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Patient Safety: Strength in Scoops: A Primer in Creatine, Protein Powder, and Pre-workout Supplementation

Learning Objectives

 

After completing this application-based continuing education activity, the pharmacist will be able to:

  • Identify differences in composition and health benefits associated with creatine, protein powder, and pre-workout supplements
  • Describe creatine dosing, common adverse effects, contraindications, and differences in available formulations
  • Determine dietary preferences, digestion tolerance, and patient's individual health goals when selecting protein powders
  • Provide timing and dosing for protein powder supplementation to maximize exercise recovery and muscle support

After completing this application-based continuing education activity, the pharmacy technician will be able to:

  • Identify differences in composition and health benefits associated with creatine, protein powder, and pre-workout supplements
  • Explain common misunderstandings about the use and safety of creatine, protein powder, and pre-workout supplements
  • Discuss nutrition labels to help patients select appropriate supplements based on patient's individual health needs
  • Infer when to refer individuals' questions to the pharmacist

    A blue scooper, which contains protein powder, sits in front of a purple container with a grey lid.

    Release Date:

    Release Date: September 20, 2025

    Expiration Date: September 20, 2028

    Course Fee

    Pharmacists: $7

    Pharmacy Technicians: $4

    ACPE UANs

    Pharmacist: 0009-0000-25-033-H05-P

    Pharmacy Technician: 0009-0000-25-033-H05-T

    Session Codes

    Pharmacist: 25YC33-HGJ14

    Pharmacy Technician: 25YC33-JHG41

    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 0009-0000-25-033-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

    Sydney A. Feeney
    PharmD Candidate 2027
    University of Connecticut
    Storrs, CT
     
    Madison C. Righi
    PharmD Candidate 2027
    University of Connecticut
    Storrs, CT
     
    Ava E. Vecchi
    PharmD Candidate 2027
    University of Connecticut
    Storrs, CT
     
    Valentina L. Maturi
    PharmD Candidate 2027
    University of Connecticut
    Storrs, CT
     
    Marissa C. Salvo, PharmD, BCACP, FCPA, FCCP
    Clinical Professor of Pharmacy Practice
    University of Connecticut
    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.

    Sydney A. Feeney, PharmD Candidate 2027 has no relationships with ineligible companies and therefore have nothing to disclose.

    Madison C. Righi, PharmD Candidate 2027 has no relationships with ineligible companies and therefore have nothing to disclose.

    Ava E. Vecchi, PharmD Candidate 2027 has no relationships with ineligible companies and therefore have nothing to disclose.

    Valentina L. Maturi, PharmD Candidate 2027 has no relationships with ineligible companies and therefore have nothing to disclose.

    Marissa C. Salvo, PharmD, BCACP, FCPA, FCCP has no relationships with ineligible companies and therefore have nothing to disclose.

    ABSTRACT

    Dietary supplements such as creatine, protein powder, and pre-workout supplements have gained significant popularity recently, especially among those seeking to enhance physical performance and physique. Many consumers use these products without a full understanding of safe and effective use. Patients frequently ask pharmacists and pharmacy technicians questions about these supplements and pharmacy staff may be limited in providing evidence-based recommendations with full confidence. This continuing education activity covers the basic essential information regarding creatine, protein powder, and pre-workout supplementation. It addresses safe and effective use, potential risks, and common misconceptions associated with these products. Finally, it provides practical counseling points for pharmacists and pharmacy technicians to better educate patients who are seeking guidance on these supplements.

    CONTENT

    Content

    INTRODUCTION

    The increasing prevalence of dietary supplement use among individuals who engage in regular physical activity has raised a variety of important health concerns.1 Manufacturers often market commonly used products—including creatine, protein powder, and pre-workout supplements—as products that enhance athletic performance, promote muscle growth, and reduce recovery time. Recovery time refers to the period of time the body needs to repair and restore itself after physical activity, in particular after intense exercise or strength training (see SIDEBAR).2 These features attract many customers in pursuit of their fitness goals; however, the increase in consumption of these supplements is not always accompanied by accurate knowledge or professional guidance. This raises an array of concerns regarding the efficacy, safety, and long-term health implications of creatine, protein powder, and pre-workout supplements.1 Given the increasing number of patients who use dietary supplements, it is imperative that pharmacy teams understand this topic to provide guidance and counseling and care.3

     

    SIDEBAR: Recovery Time and Physical Activity4

    • To stay healthy and avoid injury, the body needs time to rest and recover after physical activity.
    • Muscle fatigue depends on how much and how hard an individual exercises, and it varies from person to person.
    • Physical activity puts stress on the muscles to build strength and improve performance.

     

    Supplements can help the body recover faster by supporting muscle repair and reducing the risk of overuse injuries.

     

    OVERVIEW OF DIETARY SUPPLEMENTS

    The Dietary Supplement Health and Education Act (DSHEA) of 1994 defines a dietary supplement as a product intended for oral consumption that contains one or more dietary ingredients intended to supplement the diet. These dietary ingredients may include vitamins, minerals, herbs, botanicals, amino acids, or other substances found in the food supply, such as enzymes and live microorganisms.5 As the use of dietary supplements continues to grow, individuals turn to them for various reasons, most commonly to address nutrient or vitamin deficiencies, boost energy levels, and/or meet specific nutritional needs that may be difficult to achieve through a regular diet.6

     

    A widely used supplement, creatine, supports the rapid regeneration of adenosine triphosphate (ATP) during high-intensity, anaerobic exercise, contributing to improved strength, sprinting performance, and muscle mass.7 Protein powders are also commonly used particularly for their role in supporting and maintaining skeletal muscle mass.8 Pre-workout supplements—multi-nutrient products designed to enhance physical performance—have gained popularity for their potential to improve training capacity, accelerate recovery, and increase energy during workouts.9 Overall, creatine, protein powders, and pre-workout supplements are dietary supplements commonly used to boost physical performance, promote muscle growth, and support recovery. However, their effectiveness can vary based on the specific ingredients and formulations of each product.

     

    How Dietary Supplements are Regulated

    The Food and Drug Administration’s (FDA) Center for Food Safety and Applied Nutrition (CFSAN) is the division responsible for overseeing dietary supplements, as these products are regulated as food under United States (U.S.) law.5 The FDA’s role includes5

    • Inspecting manufacturing facilities
    • Reviewing new dietary ingredient (NDI) notifications and related submissions
    • Investigating consumer complaints
    • Monitoring adverse event reports related to supplements on the market

    While the FDA has specific and critical regulatory responsibilities, it does not approve dietary supplements or their labeling before they reach the market.5

     

    Over the past few decades, hundreds of dietary supplements have entered the market. This has limited the FDA’s ability to fulfill its responsibilities in comprehensively monitoring the supplement market.10 Because the FDA’s resources and capacity are limited, they have primarily acted only when significant quality concerns have emerged, including microbial and/or heavy metal contamination, adulteration with synthetic drugs, and inaccurate or incomplete ingredient labeling.10 When evaluating dietary supplements such as creatine, protein powder, and pre-workout supplements, pharmacy team members can be essential consultants. They should recommend products that have been verified by third-party laboratories, such as the U.S. Pharmacopeia (USP), NSF International, or ConsumerLab.com. In addition, they should educate patients about potential quality and safety concerns.10

     

    Common Misconceptions About Dietary Supplements

    Numerous misconceptions surround dietary supplements, and the growing influence of social media has accelerated their spread. One common belief is that the FDA tests and approves all dietary supplements before they reach consumers. However, the FDA does not have the capacity to evaluate these products for safety and efficacy prior to their sale.5 Another widespread misconception is that dietary supplements are safe for everyone; however, just because a product is classified as a supplement does not mean it is harmless. For example, even commonly used supplements, like creatine, are not suitable for everyone and may pose risks for certain populations who should avoid their use.

     

    CREATINE

    Creatine is an endogenous substance made in the liver, pancreas, and kidney from L-arginine, glycine, and methionine by L-glycine-arginine aminotransferase (AGAT) and guanidinoacetate methyltransferase (GAMT) enzymes.11 Once it has been synthesized, creatine travels through the bloodstream via sodium- and chloride-dependent creatine transporters to reach its target tissues, like skeletal muscle and brain.12 Inside the cell, creatine kinase converts 65% of creatine into phosphocreatine.12 Phosphocreatine stores high-energy phosphate groups that can be used quickly by skeletal muscle to make ATP, the main energy source for cells, by donating phosphate groups to turn adenosine diphosphate (ADP) back into ATP.11 Muscles rely on this conversion into ATP for energy during short-duration and high-intensity exercise.12

     

    Creatine supplementation increases the rate of phosphocreatine synthesis during recovery periods. This enhances muscle performance, recovery, and overall training outcomes, which is why many individuals are inclined to use creatine.12 Creatine also helps increase muscle mass and reduce body fat percentage, and it has been shown to enhance performance in short, high-intensity exercise.11,13

     

    Dose

    Individuals can begin using creatine with a total of 20 grams daily for up to seven days; this is described as a loading phase.14 Most creatine powder products contain 3 to 5 grams per scoop (it is important to read the product’s label), so achieving this dose typically requires using four to five scoops per day, consumed throughout the day. Mixing one scoop into a beverage of choice with each meal or snack can make it easier to incorporate into one’s routine.

     

    After the loading phase, individuals continue with the maintenance phase of 2.25 to 10 grams daily for up to 16 weeks.14 This typically equates to 1 to 2 scoops per day. While individuals may choose to continue supplementation beyond this 16-week period, most studies have been limited to around 16 weeks. Long-term data is limited, but the available studies have not reported any serious adverse effects.

     

    Of note, a loading or induction phase is not strictly necessary; alternatively, research shows that smaller, consistent daily doses are also effective if the loading phase is not desired.15 Some individuals prefer to skip the loading phase because consuming 20 grams per day (approximately four to five scoops) can be difficult to incorporate into their routine. Also, patients who experience mild adverse effects (described below) should divide their creatine consumption into smaller doses taken throughout the day.16

     

    PAUSE AND PONDER: How might a patient’s daily routine influence the recommendation between a creatine loading phase and a lower daily dose?

     

    Selecting a Product

    Creatine is available in a wide range of commercial products (see Table 1), most commonly as a powder formulation.13 It can be found in both solid and liquid dosage forms. The liquid formulation is thought to improve creatine solubility, which may allow patients to consume less. However, it has limitations in shelf life, as creatine is not stable in liquid form over extended periods.17 The solid dosage form includes powders and capsules.16

     

    The most popular form is creatine monohydrate.14 Creatine monohydrate has been used extensively without resulting in major adverse events.17 While researchers have conducted studies to evaluate different forms of creatine, creatine monohydrate remains the most researched and superior available form.11,14,17

     

    Table 1. Available Creatine Products11,14

    Type of Creatine Description Clinical Pearls
    Creatine monohydrate The most common form of creatine.

     

    Stored in muscle for quick energy.

    ·       Widely studied

    ·       Proven safe and effective

    ·       Affordable

    Creatine nitrate Creatine bound to nitrate Claims of better absorption, but this is not strongly supported by studies.
    Di-creatine malate Creatine bound to malate Claims to have increased water solubility, but research is limited.
    Creatine ethyl ester Creatine bound to esterified ethanol Claims better absorption due to increased uptake across the membrane, but evidence does not support superior efficacy over creatine monohydrate.
    Creatine gluconate Creatine bound to a glucose molecule Claims improved absorption and transport of creatine into muscle cells, but the research is limited.

     

    Should be avoided with diabetes because it could impact blood sugar levels.

    Creatine citrate Creatine bound to citric acid Claims to improve creatine solubility and absorption but has not proven superior over monohydrate
    Creatine magnesium chelate Creatine bound to magnesium Claims to enhance stability, absorption, and overall effectiveness of creatine supplementation, but further research is necessary to support these claims.

     

    Based on currently available data, creatine monohydrate is recommended when helping a patient select a creatine product. Creatine monohydrate has the strongest evidence supporting its use, primarily due to its high bioavailability and well-documented effectiveness in enhancing muscle strength and power. While formulation type is generally not a critical factor, powder is the most commonly used and widely available form.11 As mentioned earlier, when recommending dietary supplements like creatine, choosing a product that has undergone third-party testing is the safest option. For example, a creatine monohydrate supplement which has a USP or NSF seal is a reliable choice.14

     

    Safety

    Creatine is overall well tolerated with minimal adverse effects.14 The most common adverse effects associated with oral creatine include14,16

    • Dehydration
    • Diarrhea
    • Gastrointestinal upset
    • Muscle cramps
    • Water retention leading to weight gain

     

    It is rare to experience severe adverse effects when taking creatine, however, the following may occur14

    • Interstitial nephritis
    • Renal insufficiency
    • Rhabdomyolysis
    • Venous thrombosis

     

    Prior to beginning creatine supplementation, individuals with the following conditions should avoid its use until first discussed with their physician:16

    • Bipolar disease (may increase mania)
    • Diabetes
    • Kidney disease
    • Liver disease
    • Parkinson’s disease, especially in combination with caffeine (may accelerate progression of disease)
    • Pregnant or breastfeeding

     

    A pharmacy technician should refer to the pharmacist if the patient14,16

    • Has a disease state or condition listed above
    • Asks for a recommendation on which creatine supplement to use
    • Has questions or concerns regarding possible drug interactions or adverse effects
    • Has specific questions about dosing based on their condition, disease state, or current medications or use of other supplements

     

    Common Misconceptions

    People share a considerable amount of information about dietary supplements like creatine online and on other platforms, but some of this information can be inaccurate or misleading. Misinformation may discourage individuals from using a supplement that could offer benefit. Therefore, it is essential for pharmacy team members to understand key facts about creatine in order to provide accurate information and help prevent the spread of false claims. Table 2 describes many common misperceptions and provide the evidence needed to respond.

     

    Table 2. Common Misconceptions and Evidence-based Facts11,15,18

    Common Misconceptions Evidence-Based Facts
    Creatine supplementation results in weight gain. Creatine supplementation may sometimes cause water retention, particularly during the initial stages of use. However, this effect is not universal, and creatine can actually offer benefits, such as improved intracellular hydration, which may enhance muscular strength and reduce fatigue.
    Creatine is safe for everyone. Some studies have reported potential liver or kidney complications, which is why individuals with these conditions, as well as the other exclusion groups mentioned in the text, are advised to avoid creatine supplementation or need to consult with a physician prior to use.
    A loading phase is required for creatine supplementation to be effective. Creatine supplementation at lower daily doses has also been shown to be effective, making the loading phase optional.
    Creatine has the same effects as anabolic steroids. Creatine supplementation does not stimulate muscle growth via hormonal mechanisms, as anabolic steroids do.
    Creatine causes hair loss. No direct evidence indicates creatine supplementation causes hair loss or baldness. Most research attributes hair loss in individuals taking creatine to genetics and hormonal factors rather than the supplement itself.
    Creatine causes dehydration and cramping. Creatine does not increase the risk of dehydration or muscle cramping. Maintaining proper hydration during exercise is important whether or not an individual is using creatine.
    Creatine only improves lower body strength. A 2021 meta-analysis demonstrated that creatine supplementation significantly improves upper limb strength performance during short-duration exercises. These effects were observed regardless of age, sex, training protocol, or dosage.

     

    PROTEIN POWDER

    Protein is a fundamental component of a balanced diet and plays a critical role in a healthy lifestyle. It is found in both animal- and plant-based sources and is essential for biological functions, such as tissue-building and maintaining optimal health.19 However, many individuals struggle to meet their daily protein requirements, particularly when the goal is to enhance their physical appearance or athletic performance. Protein powder offers a convenient solution to help individuals reach these goals.20 Medically, it can also benefit patients who have difficulty consuming adequate daily protein intake due to chewing or swallowing limitations.21

     

    Dose

    The recommended dietary protein intake in healthy adults is based on their body mass, lean body mass, and level of physical activity.22 The Recommended Dietary Allowance (RDA) and Acceptable Macronutrient Distribution Range (AMDR) are both used as guidance on the recommended amount of protein to consume each day.22 The RDA for protein is a minimum of 0.8 grams per kilogram per day (g/kg/day) to support healthy individuals’ nutritional needs.22 It should be noted that the RDA is the minimum requirement; therefore, individuals should aim to intake 1.2 to 1.7 g/kg/day to benefit from the effects of efficient protein intake.23 When this range is achieved, older adults are at less risk of muscle loss and frailty, and athletes can see significant changes in muscle and performance.23 This can be incorporated as 0.4 g/kg/meal or about 20 g per meal depending on weight.20 In addition, the AMDR states that 10% to 35% of an individual’s energy intake (calories) should be from protein.22

     

    For active individuals who want to maximize their muscle support, the Academy of Nutrition and Dietetics, Dieticians of Canada, and the American College of Sports Medicine recommend doubling the RDA of protein.24 For example, individuals who are in resistance training may wish to consume 1.2 to 2 g/kg/day.22 In addition, to aid in recovery, active individuals may wish to consume 15 to 20 gs of protein within one to two hours after exercising. Older adults, who want to reduce their risk of muscle loss, may also consume a higher amount of protein per day.23

     

    Insufficient amounts of protein can result in adverse consequences for one’s health, including decreased protein synthesis.22 When protein synthesis is affected, it negatively influences other processes in the body including22

    • Muscle mass density and function
    • Bone and calcium homeostasis
    • The immune system
    • Fluid and electrolyte balance
    • Enzyme production and activity

     

    By consuming protein above the RDA and within the AMDR, individuals can improve muscle preservation, reduce age-related muscle loss, maintain body composition and metabolic health, and increase muscle mass and strength.22

     

    Selecting a Product

    Meeting daily protein intake goals is important for overall health and performance; however, it can be challenging through diet alone. In such cases, protein supplements, such as protein powder, can help to achieve those goals effectively.20 Selecting the appropriate type of protein powder is essential to optimize the benefits of adequate protein intake. Protein powder should be tailored to the individual’s specific needs and goals.

     

    For example, a study involving 18 women with bulimia nervosa or binge eating disorder found that consuming high-protein supplements three times daily significantly reduced the frequency of binge eating episodes. The participants reported feeling less hungry and fuller, which led to a reduction in overall food intake. This study suggests that protein supplementation may help manage disordered eating patterns in individuals with bulimia nervosa or binge eating disorder.25

     

    In contrast, protein supplements are also used in the treatment of anorexia nervosa, but to promote healthy weight gain. Registered dietitians recognize that the use of dietary supplements, including protein powders, which are often part of the standard of care in treating patients who struggle to meet their nutritional needs through food alone due to psychological or physical barriers.26 A case study reported protein supplementation helped to increase caloric intake, preserve lean body mass, and support gradual weight restoration.27

     

    Table 3 provides guidance to tailor protein powder selection.20

     

    Table 3. Types of Protein Powders20

    Whey Concentrate ·       Vary in lactose and fat content

    ·       In many protein drinks, bars, and nutritional products

    ·       Used in infant formula

    ·       Do not use if allergic to milk

    Hydrolysate ·       Hydrolyzed whey protein

    ·       Easiest to digest because its long protein chains are pre-broken down

    ·       Used in specialized infant formulas and in medical supplements for nutritional deficiencies

    ·       Do not use if allergic to milk

    Isolate ·       High in protein, low in fat or lactose

    ·       In protein bars and drinks

    ·       Suitable for lactose intolerance

    ·       Do not use if allergic to milk

    Milk protein ·       Supports immune system

    ·       Enhances muscle growth

    ·       Do not use if allergic to milk

    Egg protein ·       Released more slowly than whey

    ·       Taken throughout the day

    ·       Do not use if allergic to eggs

    Plant-based Brown rice protein ·       Suitable for vegetarians or individuals who do not consume dairy

    ·       Gluten-free

    Pea protein ·       Highly digestible

    ·       Hypo-allergenic (not likely to cause an allergy)

    Hemp protein ·       Good source of omega-3 fatty acids

     

    As described in Table 3, protein powders are available in different formulations and can be selected based on an individual’s dietary needs, allergies, or fitness goals. Milk-derived proteins, such as whey (including concentrate, isolate, or hydrolysate forms) are commonly recommended for those aiming to promote muscle growth due to their rapid absorption and high biological value.

     

    However, it is important to note that whey protein is produced during the cheese-making process. Enzymes are added to milk to separate the solid curds from the liquid whey. The liquid whey is then pasteurized and dried to create protein powder.20 Because whey is derived from milk, it should not be used in individuals with a milk allergy.20 Similarly, milk protein powders, which contain both whey and casein (milk protein), may also enhance muscle growth but should not be used in those with milk allergies. These are important factors to consider when selecting a protein, as milk allergy is one of the most common allergies in the U.S., affecting over 4.7 million adults.28

     

    For those with lactose intolerance or dietary restrictions, whey protein isolate (which is low in lactose) or plant-based proteins (including brown rice, pea, and hemp protein) may be tolerated better.20

     

    PAUSE AND PONDER: When choosing a protein powder, how might an individual’s health conditions, allergies, or fitness goals influence the type of protein powder suitable for them?

     

    Safety

    Protein is classified as a dietary supplement, and it is essential for patients to inform their healthcare providers about any supplements they are taking. Factors such as food intake, meal timing, and nutritional status can influence the pharmacokinetics of medications. The drug’s ability to be properly absorbed can be influenced by a high consumption of protein from meals and supplements. Medications such as levodopa, used in Parkinson’s disease, and beta-lactam antibiotics (such as penicillin, amoxicillin, and cephalexin) rely on transporter proteins for absorption, and their uptake may be reduced with a high protein intake. Additionally, a high-protein, low-carbohydrate diet can significantly increase the clearance of the beta-blocker propranolol and moderately increase the clearance of theophylline, potentially impacting the therapeutic efficacy of both medications. A high-protein meal can also increase the absorption of certain drugs, such as the immunosuppressant tacrolimus.29

     

    Protein supplementation for patients on anticoagulation is also a major concern because of vitamin K concentrations in protein supplements. It is important that patients, especially those on warfarin, notify their anticoagulation healthcare team about protein supplement use. Plant-based protein powders, such as those containing soy, may contain vitamin K; thus, decreasing the effect of warfarin.30 It is important to check the ingredient list in the Nutrition Facts labeled on protein supplements and look for Vitamin K. For example, protein supplement drinks such as Boost High Protein Nutritional Drink contains Vitamin K1 as an ingredient. In this situation, it is critical to select another protein powder formulation.

     

    Protein powder supplements may contain ingredients that can contribute to gastrointestinal discomfort, weight gain, or elevated blood glucose levels. Patients should review product ingredients carefully when experiencing adverse reactions. Since protein powder is a dietary supplement, the FDA does not evaluate it for safety or efficacy prior to marketing. Therefore, consumers cannot be certain that the product contains what is claimed on the label.31

     

    Furthermore, some products may contain added sugars or dextrin, maltodextrin, or sweeteners that can contribute to weight gain, which may not be ideal for individuals who want to lose or maintain weight.20 Patients with diabetes should also pay close attention to protein powders with sugar listed as one of the first three ingredients and verify that the product is low in carbohydrates.20 Patients with kidney disease may not be able to tolerate more than the recommended daily allowance of protein at one time because they can’t efficiently remove waste products during the metabolism of protein. These patients may need a product that is lower than average in protein. For example, they should select a protein powder with a lower-range protein content such as 10 to 15 g per serving.20 If patients have irritable bowel syndrome or are lactose intolerant, a protein powder without lactose sugars, artificial sweeteners, dextrin, or maltodextrin is recommended.20 It is also important to check and avoid ingredients containing gluten in patients with a gluten allergy or sensitivity.20

     

    The pharmacy technician should refer the patient to the pharmacist if the patient

    • has diabetes, kidney, or liver disease, gastrointestinal problems, or any chronic illness that require dietary oversight
    • takes prescription medications because timing of supplements may be considered
    • is a child, teen, pregnant, or breastfeeding
    • complains about adverse effects from a protein supplement
    • takes multiple protein supplements, as they are at risk of overconsumption

     

    Common Misconceptions

    Similar to other dietary supplements, information about protein used as a supplement may be inaccurate or misleading. Protein is a commonly used supplement, and it is important to address misconceptions about usage, concerns, and key information related to its use. Misinformation may come from peer influence, social media, and seemingly credible sources. It is essential for pharmacy team members to understand the uses of protein supplementation to provide accurate information and help prevent the spread of false claims.

     

    Protein powder can be used in those that need to meet their nutritional requirements and in those looking to build muscle. While it is commonly believed that only athletes require protein supplementation, individuals of all activity levels may benefit depending on their dietary needs. The RDA reflects the minimum daily protein intake needed, but it is mistaken as the target for everyone to follow.22 In contrast, the AMDR recommends that protein intake accounts for 10% to 35% of daily energy intake, measured in kilocalories.32 For example, people who consume 1,300 calories per day should aim to consume 33 to 114 grams of protein daily, based on individual needs and health goals.

     

    Some individuals may be hesitant to increase their protein intake due to concerns about its potential impact on comorbid conditions, although current evidence does not support their concerns. Table 4 clarifies misleading information to encourage individuals to use protein supplements knowledgeably and confidently as part of a healthy lifestyle.22

     

    Table 4. Common Misconceptions and Evidence-based Facts33-35

    Common Misconceptions Evidence-Based Facts
    High-protein diets weaken bones and increase the risk of osteoporosis. A high protein diet along with eating more dairy, calcium, and exercising daily can help protect the bones.
    Consuming high amounts of protein will damage kidneys, even if the individual is healthy. The National Health and Nutrition Examination Survey found that even with very high protein intake from all sources, blood urea nitrogen levels remained within the normal range, indicating that there is no risk of developing chronic kidney disease or harming the kidneys.
    High protein diets, especially from animal sources, increase the risk of heart disease and type 2 diabetes. An analysis of the Framingham Heart Study Offspring Cohort showed an inverse relationship between inflammation and dietary protein intake, showing that there was a beneficial effect for higher animal- and plant-based protein intake. No data demonstrates a relationship between dietary protein and cardiovascular disease or type 2 diabetes mellitus.

