Workforce

                  Like Miley, may pharmacy personnel worry that AI may replace pharmacists and pharmacy technicians. In the United Kingdom, researchers estimate 35% of all jobs—including some pharmacy-related positions—could be automated in the next 10 to 20 years.10 However, they also predict job losses will amount to less than 5%. This is because of factors like cost of automation technologies, labor market dynamics, and regulatory and social acceptance. These circumstances create major barriers in the widespread adoption of AI across industries and may mitigate actual job loss.10

                   

                  In healthcare, similar trends are expected. To date, AI has not eliminated jobs.10 Pharmacy student enrollment is unlikely to rise, and researchers predict that 20% of first year post-graduate residency spots will remain unfilled after the match. As a result, they anticipate the pharmacy workforce will decline.8 This projected reduction has led to expectations that AI will assist with repetitive pharmacy tasks, allowing pharmacists and technicians to focus on responsibilities that require human expertise.

                   

                  With the integration of AI into healthcare, pharmacists are expected to expand their scope of practice into areas where they can use their skills more and influence outcomes.8,10 These include managing high-cost medications, bridging gaps in primary care, applying empathy and persuasion, and taking a big-picture approach to patient care. While AI is designed to mimic certain human actions, it is not human. It lacks interpersonal skills and the ability to build relationships. Ultimately, AI will complement pharmacists by streamlining repetitive tasks, addressing workforce shortages, and enabling them to use their unique human intelligence abilities.8,10

                   

                  Adverse Drug Reactions

                  A primary responsibility for pharmacists in medication management is to mitigate patients’ risk of adverse drug reactions (ADRs). EHR systems use AI for ADR prediction and detection. For example, if a prescriber orders amiodarone for a patient who is already taking warfarin, the system is designed to alert healthcare providers that the combination leads to high bleeding risk. Current systems already deliver this alert, and an AI-assisted system may recommend providers decrease the patient’s warfarin dose empirically by 30% to 50%.54 However, like any test or algorithm, false positives and negatives can occur, meaning these systems are not foolproof. It is crucial that clinicians and pharmacists do not rely solely on these alerts for detecting ADRs or sending notifications. Instead, they should apply clinical decision-making and rely on their expertise.

                   

                  A recent study involving 412 patients used a machine learning algorithm to predict the likelihood of ADRs in neonates.55 Researchers designed the algorithm to associate a risk score to predict and prevent ADRs, rather than simply display a warning as is done currently for certain medications. The model displayed high predictive accuracies, successfully detecting ADRs in patients with allergic, renal, central nervous system, and hepatic ADRs 78.9% to 90.2% of the time.49,55 These models illustrate AI’s broad application in ADR detection which supports clinical decision-making.

                   

                  AI also offers opportunities to improve patient adherence. It can trigger patient-specific message alerts, such as medication renewal reminders for both the pharmacist and the patient. This ensures timely prescription refills, helps maintain a consistent medication supply, and supports better medication adherence for improved health outcomes. Wearable devices like smartwatches and smartphones also integrate AI technology that may encourage behavioral changes and enhance adherence.10 For example, some smartwatches offer a time-to-stand reminder. If individuals have not moved within the first 50 minutes of an hour, the watch will remind them to stand. Simple alerts like these increase movement and encourage behavior changes.

                   

                  Beyond clinical applications, AI has the potential to transform pharmacy operations. AI technology may request and process prior authorizations (something of great interest to Dolly and Miley), manage the supply chain, optimize pharmacy revenue cycles, and track financial performance.8

                   

                  CONCLUSION

                  AI technologies are likely to revolutionize healthcare by enhancing clinical decision-making, improving patient outcomes, and streamlining workflows. Through automation of routine tasks and data analysis, AI can help healthcare providers deliver more efficient care. However, significant barriers including algorithm transparency, bias, cost, and accountability concerns must be addressed before AI is widely adopted. Overcoming these challenges requires collaboration among healthcare providers, policy makers, and AI developers. Establishing clear guidelines and validation procedures will help ensure AI technologies are safe and used properly. With proper implementation and education, AI is a powerful tool that enhances healthcare professionals’ abilities. Dolly and Miley now appreciate that it cannot replace human skills like empathy, critical thinking, and personalized communication.

                   

                  PAUSE AND PONDER: Take a moment and look at this list. Which of the following are AI powered? These are the answers that we promised to provide!