     

    PRE-WORKOUT

    “Pre-workout” is a term used to describe supplements composed of multiple ingredients, intended to be taken before a workout.36 Manufacturers of these supplements propose pre-workout supplements enhance performance, energy, endurance, and focus during a workout; however, limited research supports these claims.37

     

    Common Ingredients

    Pre-workout supplements can include countless combinations of ingredients, but most multi-nutrient formulas feature a core set of commonly used components, including9,36

    • Caffeine
    • Beta-alanine
    • Creatine
    • Citrulline
    • Taurine
    • Tyrosine
    • B vitamins (B-6, B-12)

     

    While many pre-workout supplements share a core group of commonly used ingredients, their formulations can vary significantly.36 Unfortunately, many companies do not list all included ingredients and their specific quantities on the label; this variability makes it difficult for pharmacists to recommend or evaluate products.2 Much of the existing research on pre-workout supplements focuses on caffeine as the primary stimulant.37 It has been found that many products containing caffeine do not have accurate amounts listed on their label.2 Use of products with unreliable labeling can put patients at risk for adverse effects.2

     

    Selecting a Product

    Since pre-workout supplements contain ingredients similar to those found in energy drinks, it is important to distinguish between the two. Pre-workout supplements are designed to enhance both short-term exercise performance and long-term training outcomes.37 In contrast, energy drinks and shots typically consist of caffeine along with a few vitamins or amino acids, aiming primarily to increase energy and alertness. They are intended for use at any time throughout the day.37 Because of the variability in composition and unreliability of the labeling on pre-workout supplement products, it is recommended to avoid their use and rather focus on eating a balanced diet to support energy needs.2

     

    Safety

    Caffeine and beta-alanine are the most widely used ingredients included in pre-workout supplements found in 86% and 87% of products, respectively.36

     

    Beta-alanine is included because it enhances exercise capacity and performance by elevating muscle carnosine levels, which buffer the accumulation of lactic acid in muscles.38 This buffering effect helps delay fatigue during high-intensity exercise, making it especially beneficial for short bursts of activity such as weightlifting or sprinting.38 While both are generally well tolerated, long-term doses of beta-alanine that exceed 6.4 g per day or caffeine use beyond several weeks at doses above 400 mg/day may increase the risk of adverse events (see Table 5) and dependence.39,40

     

    Table 5. Potential Adverse Events of Beta-Alanine and Caffeine2,36,39-41

    Ingredient Potential Adverse Events
    Beta-Alanine

     

    ·       Mild:

    o   Flushing

    o   Paresthesia

    o   Pruritus

     

    Caffeine

     

    ·       Mild to Moderate (> 400 mg per day):

    o   Vomiting

    o   Tachycardia

    o   Hypokalemia

    o   Hypoglycemia

    o   Anxiety and restlessness

    o   Gastrointestinal upset (including diarrhea and nausea)

    o   Diuresis

    o   Headache

    o   Insomnia

    o   Palpitations

    o   Muscle tremors

    ·       Severe (10 to 14 g per day):

    o   Agitation

    o   Seizures

    o   Ventricular dysrhythmias

    o   Hypotension

    o   Shock

     

     

    Patients should be aware of their total daily caffeine intake, which includes not only coffee and energy drinks but also caffeinated beverages, medications, and multivitamins that may also contain caffeine.37 To determine if a medication contains caffeine, patients can read their medications’ list of ingredients or ask their pharmacist.

     

    Caffeine is rapidly absorbed from the stomach and small intestine, reaching peak serum concentrations within 30 to 60 minutes following oral intake. Although food may slow the absorption rate, it does not reduce the total amount that will eventually be absorbed.41 Studies have found that individuals with lower CYP1A2 activity have increased reports of symptoms of toxicity, as caffeine is hepatically metabolized by CYP1A2 which causes caffeine to be absorbed more slowly.41-43 The plasma elimination half-life ranges from 3 to 7 hours in healthy adults and 3 to 4 hours in children. This range is shortened in smokers, due to the activation of the CYP1A2 enzyme by cigarette smoke, and prolonged in the last trimester of pregnancy, in patients with cirrhosis, and in infants.41

     

    In terms of safety, most adults can consume a maximum of 400 mg of caffeine per day, while children are typically safe when ingesting up to 2.5 mg/kg of caffeine per day.41

     

    Table 6. Approximate Caffeine Content in Select Beverages
    Coffee 100 mg
    Tea 20-90 mg
    Celsius Energy Drink 200 mg
    Monster Energy Drink 160 mg

     

    Toxicity and lethality risks increase with higher doses. Life-threatening events are seen when greater than 150 to 200 mg/kg of caffeine is consumed, and fatalities have been reported when 5 to 50 g of caffeine was ingested.41 However, recovery after ingestion of 50 g has also been reported.41

     

    Pharmacists should counsel patients who are taking caffeine-containing products while concomitantly using pre-workout supplements because they are consuming high levels of caffeine.37 This increased level of caffeine can increase the risk of adverse events described above.37

     

    Regarding pre-workout supplement use, the pharmacy technician should refer to the pharmacist if the patient

    • Has pre-existing medical conditions, including high blood pressure, anxiety, seizure history, kidney or liver impairment, and heart disease or arrhythmias
    • Is pregnant or breastfeeding
    • Is asking for a recommendation on which pre-workout supplement to use
    • Is experiencing or has questions regarding possible drug interactions and adverse effects
    • Has specific questions about dosing based on their condition, disease state, or current medications/supplements

     

    For example, Jenny, a 58-year-old woman, is interested in using a pre-workout supplement to help motivate her to be active after a long day at work. When the technician asks about her current caffeine intake, she mentions that she drinks two cups of coffee each day and also has a Sparkling Fuji Apple Pear (her favorite flavor) Celsius. The technician explains that each cup of coffee contains approximately 100 mg of caffeine, and the Celsius drink contains about 200 mg. Most pre-workout supplements contain between 150 to 300 mg of caffeine. If Jenny were to add a pre-workout supplement to her routine, her total caffeine intake could exceed 500 mg per day, increasing her risk of experiencing adverse events.

     

    PAUSE AND PONDER: With the growing popularity of stimulant-containing products, how can you further assess patients’ consumption of caffeine? (Hint: Remember hidden sources of caffeine.)

     

    CONCLUSION

    With the growing popularity of supplement use in the fitness industry, products such as creatine, protein powders, and pre-workout supplements continue to be widely used. Pre-workout supplements are typically taken before exercising to enhance performance and focus, while creatine and protein powders are commonly used to support muscle growth and recovery. When used appropriately, these supplements may improve physical performance, promote muscle development, and reduce recovery time.6

     

    As pharmacists and pharmacy technicians, it is part of our professional responsibility to educate the public about the potential risks and benefits of these products and to provide evidence-based recommendations. Our role also includes advocating for patients and staying informed about the latest developments, which are becoming increasingly prominent in the wellness market. Gaining a deeper understanding of these products is essential to recognize when we can confidently make recommendations or when to refer individuals to a physician or registered dietitian for more individualized guidance.

     

    It is also important to acknowledge that these products still require more research to establish their full safety and efficacy, standards that are already well established for prescription medications.10 Additionally, current research often overlooks key individual factors such as genetics, the gut microbiome, and habitual diet, all of which can significantly influence exercise performance, recovery, and muscle growth.6

     

    Pharmacist Post Test (for viewing only)

    Pharmacist Post-test
    25-033

    After completing this continuing education activity, pharmacists will be able to
    • Identify differences in composition and health benefits associated with creatine, protein powder, and pre-workout supplements
    • Describe creatine dosing, common adverse effects, contraindications, and differences in available formulations
    • Determine dietary preferences, digestion tolerance, and patient’s individual health goals when selecting protein powders
    • Provide timing and dosing for protein powder supplementation to maximize exercise recovery and muscle support

    *

    1. Which of the following is a counseling point you, as the pharmacist, can offer to a patient who is taking a pre-workout product and experiencing anxiety symptoms, including tachycardia?
    A. Limit the use of other caffeinated products, including coffee, while using a pre-work product.
    B. Stop using the pre-workout product immediately, as it may increase the risk of adverse neurological effects.
    C. Inform the patient that their symptoms are unlikely to be related to the pre-workout product.

    *

    2. Which of the following is a common adverse effect of creatine?
    A. Muscle cramps
    B. Hair loss
    C. Constipation

    *

    3. A 56 kg female patient comes in asking for guidance on how to adequately consume protein in her diet. The patient is allergic to dairy and has no other allergies. The patient goes on a 45-minute walk daily but does not perform resistance training. Which of the following is the best answer to provide for this patient?
    A. The patient should have a goal of consuming about 22 grams of hemp protein per meal, having 3 meals per day.
    B. The patient should have a goal of consuming about 32 grams of whey protein per meal, 3 meals per day.
    C. The patient should have a goal of consuming about 10 grams of hemp protein per meal, having 3 meals per day.

    *

    4. A 45-year-old female patient wants to begin taking a dietary protein supplement. She is currently taking omeprazole, warfarin, and ibuprofen. Which of the following medications may have an interaction with dietary protein supplementation?
    A. Omeprazole
    B. Warfarin
    C. Ibuprofen

    *

    5. A 70-year-old male recovering from surgery shows signs of fatigue and poor wound healing due to protein deficiency. What type of protein supplement would be most appropriate to support his energy levels and nutrition?
    A. Whey protein concentrate
    B. Whey protein hydrolysate
    C. Whey protein isolate

    *

    6. Which of the following creatine products has the most evidence supporting its use?
    A. Creatine Monohydrate
    B. Creatine Nitrate
    C. Creatine Citrate

    *

    7. A 85-year-old female asks her primary care provider about initiating daily supplementation with 20 grams of creatine. The physician asks you for assistance in answering this question. Upon reviewing her medical chart, you note that her estimated Glomerular Filtration Rate (eGFR) is 30 mL/min/1.73m2. Given this information, would you recommend the initiation of daily creatine supplementation?
    A. Yes, creatine has no contraindications with reduced renal function and can be safely initiated.
    B. No, creatine supplementation is not recommended in patients with reduced renal function, and this patient has kidney impairment.
    C. Yes, studies have proven that reducing the creatine loading dose to 15 grams daily, rather than 20 grams, allows patients with reduced renal function to safely supplement, if renal function is closely monitored.

    *

    8. Why can it be difficult for pharmacists to recommend a pre-workout supplement?
    A. Pre-workout supplements have variability in ingredients.
    B. Pre-workout supplements have been well studied.
    C. Pre-workout supplements have consistent ingredients.

    *

    9. A 39-year-old pregnant woman presents to the pharmacy seeking information about creatine supplementation. Upon reviewing her medication profile, you note that she is currently taking aripiprazole for bipolar disorder. What amount of creatine would you, as the pharmacist, recommend for her?
    A. I would recommend 20 grams daily for 7 days, followed by 8 grams daily for 16 weeks.
    B. I would recommend 11 grams daily for 20 weeks
    C. I would not recommend creatine supplementation.

    *

    10. A 68 kg male patient seeks guidance on his recommended daily protein intake. He follows a strict vegan diet, avoiding all animal products, and does resistance training (lifts heavy weights) four times per week. What would you, as the pharmacist, recommend for this patient?
    A. Consume a diet of 130 grams of plant-based protein per day, including consuming 20 grams of protein 1 hour after exercising.
    B. Consume a diet of 130 grams of plant-based protein per day, including consuming 20 grams of protein 1 hour before exercising.
    C. Consume a diet of 175 grams of plant-based protein per meal, including consuming 20 grams of protein 1 hour after exercising.

    Pharmacy Technician Post Test (for viewing only)

    Pharmacy Technician Post-test
    25-033

    After completing this continuing education activity, pharmacy technicians will be able to
    • Identify differences in composition and health benefits associated with creatine, protein powder, and pre-workout supplements.
    • Explain common misunderstandings about the use and safety of creatine, protein powder, and pre-workout supplements.
    • Discuss nutrition labels to help patients select appropriate supplements based on patient’s individual health needs.
    • Infer when to refer individuals' questions to the pharmacist.

    *

    1. In which one of the following situations should you, as the pharmacy technician, refer the patient to the pharmacist?
    A. A patient with chronic kidney disease asks for supplements to improve their physical performance during strength training.
    B. A patient with seasonal allergies asks for a recommendation between two creatine products, one with a USP seal and the other without.
    C. A 25-year-old patient asks about what types of protein powder the pharmacy has in stock.

    *

    2. Which of the following is a plant-based protein option?
    A. Pea protein
    B. Milk protein
    C. Whey protein

    *

    3. Choose the answer that correctly matches its corresponding statement.
    A. Whey isolate protein – suitable for lactose intolerance and can be used in individuals allergic to milk.
    B. Whey hydrolysate protein – easy to digest and suitable for individuals with nutritional deficiencies.
    C. Protein powder with artificial sweeteners – can be given to patients with irritable bowel syndrome (IBS).

    *

    4. A 75-year-old individual with newly diagnosed osteoporosis is looking to improve muscle recovery as they are increasing their strength training. They are unsure which protein supplement to choose. Which response best supports the importance of selecting the right protein source?
    A. Choosing the right protein powder depends on the patient’s individual needs, goals, and preferences.
    B. Whey protein supplementation is beneficial for all individuals reaching their protein requirements; however, excessive amounts of protein will damage your kidneys.
    C. Whey protein is better than other types of protein to lessen the risk of osteoporosis.

    *

    5. A 22-year-old male comes to the pharmacy with questions regarding creatine. He has heard rumors regarding creatine’s side effects and safety. He wants to know which of the rumors he has heard are true. Which of the following statements is true regarding creatine’s side effects?
    A. Creatine may cause hair loss.
    B. Creatine may cause diarrhea.
    C. Creatine may cause kidney stones.

    *

    6. Which of the following ingredients are commonly found in pre-workout supplements?
    A. Caffeine and taurine
    B. Taurine and vitamin C
    C. Caffeine and beta-alanine

    *

    7. Which of the following creatine products has the most evidence supporting its use?
    A. Creatine Monohydrate
    B. Creatine Nitrate
    C. Creatine Citrate

    *

    8. A 22-year-old male patient wants to begin creatine supplementation. He is currently taking loratadine and acetaminophen and wants to know if creatine will interact with either of these medications. Which of the following is the best course of action you, the a pharmacy technician, should take?
    A. Use an online resource to determine if there is an interaction.
    B. Refer the patient to the pharmacist.
    C. Recommend beginning supplementation, as there is no interaction with the medications.

    *

    9. An 18-year-old female patient is interested in starting weight training to gain muscle. She has seen TikTok influencers promoting the use of pre-workout supplements, protein powder, and creatine, claiming these products support muscle growth. However, she is skeptical, as many influencers have brand deals, and she wants to avoid being misled. Which of the products are the influencers promoting that have misleading claims about building muscle?
    A. Protein powder
    B. Creatine
    C. Pre-workout supplements

    *

    10. A 19-year-old male is interested in starting creatine supplementation and wants to choose a safe and effective product. Which of the following is a counseling point to provide when making a recommendation?
    A. Always start with a loading phase.
    B. Creatine monohydrate is the most widely studied.
    C. Use products without third-party testing to save money.

    References

    Full List of References

    1. Calella P, Di Dio M, Pelullo CP, et al. Are knowledge, attitudes and practices about dietary supplements and nutraceuticals related with exercise practice and setting? A cross-sectional study among Italian adults. Int J Food Sci Nutr. 2025;76(2):194-202. doi:10.1080/09637486.2024.2437468
    2. Cohen P. High-risk dietary supplements: Patient evaluation and counseling. UpToDate. UpToDate, Inc. Updated March 21, 2025. Accessed May 29, 2025. https://www.uptodate.com
    3. Massey PB. Dietary supplements. Med Clin North Am. 2002;86(1):127-147. doi:10.1016/s0025-7125(03)00076-2
    4. Peake JM. Recovery after exercise: What is the current state of play? Current Opinion in Physiology. 2019;10:17–26. https://www.sciencedirect.com/science/article/pii/S2468867319300379. doi: 10.1016/j.cophys.2019.03.007.
    5. U.S. Food and Drug Administration. Questions and Answers on Dietary Supplements. FDA. Updated December 4, 2023. Accessed May 22, 2025. https://www.fda.gov/food/information-consumers-using-dietary-supplements/questions-and-answers-dietary-supplements
    6. Maughan RJ, Burke LM, Dvorak J, et al. IOC Consensus Statement: Dietary Supplements and the High-Performance Athlete. Int J Sport Nutr Exerc Metab. 2018;28(2):104-125. doi: 10.1123/ijsnem.2018-0020
    7. Mabrey G, Koozehchian MS, Newton AT, et al. The Effect of Creatine Nitrate and Caffeine Individually or Combined on Exercise Performance and Cognitive Function: A Randomized, Crossover, Double-Blind, Placebo-Controlled Trial. Nutrients. 2024;16(6):766. doi:10.3390/nu16060766
    8. Nunes EA, Colenso-Semple L, McKellar SR, et al. Systematic review and meta-analysis of protein intake to support muscle mass and function in healthy adults. J Cachexia Sarcopenia Muscle. 2022;13(2):795-810. doi: 10.1002/jcsm.12922
    9. Kedia AW, Hofheins JE, Habowski SM, et al. Effects of a pre-workout supplement on lean mass, muscular performance, subjective workout experience and biomarkers of safety. Int J Med Sci. 2014 Jan 2;11(2):116-26. doi: 10.7150/ijms.7073
    10. White CM. Dietary Supplements Pose Real Dangers to Patients. Ann Pharmacother. 2020 Aug;54(8):815-819. doi: 10.1177/1060028019900504
    11. Gutiérrez-Hellín J, Del Coso J, Franco-Andrés A, et al. Creatine Supplementation Beyond Athletics: Benefits of Different Types of Creatine for Women, Vegans, and Clinical Populations—A Narrative Review. Nutrients. 2025; 17(1):95. https://doi.org/10.3390/nu17010095
    12. Graham AS, Hatton RC. Creatine: a review of efficacy and safety. J Am Pharm Assoc (Wash). 1999;39(6):803-877.
    13. Fernandez MM, Hosey RG. Performance-enhancing drugs snare nonathletes, too. J Fam Pract. 2009;58(1):16-23.
    14. Creatine. Natural Medicines. Accessed June 5, 2025. https://naturalmedicines-therapeuticresearch-com.ezproxy.lib.uconn.edu/
    15. Antonio J, Candow DG, Forbes SC, et al. Common questions and misconceptions about creatine supplementation: what does the scientific evidence really show? J Int Soc Sports Nutr. 2021;18(1):13. doi: 10.1186/s12970-021-00412-w.
    16. Creatine. Cleveland Clinic. Updated April 26, 2023. Accessed June 5, 2025. https://my.clevelandclinic.org/health/treatments/17674-creatine.
    17. Jäger R, Purpura M, Shao A, et al. Analysis of the efficacy, safety, and regulatory status of novel forms of creatine. Amino Acids. 2011;40(5):1369-1383. doi:10.1007/s00726-011-0874-6
    18. Lanhers C, Pereira B, Naughton G, Trousselard M, Lesage FX, Dutheil F. Creatine Supplementation and Upper Limb Strength Performance: A Systematic Review and Meta-Analysis. Sports Med. 2017;47(1):163-173. doi:10.1007/s40279-016-0571-4
    19. Ferrari L, Panaite SA, Bertazzo A, Visioli F. Animal- and Plant-Based Protein Sources: A Scoping Review of Human Health Outcomes and Environmental Impact. Nutrients. 2022;14(23):5115. Published 2022 Dec 1. doi:10.3390/nu14235115
    20. How to choose the best protein powder for you. Cleveland Clinic. June 12, 2020. Accessed June 3, 2025. https://health.clevelandclinic.org/7-tips-choosing-best-protein-powder.
    21. Is whey protein good for you? Cleveland Clinic. January 4, 2021. Accessed June 5, 2025. https://health.clevelandclinic.org/is-whey-protein-good-for-you.
    22. Carbone JW, Pasiakos SM. Dietary protein and muscle mass: Translating science to application and Health Benefit. Nutrients. 2019;11(5):1136. doi:10.3390/nu11051136
    23. Wardlaw S. How Much Protein Do I Need if I Work Out? Mass General Brigham. January 4, 2024. Accessed June 5, 2025. https://www.massgeneralbrigham.org/en/about/newsroom/articles/how-much-protein-when-working-out.
    24. Thomas DT, Erdman KA, Burke LM. Position of the Academy of Nutrition and Dietetics, dietitians of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance. Journal of the Academy of Nutrition and Dietetics. 2016;116(3):501-528. doi:10.1016/j.jand.2015.12.006
    25. Latner JD, Wilson GT. Binge eating and satiety in bulimia nervosa and binge eating disorder: effects of macronutrient intake. Int J Eat Disord. 2004;36(4):402-415. doi:10.1002/eat.20060
    26. Hewlings SJ. Eating Disorders and Dietary Supplements: A Review of the Science. Nutrients. 2023;15(9):2076. Published 2023 Apr 25. doi:10.3390/nu15092076
    27. Hackert AN, Kniskern MA, Beasley TM. Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders. J Acad Nutr Diet. 2020;120(11):1902-1919.e54. doi:10.1016/j.jand.2020.07.014
    28. Gupta RS, Warren CM, Smith BM, et al. The Public Health Impact of Parent-Reported Childhood Food Allergies in the United States. Pediatrics. 2018;142(6):e20181235. doi:10.1542/peds.2018-1235
    29. Niederberger E, Parnham MJ. The Impact of Diet and Exercise on Drug Responses. Int J Mol Sci. 2021;22(14):7692. doi:10.3390/ijms22147692.
    30. Why vitamin K can be dangerous if you take warfarin. Cleveland Clinic. October 28, 2019. Accessed June 4, 2025. https://health.clevelandclinic.org/vitamin-k-can-dangerous-take-warfarin.
    31. The hidden dangers of protein powders. Harvard Health. August 15, 2022. Accessed July 8, 2025. https://www.health.harvard.edu/staying-healthy/the-hidden-dangers-of-protein-powders.
    32. Kelly OJ, Gilman JC, Ilich JZ. Utilizing dietary nutrient ratios in nutritional research: Expanding the concept of nutrient ratios to macronutrients. MDPI. January 28, 2019. Accessed June 4, 2025. https://www.mdpi.com/2072-6643/11/2/282
    33. Josse, A. R., Atkinson, S. A., Tarnopolsky, M. A., & Phillips, S. M. (2012). Diets higher in dairy foods and dietary protein support bone health during diet- and exercise-induced weight loss in overweight and obese premenopausal women. The Journal of clinical endocrinology and metabolism, 97(1), 251–260. https://doi.org/10.1210/jc.2011-2165
    34. Berryman CE, Agarwal S, Lieberman HR, Fulgoni VL, Pasiakos SM. Diets higher in animal and plant protein are associated with lower adiposity and do not impair kidney function in US adults. The American Journal of Clinical Nutrition. July 27, 2016. Accessed August 4, 2025. https://www.sciencedirect.com/science/article/pii/S0002916522045981?via%3Dihub.
    35. Adela H, Paul JF. Dietary protein and changes in biomarkers of inflammation and oxidative stress in the Framingham Heart Study Offspring Cohort. Current Developments in Nutrition. March 28, 2019. Accessed August 4, 2025. https://www.sciencedirect.com/science/article/pii/S2475299122130143.
    36. Jagim AR, Harty PS, Camic CL. Common Ingredient Profiles of Multi-Ingredient Pre-Workout Supplements. Nutrients. 2019;11(2):254. doi: 10.3390/nu11020254
    37. Martinez N, Campbell B, Franek M, et al. The effect of acute pre-workout supplementation on power and strength performance. J Int Soc Sports Nutr. 2016;13:29. doi: 10.1186/s12970-016-0138-7
    38. Saunders B, Elliott-Sale K, Artioli GG, et al. β-alanine supplementation to improve exercise capacity and performance: a systematic review and meta-analysis. Br J Sports Med. 2017;51(8):658-669. doi:10.1136/bjsports-2016-096396
    39. Beta-Alanine. Natural Medicines. Accessed June 5 2025. https://naturalmedicines-therapeuticresearch-com.ezproxy.lib.uconn.edu/
    40. Caffeine. Natural medicines. Accessed June 5, 2025. https://naturalmedicines-therapeuticresearch-com.ezproxy.lib.uconn.edu/
    41. Hughes A. Acute Caffeine Poisoning. UpToDate. UpToDate, Inc. Updated April 7, 2025. Accessed June 3, 2025. https://www.uptodate.com
    42. Cornelis MC, El-Sohemy A, Kabagambe EK, Campos H. Coffee, CYP1A2 genotype, and risk of myocardial infarction. JAMA. 2006;295(10):1135-1141. doi:10.1001/jama.295.10.1135
    43. Sachse C, Brockmöller J, Bauer S, Roots I. Functional significance of a C-->A polymorphism in intron 1 of the cytochrome P450 CYP1A2 gene tested with caffeine. Br J Clin Pharmacol. 1999;47(4):445-449. doi:10.1046/j.1365-2125.1999.00898.x

    Patient Safety: Polypharmacy in Vulnerable Older Adults: Why, Who, When, What, and How to Safely Deprescribe

    Learning Objectives

     

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

    1. Describe the risk of suboptimal medication use, including polypharmacy, in frail, older populations
    2. Recognize facilitators and barriers when managing polypharmacy
    3. Identify instances of inappropriate polypharmacy
    4. Apply an action plan for meaningful deprescribing

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

    1. Describe polypharmacy and its impact on frail, older population
    2. Recognize facilitators and barriers when managing polypharmacy
    3. Identify recommended strategies for deprescribing
    4. Infer when to refer patients for action plans to implement meaningful deprescribing

        Multi-colored tablets and capsules floating over a cartoon hand

        Release Date:

        Release Date: July 15, 2025

        Expiration Date: July 15, 2028

        Course Fee

        FREE

        ACPE UANs

        Pharmacist: 0009-0000-25-049-H05-P

        Pharmacy Technician: 0009-0000-25-049-H05-T

        Session Codes

        Pharmacist: 25YC49-HLK

        Pharmacy Technician: 25YC49-KHL

        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 0009-0000-25-049-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

        Lisa A. Rosenberg, PharmD, BCGP
        Clinical Initiative Manager
        CareKinesis, AnewHealth
        Moorestown, NJ
         

        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.

        Lisa A. Rosenberg, PharmD, BCGP has no relationships with ineligible companies and therefore have nothing to disclose.

        ABSTRACT

        Earlier thought was “more care is better,” and prescribers were perceived as ignoring their patients’ interests if they did not prescribe certain medications. The Choosing Wisely Campaign brought awareness about potentially doing more harm than good within healthcare. Healthcare providers are encouraged to have conversations with patients about potentially unnecessary treatments and overuse. The Beers criteria by the American Geriatrics Society and Screening Tool of Older Persons’ Prescriptions (STOPP) criteria describe potentially inappropriate medications (PIMs) in older adults. As healthcare providers engage patients and caregivers in the medication use process, conversations about deprescribing ought to occur to mitigate potential harm and overuse. To improve the safety of medication use, as with prescribing, deprescribing should be a patient-centered approach. Pharmacists must identify the right patient and the right time to consider deprescribing, and upon identifying the right medication, use an evidence-based strategy to safely deprescribe. This continuing education activity describes best practices for deprescribing with a focus on why and how to safely do so in the vulnerable older adult population.

        CONTENT

        Content

        INTRODUCTION

        The number of older adults (aged 65 years and older) is expected to exceed 1.5 billion by 2050.1 Multimorbidity is expected to affect 65% of older adults aged 65 to 84 years and up to 82% of those aged 85 years or older.1 With multimorbidity, the number of medications taken by the vulnerable older adult population increases. Along with drug-disease and drug-drug interactions, age-related physiological changes that alter pharmacokinetics and pharmacodynamics increase the risk of adverse drug events (ADEs).2

         

        Throughout this continuing education activity, consider a hypothetical patient, Ms. Polly, who is an 85-year-old female. Enrolled in a Program of All-Inclusive Care for the Elderly (PACE), she has been able to live safely at home. Table 1 lists her current medication regimen.

         

        Table 1. Medication Regimen
        Acetaminophen/diphenhydramine PM 25/500 mg, 2 tablets nightly PRN for insomnia

        Alendronate 70 mg weekly for osteoporosis

        Amlodipine 10 mg daily for hypertension

        Aspirin 81 mg daily for heart attack prevention

        Cetirizine 10 mg daily for allergies

        Donepezil 10 mg daily for Alzheimer’s disease

        Fluticasone nasal spray 2 sprays in each nostril daily for allergies

        Furosemide 20 mg daily for peripheral edema

        Gabapentin 300 mg twice daily for neuropathic pain

        Glipizide ER 5 mg daily for pre-diabetes

        Ibuprofen 200 mg three times daily for pain

        Omega-3 Fish Oil 1000 mg twice daily for hyperlipidemia

        Oxybutynin 5 mg twice daily for overactive bladder

        Pantoprazole 40 mg daily for GERD

        Paroxetine 30 mg daily for depression

        Potassium chloride 10 mEq daily for potassium deficiency

        Pravastatin 40 mg daily for hyperlipidemia

        Propranolol 40 mg twice daily for hypertension

        Senna-docusate 8.6-50 mg, 2 tablets daily for constipation

        ABBREVIATIONS: GERD = gastroesophageal reflux disease; mEq = milliequivalent; mg = milligrams; PRN = as needed

         

        Ms. Polly’s healthcare needs have become more complex with her increasing confusion, declining ability to perform activities of daily living, and a recent fall. Her daughter continues to be her main caregiver and has requested more help from PACE; thus, the prescriber has reached out to the clinical pharmacist for assistance. This CE activity will review best practices for deprescribing with a focus on why, who, when, what, and how to safely deprescribe medications in the vulnerable older adult population.

         

        WHY, WHO, AND WHEN TO DEPRESCRIBE

         

        WHY: Older Adults Have Specific Needs

        Since older adults have differing health and functional statuses, prescribers must individualize medication selection for these patients. Prescribing the right medication and dose for the right indication at the right time while providing benefit and avoiding ADEs is challenging. Comorbidities and complexity of medication regimens may result in suboptimal medication use. Suboptimal medication use comprises (1) underprescribing, (2) polypharmacy or overuse, and (3) high-risk prescribing, such as potentially inappropriate medications (PIMs), prescribing cascades, and anticholinergic and sedative effects.2

         

        Estimates suggest that as many as 65% of older adults in the United States are exposed to polypharmacy and 29% to PIMs.3,4 Polypharmacy is generally defined as the use of five or more medications and often occurs because of a prescribing cascade, which means the culprit medication causes an ADE that is mistaken for a new medical condition for which a subsequent medication is initiated as treatment. “Hyperpolypharmacy” or “excessive polypharmacy” is generally considered the use of 10 or more medications.5 Polypharmacy is associated with undesirable outcomes: frailty, cognitive decline, functional decline, falls, fractures, emergency department (ED) visits, hospitalizations, and mortality.3,5,6

         

        Evidence suggests that older age and indicators of poor health (i.e., multiple chronic conditions, cognitive decline, frailty) are risk factors for polypharmacy. The number of medications in a patient’s regimen may be the single most important predictor of ADEs.6 The likelihood of taking inappropriate medication increases with the number of drugs prescribed. Experts consider medications inappropriate in older adults when they pose individual or cumulative adverse event risk.

         

        The Choosing Wisely Campaign brought awareness and encouraged conversations between healthcare providers and patients about medication overuse and potentially doing more harm than good within healthcare. This partnership between the American Board of Internal Medicine (ABIM) Foundation and specialty societies was formed in 2012. At the time, the healthcare field and society generally thought that more care was better, and patients tended to perceive prescribers as ignoring their patients’ interests if they did not prescribe certain medications.7

         

        Understanding suboptimal prescribing allows healthcare providers to mitigate the risk of poor health outcomes in vulnerable older adults. Deprescribing is the process of healthcare professional-supervised medication withdrawal with the goal of managing polypharmacy and improving outcomes.8 Pharmacists review medication regimens comprehensively to identify and consider discontinuation of high-risk medications and those that cause more harm than benefit. Deprescribing encourages a proactive and systematic approach to mitigate potential medication-related problems (MRPs). This approach is preferable over a reactive approach (i.e., discontinuing an offending medication after an ADE occurs).

         

        PAUSE AND PONDER: Why should healthcare providers re-evaluate medications periodically?

         

        According to the World Health Organization, the global ADE-related mortality rate increased approximately 3.3-fold from 2001 to 2019, with the highest rates occurring in those aged 75 years and older.9 A systematic review of 14 hospital-based observational studies in older adults found an ADE to occur more often with an increased number of medications.10 More than 50% of ADEs could be prevented with safe prescribing practices.5 Safe medication use requires that healthcare providers ensure regimen appropriateness, considering treatment initiation, treatment optimization, and cessation of unnecessary or inappropriate medications.

         

        WHO: The Age-Friendly Movement

        The Institute for Healthcare Improvement in partnership with The John A. Hartford Foundation, American Hospital Association, and the Catholic Health Association developed the Age-Friendly Health Systems initiative to improve the care of older adults and the lives of caregivers. This framework—the Age-Friendly 4Ms, depicted in Figure 1—is a patient-centered approach to medication optimization that addresses polypharmacy and deprescribing. Conversations with healthcare providers can be re-framed to discuss “What Matters” to the patients and caregivers. Medications impact all the “M” domains: What Matters, Mentation and Mobility.11,12

         

        Figure 1. Age-Friendly Health Systems 4Ms Framework11

         

        Reasons for deprescribing may vary from patient to patient. When reviewing common goals for deprescribing, consider the perspectives of the patient, the caregiver, and the healthcare team. Identify which reasons for deprescribing may be most relevant or meaningful to each party involved in the patient’s care. Examples include

        • reducing medication regimen complexity and pill burden to improve adherence
        • reducing anticholinergic burden to improve and/or preserve cognitive function
        • reducing fall and fracture risk
        • reducing hospitalizations
        • reducing mortality
        • reducing costs

         

        These deprescribing goals improve patients’ quality of life. Deprescribing considers not only single medications but also the aggregate interaction risk from multiple medications.13

         

        Deprescribing often presents challenges due to barriers faced by healthcare providers and patients. Healthcare providers’ may have limited time and lack of training which serves as the most significant barriers. Patient-related barriers to deprescribing include satisfaction with medications, reluctance, resistance to change, and opposition to alternative treatments. Despite these challenges, many barriers can be addressed through education, communication, and shared decision-making.

         

        Although many patients express not wanting to take medications, their beliefs and acceptance of polypharmacy and discontinuing medications is poorly understood. To further understand patients’ views, preferences and willingness, researchers from the University of South Australia and University of Sydney developed the Patients’ Attitudes Towards Deprescribing (PATD) questionnaires, including the revised PATD for older adults and caregivers and the revised PATD for cognitively impaired individuals (rPATDcog).14-16

         

        A population-based survey of Medicare beneficiaries 65 years and older using PATD questions found most older adults are open to having one or more medications deprescribed and two-thirds want to reduce the number of medications taken.17 A multi-center cross-sectional survey found older adults and caregivers are open to deprescribing, with more than 90% willing to discontinue a medication if a healthcare provider initiates the conversation.18

         

        While primarily used for research, providers may use the revised PATD questionnaire clinically to target patients and caregivers who are willing to discontinue medications. The original work is available here: https://www.australiandeprescribingnetwork.com.au/925-2/.16 Understanding attitudes and willingness may enhance shared decision-making conversations about deprescribing.

         

        PAUSE AND PONDER: How do you determine which medications to deprescribe?

         

        WHEN TO DEPRESCRIBE

        Older adults are often high-risk for potential MRPs due to pharmacokinetic (the body’s effect on a medication) and pharmacodynamic (a medication’s effect on the body) changes. However, advanced age is not an independent risk factor for MRPs. Elements of high-risk patients who may benefit from deprescribing include the following19:

        • Polypharmacy: Use of multiple medications is the strongest risk factor for MRPs. Table 2 lists common types of potential MRPs.
        • Multimorbidity: Having multiple chronic conditions increases the risk of drug-disease interactions.
        • Renal impairment: Reduced renal function increases ADE risk.
        • Transitions of care: Medication management by multiple prescribers can result in miscommunication and medication discrepancies, such as inadvertent continuation.
        • Nonadherence: Patients may be nonadherent to their medication regimens due to experiencing real or perceived adverse effects and/or lack of benefit, complexity, burden, and cost.
        • Limited life expectancy/end of life care: Goals of care change from slowing disease progression and prolonging life to improving quality of life. Patients may no longer benefit from preventive medications and use certain medications for symptomatic management.
        • Frailty and dementia: Frailty—an age-related syndrome of physiologic decline—is associated with increased adverse events and risk of harm, such as falls, which can be detrimental. ADEs may worsen or exacerbate these syndromes (i.e., fatigue or cognitive impairment).

         

        Table 2. Types of Potential Medication-Related Problems
        Adverse Drug Events

        Adverse Drug Interactions

        Excessive Duration

        Inappropriate/Unnecessary Medications

        Ineffective Therapy

        No Indication

        Nonadherence

        Suboptimal Dosing

        Supratherapeutic Dosing

         

         

        Aging is not an identical experience for every person, so frailty—declining mental and physical resilience, or the ability to bounce back and recover from events like illness and injury—is a more appropriate measure of health status than age alone. Frailty has been associated with poor patient outcomes. The Edmonton Frail Scale is a validated, reliable, and multidimensional screening tool for all healthcare settings. The free tool with a training course is available here: https://edmontonfrailscale.org/. It assesses nine domains: cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence, and functional performance. The highest level of frailty is a score of 17.20 Assessing frailty severity can help with shared decision-making and determining goals of care.

         

        PAUSE AND PONDER: How can you use prescribing clinical tools for deprescribing?

         

        WHAT TO DEPRESCRIBE

        While few studies have measured the clinical implications of underprescribing, evidence has shown an association between polypharmacy and PIMs. A systematic review of 38 clinical trials found that deprescribing interventions in community-dwelling older adults (aged 65 years and older) may provide small reductions in use of PIMs and mortality.6 Prescribers and pharmacists should periodically reevaluate any medication initially prescribed for a clinical indication since benefits, risks, conditions, and comorbidities change over time, which may result in inappropriate use. Medication review should consider the following factors: goals of care, remaining life expectancy, treatment targets, time until benefit, number needed to treat (NNT, a statistical measure that indicates how many patients need to be treated with a specific intervention to prevent one additional adverse outcome), number needed to harm, and ADEs.21

         

        Collaborative approaches and numerous clinical application tools highlighted below are available for safe prescribing and to reduce medication overuse. Focusing on medications and potential ADE risk, healthcare providers can employ these clinical tools to identify medications for potential deprescribing.

         

        Risk-Benefit Analysis

        Older adults are vulnerable to ADEs associated with “high-risk” single medications and medication classes, including anticoagulants, benzodiazepines, cardiovascular agents, digoxin, hypoglycemics, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, psychotropics, and those with anticholinergic effects. “High-risk” medication combinations—for example, angiotensin-converting enzyme inhibitors, diuretics, and NSAIDs in patients with chronic kidney disease (known as the “triple whammy”)—augment ADE risk.13

         

        In a “Less is More” special communication about polypharmacy and deprescribing, experts proposed grouping medications into two categories for older adults to determine if the likely benefit outweighs potential risk/harm, while noting that medications may fall into both categories.13

         

        “Disease and/or symptom control medications” are used to manage active disease and symptoms and help maintain quality of life.13 Discontinuing these medications could result in symptom return or functional decline due to disease worsening. Examples include analgesics, anti-anginals, anti-heart failure medications, and levothyroxine. Dose reduction of disease/symptom control drugs may be appropriate if symptoms are mild or intermittent, but these should be discontinued if altogether ineffective. Notably, aggressive treatment may be inappropriate for hypertension or diabetes management in some older adults, as this could increase the risks of hypotension or hypoglycemia, respectively.13

         

        Preventive medications are intended to prevent future morbid events.13 Their use should be guided by assessment of absolute risks and benefits of treatment for individual patients, taking into consideration the time required for benefit (known as "time to benefit"), patient preferences, and estimated life expectancy. For example, osteoporosis guidelines recommend a “drug holiday” (temporary discontinuation of therapy) from bisphosphonates depending on fracture risk after five years of treatment to mitigate risk of atypical femoral fractures and osteonecrosis of the jaw. Despite discontinuation, bisphosphonates’ anti-fracture effects persist because this medication class has long half-lives and remain stored in bone for up to 10 years. Another example is statins, which are commonly used for primary prevention of cardiovascular events. Evidence suggests that statin discontinuation after eight years does not increase cardiovascular event risk.13

         

        Choosing Wisely Campaign

        The American Board of Internal Medicine’s global Choosing Wisely (CW) Campaign encourages patient engagement and healthcare provider conversation to choose care that is evidence-based, necessary, and free from harm. Since 2012, a compilation of more than 600 evidence-based statements from approximately 80 healthcare organizations advise healthcare providers, patients, and caregivers about optimization, appropriateness, and avoidance of unnecessary medical testing and treatments, available at https://www.choosingwisely.org/.7,22,23,24

         

        The American Society of Consultant Pharmacists (ASCP) convened a task force in 2018 under the CW campaign to further help pharmacists initiate and implement deprescribing. The task force reinforced deprescribing in older adults by reviewing and providing evidence-based references. ASCP’s guidance provides ten statements focused on avoiding DDIs and prescribing cascades and encouraged medication reviews to mitigate potential ADEs25:

        1. DO NOT initiate medications to treat new and emerging symptoms without first ascertaining that the new symptom is not an ADE related to an already prescribed medication.
        2. DO NOT continue medications at care transitions without reviewing and reconciling to verify accurate and complete medication lists in concert with current medical problems.
        3. DO NOT recommend highly anticholinergic medications in older adults without first considering safer alternatives or non-pharmacologic measures.
        4. DO NOT use anticholinergics concomitantly with cholinesterase inhibitors for dementia.
        5. DO NOT use two or more medications known to increase bleeding risk (e.g., antiplatelets, direct oral anticoagulants [DOACs], warfarin, aspirin, NSAIDs, corticosteroids, selective serotonin reuptake inhibitors), without evaluating the potential risks and benefits.
        6. DO NOT prescribe or routinely continue medications for older adults with limited life expectancy without consideration to individual goals of care, presence of comorbidities, and time to benefit for preventive medications.
        7. DO NOT use three or more central nervous system-active medications (e.g., antidepressants, antipsychotics, benzodiazepines, antiepileptics, Z-drugs, opioids, gabapentinoids).
        8. DO NOT combine opioids with benzodiazepines or gabapentinoids to treat pain and DO re-evaluate routinely for deprescribing during chronic use.
        9. DO NOT prescribe tramadol without consideration of the potential risks and harms related to serotonergic excess, seizures, falls, and drug-drug interactions (DDIs).
        10. DO NOT use strong CYP3A4 and P-glycoprotein inhibitors or inducers with DOACs and DO periodically assess for such DDIs.

         

        The American Geriatrics Society (AGS) also worked on the CW campaign to identify treatments that potentially have more risks than benefits in older adults, concluding the following26:

        • DO NOT use antipsychotics first-line to treat behavioral and psychological symptoms of dementia.
        • DO NOT use benzodiazepines or sedative-hypnotics first-line for insomnia, agitation, or delirium.
        • DO NOT use cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
        • DO NOT use antidiabetics to achieve hemoglobin A1c less than 7.5% in most older adults; moderate control is generally better.
        • DO NOT use antimicrobials to treat bacteriuria in older adults unless they experience specific urinary tract symptoms.
        • DO NOT maintain long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce PPI at least once per year in most patients.
        • DO NOT use NSAIDs for patients with hypertension, heart failure, or chronic kidney disease.
        • DO NOT use prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia (unexplained wasting) in older adults.
        • DO NOT prescribe medication without conducting a medication regimen review.

         

        Prescribing Cascades

        It bears repeating that providers should not initiate medications—prescription or over-the-counter (OTC)—or use a new medical device to treat new and emerging symptoms without first ascertaining that the new symptom is not an ADE of an already prescribed medication.24 This is the first CW statement endorsed by ASCP and it describes a prescribing cascade. Prescribing cascades are preventable, yet often unrecognized, even though researchers in the geriatric field first introduced the concept in the 1990s and then revisited and expanded upon it in 2017.27,28 They emphasized that “the identification and interruption of prescribing cascades is an important, actionable, and underappreciated opportunity to improve medication safety in older people.”27,28

         

        Prescribing cascades contribute to polypharmacy and adverse outcomes in vulnerable older adults. By becoming familiar with the common prescribing cascades, outlined in Table 3, pharmacists and pharmacy technicians can identify culprit and cascade medications. If culprit medications remain clinically indicated, prescribers should use the lowest possible dose, a safer alternative with fewer adverse effects, or non-pharmacologic therapy, rather than initiating a cascade medication to address the ADE.

        Table 3. Prescribing Cascades to Avoid or Amend29
        CULPRIT MEDICATION ADVERSE DRUG EVENT CASCADE MEDICATION
        ACE inhibitors Cough Cough suppressants
        Alpha-1 blockers Orthostatic hypotension Meclizine
        Amiodarone Tremor Lithium
        Hypothyroidism Thyroid hormones
        Amitriptyline Cognitive impairment Cholinesterase inhibitors
        Antipsychotics Cognitive impairment Cholinesterase inhibitors
        Extrapyramidal symptoms Benztropine
        Benzodiazepines Cognitive impairment Cholinesterase inhibitors
        Beta blockers Depression Antidepressants
        Bisphosphonates GERD PPIs/H2RAs
        Bupropion Insomnia Sedatives-hypnotics
        Calcium channel blockers Constipation Laxatives
        Peripheral edema Diuretics
        Cholinesterase inhibitors Insomnia Sedatives-hypnotics
        Urinary incontinence OAB anticholinergics
        Corticosteroids Insomnia Sedatives-hypnotics
        Diuretics Urinary incontinence OAB anticholinergics
        Dopaminergics Psychotic symptoms Antipsychotics
        Gabapentinoids Peripheral edema Diuretics
        Lithium Extrapyramidal symptoms Antiparkinsonians
        Tremor Propranolol
        Metoclopramide Extrapyramidal symptoms Antiparkinsonians
        NSAIDs GI bleeding or heartburn PPIs/H2RAs
        Hypertension Antihypertensives
        OAB anticholinergics Cognitive impairment Cholinesterase inhibitors
        SGLT2 inhibitors Urinary tract infections Antibiotics
        SSRIs/SNRIs Insomnia Sedatives-hypnotics
        Statins Myalgia NSAIDs/opioids
        Thiazide diuretics Hyperuricemia or gout Allopurinol/colchicine

        ABBREVIATIONS: GERD = Gastroesophageal reflux disease; GI = Gastrointestinal; H2RAs = Histamine-2 receptor antagonists; NSAIDs = Non-steroidal anti-inflammatory drugs; OAB = Overactive bladder; PPIs = Proton pump inhibitors; SGLT2 = Sodium glucose cotransporter-2; SNRIs = Serotonin norepinephrine reuptake inhibitors; SSRIs = Selective serotonin reuptake inhibitors

         

        Anticholinergic Medications

        Older adults are more sensitive to anticholinergic adverse effects, including confusion, dry mouth, blurry vision, constipation, and urinary retention. A large case-control observational study of 58,769 patients diagnosed with dementia and 225,574 matched controls found statistically significant associations of dementia risk with exposure to anticholinergic medications, such as antidepressants, antipsychotics, antiparkinsonians, antiepileptics, and bladder anticholinergics.30 Participants who took a single strong anticholinergic medication daily for three years had almost 50% increased odds of dementia within a 10-year period. Dementia risk was increased in patients taking more than one anticholinergic medication due to the cumulative impact.30 Pharmacists can use one or a combination of multiple validated expert anticholinergic scales to calculate aggregate anticholinergic scores. An anticholinergic burden score of three or higher is associated with increased cognitive impairment and mortality. The most frequently validated scale is the Anticholinergic Cognitive Burden (ACB) scale.31,32 An Anticholinergic Burden Calculator is available at no cost for use here: https://www.acbcalc.com/.

         

        A small longitudinal study of 69 participants found those who took an anticholinergic medication in combination with the cholinesterase inhibitor donepezil over a two year period declined by seven points on the Mini-Mental State Examination as compared with a three point decline in those taking donepezil alone.33 Thus, concomitant therapy with anticholinergics may counteract efficacy of cholinesterase therapy, resulting in a more rapid cognitive and functional decline.

         

        Revisiting the case, Ms. Polly is taking donepezil for Alzheimer’s disease. Her prescriber consults with the pharmacist to initiate memantine for her progressive dementia due to increasing confusion and declining function. Medication review identifies several medications with anticholinergic effects that may be worsening Ms. Polly’s cognitive function, including cetirizine, diphenhydramine, furosemide, oxybutynin, and paroxetine. The pharmacist recommends deprescribing anticholinergic medications for which risk outweighs benefit. With reducing aggregate anticholinergic burden, donepezil may be more effective. This avoids added polypharmacy by initiating memantine, effectively preventing a prescribing cascade. Following discontinuation of these medications, the pharmacy technician can follow up with Ms. Polly and her caregiver to assess if there has been improvement.

         

        Resources are available to assess polypharmacy and identify PIMs in vulnerable, older adults. The following section provides an overview, applicability, and utility in practice for the most common clinical tools: Beers Criteria, STOPP/START Criteria, STOPPFall Criteria, STOPPFrail Criteria, and the Medication Appropriateness Index.

         

        Beers Criteria

        The late Mark Beers, MD and his colleagues developed the Beers Criteria in 1991 with a mission to identify medications for which potential harm outweighed expected benefit and that should be avoided in long-term facilities. Since then, several updates have expanded the criteria to apply to older adults aged 65 years and older in ambulatory, acute, and institutionalized care settings, except end-of-life and hospice. Upon Dr. Beers’s death, AGS assumed responsibility for maintaining the criteria.

         

        The 2023 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is a well-known, widely available clinical tool to support shared clinical decision-making. It is available for free in the Journal of the American Geriatrics Society.34 For ease of clinical practice application, the AGS provides a pocket card and an app, for a fee, available at https://geriatricscareonline.org/. To encourage engagement and conversation, AGS provides patient and caregiver educational resources that are available for free at https://www.healthinaging.org/.

         

        The AGS Beers Criteria lists medications and medication classes that the society and its geriatric expert panel consider potentially inappropriate for use in older adults. The criteria are structured by category with each section including a clear rationale and recommendation:

        1. Medications considered potentially inappropriate
        2. Medications potentially inappropriate in patients with certain diseases or syndromes
        3. Medications to use with caution
        4. Potentially inappropriate drug-drug interactions
        5. Medications to avoid or adjust dosages based on renal function
        6. Medications with strong anticholinergic effects

         

        Importantly, the identified medications are “potentially inappropriate” rather than “definitely inappropriate.” The key word is “potentially,” as the prescribing and deprescribing processes are to be patient centric. The AGS panel recognizes that harm is typically more pronounced in the “old-old” than in the “young-old” and in patients with complex multi-morbidity and frailty.34 The indicators are categorized based on whether they involve avoiding the initiation of a PIM or discontinuing one that is already prescribed. To apply the AGS Beers Criteria, prescribers and pharmacists must identify the PIMs and, when clinically appropriate, consider safer pharmacologic or nonpharmacologic alternatives.

         

        STOPP/START Criteria

        The Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria are additional resources for identifying potentially inappropriate prescribing in older adults. These aim to identify PIMs and potential prescribing omissions, respectively.35 The STOPP criteria are most helpful in the context of polypharmacy. The original version, published in 2008, included 65 STOPP criteria, which more than doubled in the third version, updated in 2023, with 133 STOPP criteria. These more expansive criteria assist pharmacists and pharmacy technicians in identifying and preventing more DDIs, drug-disease interactions, and potential ADEs during medication reviews.

         

        The STOPP criteria is divided into sections by organ systems—including cardiovascular, coagulation, central nervous, renal, gastrointestinal, respiratory, musculoskeletal, urogenital, and endocrine—with separate sections for drugs that increase fall risk, analgesics, and antimuscarinic or anticholinergic drugs.35 The criteria also address the need to clarify an indication for each medication, labeling the following as PIMs:

        • Any medication prescribed without a clinical indication
        • Any medication prescribed beyond recommended duration
        • Any duplicate medication class

         

        Additional variations of the STOPP criteria help healthcare providers to identify PIMs in older adults with a high risk of falls (STOPPFall) and in those with limited life expectancy (STOPPFrail).36,37 STOPPFall identifies medication classes considered to be fall-risk-increasing-drugs (FRIDs). To further assist in shared-decision making of deprescribing, practical decision trees based on the STOPPFall guidance are available online (https://kik.amc.nl/falls/decision-tree/).36

         

        While most prescribing tools are designed to identify and prevent PIMs in the general older population, STOPPFrail consists of 27 potentially inappropriate prescribing indicators to assist healthcare providers in deprescribing in frail older adults.37 Deprescribing in frail older adults may improve their quality of life through a reduction in adverse events, hospitalizations, and mortality. Medication review in this population should focus on deprescribing and symptom management, rather than preventive and intensive treatment. STOPPFrail is applicable in adults aged 65 or older who meet all the following criteria37:

        • End-stage irreversible pathology
        • Poor one year survival prognosis
        • Severe functional or cognitive impairment or both
        • Symptom control is priority rather than preventing disease progression

         

        Example criteria include37

        • Avoid antiplatelets for primary cardiovascular prevention due to lack of evidence
        • Bisphosphonates are unlikely to be beneficial for short-term osteoporosis treatment
        • Aim for antidiabetic monotherapy with less stringent glycemic control (i.e., hemoglobin A1c goal of less than 8%)

         

        End-of-Life Care

        Prescribers and pharmacists should re-evaluate medications and minimize the pill burden for patients receiving palliative care, particularly at end-of-life (i.e., life expectancy of less than three months). Prevention of long-term complications is no longer indicated.21 Rather, the goal is comfort care through symptom-specific medications (SSMs) to treat pain, dyspnea (shortness of breath), nausea, cognitive disturbances, anxiety, and depression. The number of SSMs increases while the number of medications intended to treat comorbidities decreases. Therefore, the definition of polypharmacy shifts for end-of-life care, focusing on inappropriate medication use.

         

        The shared decision-making process must still consider patient and caregiver preferences. While some patients may prefer only symptomatic treatment without life-prolonging measures, other patients may feel neglected following discontinuation of certain long-term medications.21 A literature review of 67 articles established preliminary recommendations for long-term medication classes shown in Table 4.21

         

        Table 4. Deprescribing at End-of-Life21
        MEDICATION CLASS RECOMMENDED ACTION PLAN GDR
        Anticoagulants Discontinue for deep vein thrombosis primary prevention No
        Antihyperglycemics Reduced dosages to prevent hypoglycemia Variable
        Antihypertensives Discontinue for hypertension Yes
        Antimicrobials Variable: goal is symptom control No
        Statins Discontinue No

        ABBREVIATIONS: GDR = gradual dose reduction

         

        Medication Appropriateness Index

        Unlike the previously mentioned clinical tools that are PIMs and medication class lists developed by expert consensus; the Medication Appropriateness Index (MAI) is patient centric. The MAI, developed more than 30 years ago, is a patient screening tool that measures potentially inappropriate prescribing in older adults. The 10 simple questions focus on indication, effectiveness, dosing, duration, and potential for interactions to ultimately rate medications as appropriate, marginally appropriate, or inappropriate.38,39 A MAI Calculator is available at no cost for use here: https://globalrph.com/medcalcs/medication-appropriateness-index-calculator/.