                  • Air conditioner
                  • Automatic washing machine
                  • Basic calculators
                  • Customer service chat box
                  • Email services
                  • Facial recognition
                  • Media/playlist recommendations
                  • Purchase recommendations
                  • Refrigerators
                  • Social media
                  • Television remote control
                  • Voice assistants
                  • Wearable fitness trackers

                   

                  Answers Examples
                  Customer service chat box ·         Chatbots answering basic customer service questions
                  Email services ·         Emails automatically categorized as spam
                  Facial recognition ·         Unlocking devices

                  ·         Password security

                  ·         Tagging individuals in social media posts

                  Media/playlist recommendations ·         Spotify or Apple Music playlists

                  ·         Audiobook platforms

                  ·         Streaming services

                  Purchase recommendations ·         Social media advertisements

                  ·         Web browser advertisements

                  Social media ·         Facial recognition

                  ·         “For you” page geared to user interests

                  Voice assistants ·         Siri

                  ·         Alexa

                  ·         Google Home

                  Wearable fitness trackers ·         ECG monitoring

                  ·         Fall detection

                   

                   

                  Pharmacist and Pharmacy Technician Post Test (for viewing only)

                  PHARMACIST AND PHARMACY TECHNICIAN LEARNING OBJECTIVES
                  After completing this continuing education activity, learners will be able to
                  • Recognize artificial intelligence (AI) and the models underlying these technologies
                  • Describe the implications of AI within the healthcare and pharmacy fields
                  • List the opportunities and challenges that AI introduces to healthcare and pharmacy services
                  • Recognize AI’s impact on the pharmacy workforce and its implications in shaping the future of pharmacy practice

                  1. An artificial intelligence developer uses an algorithm that mimics the human brain and consists of nodes that mimic human neurons to process and learn from data. What model is the developer using?
                  A. Deep learning
                  B. Neural network
                  C. Rule-based expert system

                  2. Which of the following is the BEST descriptor of a possibility associated with AI?
                  A. Performs tasks in predictable and unpredictable conditions with minimal human oversight
                  B. Performs tasks in predictable conditions only with minimal human oversight
                  C. Performs tasks in unpredictable conditions only with direct human oversight

                  3. An AI algorithm is designed with the following input and output: “if the patient has diarrhea and vomiting, then consider the possibility of norovirus infection.” What model does this rule represent?
                  A. Deep learning
                  B. Neural network
                  C. Rule-based expert system

                  4. When generative AI uses machine models to analyze data patterns and create content in healthcare, how might it enhance patient care?
                  A. It can assist with medical image interpretation, inform disease diagnosis, and identify care gaps.
                  B. It can replace the clinician’s need to be present at clinic appointments.
                  C. It can make decisions for clinicians, write treatment plans, and prescribe medications.

                  5. Effective diabetes management requires a collaborative, specialized approach. Since primary care alone is insufficient to handle this complex condition, which of the following current barriers to diabetes management could AI BEST help overcome?
                  A. It can help urban areas that have unlimited access to care for diabetes management.
                  B. It can help rural areas struggling with limited access to care for diabetes management.
                  C. It can help primary care providers eliminate challenges in diagnosing patients with diabetes.

                  6. Which of the following represents the MOST significant implication for AI models in cancer imaging?
                  A. AI models can improve the efficiency, reproducibility, and quality of tumor measurements.
                  B. AI models can improve the accuracy of tumor detection and consider patient’s medical history.
                  C. AI models have the potential to enhance the accuracy in detection, monitoring, and make decisions for providers.

                  7. Which of the following is a CHALLENGE associated with AI use in healthcare?
                  A. Identifying patients by their unique identifiers may be impossible.
                  B. Identifying solutions with good specificity and sensitivity is difficult.
                  C. Identifying who holds responsibility when an error occurs may be unclear.

                  8. Dr. Smith is interested in integrating AI technologies. He mentions difficulty reading patients’ notes and getting a complete understanding due to residents copying notes from previous days without updating important details. How can AI technologies BEST address this issue?
                  A. NLP-based systems can transcribe interactions, such as medication reconciliations.
                  B. NLP-based systems can prepare reports, such as patient notes within the EHR.
                  C. NLP-based systems can analyze text, such as patient notes within the EHR.

                  9. The Dolly Hospital is a 100- bed facility located 100 miles from the nearest large city. Which of the following is MOST likely a CHALLENGE for AI integration at this institution?
                  A. They may struggle to secure the necessary funds.
                  B. They may struggle to demonstrate a clear return on investment.
                  C. They may struggle to obtain accurate cost avoidance data.

                  10. Why is it UNLIKELY that AI will replace pharmacists and cause widespread job loss?
                  A. Experts anticipate AI has reached its heyday and will be difficult to develop in new ways.
                  B. Experts anticipate the federal government will implement laws preventing AI use in healthcare.
                  C. Experts anticipate the pharmacy workforce will decline, making more jobs to be filled.

                  11. With the integration of AI into healthcare, how is AI expected to complement pharmacists?
                  A. By assisting with repetitive tasks, allowing pharmacists to focus on responsibilities that require human expertise
                  B. By assisting with relationship-building, allowing pharmacists to focus on responsibilities that require human expertise
                  C. By assisting with personalized communication, allowing pharmacists to focus on responsibilities that require human expertise

                  12. Molly needs to provide discharge medication counseling to a patient but is pressed for time. She sends an AI robot to provide the counseling instead. However, the patient refuses this service. Why is it LIKELY that the patient declined the AI robot’s counseling service?
                  A. The patient did not want to pay for AI’s automated labor.
                  B. The patient did not want to accept AI technologies.
                  C. The patient did not want AI-related errors in counseling.

                  References

                  Full List of References

                  References

                     

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