         

        HOW TO SAFELY DEPRESCRIBE

         

        Deprescribing Tools

        Once polypharmacy and PIMs are identified, many clinical tools are available to analyze benefit versus risk and guide pharmacy teams on how to safely discontinue specific medications and medication classes.

         

        Deprescribing.org

        https://deprescribing.org/resources/

        Canadian Medication Appropriateness and Deprescribing Network

        https://www.deprescribingnetwork.ca/professionals

         

        Deprescribing.org is a website developed by Canadian pharmacists that provides guidance, tools, and approaches for deprescribing.40 Included within these resources are evidence-based guidelines and easy to use algorithms to determine when and how to stop specific medication classes: antihyperglycemics, antipsychotics, benzodiazepines, cholinesterase inhibitors, memantine, and PPIs.40 The companion site, Canadian Medication Appropriateness and Deprescribing Network, provides additional guidance on commonly inappropriate medications for healthcare providers and patients, including a Deprescribing Educational Program and brochures.41

         

        US Deprescribing Research Network https://deprescribingresearch.org/resources-2/resources-for-clinicians/

        The US Deprescribing Research Network is a tool funded by the National Institute of Aging to develop and provide information on deprescribing for older adults.42 The network’s efforts center around four “cores” addressing the needs of different stakeholders (e.g., researchers, patients) and a series of working groups focusing on research and standardized outcome measures. Resources for healthcare providers promote education by providing guides for specific medication classes and reference the deprescribing tools described above.42

         

        Primary Health Tasmania https://www.primaryhealthtas.com.au/resources/deprescribing-resources/

        Primary Health Tasmania is a not-for-profit organization in Australia that provides a comprehensive guide to personalized deprescribing, including principles, assessment of benefit versus harm, and patient and healthcare provider perceptions. These in-depth guidelines recommend deprescribing strategies for an extensive list of common medication classes: allopurinol, anticholinergics, anticoagulants, antiepileptics, antihyperglycemics, antihypertensives, antiplatelets, antipsychotics, benzodiazepines, bisphosphonates, cholinesterase inhibitors, gabapentinoids, glaucoma ophthalmics, inhaled corticosteroids, long-acting nitrates, NSAIDs, opioids, PPIs, statins, and calcium and vitamin D.43

         

        MedStopper https://medstopper.com/

        MedStopper is an online clinical tool for polypharmacy that assists healthcare providers, patients, and caregivers in the shared decision-making process and prioritization of deprescribing.44 Upon entering a patient’s regimen, MedStopper arranges the medications from “more likely to stop” to “less likely to stop,” based on the criteria in Table 5. A team of clinicians and researchers affiliated with Canadian healthcare institutions, including the University of British Columbia and the Centre for Effective Practice developed this site and is grounded in evidence-based resources such as the Beers and STOPP/START Criteria. However, it remains in the Beta testing phase, so pharmacy teams should still use it with caution.44

         

        Table 5. Deprescribing Opportunities and Prioritization44
        Medication Conversation
        Potential to improve symptoms Is the medication helping symptoms?
        Potential to reduce the risk of future illness Does the effectiveness justify the potential adverse effects, inconvenience, and cost?
        Likelihood to cause harm Are symptoms caused by medications?

         

        Using the Edmonton Frail Scale, healthcare providers can identify patients as frail to adjust MedStopper’s “may cause harm” ranking. The specific indication for each medication affects the ranking categories for “may improve symptoms” or “may reduce future illness.” Categories are based on the rating levels of an unhappy, neutral, or happy face, with a color-coded discontinuation priority. Medications and indications also include links for resources, such as calculators for risk/benefit assessment, NNT, Beers Criteria, or STOPP Criteria. Healthcare providers can reference the tapering suggestions and symptom monitoring, as appropriate.44

         

        Go back and review Ms. Polly’s medication regimen in Table 1. Which medications may be inappropriate based on the numerous prescribing and deprescribing tools that are readily available? Figure 2 shows a snapshot of a suggested plan for deprescribing utilizing the MedStopper clinical tool.

         

        Figure 2. Deprescribing Plan Based on Stopping Priority by MedStopper

        NOTE: Incomplete medication regimen

         

        PAUSE AND PONDER: When do medications need a gradual dose reduction for discontinuation?

         

        Pharmacist-Led Deprescribing

        Research shows that comprehensive medication reviews may reduce PIM use and mortality in community-dwelling older adults aged 65 years and older.6 A narrative review of 25 global randomized controlled trials found that pharmacist-led deprescribing interventions had a beneficial effect on 69% of medication outcomes—including discontinuation, dose reductions, and medication changes—for patients with a mean age of 60 years or older residing in the community and nursing facilities.45

         

        Pharmacists must follow a stepwise, patient-centric approach to deprescribing, while performing a comprehensive medication review of prescription and OTC medications as depicted in Figure 3. Since prescribing and deprescribing clinical tools do not consider preferences, life expectancy, and goals of care, it is essential to understand “what matters” to the patient and/or caregiver.

         

        Figure 3. Stepwise Approach to Deprescribing

        ABBREVIATIONS: MRPs = medication-related problems

         

        Prescribers, pharmacists, and pharmacy technicians should assess if patients are not adhering to prescribed medications and, if not, why. Opportunities to deprescribe may be identified by asking just one question to a patient and/or caregiver. Pharmacy technicians are typically trained to ask, “do you have any questions for the pharmacist about your medication?” Instead, open-ended questions, such as “how do you feel about the number and types of medication you take?” or “how did your new medication help with your symptoms?” could gather more useful information. It is also important to ask if patients experience any adverse effects from their medications.

         

        What Matters and Shared Goals

        Deprescribing conversations ought to involve shared decision-making. Research shows older adults’ priorities are typically maintaining cognition, function, and independence over life extension.46,47 Patient preferences and health status change over time. Knowing a patient’s priorities and preferences about medication use helps align treatment decisions and guide deprescribing.

         

        To determine a patient’s health priorities and preferences, healthcare providers can use the universal health Outcome Prioritization Tool (OPT) which is nonspecific to diseases and treatments. This simple tool elicits the preferences of older adults by having them consider trade-offs and rank the relative importance of four health outcomes46,47:

        1. extending life (regardless of health)
        2. preserving independence/maintaining function and activities of daily living
        3. reducing or eliminating pain
        4. reducing or eliminating symptoms (e.g., dizziness, fatigue, nausea, shortness of breath)

         

        Several studies found that preserving independence and reducing pain were the most important health outcomes, whereas life extension was the least important.18,48,49 In the Older Patients’ Perceptions of Medicines and Willingness to Deprescribe survey, of the 50 participants, 76% wanted to keep their symptomatic medications and 61% wanted to keep their preventive medications.18

         

        The “What Matters to You?” study of 350 patients used the OPT to assess the most important health outcome for older adults.50 Patients with cognitive impairment more often prioritized life extension. Importantly, cognitively impaired patients may struggle to understand health outcomes and the “trade-off principle”—prioritizing one health outcome while accepting potential deterioration in other health outcomes—which makes patients weigh and prioritize health goals. Patients with declining health status are generally more accepting of further decline. A secondary outcome found that the OPT is feasible for intensive treatment decision-making. For those patients who are unable to prioritize the four health outcomes, the OPT is still useful to facilitate a conversation about patient preferences and trade-offs to align decision-making.50

         

        Considering Ms. Polly: how can the 4Ms aid in recommending oxybutynin discontinuation to her prescriber? “What matters to the patient is being able to continue to live in her home. Oxybutynin is anticholinergic and is negatively affecting her mentation and mobility as she has recent falls. Please consider a discontinuation trial of oxybutynin and non-pharmacologic options for overactive bladder.”

         

        Identifying Medications for Discontinuation

        Upon establishing goals of care, the next step is to engage the patient or caregiver and decide whether to deprescribe any medications. Common reasons for deprescribing include

        1. No active indication (e.g., health condition resolved)
        2. New or worsening condition
        3. Potential risks outweigh anticipated benefits
        4. Preventive indication with life-limiting conditions
        5. Lack of benefit or ineffectiveness
        6. Result of a prescribing cascade
        7. Nonadherence
        8. Interactions or ADEs

         

        Prescribers and pharmacists can use the available prescribing and deprescribing clinical tools, but they must also review all medications and assess the benefit versus risk for individualized patients.

         

        Developing an Action Plan

        Upon identifying medications to deprescribe, prescribers and pharmacists must collaborate to develop an action plan to implement, monitor, and follow-up. When deprescribing, withdraw medications one-by-one by prioritizing those that are inappropriate and/or increase the risk of harm. It is critical to continuously consider “what matters” to the patient. Multiple medications can be withdrawn simultaneously if patients are experiencing ADEs, medications are easy to discontinue, or if they have minimal withdrawal effects.

         

        If deprescribing is justified, prescribers, pharmacists, and pharmacy technicians need a plan of action for each medication (i.e., whether to abruptly stop or if gradual dose reduction (GDR) is necessary). Healthcare providers need to educate patients or caregivers on withdrawal symptoms to look for and emphasize the need to promptly report them.

         

        Certain medications require a GDR or taper to prevent an adverse drug withdrawal event—meaning discontinuation results in clinically significant symptoms or signs—or worsened conditions.51 GDRs can identify the lowest effective dose, minimize symptom re-occurrence, and encourage patient willingness. For example, discontinuing benzodiazepines may cause agitation. If this withdrawal symptom is unfamiliar to healthcare providers, then a prescribing cascade may occur with initiation of an antipsychotic.43

         

        Most medications have limited evidence and few guidelines for deprescribing. If no guidance is available, it is safer to attempt a GDR over weeks to months to discontinue rather than abruptly discontinuing. If a deprescribing guideline is unavailable, taper and discontinue medications in reverse of guideline recommended treatment. For example, the prescribing information for donepezil recommends initiation of therapy at 5 mg daily for four to six weeks, then increase the dose to 10 mg daily. To taper donepezil, decrease the 10 mg daily dose to 5 mg daily for four to six weeks and then discontinue therapy. Pharmacists can recommend a GDR plan in consideration of pharmacokinetics (e.g., half-lives), pharmacodynamics, dose, and duration of medications.51

         

        To achieve successful deprescribing, a trusting relationship, ongoing communication, and adequate documentation is essential between prescribers, pharmacists, pharmacy technicians, patients, and caregivers. Using the word “trial” is reassuring to patients and caregivers since it implies patients can restart the medication if needed.

         

        Returning to Ms. Polly, the pharmacist can initiate the conversation with her daughter by saying, “I understand you feel overwhelmed. It seems now would be a good time to take another look at your mother’s medications. We can ease the burden of her medication regimen and simplify it for her. This trial of stopping a couple of her medications may help with her confusion and lower her fall risk.”

         

        CONCLUSION

        Deprescribing is an essential part of good prescribing and an important strategy. It ensure older adults are not taking suboptimal medications. Effective and safe deprescribing requires a patient-centered, shared decision-making approach with evaluation of preferences, level of functioning, life expectancy, and goals of care. Numerous clinical resources are available to reduce polypharmacy, assess benefit versus risk, and provide guidance and approaches for how to discontinue specific medications. Deprescribing inappropriate or unnecessary medications impacts clinical outcomes—such as reduction in hospitalizations, ED visits, falls and overall healthcare costs—mitigates ADEs, and improves quality of life. Simplifying more complex medication regimens may also improve patient adherence to essential medications.

         

        With a strong foundation in deprescribing principles and tools, it’s time to reevaluate Ms. Polly’s medication regimen one last time. What other medications should be considered for deprescribing to reduce polypharmacy, mitigate ADEs, and improve quality of life for both Ms. Polly and her daughter?

         

        Pharmacist Post Test (for viewing only)

        1. What is the primary goal of deprescribing?
        A. To discontinue preventive medications
        B. To increase medication adherence regardless of appropriate therapy
        C. To manage polypharmacy and improve outcomes

        2. Which of the following best characterizes the impact of polypharmacy and high-risk prescribing in older adults?
        A. Increases the risk of potential adverse drug effects
        B. Reduces the risk of hospitalization
        C. Optimizes disease prevention and management

        3. Which of the following is true regarding the “mentation” domain of the Age-Friendly 4Ms Framework?
        A. It focuses on ensuring older adults are physically active
        B. It involves assessing and addressing cognitive function, such as dementia and depression
        C. It refers only to medication adjustments in older adults

        4. You assess a patient using the Edmonton Frail Scale (EFS) and the result is 14/17, indicating severe frailty. Which of the following deprescribing strategies is most appropriate for this patient?
        A. Maintain all preventive medications to avoid complications
        B. Focus on medications that preserve functional independence
        C. Discontinue all medications at once to simplify the regimen

        5. You are reviewing medications for a frail 91-year-old woman who lives in a long-term care facility. She is on a statin, a bisphosphonate, memantine, and metformin. She has difficulty swallowing and advanced dementia. Which deprescribing action is MOST aligned with STOPPFrail guidance?
        A. Recommend changing the bisphosphonate to denosumab, a monoclonal antibody, due to difficulty swallowing
        B. Recommend discontinuing memantine since she has advanced dementia without discussing with her family
        C. Recommend discontinuing the statin and bisphosphonate due to limited short-term benefit

        6. Refer to the available AGS 2023 updated Beers criteria. Which deprescribing principle applies most appropriately to glipizide?
        A. Glipizide is on the Beers Criteria since may cause hypoglycemia and may not be indicated in pre-diabetes or limited life expectancy
        B. Glipizide is indicated as preventive treatment for pre-diabetes
        C. Glipizide is indicated to achieve glucose control of HgbA1c < 6.5% for older adults 7. Ms. Polly, an 85-year-old woman, started taking amlodipine six months ago. She now takes furosemide for new-onset peripheral edema and docusate-senna for constipation. Which concept does this scenario most likely illustrate?
        A. Appropriate polypharmacy
        B. Prescribing cascade
        C. Suboptimal dosing

        8. Ms. Polly, an 85-year-old woman, recently experienced a fall when she was walking to the bathroom in the middle of the night. She has shown increased confusion and difficulty performing activities of daily living. Which medication is the most appropriate to first target for deprescribing to reduce anticholinergic burden and support cognitive function?
        A. Donepezil
        B. Diphenhydramine
        C. Furosemide

        9. George, a 70-year-old man, is receiving palliative end-of-life care and having increasing difficulty adhering to his medication regimen. His medications include pravastatin (for primary prevention), lisinopril (for hypertension), and acetaminophen as needed (for arthritis pain). Which medication is the most appropriate to consider deprescribing first?
        A. Pravastatin
        B. Lisinopril
        C. Acetaminophen

        10. Ms. Polly, an 85-year-old woman, is currently taking donepezil for Alzheimer’s disease. Upon medication review, you identify that she is also taking paroxetine and propranolol. What is the most appropriate recommendation?
        A. If a beta blocker is indicated, consider changing propranolol to metoprolol. Then, consider attempting a gradual dose reduction of paroxetine to possibly discontinue or change to a safer alternative, such as sertraline.
        B. Consider discontinuing donepezil since it may no longer have benefit. If Ms. Polly’s caregiver is adamant about continuing, consider initiation of memantine for synergistic effects.
        C. Continue all medications with close monitoring since they treat her co-morbidities and consider additional medications if she is experiencing new symptoms.

        Pharmacy Technician Post Test (for viewing only)

        1. Which of the following is a primary goal of deprescribing in frail older adults?
        A. Enhance polypharmacy for preventive medications
        B. Reduce polypharmacy to avoid potential medication-related problems
        C. Optimize medication therapy for aggressive disease management

        2. What is the most significant predictor of adverse drug events in older adults?
        A. Number of medications
        B. Age older than 75 years
        C. Renal impairment

        3. Which of the following is a common patient-related barrier to deprescribing?
        A. Fear of forgetting to take medications
        B. Desire to stop all medications
        C. Belief that all medications are necessary

        4. Ms. Polly, an 85-year-old woman, lives at home with support from her daughter. She values staying independent. She’s currently prescribed oxybutynin for overactive bladder (OAB) and has experienced two recent falls. The pharmacist suspects the falls may be related to the oxybutynin. Using the 4Ms framework, which "M" should most strongly guide a recommendation to deprescribe oxybutynin?
        A. What Matters
        B. Mobility
        C. Mentation

        5. Which of the following describes a prescribing cascade?
        A. A method of simplifying medication regimens by using combination products
        B. Gradually decreasing medication dosages over time before discontinuing
        C. Initiating a new medication to treat an adverse effect caused by another medication

        6. You are handed two prescriptions for oxybutynin and paroxetine. The older adult asks you where he can find Tylenol PM (acetaminophen/diphenhydramine). Why is it important to check with the pharmacist if there are any potential drug-drug interactions with the new prescriptions prior to telling the patient where to find Tylenol PM?
        A. One of the new prescriptions may help the patient to sleep and he may not need the Tylenol PM
        B. Older adults are more susceptible to medication-related problems, such as adverse effects
        C. The Tylenol PM may negate the effect of one of the prescriptions, resulting in reduced efficacy

        7. A prescriber has prescribed an SSRI and NSAID for a 78-year-old woman with depression and osteoarthritis pain. She recently had a minor gastrointestinal (GI) bleed. According to Choosing Wisely recommendations, what is the best action?
        A. Add a PPI to prevent GI bleeding
        B. Discontinue the NSAID
        C. Continue both medications with no changes

        8. A patient's medication list is entered into Medstopper. The tool recommends stopping pantoprazole due to long-term use without indication. What is the likely prioritization factor influencing this recommendation?
        A. High cost
        B. Low likelihood of benefit and potential for harm
        C. No longer effective for symptom control

        9. You are conducting a medication reconciliation for an 88-year-old patient. She seems overwhelmed and says, “I feel like I’m taking pills all day long.” What is the most appropriate response to support deprescribing efforts?
        A. “Let me ask the pharmacist to review your medication list.”
        B. “You can stop taking the medications you think aren’t helping.”
        C. “Your doctor knows what’s best for you, ask them for help.”

        10. A patient tells you he stopped taking his blood pressure medication because it made him feel dizzy and weak. What is the best next step?
        A. This should not be deprescribed; advise the patient to restart it immediately
        B. Suggest taking half the dose so that his blood pressure remains controlled
        C. Refer the patient to the pharmacist for further evaluation and counseling

        References

        Full List of References

        1. World Health Organization. National Institute on Aging. National Institutes of Health. Global Health and Aging. NIH Pulication no. 11-7737. October 2011. https://www.nia.nih.gov/sites/default/files/2017-06/global_health_aging.pdf
        2. Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49(2):200-209. doi:10.1046/j.1532-5415.2001.49042.x
        3. Keller MS, Qureshi N, Mays AM, Sarkisian CA, Pevnick JM. Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy. JAMA Netw Open. 2024;7(1):e2350963. Published 2024 Jan 2. doi:10.1001/jamanetworkopen.2023.50963
        4. Tian F, Chen Z, Zeng Y, Feng Q, Chen X. Prevalence of Use of Potentially Inappropriate Medications Among Older Adults Worldwide: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2023;6(8):e2326910. doi:10.1001/jamanetworkopen.2023.26910
        5. Lee GB, Etherton-Beer C, Hosking SM, Pasco JA, Page AT. The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review. Ther Adv Drug Saf. 2022;13:1-41. doi:10.1177/20420986221100117
        6. Bloomfield HE, Greer N, Linsky AM, et al. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. J Gen Intern Med. 2020;35(11):3323-3332. doi:10.1007/s11606-020-06089-2
        7. Born KB, Levinson W. Choosing Wisely campaigns globally: A shared approach to tackling the problem of overuse in healthcare. J Gen Fam Med. 2018;20(1):9-12. Published 2018 Dec 21. doi:10.1002/jgf2.225
        8. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254-1268. doi:10.1111/bcp.12732
        9. Koyama T, Iinuma S, Yamamoto M, et al. International Trends in Adverse Drug Event-Related Mortality from 2001 to 2019: An Analysis of the World Health Organization Mortality Database from 54 Countries. Drug Saf. 2024;47(3):237-249. doi:10.1007/s40264-023-01387-0
        10. Alhawassi TM, Krass I, Bajorek BV, Pont LG. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging. 2014;9:2079-2086. doi:10.2147/CIA.S71178
        11. Institute for Healthcare Improvement. Age-Friendly Health Systems. Accessed March 17, 2025. Available from: https://www.ihi.org/networks/initiatives/age-friendly-health-systems
        12. Monette PJ, Schwartz AW. Optimizing Medications with the Geriatrics 5Ms: An Age-Friendly Approach. Drugs Aging. 2023;40(5):391-396. doi:10.1007/s40266-023-01016-6
        13. Scott IA, Hilmer SN, Reeve E, et al. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Intern Med. 2015;175(5):827–834. doi:10.1001/jamainternmed.2015.0324
        14. Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Development and validation of the patients' attitudes towards deprescribing (PATD) questionnaire. Int J Clin Pharm. 2013;35(1):51-56. doi:10.1007/s11096-012-9704-5
        15. Reeve E, Low LF, Shakib S, Hilmer SN. Development and Validation of the Revised Patients' Attitudes Towards Deprescribing (rPATD) Questionnaire: Versions for Older Adults and Caregivers. Drugs Aging. 2016;33(12):913-928. doi:10.1007/s40266-016-0410-1
        16. Australian Deprescribing Network. Patients’ Attitudes Towards Deprescribing questionnaires. Accessed March 17, 2025. https://www.australiandeprescribingnetwork.com.au/925-2/
        17. Reeve E, Wolff JL, Skehan M, Bayliss EA, Hilmer SN, Boyd CM. Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States. JAMA Intern Med. 2018;178(12):1673–1680. doi:10.1001/jamainternmed.2018.4720
        18. Arnoldussen DL, Keijsers K, Drinkwaard J, Knol W, van Marum RJ. Older Patients' Perceptions of Medicines and Willingness to Deprescribe. Sr Care Pharm. 2021;36(9):444-454. doi:10.4140/TCP.n.2021.444
        19. Steinman M, Reeve E. Editor: Schmader, KE, Givens J. Deprescribing. UpToDate. Wolters Kluwer. 2025. Accessed May 14, 2025.
        20. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-529. doi:10.1093/ageing/afl041
        21. van Nordennen RT, Lavrijsen JC, Vissers KC, Koopmans RT. Decision making about change of medication for comorbid disease at the end of life: an integrative review. Drugs Aging. 2014;31(7):501-512. doi:10.1007/s40266-014-0182-4
        22. ABIM Foundation. Choosing Wisely. Accessed March 17, 2025. https://www.choosingwisely.org
        23. Baron RJ, Lynch TJ, Rand K. Lessons from the Choosing Wisely Campaign's 10 Years of Addressing Overuse in Health Care. JAMA Health Forum. 2022;3(6):e221629. Published 2022 Jun 3. doi:10.1001/jamahealthforum.2022.1629
        24. Beier MT, Brodeur MR. ASCP's 2021 Choosing Wisely® Recommendations: A Proud Accomplishment. Sr Care Pharm. 2022;37(5):171-180. doi:10.4140/TCP.n.2022.171
        25. American Society of Consultant Pharmacists (ASCP). Ten Things Physicians and Patients Should Question. Updated June 8, 2022. www.choosingwisely.org
        26. American Geriatrics Society (AGS). Ten Things Physicians and Patients Should Question. Updated April 23, 2015. Accessed May 14, 2025. https://www.healthinaging.org/sites/default/files/media/pdf/HIA_TIP_Choosing%20Wisely%202016.pdf
        27. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1096-1099. doi:10.1136/bmj.315.7115.1096
        28. Rochon PA, Gurwitz JH. The prescribing cascade revisited [published correction appears in Lancet. 2017;389(10085):2192. doi: 10.1016/S0140-6736(17)31315-6.]. Lancet. 2017;389(10081):1778-1780. doi:10.1016/S0140-6736(17)31188-1
        29. McCarthy LM, Savage R, Dalton K, et al. ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People. Drugs Aging. 2022;39(10):829-840. doi:10.1007/s40266-022-00964-9
        30. Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677
        31. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr. 2015;15:31. Published 2015 Mar 25. doi:10.1186/s12877-015-0029-9
        32. Boustani M, Campbell N, Munger S, Maidment I, Fox C. Impact of anticholinergics on the aging Brain: A review and Practical application. Aging Health. 2008;4(3):311-320. doi:10.2217/1745509x.4.3.311
        33. Lu CJ, Tune LE. Chronic exposure to anticholinergic medications adversely affects the course of Alzheimer disease. Am J Geriatr Psychiatry. 2003;11(4):458-461.
        34. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372
        35. O'Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3 [published correction appears in Eur Geriatr Med. 2023 Aug;14(4):633. doi: 10.1007/s41999-023-00812-y.]. Eur Geriatr Med. 2023;14(4):625-632. doi:10.1007/s41999-023-00777-y
        36. Seppala LJ, Petrovic M, Ryg J, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing. 2021;50(4):1189-1199. doi:10.1093/ageing/afaa249
        37. Lavan AH, Gallagher P, Parsons C, O'Mahony D. STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age Ageing. 2017;46(4):600-607. doi:10.1093/ageing/afx005
        38. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045-1051. doi:10.1016/0895-4356(92)90144-c
        39. Hanlon JT, Schmader KE. The medication appropriateness index at 20: where it started, where it has been, and where it may be going. Drugs Aging. 2013;30(11):893-900. doi:10.1007/s40266-013-0118-4
        40. Deprescribing.org. Resources for Patients and Healthcare Providers. Accessed March 17, 2025. https://deprescribing.org/resources/
        41. Canadian Medication Appropriateness and Deprescribing Network. Deprescribing algorithms. Accessed March 17, 2025. https://www.deprescribingnetwork.ca/algorithms
        42. US Deprescribing Research Network. Resources for clinicians. Accessed March 17, 2025. https://deprescribingresearch.org/resources-2/resources-for-clinicians/
        43. Primary Health Tasmania. Medication management – deprescribing. Accessed March 17, 2025. https://www.primaryhealthtas.com.au/resources/deprescribing-resources/
        44. MedStopper Beta. Accessed March 17, 2025. http://medstopper.com
        45. Nguyen M, Beier MT, Louden DN, Spears D, Gray SL. The Effect of Pharmacist-Initiated Deprescribing Interventions in Older People: A Narrative Review of Randomized Controlled Trials. Sr Care Pharm. 2023;38(12):506-523. doi:10.4140/TCP.n.2023.506
        46. Stegmann ME, Festen S, Brandenbarg D, et al. Using the Outcome Prioritization Tool (OPT) to assess the preferences of older patients in clinical decision-making: A review. Maturitas. 2019;128:49-52. doi:10.1016/j.maturitas.2019.07.022
        47. Fried TR, Tinetti M, Agostini J, Iannone L, Towle V. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns. 2011;83(2):278-282. doi:10.1016/j.pec.2010.04.032
        48. Fried TR, Tinetti ME, Iannone L, O'Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med. 2011;171(20):1854-1856. doi:10.1001/archinternmed.2011.424
        49. van Summeren JJ, Haaijer-Ruskamp FM, Schuling J. Eliciting Preferences of Multimorbid Elderly Adults in Family Practice Using an Outcome Prioritization Tool. J Am Geriatr Soc. 2016;64(11):e143-e148. doi:10.1111/jgs.14415
        50. Festen S, van Twisk YZ, van Munster BC, de Graeff P. 'What matters to you?' Health outcome prioritisation in treatment decision-making for older patients. Age Ageing. 2021;50(6):2264-2269. doi:10.1093/ageing/afab160
        51. Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc. 2008;56(10):1946-1952. doi:10.1111/j.1532-5415.2008.01916.x

        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
                  10. The Confidentiality of Incident Reports: A Crucial Consideration. SafeQual. Accessed April 30, 2025. https://www.safequal.net/sb/the-confidentiality-of-incident-reports-a-crucial-consideration/
                  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

                  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

                  Patient Safety: Cheers to the Beers: Unpacking the Latest Updates for Safer Prescribing -RECORDED WEBINAR

                  About this Course

                  This course is a recorded (home study version) of the 2024 CE Finale Encore Webinars.

                   

                  Learning Objectives

                  Upon completion of this application based CE Activity, a pharmacist will be able to:

                  Review the role of the Beers Criteria in reducing potentially inappropriate medication (PIM) use and enhancing patient safety in older adults
                  Identify recent updates to the Beers Criteria and their implications for medication management in geriatric care
                  Apply the updated Beers Criteria to real-world scenarios, optimizing medication selection and minimizing risks in older adults

                  Release and Expiration Dates

                  Released:  December 13, 2024
                  Expires:  December 13, 2027

                  Course Fee

                  $17 Pharmacist

                  ACPE UAN

                  0009-0000-24-045-H05-P

                  Session Code

                  24RW45-XTY89

                  Accreditation Hours

                  1.0 hours of CE

                  Additional Information

                   

                  How to Complete Evaluation:  When you are ready to submit quiz answers, go to the BLUE take test/evaluation button.  Don't forget to use the session code above, or that was sent to you in your confirmation email NOT the one on the presentation!

                  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 up to 1.0 CE Hours (or 0.1 CEUs)  for completing the activity ACPE UAN 0009-0000-24-045-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

                  Kelsey Giara, PharmD
                  Freelance Medical Writer
                  Adjunct Faculty
                  University of Connecticut School of Pharmacy
                  Pelham, NH

                  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.

                  • Dr. Giara has no financial 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

                  Handouts

                  Post Test

                  Learning Objectives
                  • Review the role of the Beers Criteria in reducing potentially inappropriate medication (PIM) use and enhancing patient safety in older adults
                  • Identify recent updates to the Beers Criteria and their implications for medication management in geriatric care
                  • Apply the updated Beers Criteria to real-world scenarios, optimizing medication selection and minimizing risks in older adults

                  1. About how many older adults are prescribed potentially inappropriate medications?
                  A. One in seven
                  B. One in five
                  C. One in three

                  2. Which of the following describes how age-related physiologic changes affect older adults?
                  A. Decreased renal and hepatic blood flow slows drug excretion, causing toxicity
                  B. Frailty increases activity in drug metabolizing pathways, making drugs less effective
                  C. Decreased body fat and dehydration affect drug distribution and cause toxicity

                  3. Which of the following best describes a potentially inappropriate medication?
                  A. A drug that is contraindicated in patients older than 65 years
                  B. A drug for which risks outweigh benefits in older adults
                  C. A drug that should only be used in hospice or end-of-life care

                  4. Which of the following is TRUE?
                  A. Older adults should always avoid SGLT2 inhibitors
                  B. The updated criteria removes doxepin < 6 mg/day C. Dabigatran is the safest anticoagulant for older adults 5. Which of the following best describes Beers Criteria guidance on proton pump inhibitors (PPIs)? A. Deprescribe after 8 weeks of scheduled use, unless the patient is high-risk B. After 8 weeks of scheduled use, reevaluate risks and benefits and continue if tolerated C. Avoid scheduled use completely and advise patients to use intermittent antacids 6. Which of the following is a reason to deprescribe a medication found on the Beers Criteria? A. The drug is being used to treat cancer but carries a risk of acid reflux B. The drug is being used to treat two indications at once C. The drug was prescribed to address the adverse effect of another drug 7. Mrs. Taylor, a 78-year-old woman with a history of AFib and diabetes, is prescribed rivaroxaban for stroke prevention and glyburide for glycemic control. During a consultation, she reports episodes of dizziness and has a recent lab result showing a creatinine clearance of 35 mL/min. Which of the following is the BEST plan of action? A. Recommend switching glyburide to glipizide B. Advise switching rivaroxaban to warfarin C. Continue both medications with increased monitoring for AEs

                  VIDEO

                  Patient Safety: Teaching Old Dogs New Tricks: Dispensing for Companion Animals in Community Pharmacy – 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 Veterinary Medicines.

                  Learning Objectives

                  • Describe the types of animals and health problems most likely to be encountered in community pharmacies
                  • List the most common prescriptions for companion animals and key dispensing considerations
                  • Identify reliable resources when filling prescriptions for animals

                  Activity Release Dates

                  Released:  April 25, 2024
                  Expires:  April 25, 2027

                  Course Fee

                  $17 Pharmacist

                  ACPE UAN Codes

                   0009-0000-24-020-H05-P

                  Session Code

                  24RS20-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 0009-0000-24-020-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

                  Isabella Bean, PharmD, FSVHP
                  Staff Pharmacist
                  Encompass Health Rehab Center
                  Sioux Falls, SD

                  Faculty Disclosure

                  • Isabella Bean 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

                  Patient Safety: Herbal Products and Potential Organ Dysfunction

                  Learning Objectives

                   

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

                  • List herbal products associated with liver, kidney, and heart damage
                  • Describe potential drug interactions with herbal medications
                  • Discuss the potential for contaminants in herbal products

                   

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

                  • List herbal products associated with liver, kidney, and heart damage
                  • Recognize the potential for herbal products to be unsafe
                  • Describe certificates of analysis and how to retrieve them from manufacturers

                   

                  Release Date: February 15, 2024

                  Expiration Date: February 15, 2027

                  Course Fee

                  Pharmacists: $7

                  Pharmacy Technicians: $4

                  There is no grant funding for this CE activity

                  ACPE UANs

                  Pharmacist: 0009-0000-24-009-H05-P

                  Pharmacy Technician: 0009-0000-24-009-H05-T

                  Session Codes

                  Pharmacist:  21YC04-XAB34

                  Pharmacy Technician:  21YC04-BAX43

                  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 0009-0000-24-009-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

                  James Lu,
                  PharmD Candidate 2021
                  UConn School of Pharmacy
                  Storrs, CT

                   

                  Canyon Hopkins,
                  PharmD Candidate 2021
                  UConn School of Pharmacy
                  Storrs, CT

                                                     

                  Jeannette Y. Wick, RPh, MBA
                  Asst. Director OPPD
                  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.

                  James Lu, Canyon Hopkins and Jeannette Wick do not have any relationships with ineligible companies and therefore have nothing to disclose.

                   

                  ABSTRACT

                  As part of complementary and alternative medicine, herbal products are gaining popularity in the United States. Approximately one in five Americans use herbal products. Although people may perceive them as harmless due to their "natural" origin, studies and case reports on herbal toxicity dispute that belief. Injuries to liver, kidney, and heart; herb-drug interactions; and contamination and mislabeling are grave health risk concerns with some herbal products. Although non-prescription, herbal products' ubiquitous presence in all kinds of
                  shops, pharmacies, and Internet vendors causes many people to consider them important to their overall well-being. Pharmacists and technicians can help patients reduce health risks associated with herbal products. Ample knowledge of popular herbal products will help pharmacy teams identify health risks quickly.

                  CONTENT

                  Content

                  Due to this being a REACCREDITED CE (from 2021), an HTML version is not available.

                  Pharmacist Post Test (for viewing only)

                  Herbal Products and Health Risks

                  Pharmacist Post-test

                  After completing this continuing education activity, pharmacists will be able to
                  • List herbal products associated with liver, kidney and heart damage
                  • Describe potential drug interactions with herbal medications
                  • Discuss the potential for contaminants in herbal products

                  1. Which of the following agencies reviews and inspects herbal products before coming to market?
                  A. United States Food and Drug Administration
                  B. National Center for Complementary and Alternative Medicine
                  C. International Association of Traditional Chinese Medicine

                  2. John Goodman, a frequent customer at your pharmacy, comes to the counter to pick up his monthly medications. He asks, “Would it be a bother to have you check out the rest of my items here as well?” Always one to help a customer, you tell him, “Of course, that’s fine!” You notice he has a botanic extract tincture that claims to help with heartburn. The ingredient list includes greater celandine (Chelidonium majus). Mr. Goodman is also picking up his 30-day supply of Questran (cholestyramine). What organ dysfunction could be a concern?
                  A. Liver injury
                  B. Kidney injury
                  C. Heart damage

                  3. A patient presents to the emergency room suffering from acute kidney injury and liver injury. Lab tests show glutathione depletion, and the physician recommends N-acetylcysteine as a possible antidote. Upon opening the patient’s bag, you notice three natural product supplements: pennyroyal essential oils, germander weight loss tea, and impila fertility boost capsules. Which product may be responsible for BOTH the kidney and liver injury?
                  A. Pennyroyal essential oils
                  B. Germander weight loss tea
                  C. Impila fertility boost capsules

                  4. Mr. Goodman returns to your pharmacy. He explains he has been trying to live a healthier lifestyle, but has been feeling exceptionally tired after taking his as-needed alprazolam. When asked what over-the-counter products he uses, Mr. Goodman tells you, “Oh, you know the usual stuff: echinacea, garlic, ginger…” You are concerned because an interaction between alprazolam and ______ could be causing the excessive drowsiness.
                  A. Echinacea
                  B. Garlic
                  C. Ginger

                  5. Johnathan Bravo comes to the counter with a melancholic look on his face. “You know… getting older is not easy, especially when your wife looks so much better than you. I have tried everything: gym, new haircut, self-help books; and nothing seems to work.” He then proceeds to tell you about this supplement used in Southeast Kazakhstan that his gym buddy recommended. “Yeah, he says he’s seen guys lose weight, look better than ever and… well… you know… have a better relationship with their wife.” This sounds too good to be true; you are concerned this product has been _____________.
                  A. Mishandled
                  B. Mistaken
                  C. Mislabeled

                  6. Which of the following are chemists mainly concerned about when they look for contaminants in herbal products?
                  A. Metal
                  B. Glutathione
                  C. Poisons

                  7. Which of the following patients is most at risk of a serious adverse event associated with henbane (Hyoscyamus niger)?
                  A. A 27-year-old female with an irregular menstrual cycle
                  B. A 48-year-old male with a history of atrial fibrillation
                  C. A 62-year-old male with new onset major depressive disorder

                  8. Mrs. Jin is a longtime customer of your pharmacy who is on warfarin therapy for her atrial fibrillation. Her dose has been stable for quite some time, but today, you are surprised to see a change to her warfarin dosing. You call her cardiologist to double check the prescription and she tells you, “Yeah, it’s really crazy; three years no change in INR and out of nowhere a 0.2-point decrease.” Upon picking up her prescription, you ask Mrs. Jin about complementary and alternative medicine use. What herbal supplement might be a possible explanation for Mrs. Jin’s INR decrease?
                  A. Chamomile
                  B. Kava kava
                  C. American ginseng

                  9. “These kids nowadays takin’ that codeine, and that awful dextromethorphan!” exclaimed Mr. O’Timer. “When I was a kid, and even now, all I ever took was licorice. My mom, bless her soul, would never let any poison enter MY body. To this day that’s all I use when I get a cold.” Trying to move him along before he inevitably tries to talk to you about politics, you stop as he mentions his busy day full of specialist appointments. Which specialist would be MOST LIKELY to know Mr. O’Timer is using licorice for his colds?
                  A. Dentist
                  B. Podiatrist
                  C. Cardiologist

                  10. Which of the following patients would be at greatest risk if they accidentally took Asian ginseng instead of American ginseng?
                  A. A 23-year-old female taking fluvoxamine for obsessive compulsive disorder
                  B. A 40-year-old female taking ondansetron for chemotherapy-induced nausea
                  C. A 67-year-old male taking clopidogrel after a myocardial infarction

                  Pharmacy Technician Post Test (for viewing only)

                  Pharmacy Technician Post-test

                  After completing this continuing education activity, pharmacy technicians will be able to
                  • List herbal products associated with liver, kidney and heart damage
                  • Recognize the potential for herbal products to be unsafe
                  • Describe certificates of analysis and how to retrieve them from manufacturers

                  1. Which of the following agencies review and inspect herbal products before coming to market?
                  A. United States Food and Drug Administration
                  B. National Center for Complementary and Alternative Medicine
                  C. International Association of Traditional Chinese Medicine

                  2. John Goodman, a frequent customer at your pharmacy, comes to the counter to pick up his monthly medications. He asks, “Would it be a bother to have you check out the rest of my items here as well?” Always one to help a customer, you tell him, “Of course, that’s fine!” You notice he has a botanic extract tincture that claims to help with heartburn. The ingredient list includes greater celandine (Chelidonium Majus). What organ dysfunction has been associated with this herb?
                  A. Liver injury
                  B. Kidney injury
                  C. Heart damage

                  3. A patient brings a brown bag of herbs and supplements for you to list on his profile. Which product may increase this patient’s risk for BOTH kidney and liver injury?
                  A. Pennyroyal essential oils
                  B. Germander weight loss tea
                  C. Impila fertility boost capsules

                  4. Mr. Goodman returns to your pharmacy. He explains he has been trying to live a healthier lifestyle, but has been feeling exceptionally tired after taking his as-needed alprazolam. Mr. Goodman goes on to tell you he’s added a new herbal supplement to his daily routine. You refer the patient to the pharmacist because you know and interaction between alprazolam and ______ could be causing the excessive drowsiness.
                  A. Echinacea
                  B. Garlic
                  C. Ginger

                  5. A customer at your pharmacy asks you for help in the herbal supplement aisle. She wants to take echinacea to boost her immune system, but she’d like more information about the manufacturer’s quality testing. You call the manufacturer for a certificate of analysis (CoA) only to be told they do not release them. Which of the following is most appropriate to tell this customer?
                  A. All herbal manufacturers are held to the same standards, so this brand is safe to use
                  B. This company likely has no quality assurance process; we should look for a better brand
                  C. This means the company uses an in-house laboratory for testing, so it is trustworthy

                  6. Your pharmacy is now selling a new herbal product. Curious about the contents, you decide to search for a certificate of analysis. On the bottle, you are looking for what three pieces of information?
                  A. product name, lot number, and expiration date
                  B. product name, manufacturer, and country of production
                  C. manufacturer, lot number, and date of production

                  7. Which of the following patients is most at risk of a serious adverse event associated with henbane (Hyoscyamus niger)?
                  A. A 27-year-old female with an irregular menstrual cycle
                  B. A 48-year-old male with a history of atrial fibrillation
                  C. A 62-year-old male with new onset major depressive disorder

                  8. Mrs. Jin is a longtime customer of your pharmacy who is on warfarin therapy for her atrial fibrillation. You ask to update her medication list in the system, including prescription, over-the-counter, and herbal supplements. Which of the following herbals would prompt you to refer Mrs. Jin to the pharmacist for counseling?
                  A. Chamomile
                  B. Kava kava
                  C. American ginseng

                  9. “These kids nowadays takin’ that codeine, and that awful dextromethorphan!” exclaimed Mr. O’Timer, “When I was a kid, and even now, all I ever took was licorice. My mom, bless her soul, would never let any poison enter MY body. To this day that’s all I use when I get a cold.” Trying to move him along before he inevitably tries to talk to you about politics, you stop as he mentions his busy day full of specialist appointments. Which specialist would be MOST LIKELY toned to know Mr. O’Timer is using licorice for his colds?
                  A. Dentist
                  B. Podiatrist
                  C. Cardiologist

                  10. Which of the following patients would be at greatest risk if they accidentally took Asian ginseng instead of American ginseng?
                  A. A 23-year-old female taking fluvoxamine for obsessive compulsive disorder
                  B. A 40-year-old female taking ondansetron for chemotherapy-induced nausea
                  C. A 67-year-old male taking clopidogrel after a myocardial infarction

                  References

                  Full List of References

                  Patient Safety: The Risk of Treatment: Antibiotic-Induced Adverse Events

                  Learning Objectives

                   

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

                  · Describe mechanisms of action that cause antibiotic induced adverse effects
                  · Analyze risks and sequelae to determine adverse event or causative medication
                  · Recommend appropriate treatment for antibiotic induced adverse effect
                  · Discuss counseling points for outpatient antibiotic use

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

                    · List adverse effects induced by antibiotics
                    ·Recognize patients at risk of adverse effects
                    · Recall medications used to treat adverse effects
                    · Identify when to refer patient to pharmacist for recommendation or referral

                     

                    Release Date: February 15, 2024

                    Expiration Date: February 15, 2027

                    Course Fee

                    FREE

                    There is no grant funding for this CE activity

                    ACPE UANs

                    Pharmacist: 0009-0000-24-011-H05-P

                    Pharmacy Technician: 0009-0000-24-011-H05-T

                    Session Codes

                    Pharmacist:  24YC11-ABC48

                    Pharmacy Technician:  24YC11-CAB84

                    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 0009-0000-24-011-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

                    Ellie Provisor, PharmD
                    Pharmacy Program Coordinator
                    Maine General Medical Center
                    Augusta, ME

                    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.

                    Dr. Proviso does not have any financial relationships with ineligible companies.

                     

                    ABSTRACT

                    When a patient is diagnosed with an infection, an antibiotic is usually the first line of treatment to cure the ailment. Antibiotics are effective treatments when patients have validated infections. Most often, treatment with antibiotics is benign. Typically, it does not pose a risk to patients, but antibiotics are associated with several risks to consider before initiating treatment. Risks of antibiotic use range from mild adverse effects of gastrointestinal upset and mild rash to life-threatening allergy development, toxic megacolon, and death. Recognizing and understanding the risks associated with antibiotic use is crucial in preventing severe patient complications.

                    CONTENT

                    Content

                    INTRODUCTION

                    An injury or response that results in any harm to a patient after medication administration is an adverse drug reaction (ADR). Every medication can potentially cause ADRs, but antibiotics are notorious for causing several individual and class-wide type reactions. A 2017 study (N = 1488) showed that 20% of all inpatients who receive antibiotics will develop an ADR within 24 hours of therapy. That risk increases by 3% every ten days of therapy.1 Education and recognition of ADRs from antibiotics are essential components in the campaign against antibiotic resistance. The Centers for Disease Control and Prevention (CDC) developed the Core Elements of Antibiotic Stewardship to optimize antibiotic use by decreasing unnecessary antibiotic prescribing and helping fight antibiotic resistance in different practice settings. One Core Element is education directed at prescribers, nurses, pharmacists, and patients about the adverse reactions associated with antibiotic use.2

                     

                    Antibiotic Resistance

                    One of the most noxious antibiotic-induced ADRs is the development of antibiotic resistance. Antibiotic resistance is a global health threat to the world population and affects food security.3 Antibiotic resistance develops when a bacteria is no longer susceptible to a previously effective antibiotic, which can stem from unnecessary antibiotic use.1 A 2011 study that surveyed American acute care hospitals found that almost half of all inpatients will receive at least one day of antibiotic therapy.4 A separate U.S. study found that one-third of all antibiotic treatment days are inappropriate.5

                     

                    Antibiotic resistance kills at least 1.27 million people worldwide every year.6 The United States (U.S.) has reported more than 2.8 million antimicrobial-resistance infections yearly, with 35,000 deaths.7 Antimicrobial resistance can affect anyone at any age, at all different types of healthcare facilities, and in veterinary and agricultural industries.6 Antibiotic resistance prevents patients from using first or second-line therapy for indicated infections, making patients more susceptible to severe ADRs.

                     

                    Antibiotic Allergies

                    Allergic reactions reportedly account for 20% of adverse drug events and are seen in about 8% of the population.8 Antibiotics are the most common medication reported as an allergy.9 Elderly and female patients are more likely to report antibiotic allergies.9,10 Typically, antibiotic allergic reactions present as mild rash and hives but approximately 3% of the population’s health records documented past anaphylaxis.11

                    In the 1960s, Robert Coombs and Philip Gell established a classification system for hypersensitivity reactions. Coombs is most notable for developing the Coombs test that detects anti-Rh antibodies on red blood cells in 1945.12 Their classification system has four presentations of hypersensitivity reactions involving different immune mediators that develop into various manifestations. Table 1 summarizes the Coombs classification.

                    Table 1 - Classification of Allergic Reactions13-15
                    Type Description Mechanism Timing Clinical features
                    I IgE-mediated, immediate-type hypersensitivity IgE serves to protect and eliminate parasitic infections. IgE antibodies form after exposure to allergens, such as food, drugs, or other environmental elements. Re-exposure triggers an immediate hypersensitivity reaction. Minutes to hours after exposure ·     Anaphylaxis

                    ·     Angioedema

                    ·     Bronchospasm

                    ·     Hives

                    ·     Hypotension

                    ·     Asthma

                    ·     Allergic rhinitis

                    II Antibody-dependent cytotoxicity The drug binds to the surface of the cell. Antibodies then bind to the cell surface and are targeted for clearance by macrophages.

                    Usually involves IgG or IgM

                    Appear 5-8 days after exposure but can take longer ·    Hemolytic anemia

                    ·    Thrombocytopenia

                    ·    Neutropenia

                    III Immune complex disease Soluble drug in bloodstream forms a complex with IgG or IgM. The immune complexes can activate complement and then deposits in various tissue like small blood vessels, joints, and renal glomeruli One or more weeks to develop after drug exposure ·     Serum sickness

                    ·     Arthralgias

                    ·     Acute glomerulonephritis

                    ·     Vasculitis

                    IV Cell-mediated hypersensitivity Stimulation of T cells At least 48-72 hours, but can take days to weeks following exposure ·     Stevens-Johnson syndrome/ toxic epidermal necrolysis (SJS/TEN)

                    ·     Drug rash with eosinophilia and systemic symptoms (DRESS)

                    ·     Contact dermatitis

                     

                    Antibiotic allergy reporting is essential to prevent patients from severe adverse effects, but it also comes with a risk. Prescribers overuse and overprescribe antibiotics. Overprescribing of antibiotics is associated with a higher incidence of new antibiotic allergies.9 In countries with low antibiotic usage, antibiotic allergies are less prevalent.9 Antibiotic overprescribing is especially notorious at urgent care facilities. A study showed that in patients presenting to urgent care for upper respiratory infections, healthcare providers prescribed antibiotics approximately twice as much as in emergency departments and nearly three times as much in primary care.16 This is concerning; nationwide, there are more than 10,000 urgent care facilities, and that number is growing.16

                    Inaccurate allergy documentation is another concern with antibiotic allergy reporting. Five percent to 15% of patients have documented penicillin allergies; however up to 90% of those patients can safely receive a penicillin antibiotic.17,18 Antibiotic allergies prevent patients from receiving first-line therapy, which can increase health care costs, and increase the risk of treatment failures and adverse events.17 A study from 2003 showed that patients labeled with a penicillin allergy had a 63% greater cost for antibiotics than patients without a penicillin allergy.19

                    PAUSE AND PONDER: What are some individual antibiotics that make up penicillins and cephalosporins?

                    The best treatment for allergies is prevention. Before initiating any new antibiotic, the prescriber should obtain an allergy history. Pharmacists must review patients' profiles for allergies to beta-lactams and consider cross-reactivity. There is about a 2% risk of cross-sensitivity between penicillins and cephalosporins.17 Treatment for allergies depends on the type of reaction. Type I reactions are usually a medical emergency, and patients need immediate care. Antibiotic rechallenge is appropriate for patients with mild reactions like gastrointestinal distress or mild itching or rashes but should not occur for any patient who develops a severe reaction, like anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis, or hemolytic anemia.10 Reactions that occur need documentation with sufficient detail, including medication used and time to reaction.17

                    Antibiotic-Associated Diarrhea

                    A frequent adverse event associated with antibiotic use is diarrhea, defined as three or more loose stools in 24 hours.20-22 Antibiotic-associated diarrhea reportedly occurs in 5% to 30% of patients while receiving or up to two months after receiving treatment.23 Antibiotic-associated diarrhea’s clinical presentation can range from mild diarrhea to pseudomembranous colitis.23,24 Essentially all antibiotics can cause diarrhea, especially those that cover anaerobic microorganisms (organisms that grow without oxygen) like amoxicillin/clavulante, cephalosporins, and clindamycin.21-23

                    Antibiotic-associated diarrhea can occur from multiple mechanisms. First, antibiotics disrupt normal microflora, allowinge overgrowth of microorganisms known to cause diarrhea.23 Clostridium difficile (C. diff), which will be discussed later, is the most common of those pathogens. Other pathogens are Salmonella, C. perfringens type A, Staphylococcus aureus, and Candida albicans.20,24 Antibiotics can directly affect the intestinal mucosa, independent of any antibiotic activity. For example, erythromycin stimulates a receptor that increases contractions in the stomach and small intestines, and clavulanate can activate small bowel motility.20,24 Last, antibiotics can decrease normal fecal flora that breakdown carbohydrates and bile acids in the colon. The increase of carbohydrates and bile acid causes an influx of water into the colon, causing osmotic diarrhea.20,24

                    Treatment of antibiotic-associated diarrhea depends on its severity. Mild to moderate disease treatment should focus on rehydration, discontinuation of the provoking antibiotic, or changing to a lower-risk antibiotic like quinolones, sulfamethoxazole/trimethoprim, or aminoglycosides, if appropriate.22,23 Clinicians should order C. diff testing in patients with severe or persistent disease or any microbes mentioned above.23

                    Probiotics are an alternative method to decrease antibiotic-associated diarrhea, but mixed evidence surrounds their use. A 2021 meta-analysis reviewed 82 randomized controlled trials and found a statistically significant association between probiotic administration and the reduction of antibiotic-associated diarrhea.25 The results are difficult to translate to a specific recommendation as the meta-analysis included many randomized controlled trials that did not document the exact probiotics used. In addition, the study excluded antibiotics that are more likely to cause diarrhea and specific subsets of patients like geriatrics.25 Probiotic use is low risk for most patients, but immunocompromised patients should use caution when considering therapy.26,27 Probiotics are associated with rare secondary bacterial and fungal infections, which can be more prevalent in immunocompromised patients.28-30 The most ideal way to prevent antibiotic-associated diarrhea is to limit antibiotic use.2

                    C. diff is a spore-forming bacteria that produces two separate exotoxins, A and B, that cause mucosal damage and inflammation.22,23 Patients with C. diff infection (CDI) account for 10% to 25% of antibiotic-associated diarrhea cases, but CDI causes the majority of pseudomembranous colitis associated with antibiotic therapy.23,24 Patients with CDI typically present with fever, lower abdominal pain, and cramping. CDI stool usually contains visible mucous and is foul-smelling.22 Significant risk factors include age older than 65, hospitalization, proton pump inhibitor use, and previous diagnosis of CDI.22,24 Patients older than 60 have a much greater risk of developing CDI than patients aged 10 to 20 years.24,31 Prescribers should consider C. diff testing after a patient has three or more unformed new or unexplained stools in 24 hours.12

                    Multiple diagnostic criteria confirm CDI. Lab results from CDI patients show elevated white blood cell count, decreased albumin, and fecal leukocytes.24 Imaging with a CT scan can show inflammation and thickening of the colon, but it is not specific to CDI.24 The Gold Standard testing for CDI is to test for toxins A and B with polymerase chain reaction (PCR) tests, but patients need to have unformed stool (bowel movement that is watery or soft) for this test. Patients with solid-formed stools do not have diarrhea and therefore do not have CDI, so testing is not warranted. Enzyme immunoassay (EIA) is another option that produces results much faster than the PCR test but has much lower sensitivity.22,32

                    Providers should start treatment for C. diff after a positive test or before positive testing if a strong clinical suspicion exists.24,32 Clinical guidelines do not recommend routine testing of C. diff in asymptomatic patients as C. diff colonization frequently occurs, especially in hospitalized patients and residents of long-term care facilities.32 Severity of disease, initial or recurrent occurrence, and other risk factors determine treatment. Disease severity can be non-severe, severe, or fulminant. In severe illness, the patient will have leukocytosis with a white blood cell count (WBC) of at least 15,000 cells/mL and a serum creatinine (Scr) level higher than 1.5 mg/dL. In non-severe disease, WBC and Scr levels are less than that of severe. Fulminant severity presents with hypotension or shock, ileus (an obstruction of the intestines), or megacolon (abnormal widening of the colon that is not caused by an obstruction).12 Vancomycin and metronidazole have been the mainstay of treatment for more than 30 years until the development of newer medications. Fidaxomicin and bezlotuxumab are newer agents recently added to the Infectious Disease Society of America (IDSA) guidelines for CDI treatment.33 Refer to 2021 IDSA guidelines for specific treatment recommendations.

                    Antibiotic-Induced Kidney Injury

                    Medications cause an estimated 20% to 40% of cases of acute kidney injury, with that estimation reaching almost 60% in the elderly population.34,35 Antibiotics are a well-known cause of medication-induced renal dysfunction. Antimicrobials cause kidney dysfunction through tubular injury, severe tubular necrosis with cellular death, intratubular obstruction from crystal formation, and other mechanisms.34 The direct cause is increased drug concentration, decreased excretion, and genetic differences predisposing some individuals to increased cell death or mitochondrial injury after exposure to certain antibiotics. In addition, patients with underlying kidney disease, acid-base disorders, and dehydration are at a greater risk of crystal formation with antibiotics that are insoluble in urine.34,36 Most classes of antibiotics have varying degrees of risk for the development of renal dysfunction, but it is most commonly associated with aminoglycosides, beta-lactams, and vancomycin.34,37

                    Renal dysfunction will develop in 10% to 25% of patients on aminoglycosides.34,38 Symptoms of renal dysfunction develop five to seven days after initiation of therapy and will take up to 20 days for complete recovery after discontinuation of the aminoglycoside.34,38 The risk for AKI increases in patients with longer therapy durations, exposure to concomitant nephrotoxins, and other comorbidities like chronic kidney disease.38 Patients on aminoglycosides most commonly develop renal toxicity in the proximal tubule. Gentamicin has the highest potential to cause nephrotoxicity, followed by tobramycin and amikacin. Clinical practice has moved away from using neomycin systemically as it has an increased risk of causing nephrotoxicity, neurotoxicity, and ototoxicity.34

                    Beta-lactams have a high risk of causing renal dysfunction, with carbapenems causing more renal toxicity than penicillins or cephalosporins.34 Beta-lactams cause a wide range of renal toxicity, including acute glomerulonephritis, acute tubular necrosis, and acute interstitial nephritis.34,39 Prolonged infusions of beta-lactams possess a similar risk of AKI compared to intermittent infusions.39

                    Vancomycin’s incidence of nephrotoxicity is between 5% and 43%.38,37,40 Vancomycin nephrotoxicity was initially associated with manufacturing impurities, but new manufacturing methods have eliminated this cause.41-43 Onset occurs four to eight days after initiation of vancomycin and improves after discontinuation.34,43 The overall pathophysiology of vancomycin-induced AKI is poorly understood as several mechanisms most likely contribute. Most patients who develop AKI on vancomycin do not undergo renal biopsies, and it is commonly prescribed with other nephrotoxic agents, which hinders a conclusive diagnosis.34,38,43 Patients with pre-existing kidney disease, severe illness, a combination of nephrotoxic agents, obesity, and daily cumulative doses greater than four grams are at a higher risk of AKI.34,41,44 Adjusting the vancomycin dose based on weight, levels, and renal function can help decrease the risk of kidney injury.34 Pharmacists monitor vancomycin levels as trough and peaks which are low and high measurements of the actual medication in the patient.

                    Evidence of the risk of nephrotoxicity from the combination of vancomycin and piperacillin/tazobactam (VPT) has been conflicting.   Previous evidence has shown VPT to carry a two to three-fold higher risk than vancomycin alone, but this is unclear due to piperacillin/tazobactam being a pseudo-nephrotoxin.42,45 Prescribing information states that piperacillin/tazobactam can increase serum creatinine causing a pseudo-nephrotoxicity.46 Most studies that reported increased risk of nephrotoxicity used increased creatinine as an indicator of acute kidney injury (AKI). 45,47 A 2022 study looked at levels of cystatin C (a biomarker used to test kidney function) and found no significant change in its value for patients on VPT.  Further, it also showed VPT combination did not lead to higher rates of dialysis or death.48 Most recently in 2023, Chen et al. looked retrospectively at 35,644 patients receiving either VPT, vancomycin plus meropenem, or vancomycin plus cefepime.  This study found that the combination of VPT has a greater risk of AKI, dialysis, and mortality in patients receiving treatment for greater than 48 hours.49 At this time, available research on the VPT combination’s nephrotoxicity is conflicting. Clinicians should exercise caution when using VPT and consider other therapies in patients at high risk of renal dysfunction, especially if the combination will continue for longer durations.

                    Overall, antibiotics pose a significant risk to renal function, so the clinical team must assess risk factors of age and co-morbid conditions before initiating therapy.34 A few ways to prevent the development of AKI are34,38

                    • dosages adjusted based on creatinine clearance and glomerular filtration rate (GFR)
                    • changing the dose based on trough or random levels
                    • adequate hydration, especially when using agents that form crystals in the urine
                    • avoiding concomitant nephrotoxins (i.e., NSAIDs, contrast, etc.) and
                    • regular monitoring of kidney function for long-term antibiotic use or when a patient has known risk factors for developing kidney dysfunction.

                    Clinicians must always practice good antimicrobial stewardship by prescribing shorter therapy courses to lower nephrotoxic agent exposure to the kidneys.34

                    Sulfamethoxazole/Trimethoprim-Induced Hyperkalemia

                    The early 1980s through 1990s saw a significant rise worldwide of the human immunodeficiency virus (HIV) which also coincided with the first reported cases of hyperkalemia (high potassium levels) from sulfamethoxazole/trimethoprim (SMX/TMP). The CDC published a report in Morbidity and Mortality Weekly Report (MMWR) in June of 1981 describing the incidence of Pneumocystis carinii pneumonia (PCP; now known as Pneumocystis jirovecii), in five previously healthy young men.50 This CDC report documents the first known cases of HIV. Before the discovery of HIV, P. jirovecii was a disease associated with malnourished and immunocompromised patients. Premature and malnourished infants often contracted P. jirovecii during World War II, and patients with hematologic malignancies in later years.51 Dr. Walter Hughes, known for his research with P. jirovecii, first recommended SMX/TMP for prophylaxis in 1977 and then for treatment in 1989.52-54 Emerging cases of hyperkalemia associated with SMX/TMP usage increased significantly at the start of the HIV epidemic as P. jirovecii treatment requires high doses and HIV patients are prone to the development of hyperkalemia.55,56

                    SMX/TMP causes hyperkalemia because trimethoprim is structurally similar to the potassium-sparing diuretics amiloride and triamterene.55,57 Trimethoprim blocks channels that excrete potassium into the urine, causing a potential 40% reduction of urinary potassium excretion.58,59 Inhibition of urinary potassium excretion also decreases potassium in the urine.55,58 Hyperkalemia will subside after discontinuation of trimethoprim.58

                    Although SMX/TMP-induced hyperkalemia is low risk for most outpatients, it is essential to recognize risk factors and drug interactions because hyperkalemia is a medical emergency if untreated.60 Trimethoprim is excreted in the kidneys and will accumulate during acute and chronic kidney disease, which can increase the risk of hyperkalemia.61 Chronic kidney disease increases potassium levels, making it the most critical factor to consider when assessing risk for hyperkalemia.57,62 Age greater than 65 and dose of greater than 20 mg/kg of trimethoprim for longer than a week also increases risk.57,58

                    Risk assessment should include a review of any disease states or concomitant medications that could cause hyperkalemia (see Table 2). Studies have examined spironolactone’s effect when taken concurrently with SMX/TMP. A 2011 Canadian study examined patients receiving spironolactone and SMX/TMP prescriptions over 18 years. The study found that elderly patients treated with both medications had a 12-fold increased risk of hospital admission.63 A 2015 Canadian study over 17 years looked at 206,319 patients to find an association between sudden death for patients taking spironolactone and antibiotics. Patients taking SMX/TMP were twice as likely to suffer from sudden death when compared to amoxicillin.59

                    Table 2. Alternate Causes of Increased Risk of Hyperkalemia 57,60,62
                    Disease States Medications
                    Renal insufficiency NSAIDs
                    AIDS patients ACE/ARBs
                    Diabetes Mellitus Direct Renin Inhibitors
                    Congestive Heart Failure Beta-blockers
                    Metabolic Acidosis Heparin
                    Congenital Adrenal Hyperplasia Digoxin
                    Hypoaldosteronisim & Pseudohypoaldosteronism Cyclosporine and tacrolimus
                    Pentamidine
                    Potassium-sparing Diuretics

                     

                    Prevention of hyperkalemia from SMX/TMP should include decreasing the dose in patients with impaired renal function. SMX/TMP is contraindicated in patients with severe hepatic damage and severe renal disease if the patient does not have monitoring of renal function and electrolytes.57,61 If hyperkalemia develops, prescribers should discontinue SMX/TMP and treat hyperkalemia following guideline recommendations.58

                    Daptomycin-Induced Eosinophilic Pneumonia

                    The FDA approved daptomycin, a lipopeptide antibiotic, in 2003. Providers use it to treat complicated infections due to methicillin-resistant staph and vancomycin-resistant enterococci. Daptomycin has been an effective treatment alternative for patients who cannot use vancomycin due to intolerance or drug resistance.64 Daptomycin’s approved labeling lists eosinophilic pneumonia and myopathies as severe adverse events.

                    Eosinophilic pneumonia (EP) is a rare respiratory illness that can present with severe dyspnea, hypoxemia, and respiratory failure.65-67 It is caused by eosinophil accumulation in the lungs as an acute or chronic process. Acute EP symptoms last less than one month and typically less than one week, while chronic presentation can take an average of five months before diagnosis.68 Patients with acute EP present with a varying range in the presentation of symptoms. Some patients may have very mild symptoms and require no treatment, while some studies have shown much more severe manifestations, with more than 50% of patients requiring mechanical ventilation.68,69 Patients typically present with a dry cough, chest pain, and fever.68

                    EP develops when alveolar macrophages detect an antigen, which initiates an inflammatory process, eventually producing eosinophils and their subsequent migration to the lungs. Eosinophils are white blood cells that provide an essential defense against helminth parasites (worms). Reactions will develop in humans to presumably benign agents that incite a release of eosinophils.70 In daptomycin-induced eosinophilic pneumonia, daptomycin is the inciting agent.

                    Accumulating eosinophils in the lungs or any tissue can cause significant damage.71 Eosinophils release toxic granule products like major basic protein and eosinophil peroxidase that can damage epithelial cells and nerves. They also release cytokines like transforming growth factors (TGF)-alpha and beta, which are associated with tissue remodeling and fibrosis.71 Alveolar macrophages, pulmonary endothelial cells, and airway smooth muscle cells also produce eotaxin, a potent chemoattractant of eosinophils.65,72

                    EP’s primary causes are idiopathic.68,72 Secondary reasons for EP are drugs or toxins and less commonly, parasitic or fungal infections.68,72 The most frequently cited medications causing EP are daptomycin, mesalamine, sulfasalazine, and minocycline.68 Daptomycin-induced EP was initially reported in 2007 after the drug’s approval.65 Its pathophysiology is poorly understood. One proposed mechanism is that daptomycin may bind to human surfactant and accumulate in the alveolar space causing injury to the epithelium and subsequent eosinophil migration to the damaged tissue.65,66,73 The second proposed mechanism is that daptomycin interacts with surfactant resulting in abnormal lipids. This contact induces an allergic reaction causing the release of several inflammatory markers and eventually shifts eosinophils into the respiratory tissue at least one week after the start of daptomycin therapy.65,66,73

                    The Food and Drug Administration (FDA) has issued guidance for the diagnosis of daptomycin-induced EP with all of the following sequelae confirming a diagnosis of EP74:

                    • Concurrent exposure to daptomycin
                    • Fever
                    • Dyspnea with increasing oxygen demands requiring mechanical ventilation
                    • New infiltrates on chest X-ray or CT
                    • Bronchoalveolar lavage (BAL) with >25% eosinophils
                    • Clinical improvement with daptomycin withdrawal

                    Risk factors have not been well established for daptomycin-induced EP. A 2016 study that reviewed 43 cases in systematic literature found that most patients were male (83%) and elderly (mean age of 65 years old). The same study found that dose or duration was not a risk factor.66 A 2020 review looked specifically for risk with daptomycin and EP and found no association with age and sex. It also did not find an increased risk with high treatment doses. The study found, however, that around 30% of patients had diabetes or renal impairment.75

                    Discontinuation of daptomycin should occur after a probable or definitive diagnosis of daptomycin-induced EP. Patients can experience respiratory failure from EP and may require oxygen supplementation or mechanical ventilation. Treatment can include a steroid taper starting with methylprednisolone and converting to prednisone over two to six weeks if appropriate.65,66

                    Daptomycin-Induced Myopathy

                    Skeletal muscle effects are a rare but serious adverse event associated with daptomycin use. This adverse event presents as muscle weakness and pain, typically preceded by creatine phosphokinase (CPK) elevations.76 In clinical trials, up to 6.7% of patients had elevated CPK levels, and daptomycin-associated myopathy occurred in 2% to 14% of patients.77,78 During early clinical trials in the 1990s, researchers used 12-hour dosing intervals, but adverse skeletal muscle effects prohibited the trials from continuing.79 Trials eventually restarted when once-daily dosing in dogs showed a lower incidence of CPK elevations.80 Dosing frequency has a more direct relationship on skeletal muscle than peak plasma concentrations, making once daily daptomycin safer to administer than twice daily.80

                     

                    Skeletal muscle releases CPK from cells after various circumstances, including infections, intramuscular injections, and intense physical activity.81 The effect of daptomycin on skeletal muscle is thought to be from the drug's mechanism of action. Daptomycin works by breaking down the cell wall of bacteria, creating an opening, and causing a release of intracellular ions. In skeletal muscle, daptomycin also opens the cell wall and causes a release of intracellular CPK.82 Less frequent administration of daptomycin decreases the likelihood of CPK release as it allows skeletal muscle cells more time to repair.82

                     

                    Patients on concurrent statin therapy or who are obese (BMI >30) are at an increased risk of developing myopathies.78 Daptomycin-induced myopathy is more likely to be seen with elevated daptomycin trough levels, but testing trough levels is expensive. Monitoring recommendations include weekly CPK levels to prevent skeletal muscle adverse events. More frequent monitoring should occur in patients with risk factors.64,76 Holding statins when appropriate can help prevent adverse events during daptomycin administration.78 Adverse skeletal muscle effects are reversible upon discontinuation of daptomycin.76 Clinicians should discontinue daptomycin when CPK levels are more than 2000 U/L in asymptomatic patients or patients with CPK levels greater than 1000 U/L in symptomatic patients with no other reasoning for myopathies.64

                     

                    QT Prolongation

                    Medications are the most common cause of QT prolongation.83 Medications can block specific outward potassium channels (IKr channels) in the heart, leading to QT prolongation. The slowing of outward potassium increases the plateau phase of the action potential, and electrocardiograms show a longer QT interval.84 When potassium remains in the heart, the heart is kept at a positive charge that can prolong the repolarization phase. During this time, an ectopic beat generated by the heart can lead to Torsades de Pointe (TdP), a very dangerous and sometimes fatal arrhythmia.85 Antibiotics like fluoroquinolones (FQ) and macrolides block IKr channels and can cause QT prolongation, which can potentially cause harm in patients with risk factors.

                    Macrolides and FQs are the most widely prescribed drugs in the inpatient and outpatient setting.83 Levofloxacin and erythromycin have been cited most frequently for prescriptions in critical care and outpatient settings that cause QT prolongation.86,87 A 2003 study found that a single dose of FQ administered to healthy patients can significantly prolong the QT interval when compared to placebo. The study demonstrated that moxifloxacin caused the most notable change, followed by levofloxacin and ciprofloxacin.88 Ciprofloxacin and levofloxacin have more case reports of TdP than other fluoroquinolones but have a lower risk of QT prolongation. Their widespread use plays a more significant role in the incidence of TdP than their actual risk of developing QT prolongation.83

                    A study reviewed the FDA Adverse Event Reporting System for patients who developed TdP. One-half of reports included macrolide use with no other concurrent QT-prolonging medications.89 Of all the reports, 53% involved erythromycin use, while clarithromycin and azithromycin were 36% and 11%, respectively; further, in all of the reports that included erythromycin, 49% used intravenous (IV) erythromycin.89 Of note, IV erythromycin use accounts for much less than other dosage forms with ointment at 66.1% of all prescriptions in 2020, oral dosages at 29.8% and all other forms including IV at 4.1%.90

                    PAUSE AND PONDER:  What medications can indirectly affect QT?

                    The risk of QT prolongation with antibiotics is difficult to assess as several factors can influence risk. Potassium channel blockade is concentration dependent; anything that increases the medication’s concentration will increase risk of QT prolongation.83 Examples are rapid intravenous administration and impaired clearance through inhibition of hepatic metabolism.83,91 Another important risk factor to consider is female sex, especially elderly females.83,84,91,92 Female patients have consistently developed prolonged QT at a rate much higher than males and are more commonly prescribed medications that prolong the QT interval than males.87 Older patients are more at risk for QT prolongation but are also more likely to have structural heart disease, drug interactions, and decreased drug clearance.93 Risk assessments for QT prolongation should consider structural heart disease, subclinical long QT syndrome or genetic abnormalities, electrolyte abnormalities like hypokalemia and hypomagnesium, and patients with a family history of sudden death.83,91,92 Pharmacists need to review concurrent medications for drug interactions that cause direct QT prolongation and medications that can affect QT indirectly, like diuretics, which can lead to electrolyte abnormalities.92

                    For inpatients, baseline and subsequent electrocardiogram monitoring is an option for patients at high risk for QT prolongation, but it is too expensive to perform on every patient.92 Counseling for outpatients should include warning signs of arrhythmias like palpitations and near-syncope or syncope and other conditions that can affect potassium levels, like gastroenteritis or the addition of a diuretic.92 A risk assessment for QT prolongation is imperative for every patient started on a fluoroquinolone or macrolide.

                     

                    Tendinopathy with Fluoroquinolones

                    In 1995, the FDA warned about the possibility of tendon rupture with fluoroquinolones.94 Since then, several studies have looked at the risk of tendinopathies with FQ and found that they are associated with a two to four times increased risk of acute tendinopathy and tendon rupture. The risk is highest in the first month after drug exposure.94,95 The Achilles tendon is most commonly involved as it is a weight-bearing tendon and more susceptible to injury, but any can occur in any tendon.95-97

                    The mechanism of action of tendinopathy from fluoroquinolones needs to be better understood and may be multifactorial. One proposed mechanism is that fluoroquinolones increase substances known to cause tendons’ breakdown. In a study, matrix metalloproteinase (MMPs) increased after exposure to ciprofloxacin. MMPs cause collagen breakdown, which makes up 70% of tendons.98 Another proposed mechanism is chelation. A study looked at connective tissue of magnesium-deficient dogs and found that the tissue had a similar damaged appearance to tissue treated with FQs. The study hypothesized that because FQs chelate with cations like magnesium, its effect on joints is similar to magnesium deficiency.99

                    Patients are at a higher risk of developing tendinopathies with FQs if they are older than 60 years, transplant recipients, or on concurrent corticosteroid therapy.94 Prescribers should avoid concurrent use of steroids and FQ as the risk of tendon rupture increases by 14-fold.94 Treatment recommendations are discontinuing the offending agent and using supportive therapy like analgesia and physical therapy.95 Approximately 90% of patients recover without surgery in one month, but 10% develop long-term adverse effects like difficulty walking, decreased mobility, and pain.96

                    Cefepime-Induced Neurotoxicity

                    Cefepime is a 4th generation cephalosporin available since 1997.100 The package insert for cefepime warns against neurotoxicity, but it is a potential adverse effect with all beta-lactam antibiotics.101 Beta-lactams cause neurotoxicity because they antagonize the gamma-aminobutyric acid (GABA) receptor to varying degrees.102 Beta-lactams all have an affinity for GABA receptors because they are all structurally similar to GABA.103,104 Cephalosporins, including cefepime, competitively inhibit the GABA receptor by binding directly to the receptor.105,106

                    Cefepime-induced neurotoxicity (CIN) typically presents as encephalopathy, somnolence, agitation, confusion, and disorientation, while aphasia and hallucinations are less common.107-109 Patients occasionally will develop convulsions or non-convulsive status epilepticus.110

                    The most significant risk factor for CIN is renal dysfunction.100,104,108 When a patient with poor renal function receives cefepime, a higher concentration of unbound medication stays within the cerebrospinal fluid, causing symptoms when it enters the central nervous system.108 A study of 42 patients with CIN found that 93% of patients with neurotoxicity had abnormal renal function, and 76% of the studied patients had their cefepime dose adjusted appropriately.102 A study has shown that CIN occurred despite dose reductions and even in dosages of 500 mg daily in patients with ESRD.111

                    In addition to renal dysfunction, several other risk factors for CIN need review. Overdose or use of excessive dosages puts patients at risk for CIN, and it is much more likely to be seen in patients without appropriate dose adjustments.108,109 Drug monitoring sometimes includes measurement of the medication in the blood called a peak (highest) and trough (lowest) levels. A study has associated CIN with high trough levels. The study showed neurotoxicity did not occur at troughs of less than 7.7 mg/L, while it always manifested at troughs at or exceeding 38.1 mg/L. The study’s author has suggested a trough of 7.5mg/L as a potential target.112 Patients 65 and older are at risk because of pharmacokinetic changes.100,113 Although age is a significant risk factor, CIN will occur in 25% of patients younger than 65.100 Last, patients with underlying brain diseases like cerebrovascular accident, Korsakoff’s syndrome, small-vessel disease, Alzheimer’s disease, benign brain tumor, malignancy, or previous seizures are at risk for CIN.108,114

                    Prescribers should discontinue cefepime in patients who develop suspected CIN.100,108 It typically takes two to three days to resolve symptoms.100,108 Providers can initiate dialysis in patients experiencing severe symptoms as it can rapidly decrease the concentration of cefepime.114 Medications that stimulate the GABA receptor, like benzodiazepines or barbiturates, are more effective than phenytoin in patients who develop seizures.104 Last, switching antibiotics can sometimes resolve symptoms, but symptom prolongation can occur with other beta-lactams like piperacillin and meropenem. Consider alternative antibiotic classes in appropriate patients.108

                    Linezolid-Induced Thrombocytopenia

                    Linezolid belongs to a class of medications called oxazolidinones. The discovery and investigation of oxazolidinones occurred in the late 1980s, but development did not continue due to severe adverse events in animals.115 In the 1990s, scientists from the Pharmaca Corporation derived linezolid from the oxazolidinones class, and the FDA approved its use in April 2000 after clinical safety testing.116 Linezolid has a considerable advantage for treating severe gram-positive infections as it is available intravenous (IV) but also has 100% oral bioavailability.117 Another advantage of linezolid is it’s relatively safe to use, with only 0.4% of patients experiencing severe adverse effects in phase 3 trials.115 Several case reports of adults experiencing varying types of myelosuppression, like anemia or pancytopenia, emerged following linezolid’s clinical approval, but thrombocytopenia (low platelets) is the most prevalent.115

                    Linezolid-induced thrombocytopenia (TP) takes approximately seven to 14 days before onset.115,118 Reports of TP differ depending on geographical location or definition used.118-120 TP typically takes around 14 days to develop because the platelet has a seven to ten day life cycle.115 Although studies have proposed several mechanisms, a definitive cause has yet to be established.120

                    Patients with the following risk factors need monitoring for the development of thrombocytopenia115,118,121,120:

                    • Prolonged treatment course greater than 14 days
                    • Underlying disease with a predisposition to hematologic abnormalities
                    • Renal dysfunction, CrCl less than 30 ml/min, and dialysis. Linezolid is not primarily cleared renally but metabolized into two compounds. These compounds are renally eliminated and can accumulate in patients with renal dysfunction and may play a role in the development of thrombocytopenia
                    • Chronic liver failure
                    • History of vancomycin use
                    • Low baseline platelet level of less than 200
                    • Low body weight–Linezolid dosing does not change for adults nor require renal or hepatic impairment adjustment. When body weight decreases and total mg/kg of linezolid increases, the risk of thrombocytopenia increases. A study found that daily mg/kg doses between 22-27 (body weight between 55-70 kg) had a 48% chance of developing thrombocytopenia versus 72% in dosages greater than 27 mg/kg (body weight less than or equal to 45kg).

                    Discontinuation of linezolid should occur for patients who develop thrombocytopenia or any myeloid cell abnormality while on therapy.115 Myelosuppression is reversible after discontinuation of linezolid. Patients actively receiving therapy should have weekly monitoring of complete blood count and renal function monitoring.121 Monitoring is essential in patients receiving treatment for longer than 14 days, have pre-existing myelosuppression, take concurrent medications that cause myelosuppression, or have received prior antibiotic therapy from a chronic infection.117

                     

                    Reporting ADRs

                    Identifying ADRs as they occur is vital to comprehensive patient care, but reporting ADRs is equally essential. The FDA established MedWatch in 1993 as a tool for healthcare providers and consumers to voluntarily report ADRs. ADRs can be reported through MedWatch or directly to drug manufacturers, who then are required to report ADRs to the FDA. The FDA uses the reported ADRs to make up the Adverse Event Reporting System (AERS), a postmarketing surveillance database. The information entered into AERS helps identify trends that are useful in determining causes and preventing prospective events.122,123

                    PAUSE AND PONDER: Why is it important to include so much information when reporting ADRs?

                    The FDA defines a serious Adverse Drug Event (ADE) as fatal, life-threatening, incites hospitalization or prolongation of existing admission, causes significant disability, or congenital disability or anomaly to the patient.124 The FDA asks healthcare providers and manufacturers to report all serious ADEs. Healthcare providers, including pharmacists, should also report any non-serious unexpected ADEs. These reports are helpful, even if the reaction is not directly related to the drug, as the reports may help discover unidentified ADEs. Healthcare providers should submit as much information as possible that is relevant to the ADE.122 Table 3 includes essential information to include in ADE reporting.

                    Table 3. Key-Inclusions for High-Quality ADE Report125
                    ·        Clear description of event or outcome, include time to onset of signs and symptoms;
                    ·        Suspected and concurrent medications details: dose, lot number, schedule, dates, duration (Include non-prescription medications, dietary supplements, and any recently discontinued medications);
                    ·        Patient characteristics, including demographics (e.g., age, sex, race), baseline medical condition prior to treatment, co-morbid conditions, medication allergies, relevant family history, other risk factors;
                    ·        Documentation of diagnosis, including methods of making diagnosis;
                    ·        Clinical course of event and outcome (e.g., death, hospitalization, treatment);
                    ·        Relevant objective information (e.g., laboratory data) at baseline, during therapy, and after therapy;
                    ·        Response to discontinuation of therapy and re-initiation if available;
                    ·        Any other relevant information.

                     

                    Conclusion

                    This continuing education activity discusses only a fraction of commonly experienced adverse drug reactions associated with antibiotics. It is not an exhaustive list, but it provides valuable guidance for healthcare providers for antibiotics with established reactions and serves as a reminder to report any serious or atypical reactions that may occur while using new antibiotics.

                    Antibiotic-associated adverse drug reactions are a significant concern in healthcare. These reactions occur when antibiotics lead to unintended harmful effects, such as allergic reactions, organ damage, or antibiotic resistance. Inappropriate use or overuse of antibiotics increases risk of adverse reactions. Decreased renal and hepatic function, elderly patients, and drug interactions are common risks of developing ADRs in antibiotics. Recognizing risks and following recommended monitoring can help prevent ADRs from occurring. Anyone directly involved in direct patient care should report suspected ADRs and educate patients on the impact of these events to ensure the safe and effective use of antibiotics.

                     

                     

                     

                     

                    Pharmacist Post Test (for viewing only)

                    Title: Patient Safety: The Risk of Treatment: Antibiotic induced adverse events
                    Objectives
                    Pharmacists
                    • DESCRIBE mechanisms of action that can cause antibiotic induced adverse effects
                    • ANALYZE risks and sequelae to determine adverse event or causative medication
                    • RECOMMEND appropriate treatment for antibiotic induced adverse effect
                    • DISCUSS counseling points for outpatient antibiotic use

                    1. A patient recently filled penicillin for treatment of strep throat. She returns back to the pharmacy the following day with a prescription for a new antibiotic and an epi-pen. She describes having a sudden reaction of hives, shortness of breath and facial swelling after a dose of penicillin and having to go to the hospital for treatment. What type of reaction did the patient have?
                    A. Type I
                    B. Type II
                    C. Type III

                    2. What type of reaction is appropriate to consider re-challenging an antibiotic if a patient develops an allergy?
                    A. Steven Johnsons Syndrome
                    B. Mild Itching
                    C. Anaphylaxis

                    3. A 40-year-old female with history of kidney transplant on immunosuppressants was started on antibiotics for pneumonia. The patient is afebrile has developed mild to moderate diarrhea from antibiotics and the medical team is looking for recommendations. What is appropriate treatment for this patient?
                    A. Probiotics
                    B. Start treatment for C diff infection
                    C. Rehydration

                    4. Sara is an 80-year-old female who has recently been diagnosed with a UTI and started on sulfamethoxazole/trimethoprim. She also has heart failure, DVT and COPD and also uses spironolactone, apixiban and albuterol nebulizer. What comorbid condition and medication increase her risk of hyperkalemia from SMX/TMP?
                    A. Heart failure patient on spironolactone
                    B. DVT on apixiban
                    C. Asthma exacerbation on albuterol nebulizers

                    5. Paul is a 75-year-old male who was admitted to the hospital for septic arthritis and started on vancomycin. After three doses of vancomycin, Paul develops an allergic reaction and he is switched to daptomycin. Five days later, Paul starts coughing, develops a fever, and his oxygenation levels drop. The attending physician orders a BAL; it shows an increase of eosinophils. He is diagnosed with eosinophilic pneumonia from daptomycin. What is an appropriate treatment recommendation?
                    A. An alternative antibiotic to treat the pneumonia
                    B. Albuterol to increase oxygenation levels
                    C. Discontinuation of daptomycin and start steroids

                    6. At a community pharmacy, a patient asks what you recommend for pain medication for muscle aches. Upon further questioning, you find that the patient has been on outpatient infusions of daptomycin for a diabetic foot infection for a few weeks. The patient is obese and says he thinks the muscle aches must just be from getting old. What is this patient most likely experiencing?
                    A. Daptomycin induced myopathy
                    B. Diabetes induced neuropathy
                    C. Muscle aches from infection

                    7. What laboratory value increases when patients develop daptomycin-related myopathy?
                    A. Scr
                    B. CPK
                    C. Eosinophils

                    8. What medication causes an indirect risk for this patient to develop QT prolongation?
                    A. Furosemide
                    B. Acetaminophen
                    C. Amiodarone

                    9. You have phoned Cecelia’s provider and determined he wants to continue ciprofloxacin despite the risk of QT prolongation. What is appropriate to include when counseling?
                    A. Patient needs daily EKG monitoring while taking ciprofloxacin and can use her iWatch to do the monitoring
                    B. Any new diarrhea does not need to be reported to the provider as its expected with antibiotics
                    C. Patient should be aware of warning signs of arrhythmias like palpitations and near-syncope or syncope
                    .
                    10. What medication should be avoided concurrently with fluoroquinolones because it increases the risk of tendon rupture?
                    A. Magnesium
                    B. Ibuprofen
                    C. Prednisone
                    .
                    11. Why are beta-lactams associated with causing neurotoxicity?
                    A. They deplete the availability of GABA
                    B. They increase the production of GABA
                    C. They are structurally similar to GABA
                    .
                    12. Paul is a 41 YO male with a history of end stage renal disease admitted to the hospital for pneumonia. He is initially started on dose adjusted cefepime and vancomycin and starts to improve. Three days after initial therapy cultures come back growing pseudomonas sensitive to cefepime, ciprofloxacin, and piperacillin/tazobactam but he has altered mental status and is very somnolent. What is your recommendation for treatment?
                    A. Discontinue cefepime and switch to non-beta lactam antibiotic
                    B. Discontinue cefepime and switch to alternative beta-lactam antibiotic
                    C. Continue cefepime and discontinue vancomycin

                    13. Patti comes to your pharmacy with a prescription for a brand new antibiotic that has recently been approved for UTI. After discussing expected adverse effects, what is also important to include about adverse effects?
                    A. She should ignore any other adverse effects she experiences as they have not been reported so they could not possibly be from the new antibiotic
                    B. She should report any undocumented adverse effects to her prescriber or pharmacist as it can help discover unidentified adverse drug reactions
                    C. She should post about any new adverse effects on her social media because all drug companies use artificial intelligence to screen for new adverse effects

                    Pharmacy Technician Post Test (for viewing only)

                    Title: Patient Safety: The Risk of Treatment: Antibiotic induced adverse events
                    Objectives
                    Technicians
                    • LIST adverse effects induced by antibiotics #6
                    • RECOGNIZE patients at risk of adverse effects #3
                    • RECALL medications used to treat adverse effects #2
                    • IDENTIFY when to refer patient to pharmacist for recommendation or referral #2

                    1. What is the most common pathogen known to cause antibiotic-associated diarrhea?
                    A. Clostridium difficile
                    B. Staphylococcus aureus
                    C. Candida albicans
                    .
                    2. A patient comes to the pharmacy to drop off a new prescription for cephalexin. When reviewing the profile, you notice an allergy for amoxicillin. There is no information about what the reaction is to amoxicillin. What is the appropriate action?
                    A. Ignore the allergy and fill the prescription, the risk of cross-reactivity is low.
                    B. Instruct the patient to contact the prescriber for a different antibiotic
                    C. Alert the pharmacist and let them determine the appropriate actions
                    .
                    3. Which of the following conditions can be treated with fidaxomicin?
                    A. C difficile infection
                    B. Antibiotic allergies
                    C. Kidney dysfunction
                    .
                    4. Which antibiotic is more likely to cause kidney injury
                    A. Clindamycin
                    B. Metronidazole
                    C. Gentamicin
                    .
                    5. What electrolyte does sulfamethoxazole/trimethoprim increase?
                    A. Magnesium
                    B. Potassium
                    C. Sodium

                    6. What medication can be used to treat daptomycin-induced eosinophilic pneumonia?
                    A. Methylphenidate
                    B. Methylprednisolone
                    C. Methylnaltrexone
                    .
                    7. What patient is at increased risk for daptomycin induced myopathy?
                    A. BMI <18.5 B. BMI 18.5-30 C. BMI >30
                    .
                    8. Macrolides and quinolones cause a certain cardiac side effect. What is it?
                    A. Congestive heart failure
                    B. Endocarditis
                    C. QT prolongation
                    .
                    9. What tendon is most often associated with tendon rupture from fluoroquinolones?
                    A. Achilles Tendon
                    B. Quadriceps Tendon
                    C. Biceps Tendon
                    .
                    10. Which antibiotic has been associated with neurotoxicity as an adverse effect?
                    A. Clindamycin
                    B. Cefepime
                    C. Clarithromycin

                    11. What organ dysfunction makes patients more at risk for adverse drug reactions associated with cefepime?
                    A. Kidney
                    B. Liver
                    C. Heart
                    .
                    12. Which of the following increases patients’ risks for linezolid induced thrombocytopenia?
                    A. Short therapy course
                    B. Obesity
                    C. Low baseline platelets
                    .
                    13. A patient comes to the pharmacy stating that ever since he started taking a new antibiotic, sarecycline, he has lost his appetite and found it difficult to eat. The patient tried to research if the medication causes that reaction but could not find any information. What should you do?
                    A. Refer the patient to the pharmacist; this reaction may need to be reported as a potential adverse drug event to the drug manufacturer and FDA
                    B. Tell the patient to not worry as if he cannot find any information about it, this adverse effect is not related to the medication
                    C. Instruct the patient to not trust information from the Internet because in most cases, an unreliable source posted the information

                    References

                    Full List of References

                    1. Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of adverse events with antibiotic use in hospitalized patients. JAMA Internal Medicine. 2017;177(9):1308. doi:10.1001/jamainternmed.2017.1938
                    2. Core Elements of Hospital Antibiotic Stewardship Programs. Centers for Disease Control and Prevention. Published April 28, 2021. Accessed January 3, 2023. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html#anchor_1617121904865
                    3. World Health Organization. Antibiotic Resistance. World Health Organization. Published July 31, 2020. Accessed January 9, 2023https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance
                    4. Magill SS, Edwards JR, Beldavs ZG, et al. Prevalence of antimicrobial use in US acute care hospitals, May-September 2011. JAMA. 2014;312(14):1438-1446. doi:10.1001/jama.2014.12923
                    5. Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med. 2003;163(8):972-978. doi:10.1001/archinte.163.8.972
                    6. Antibiotic / antimicrobial resistance. Centers for Disease Control and Prevention. Published December 17, 2021. Accessed January 9, 2023. https://www.cdc.gov/drugresistance/index.html.
                    7. Antibiotic Resistance Threats in the United States, 2019. Centers for Disease Control and Prevention. Accessed May 16, 2023. https://stacks.cdc.gov/view/cdc/82532
                    8. Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. The Lancet. 2019;393(10167):183-198. doi:10.1016/s0140-6736(18)32218-9
                    9. Macy E. Addressing the epidemic of antibiotic “allergy” over-diagnosis. Annals of Allergy, Asthma & Immunology. 2020;124(6):550-557. doi:10.1016/j.anai.2019.12.016
                    10. Macy E, Ho NJ. Multiple drug intolerance syndrome: prevalence, clinical characteristics, and management. Ann Allergy Asthma Immunol. 2012;108(2):88-93. doi:10.1016/j.anai.2011.11.006
                    11. Goss FR, Lai KH, Topaz M, et al. A value set for documenting adverse reactions in electronic health records. J Am Med Inform Assoc. 2018;25(6):661-669. doi:10.1093/jamia/ocx139
                    12. McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1-e48. doi:10.1093/cid/cix1085
                    13. Uzzaman A, Cho SH. Chapter 28: Classification of hypersensitivity reactions. Allergy Asthma Proc. 2012;33 Suppl 1:96-99. doi:10.2500/aap.2012.33.3561
                    14. Weiss ME, Adkinson NF. Immediate hypersensitivity reactions to penicillin and related antibiotics. Clin Allergy. 1988;18(6):515-540. doi:10.1111/j.1365-2222.1988.tb02904.x
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                    34. Morales-Alvarez MC. Nephrotoxicity of Antimicrobials and Antibiotics. Adv Chronic Kidney Dis. 2020;27(1):31-37. doi:10.1053/j.ackd.2019.08.001
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                    Patient Safety: Gabapentin and Trazadone: Off-label Use is Out of Control-Recorded Webinar

                    About this Course

                    This course is a recorded (home study version) of the CE Finale Encore Webinars.

                     

                    Learning Objectives

                    Upon completion of this knowledge based CE Activity, a pharmacist will be able to:

                    ·        LIST the numerous off label uses of gabapentin and trazodone.
                    ·        DESCRIBE which of those uses are supported by actual evidence
                    ·        INDICATE the potential adverse effects and medication related problems that patients who take these drugs may experience
                    ·        ARTICULATE ways to approach prescribers with alternative suggestions

                    Release and Expiration Dates

                    Released:  December 15, 2023
                    Expires:  December 15, 2026

                    Course Fee

                    $17 Pharmacist

                    ACPE UAN

                    0009-0000-23-044-H05-P

                    Session Code

                    23RW44-WYX48

                    Accreditation Hours

                    1.0 hours of CE

                    Additional Information

                     

                    How to Complete Evaluation:  When you are ready to submit quiz answers, go to the BLUE take test/evaluation button.

                    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 knowledge-based activity and will receive up to 1.0 CE Hours (or 0.1 CEUs)  for completing the activity ACPE UAN 0009-0000-23-044-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

                    Jeannette Y. Wick, RPh, MBA, FASCP
                    Director OPPD
                    University of Connecticut 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  Wick has no 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

                    Patient Safety: Gabapentin and Trazodone, Off-label Use is Out of Control
                    LEARNING OBJECTIVES
                    At the end of this continuing education activity, pharmacists will be able to
                    1. LIST the numerous off label uses of gabapentin and trazodone
                    2. DESCRIBE which of those uses are supported by actual evidence
                    3. INDICATE the potential adverse effects and medication related problems that patients who take these drugs may experience
                    4. ARTICULATE ways to approach prescribers with alternative suggestions

                    1. Which of the following is an off-label use for gabapentin?
                    A. Postherpetic neuralgia
                    B. Adjunctive therapy in partial seizures
                    C. Migraine prophylaxis

                    2. Which of the following is an off-label use for trazodone?
                    A. Chronic insomnia
                    B. Major depressive disorder
                    C. Pruritis

                    3. Which of gabapentin’s off-label uses has the strongest evidence to support it?
                    A. Bipolar disorder
                    B. Alcohol withdrawal syndrome
                    C. Pain syndromes

                    4. Which of trazodone’s off-label uses has the strongest evidence to support it?
                    A. Little evidence is available to support the use of trazodone in any of its purported off-label uses.
                    B. The best evidence supports its use in chronic insomnia, with more than 15 RCTs indicating it is effective.
                    C. A surprise finding has been that it is effective for behavioral issues in kids who have ADHD; it may help adults, too.

                    5. Which if the following links gabapentin and trazodone to a most common adverse effect?
                    A. Gabapentin = dose-dependent CNS and respiratory depression; trazodone = nausea/vomiting, xerostomia, dizziness, drowsiness
                    B. Gabapentin = dose-dependent CNS priapism and suicidal ideation; trazodone = hypersensitivity reactions and peripheral edema
                    C. Gabapentin = cardiac arrythmias and QT prolongation; trazodone = cumulative depressant effects when given with SSRIs

                    Handouts

                    VIDEO

                    Patient Safety: Workplace Bullying

                    Learning Objectives

                     

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

                    1. Define workplace bullying in the healthcare setting
                    1. Explain the impact of workplace bullying on individuals, organizations, and patient care
                    1. Differentiate workplace bullying from harassment and workplace dysfunction
                    1. Describe the necessary steps to address and counteract workplace bullying

                      Individuals talking to each other behind another individual's back

                       

                      Release Date: November 20, 2023

                      Expiration Date: November 20, 2026

                      Course Fee

                      Pharmacists: $7

                      FREE FOR UConn Preceptors

                      Pharmacy Technicians: $4

                      There is no funding for this CE.

                      ACPE UANs

                      Pharmacist: 0009-0000-23-058-H05-P

                      Pharmacy Technician:  0009-0000-23-058-H05-T

                      Session Codes

                      Pharmacist:  23YC58-ABC28

                      Pharmacy Technician: 23YC58-BCA49

                      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 0009-0000-23-058-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

                      Giovanni Fretes, PharmD Candidate 2025
                      UConn School of Pharmacy
                      Storrs, CT

                                                         

                      Jeannette Y. Wick, RPh, MBA, FASCP
                      Director OPPD, 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.

                      Giovanni Fretes and Jeannette Wick have no relationships with ineligible companies.

                       

                      ABSTRACT

                      Several healthcare professional organizations have identified workplace bullying as a problem. Workplace bullying can decrease morale, but additionally, it can also compromise patient safety. Some studies have found that physicians tend to be identified most often as workplace bullies, but additional studies indicate that bullying in pharmacy is present and under reported. The most likely type of workplace bullying in pharmacy is verbal bullying, which includes mocking, name-calling, teasing, or intimidating a target. In some instances, physical or nonverbal bullying may occur. Unaddressed bullying can lead to diminished morale, strained employee relations, loss of respect for management, and increased absenteeism or tarnished reputation of the workplace. Establishing a reasonable definition of bullying, differentiating it from harassment, and training employees in bystander intervention can help improve the workplace and decrease the likelihood of damage from bullying.

                      CONTENT

                      Content

                      INTRODUCTION

                      Bullying is a popular topic these days. Hardly a day goes by without a story in the media about school bullies, social media bullies, celebrity bullies, political bullies, and even chef bullies. In addition, lawsuits have found people and organizations liable for suicides when they bullied the victim (called the target) or failed to address bullying.1 And many times, serial killers or individuals who conduct mass shootings are later identified as having been bullied. Clearly, the United States (U.S.) has a bullying problem. Does healthcare and, on a smaller scale, pharmacy, have a bullying problem?

                      This continuing education activity discusses bullying in the workplace because healthcare and on a smaller scale, pharmacy, do have bullying problems and students sometimes experience bullying as they are introduced to the profession on rotations or in residencies. Unlike harassment, bullying isn’t illegal in the U.S., but it has serious repercussions to individuals and organizations. Recognizing and addressing workplace bullying is essential to foster healthy and supportive work environments in healthcare settings, ultimately benefiting both staff and patients. Although the authors drafted this activity to address the bullying that students sometimes experience in experiential rotations, during extensive peer review, reviewers indicated this topic is of interest to all pharmacy personnel, not just preceptors.

                      Mock, Taunt, Intimidate

                      Workplace bullying is a widespread issue that affects various industries, including pharmacies and other healthcare settings. Most of the data in healthcare comes from studies of physicians’ interactions with other disciplines, and the American Medical Association (AMA) recognizes the problem. AMA defines workplace bullying as “repeated, emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating or threatening behavior targeted at a specific individual.”2 Bullying’s purpose is to control, embarrass, undermine, threaten, or cause harm toward an individual. Various factors at the individual, organizational, and health system level can contribute to creation of an unprofessional workplace climate or culture.2

                      Workplace bullying is important to address because it can impact patient care, resulting in preventable mistakes. In a 2021 survey, roughly 35% of healthcare providers had concerns about medication orders but chose to assume correctness to avoid engaging with specific providers. One pharmacist was shamed by a colleague after seeking an independent double check for a vancomycin order with incorrect timing. Multiple errors like this occur annually because of the culture of shaming.3 Some data about how bullying affects the medication prescribing and administration process demonstrates this subject’s importance.

                      Every few years, the Institute for Safe Medication Practices (ISMP) surveys healthcare professionals about disrespectful behaviors and intimidation in the workplace.4,5 ISMP conducted its most recent survey in September 2021.3 Among the 1,047 respondents, 26% worked in the pharmacy, suggesting that bullying is a problem in pharmacies since a disproportionate number of pharmacy employees responded compared to more populous health care providers like physicians and nurses. A full 37% of respondents were pharmacists and 6% were pharmacy technicians.3

                      Disrespectful behaviors were clearly linked to medication concerns3:

                      • 40% of respondents said past disrespectful behaviors had altered the way they handled order clarifications or questions about medication orders.
                      • Roughly half of respondents said that they had relied on colleagues to interpret or validate an order rather than contact the prescriber in the past year; the reason was to avoid contact with the disrespectful prescriber.
                      • 11% of respondents indicated they avoided talking to a prescriber to interpret or validate an order’s safety more than ten times in the previous year.
                      • 7% said that they had been pressured to accept an order, dispense a product, or administer a drug despite safety
                      • Slightly more than one-third reported having concerns about a medication order but assumed it was correct rather than interact with a specific prescriber; roughly the same number of respondents said that a prescriber’s stellar clinical reputation often made them reluctant to question or clarify orders even if they had concerns.

                      TYPES OF WORKPLACE BULLYING IN HEALTHCARE

                      In the limited research that addresses workplace bullying in pharmacies and other health care settings, researchers frequently bemoan the fact that, the AMA’s definition aside, we have no consensus definition of bullying. It would be ideal if we could provide a concise definition of bullying or a checklist that would help managers, supervisors, coworkers, and preceptors ascertain when bullying is occurring. In fact, bullying occurs in many different forms.

                       

                      Verbal Bullying

                      Verbal bullying encompasses various forms of harmful language and communication. Examples of verbal bullying include mocking, name-calling, teasing, or intimidating someone to belittle or demean them. Insults and derogatory comments can degrade a person's self-esteem, creating a hostile working environment. Fans of the television show NCIS may recall that the section supervisor, Leroy Jethro Gibbs, always dubbed the newest hire “Probie,” which appears to have been short for probationary employee. People watching this show who are familiar with human resources regulations often shuddered when Gibbs did this, as it could be perceived as a form of bullying. Especially in government organization where the rules are very clear, such behavior would be dangerous. In pharmacies, calling people by unwelcome nicknames could be perceived as bullying.

                      Public humiliation is another form of verbal bullying that aims to embarrass the person who is being bullied in front of others. Trainees commonly report persistent attempts from their preceptors or trainers to humiliate them in front of colleagues. According to a study, “The abuse of students is ingrained in medical education and has shown little amelioration despite numerous publications and righteous declarations by the academic community over the past decade.”6

                      PAUSE AND PONDER: A preceptor asked a student a question in front of the rounding team. The student, who was unable to answer, blushed and stuttered. The preceptor said, “What school of pharmacy did you go to again? I need to call them and ask them what they're teaching because you clearly should have known the answer to this question.” The student reddened even more, and the preceptor said, “Oh! So, you're a blusher are you?” Was this teasing, was this misplaced humor, or was it bullying?

                      The term bullying does not appear in the Accreditation Council for Pharmacy Education (ACPE) standards. Researchers reviewed the professional literature and American Association of Colleges of Pharmacy (AACP) survey data collected from student evaluations of preceptors (N = 2087); students provided low evaluations for preceptors in at least one area in 119 evaluations.6 When the researchers scanned the comments for words or phrases closely associated with bullying, they found respondents reported 34 instances indicating bullying. Figure 1 shows the distribution of comments and includes examples of troublesome comments.6

                      Comments related to workplace bullying involve offensive behavior, humiliation, intimidation, exclusion or denial to opportunities, and excessive criticisms.

                      Figure 1. Comments Related to Bullying from Pharmacy Survey Data6

                      This data came from one college of pharmacy, but the researchers compared their data to that of a national study.6 It was similar. Although the rates of bullying seemed low, the researchers believed that bullying is seriously underreported in pharmacy. Some reasons may include the small number of pharmacists compared to physicians and nurses, the use of assessment tools that are not intended to identify bullying (asking the wrong questions), and students’ reluctance to complain because it may be perceived as unprofessional. Students may also be afraid that reporting bullying may affect their grades. The researchers recommend ACPE place more emphasis on bullying and develop of a consensus definition.6

                      Intimidation and threats instill fear and anxiety, leaving the target feeling vulnerable and powerless. Intimidating behaviors in the healthcare workplace are far from isolated incidents. A survey conducted with more than 2,000 healthcare providers revealed that subtle, yet effective forms of intimidation were more common than explicit forms.4 Respondents reported encountering behaviors such as condescending language, impatience with questions, and reluctance to answer or return calls. Physicians and prescribers were identified as the primary perpetrators of intimidation, exhibiting behaviors such as condescension, reluctance to answer questions, and verbal abuse more frequently than other healthcare providers.4

                      Additionally, destructive criticism is another unjustified way in which someone can wear down the target emotionally and psychologically. Constructive criticism and destructive criticism differ based on their delivery and the ways in which they impact individuals and their work.7 Constructive criticism uplifts people by providing suggestions and potential solutions while highlighting both positive aspects of someone's work and identifying areas for improvement. Destructive criticism undermines confidence, belittles efforts, and focuses on ridicule, leading to decreased morale and performance. It creates a hostile atmosphere and restrains productivity.7

                      Constructive feedback begins and ends with positive comments and present information in a supportive way, as this “compliment sandwich” exemplifies:

                      “Jacob, I appreciate your dedication and commitment to our pharmacy team. However, I've observed a higher number of medication errors when you’re dispensing prescriptions, which is unusual based on your work history. I know how dedicated you are to the team, so if you're facing any challenges that may be impacting your performance, please don't hesitate to reach out to me or any team member. We are here to support you and provide the best patient care possible."

                      Destructive feedback is replete with negativity:

                      "Jacob, your work recently in the pharmacy has been extremely disappointing. Why are you making so many mistakes? It's causing a lot of problems for the team, and frankly, I don't have the time or patience to fix everything for you. You really need to step up and improve your performance because it's negatively impacting our overall productivity."

                      It’s not always possible to use a compliment sandwich when addressing issues in the pharmacy. It is always possible to be kind.

                      Verbal bullying is usually easy to spot if the bully conducts the browbeating in public. In one pharmacy, a seasoned technician seemed to have a bias against students who were accruing IPPE or APPE hours. She would frequently tell students loudly, “If you can’t work any faster, it would be lovely if you would just get out of the way.” Her colleagues would turn a blind eye, but the section supervisor eventually took action and referred her to employee assistance. However, many bullies are adept at mounting their campaigns of terror when no one is looking. (Remember that the most likely place for bullying is schools is in the most difficult place to supervise: the playground.8)

                       

                      Non-Verbal Bullying

                      Non-verbal bullying in healthcare manifests through actions that undermine and harm the target without using explicit words.9 Bullies use exclusion and social isolation to insulate targets from their colleagues, fostering a sense of loneliness and alienation. Undermining and sabotage minimize the target's work and efforts, eliminating a culture of safety.9

                       

                      PAUSE AND PONDER: A preceptor assigned one pharmacy student to sort and file a large backload of paperwork. She also assigned a technician to explain what needed to be done and how. The technician was frustrated by the student’s questions, but two hours later, the student finished sorting. He asked the technician to check his work before he filed it. The technician riffled through the pile, said, “This is correct,” and then said, “Oops!” and intentionally dropped the entire pile on the floor. Was that bullying?

                       

                      Ignoring and dismissing ideas invalidates targets’ contributions and suggestions which diminishes their confidence and ability to perform well.10 Additionally, intentionally withholding information deprives targets of essential knowledge needed to perform their assigned tasks effectively.9 Individuals who use “the silent treatment” (refusing to engage in discussion and making no eye contact) are also bullies. Researchers have found that people in positions of power who use the silent treatment also frequently assign unreasonable or unnecessary tasks.11

                       

                      Finally, bullies may also use noise in subtle ways to intimidate or disturb targets. In one situation, students were assigned to work in an office across from a pharmacist who did not like to precept but did so because he was assigned the task. He kept his door closed most of the time but would slam it hard when coming and going. He’d watch to see if the students reacted.

                       

                      Physical Bullying

                      While less common in healthcare, physical bullying involves direct aggression towards the target.12 This can include pushing or shoving, which poses a threat to the target’s safety and well-being. Damaging personal belongings is another form of physical bullying, violating the target's personal space and property. Also forcing physical exertion on the target, such as excessive workloads or tasks beyond their capacity, can cause physical harm and exhaustion.12

                      Healthcare workers are already at risk for physical violence, and four times more likely to experience violence requiring an absence from work than people employed in other industries.12 According to 2013 Bureau of Labor Statistics (BLS) data, 80% of serious violent incidents were a result of interactions with patients. The remaining incidents were attributed to visitors, coworkers, or individuals outside of the healthcare facility with 3% of the incidents from coworkers.12

                      BLS found one fact of particular note: Employees were significantly less likely to report bullying and other forms of verbal abuse. They cited three contributing reasons: (1) lack of a reporting policy, (2) lack of faith in the reporting system, and (3) fear of retaliation, which is discussed below.12 Although healthcare workers appear to be more likely to be bullied by patients than coworkers, concerns about reporting flaws and retaliation may skew the data.12

                      SIGNS AND EFFECTS OF BULLYING

                      Absent a clear definition, healthcare managers and workers may struggle to identify bullying or differentiate it from harassment. Signs may be obvious—as in the example of the technician who tells students to get out of the way—or subtle.

                      Signs of Workplace Bullying

                      Recognizing the signs of workplace bullying is crucial for early intervention. Behavioral changes in targets, such as increased irritability, anxiety, or withdrawal, may indicate they are experiencing bullying.13

                      Effect on Workers and Patients

                      Workplace bullying has detrimental effects on both healthcare professionals and the quality of patient care.9 The emotional and psychological impact on targets can lead to heightened levels of stress, anxiety, and depression. This affects their well-being and their ability to provide optimal care to patients. Bullying can contribute to higher rates of medication errors, increased infections, and other negative patient outcomes. This is partly due to staff members' fear of speaking up against physicians or prescribers who are bullies.14 Physician Alan Rosenstein, an expert in disruptive behavior, highlights the existence of a "hidden code of silence" that keeps coworkers or colleagues from reporting or appropriately addressing many incidents.14

                      Rosenstein has collected anecdotes from his work. He doesn’t report any from situations involving pharmacists or technicians, some examples of disparaging remarks/actions may feel somewhat familiar to pharmacy workers who have had unfortunate interactions with prescribers14:

                      • During a tense operation, a surgeon insulted a male nurse, who had a special needs son, by saying, "You're a [r-word] just like your boy." The nurse filed a written complaint because of the insulting, disrespectful remark.
                      • At Vanderbilt University Medical Center in Nashville, a surgeon proceeded with an operation without washing his hands. Instead of openly addressing the issue, a nurse discreetly offered the surgeon gloves, but he simply discarded them into the trash.
                      • An OB/GYN patient was experiencing excruciating pain while the doctor sutured without providing sufficient anesthetic. When questioned by a medical student, the doctor made a joke saying that the patient could be given memory-erasing ketamine to forget about the experience.

                      It is essential for pharmacy owners to recognize the consequences of workplace bullying on their businesses. Table 1 lists negative consequences of unaddressed bullying and provides examples. Preceptors, supervisors, mentors, and organizations must address factors that promote bullying (like power imbalances, addressed below) and provide employees with support to maintain healthy, successful pharmacy settings.

                      Table 1. Negative Consequent of Unaddressed Bullying15

                      Consequences Examples
                      Diminished morale A seasoned pharmacy technician (whose pronouns = they/them), who has been working diligently for years, consistently faces belittling comments and criticism from the pharmacist. As a result, their overall enthusiasm for their work decreases, affecting their productivity and leading to a sense of resignation or disengagement. The rest of the staff will also feel disengaged and resigned.
                      Strained employee relations One pharmacist consistently questions another pharmacist’s decisions and recommendations in front of colleagues and patients leading to tension and hostility between them. This strained relationship might extend beyond work-related matters, making collaboration difficult and creating an uncomfortable atmosphere for other team members.
                      Loss of respect for management Employees witness a manager ignoring complaints, failing to provide a safe and supportive environment. The affected employees lose respect for the management team as they perceive the lack of intervention as a sign of management’s incompetence, leading to a diminished view of their leadership abilities.
                      Increased absenteeism/

                      tarnished reputation

                      Over time, employees are subjected to behaviors of bullying and begin to experience high levels of stress and anxiety due to the hostile environment. So, the employees start taking more sick days or even extended leaves of absence to cope with bullying’s emotional toll. The toxic work environment spreads through word of mouth among colleagues, potential hires, and even patients. The pharmacy’s reputation suffers as news of the toxic work environment and unaddressed bullying gets around.

                      Ultimately, workplace bullying may reduce everyone’s job satisfaction and productivity resulting from the negative work environment created by workplace bullying.16 Extensive studies have confirmed the association between workplace bullying and perceptions of organizational settings, including job satisfaction and commitment. Job dissatisfaction, which leads to emotional distress, can be regarded as a factor that influences employees’ commitment to their work.16

                       

                      CAUSES AND RISK FACTORS

                      To effectively address workplace bullying, preceptors—and all staff—need to understand the underlying causes and risk factors contributing to its occurrence in healthcare settings.

                       

                      Power Imbalances

                      Power imbalances can contribute to disruptive behavior in healthcare settings, leading to a range of negative consequences. (Yes, this means the bully might be the boss!8) While some may associate disruptive behavior with overt bullying and intimidation, the broader definition preferred by experts includes any actions that undermines safety culture.14

                      The issue of power imbalances in pharmacy is a growing concern, as evidenced by a 2015 report from the United Kingdom’s Advisory, Conciliation, and Arbitration Service (ACAS).15 Workplace bullying has been on the rise in the U.K., with a staggering 20,000 calls annually reporting bullying incidents to ACAS. Disturbingly, this problem extends to community pharmacies, where staff members face bullying from pharmacy owners, managers, supervisors, and colleagues.15 The level of labor stability also has a significant impact on vulnerability to bullying because lower-status employees often hold the most unstable and temporary jobs. An empirical study (a study that uses observation, measured phenomena, and participant’s experience rather than theory or belief) conducted among university employees in an academic center aimed to demonstrate that flexible working arrangements contribute to the prevalence of bullying.16 One reason for the increase in bullying within organizations is the restructuring processes and higher levels of outsourcing, which have widened the power gap between managers and employees.16

                      High Stress Levels and Demanding Work Environment

                      The demanding nature of healthcare work, coupled with high stress levels, can create an environment prone to workplace bullying.16 Healthcare professionals often face intense pressure, long working hours, and challenging situations that may increase tension and exacerbate conflicts. Stress can amplify negative behaviors and create a breeding ground for bullying. Bullying within a stressful environment can lead to burnout and cause talented, compassionate individuals to leave the healthcare profession.17,16

                       

                      Do pharmacy employees experience stress? In a recent survey, 61.2% of pharmacists reported experiencing significant burnout in their practices.17 This trend is prevalent among hospital pharmacists, with consistent rates across various practice settings and areas. The study reveals that those most affected by burnout were often unmarried, had no children, and worked extended hours, surpassing 40 hours per week. Pharmacists can be impacted by stress and burnout in all practice settings. Thus establishing support systems with family, friends, and coworkers is vital to enhancing morale and alleviating feelings of burnout.17

                       

                      High Expectations from Society

                      Healthcare professionals are entrusted with caring for the health and well-being of individuals, and society places high expectations on them. The pressure to meet these expectations, combined with limited resources and time constraints, can contribute to stressful work environments that may foster workplace bullying.18 Most healthcare workers feel like they are held to higher standards than the general public. This feeling is rooted in centuries of traditions and most medical organizations emphasize respect in personal interactions.18

                       

                      Healthcare workers also believe that the general public’s expectations of them outside the healthcare setting are set too high.12 The demanding and high-stress nature of healthcare work can make it challenging for professionals to enjoy their personal lives. The constant feeling of being at work and the fear that their actions could be scrutinized even during off-hours creates additional stress and anxiety. This work-life imbalance can have a significant impact on well-being and overall quality of life.18

                       

                      Lack of Policies and Procedures to Address Bullying

                      The absence of comprehensive policies and procedures specifically targeting workplace bullying in healthcare settings can perpetuate its occurrence.19 Without clear guidelines and protocols in place, both targets and bystanders may feel powerless and unsure of how to address and report bullying. Instances of bullying and verbal abuse are often under-reported for various reasons. As revealed by the 2022 National Pharmacy Workplace Survey by industry experts, the lack of robust policies and procedures to address bullying in the pharmacy profession is a pressing concern.19 The study highlights the absence of a formal mechanism for pharmacists and pharmacy personnel to discuss workplace issues with supervisors and management. This leads to an unwelcoming atmosphere, resulting in heightened stress and eventual burnout. Over 60% of respondents indicated that their employers did not actively seek their opinions, nor did employers respect or value employee input.19 Employers, insurers, lawmakers, and the public must come together to ensure ample resources, address patient safety concerns, and promote the well-being of pharmacy personnel.

                       

                      One topic also needs more attention: the bullying individual. The SIDEBAR provides information about people who tend to bully others.

                       

                      SIDEBAR: Some People are Simply Bullies20,8,21,22

                       

                      Bullies Unveiled: Bullies are individuals who employ intimidation and control tactics to further their own objectives. While they might appear cooperative when their goals align with the team’s or the employer’s, their methods are unfair and dishonest. In the workplace, bullies often target coworkers in lateral or lower responsibility positions, resorting to manipulation and terrorizing behaviors. They may even intimidate superiors, using tactics like threats of resignation during crises.

                       

                      The Hidden Shame: Some psychologists attribute bullying to ingrained shame, although others cite insecurities, disparate socioeconomic backgrounds, personality traits that make them outliers, and basic insecurities. Some theories indicate that targets of bullying are more likely to become bullies. Contrary to common belief, bullies don't necessarily suffer from low self-esteem. Instead, their behavior can stem from internalized shame. While some individuals who harbor shame may have low self-esteem, those who engage in bullying tend to have high self-esteem, and hubristic (overbearing or presumptuous) pride. Bullies may also be quite clever. Their attacks on others are defense mechanisms to alleviate their own feelings and ignore their real emotions.

                       

                      Shame's Impact on Coping: Early in life, people develop various responses to shame, which solidify into personality traits by adulthood. These coping mechanisms can be categorized by attacking others, self-attacking, avoidance, and withdrawal. For those who bully, the fear of shame, such as being perceived as inadequate at work, drives them to target others. Bullies exploit others' vulnerabilities—and especially others’ insecurities—and redirect their own shame onto their targets. The bully’s ultimate feeling is power.

                       

                      Narcissism and Withdrawal: Some bullies ultimately develop narcissistic traits, continually attacking others as a means to cope with deeply rooted shame. Conversely, targets are often sensitive individuals who respond to shame by self-blame. This response might maintain a connection with the bully and perpetuates a victim or target mentality. Withdrawal, another reaction to shame, involves concealing one's emotions and can lead to depression. Prolonged exposure to workplace bullying often triggers this response, proving just as harmful as self-attacking.

                       

                      Seeking Solutions: Bullying deflects a bully's shame and also provides a sense of power. However, many bullies remain unaware of their own inadequacies. The key to dealing with workplace bullies is solidarity among coworkers. Banding together against a bully offers support, as targets of bullying often face isolation and by confronting the bully's behavior collectively, coworkers can neutralize their power. Banding together does not mean ganging up on the bully. It means using the principles of bystander intervention (discussed below) and firmly calling out bullying when one sees it in a respectful but direct manner. Documenting repeated episodes of bullying is also critical.

                       

                      Readers should note, however, that when the bully’s target is someone that others tend to dislike or find little sympathy for, the team may not coalesce to support the target. Supervisors, managers, or observers who are leaders need to jump in and remind staff that bullying is unacceptable, and if the target leaves, who knows who will be next. Further, some research indicates that bullies may eventually become targets; backlash is not an ideal solution.

                       

                      A Path Forward: Ultimately, bullies can change their behavior by developing better coping mechanisms and learning to process their feelings constructively. Recognizing that bullies are driven by a response to shame or other factors, rather than consciously acknowledging it, is essential for devising effective strategies to address this issue. Supervisors and managers should refer employees with bullying tendencies to their employee assistance programs or similar programs.

                       

                      DIFFERENTIATING WORKPLACE BULLYING, HARASSMENT, AND DYSFUNCTION

                      To address workplace bullying effectively, healthcare workers and managers must differentiate it from harassment and dysfunction within the healthcare setting.

                       

                      Key Differences in Behaviors and Intent

                      While workplace bullying and harassment share similarities, such as the creation of a hostile work environment, they differ in terms of intent and behaviors. Again, bullying is often described as offensive, intimidating, malicious, or insulting behavior intended to undermine, humiliate, denigrate, or injure the recipient, and it may involve individuals or groups.23 It can take various forms, including spreading rumors, excluding someone, giving unachievable tasks, and more.

                       

                      Harassment, as defined by U.S. employment discrimination laws, involves unwelcome conduct based on various protected characteristics including race, color, religion, sex, national origin, age, disability, or genetic information. Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act of 1967 (ADEA), and the Americans with Disabilities Act of 1990 (ADA) all prohibit harassment as a form of employment discrimination.24 The difference between bullying and harassment is subtle. For example, calling a coworker or a student a skinny witch is bullying. Calling a coworker or a student a skinny Catholic witch introduces the element of religion. While neither is acceptable, the introduction of religion crosses the line to harassment. While bullying is not necessarily illegal, harassment based on protected characteristics is unlawful.

                       

                      PAUSE AND PONDER: Consider a technician who announces to all who are on duty that the new student smells terrible. Is that bullying or harassment? If he follows it up with, “It’s because people from his culture cook all that stinky food!” Is that bullying or harassment?

                       

                      Laws and Regulations against Workplace Harassment

                      Various laws and regulations protect employees against workplace harassment. Title VII, ADEA, and ADA prohibit harassment on a federal level, while individual states also have laws that require employers to enact anti-harassment policies.24,25  Harassment is illegal and someone—meaning anyone who is harassed or observes harassment—should report it when it creates a work environment that a reasonable person would find intimidating, hostile, or abusive. It is crucial to prevent harassment, and employers should establish clear anti-harassment policies, provide training, and address complaints appropriately.

                       

                      Supervisors, co-workers, or non-employees may harass others, and the employer may be liable for harassment by supervisors resulting in disciplinary actions.24,25 For non-supervisory harassment, employers can be liable if they knew or should have known about the harassment and failed to take corrective action. The Equal Employment Opportunity Commission (EEOC) assesses each case of harassment individually by considering the nature and context of the conduct. Overall, addressing harassment requires proactive measures and a commitment to maintaining a respectful work environment. 24,25

                       

                      Protection of Whistleblowers

                      Whistleblowers are protected under OSHA’s Whistleblower Protection Program, which enforces provisions from more than 20 whistleblower statutes safeguarding employees from retaliation for reporting violations.26 Retaliation is strictly prohibited under these laws and encompasses actions such as firing, demoting, denying benefits, intimidation, harassment, and other adverse actions. Retaliative actions may dissuade an employee from raising concerns about potential violations. Subtle actions like exclusion from important meetings or false accusations of poor performance can be considered retaliation. Temporary workers supplied by staffing agencies are also protected from retaliation. OSHA's program not only safeguards whistleblowers reporting violations, but also shows some similarities between retaliation and workplace bullying. Exclusion and intimidation are shared tactics in both retaliation and bullying, mainly differing in the employer's intent.26 Many experts in bullying indicate that given these parallels, employees who are targets of bullying should be protected in the same manner that whistleblowers are safeguarded. This approach would foster a work environment where all individuals can voice concerns and engage in their roles without fear of adverse consequences.

                       

                      PREVENTION AND INTERVENTION STRATEGIES

                      Although the U.S. hadn’t yet addressed workplace bullying formally, Australia has.27 Its Fair Work Act 2009 (Cth), allows its Fair Work Commission to hear bullying claims and order any corrective action other than monetary compensation) to stop bullying from continuing. In 2019, the Fair Work Commission heard a claim from a pharmacist. The SIDEBAR summarized the case, which ended in a ruling in favor of the employer but raised many questions. It highlights the complexities of these kinds of cases and the fact that some people have little insight into their behaviors.

                       

                      SIDEBAR: Who’s Bullying Who?27

                      A pharmacist alleged the pharmacy’s management was bullying him by scheduling him to work on Saturdays without adequate assistance. The employer had replaced a dispensing technician with an intern pharmacist who he considered incompetent. The pharmacist claimed it created unnecessary stress, doubling his work. He alleged that the pharmacy’s Saturday workload was similar to weekday workloads and required more staff.

                       

                      The employer demonstrated successfully that its Saturday workflow was significantly lower than weekdays. CCTV footage revealed that the pharmacist spent considerable time on Saturdays looking at his phone rather than working. The employer also indicated the pharmacist engaged in aggressive and intimidating conduct, even reducing the intern to tears on one occasion. His hostile behavior extended to other employees, leading two of them to seek counseling. The employer stated that the pharmacist's inability to work cooperatively with colleagues was the root of the problem, not the intern's competence.

                      The deciding official ruled no one acted unreasonably towards the pharmacist. He acknowledged the pharmacist's unacceptable behavior that involved mistreating several other employees. Some readers are no doubt reading this and nodding their heads, having seen, been subject to, or accused of bullying rightly or wrongly. Others are thinking, “Why is this guy still employed?”

                      To combat workplace bullying effectively in healthcare, a multi-faceted approach involving various strategies is necessary.

                       

                      Policy Development and Enforcement

                      It is essential to develop policies to combat workplace bullying in all pharmacy settings. Drawing from the AMA's report, pharmacy management can adopt key steps to create an effective anti-bullying policy and cultivate a positive work environment.2 Everyone involved needs to realize that developing a policy takes time, and implementing it requires an endless, consistent effort on the part of managers, supervisors, and staff. People from every level of the organization should have input into the draft and the review process. Putting the issue on the department’s staff meeting agenda will ensure that it doesn’t fall through the cracks.8

                       

                      First, management must ensure that the administration is fully aware of the impact of unprofessional behavior. The team can create strategies proactively to address and prevent bullying by recognizing the problem. One strategy might be to identify when and where the bullying occurs. Changes to the workflow, the schedule, or the supervision can improve the situations.8

                       

                      Second, management can arrange to educate the entire pharmacy staff about the harmful consequences of unprofessional or hostile conduct. When employees perceive that their leaders are committed to addressing bullying, they are more likely to report incidents or even intervene when witnessing inappropriate behavior among colleagues. Two types of education can help28:

                      • Federal law requires certain organizations to provide compliance training on harassment and discrimination. The U.S. Equal Employment Opportunity Commission also recommends (but does not require) workplace civility training. Workplace civility training promotes workplace respect and civility. Good training would include workplace norms, appropriate and inappropriate behaviors in the workplace, and possibly interpersonal skills, conflict resolution, and effective supervisory techniques.
                      • Bystander intervention training, usually associated with sexual harassment in schools, is increasingly recognized as a critical element of efforts to decrease harassment and inappropriate behaviors. Its goal is to refine employees’ sensitivity to harassment or bullying and empower them act. This training would need to identify offensive behaviors, describe employment non-discrimination laws, and explain how bystanders should respond upon witnessing a harassment incident.

                       

                      These crucial management steps and well-structured anti-bullying policies can foster a respectful and supportive workplace, promoting the well-being of all employees and enhancing overall patient care.

                       

                      Promoting a Supportive and Respectful Workplace Culture

                      Healthy working relationships are crucial to promoting a supportive and respectful workplace culture in the pharmacy. The most important characteristics that build good working relationships include29

                      • mutual respect
                      • open communication
                      • empathy
                      • building rapport with every member of the team.

                      Table 2 defines these terms. Practicing mindfulness (awareness of one’s feelings and the impact they have on themselves and others) can further improve relationships by reducing stress and anxiety, increasing emotional intelligence, and improving communication. It is essential to address inappropriate behavior promptly to prevent escalation, with support and guidance available to deal with bullying or harassment.

                       

                      Table 2. Key Characteristics of Healthy Working Relationships29

                      Characteristic Definition
                      Mutual respect The foundation of a healthy workplace where all members of the pharmacy team are valued and their views are acknowledged.
                      Open communication Free expression of ideas without fear of criticism, fostering trust and understanding
                      Empathy Compassionate comprehension of others’ states when connecting with colleagues and patients so effective communication, negotiation, problem-solving, and assertiveness to enhance collaboration and conflict resolution is possible.
                      Building rapport Fostering a positive dynamic with every team member to enhance workplace happiness

                       

                      PAUSE AND PONDER: Janine supervises three employees, Mary, Alice, and Siobhan. Mary and Alice are very close and tend to gossip. They dislike Siobhan, speak badly of her to others, and often fail to provide the information Siobhan needs to complete her work. They criticize her work cruelly in the weekly staff meeting. Siobhan’s name is pronounced shi-VON, but Mary and Alice consistently mispronounce it and misspell it. What should Janine do, and how can she support Siobhan?

                       

                      Encouraging Reporting and Providing Confidential Channels

                      Managers, supervisors, and preceptors should encourage healthcare workers to report incidents of bullying without fear of retaliation.14 They should establish confidential reporting channels to protect the identities of those who come forward.14

                       

                      When addressing bullying within the pharmacy setting, it is essential to establish a comprehensive reporting system that includes confidential channels for employees to voice their concerns.14 Vanderbilt University uses a slowly escalating corrective approach, where trained professionals engage in open discussions with alleged offenders, fostering an environment of respect and mutual understanding. Second offenses are met with warnings, followed by formal letters outlining the issues and potential interventions such as mental and physical screening (in case a health condition is causing symptoms of anger, frustration, and lack of patience). Repeat offenders may face the consequence of losing staff privileges.14

                       

                      Apart from corrective measures, effective strategies can also focus on providing help and support to offenders, such as anger management classes, counseling, or assistance with medical or addiction issues.14 Creating a reporting system that ensures confidentiality empowers pharmacy staff to come forward with their concerns, enabling prompt intervention.

                       

                      CONCLUSION

                      Workplace bullying in healthcare is a pressing issue that requires attention and action. It negatively impacts healthcare professionals’ well-being and compromises patient care. It is crucial to define and emphasize workplace bullying so we can shed light on the significance of addressing this problem. To reiterate

                      • Understanding the types, signs, and effects of workplace bullying allows us to recognize its presence and take appropriate measures.
                      • Identifying the causes and risk factors helps us understand the underlying factors contributing to its persistence in healthcare settings.
                      • Differentiating workplace bullying from harassment and dysfunction clarifies the specific behaviors and intent involved, leading to more effective interventions.
                      • Upholding laws and ethical obligations, along with whistleblower protection, ensures legal and ethical accountability.
                      • Creating prevention and intervention strategies, such as developing policy and promoting a supportive culture, provide a framework for addressing workplace bullying.
                      • Reporting incidences through mechanisms and confidential channels empower individuals to seek help and create a safer environment.

                      In conclusion, by recognizing, preventing, and intervening in cases of workplace bullying, healthcare organizations can create a better work environment that supports their employees and promotes optimal patient outcomes.

                      Pharmacist Post Test (for viewing only)

                      Patient Safety: Workplace Bullying
                      Post-test
                      Learning objectives
                      After completing this continuing education activity, pharmacists and pharmacy technicians will be able to
                      1. Define workplace bullying in the healthcare setting
                      2. Explain the impact of workplace bullying on individuals, organizations, and patient care
                      3. Differentiate workplace bullying from harassment and workplace dysfunction
                      4. Describe the necessary steps to address and counteract workplace bullying
                      1. Which of the following statements correctly describes findings about bullying in pharmacies?
                      A. Researchers have a consistent definition to identify bullying in pharmacy and it includes behaviors that are mocking, taunting, or intimidating.
                      B. Leading pharmacy organizations have embraced the AMA's definition of workplace bullying and apply it consistently.
                      C. One study found several comments related to bullying, but the study wasn't designed to identify bullying and rates are probably higher.

                      2. What is the focus of the Institute for Safe Medication Practices periodic survey of health care professionals?
                      A. Disrespectful behaviors and intimidation
                      B. Causes of medication errors
                      C. Harassment as defined by the US government

                      3. Which of the following did approximately half of ISMP survey respondents report?
                      A. Respondents said that they had been pressured to accept an order or administer a drug despite safety concerns.
                      B. Respondents said they had avoided talking to a prescriber to validate an order about a safety concern more than ten times in the previous year.
                      C. Respondents said they relied on colleagues to interpret or validate an order rather than contact the prescriber.

                      4. A competent floating pharmacist is occasionally assigned to a store where a technician consistently calls out, “How many times do I have to tell you this? You've worked here before! You should know where these things are!” every time he asks her a question. Which of the following might the staff experience when observing this behavior?
                      A. Decreased absenteeism
                      B. Diminished morale
                      C. Relief that they are not targets

                      5. A prescriber who works in a hospital is notorious for his disrespectful treatment of nurses and pharmacists. He frequently scolds nurses if they call to clarify orders, and he often hangs up by slamming the phone in pharmacists’ ears. Which of the following potential negative patient outcomes have studies associated with this type of behavior?
                      A. Higher medication error rates and increased infections
                      B. Increased rates of falls and hip fracture
                      C. Strained employee relations reducing collaboration

                      6. Aadhil is a practicing Muslim who steps away from the work site to pray a couple of times a day. He's also a new father and has been up all night. He mentions this fact to his coworkers during the morning huddle, and asks for their support during the day. The pharmacist on duty finds that Aadhil has made two mistakes in filling a physician's order within the first three hours of work. He calls out, “Hey Aadhil, maybe next time you go to pray you could pray for better accuracy!” Aahil laughs uncomfortably. How would you classify this behavior?
                      A. The pharmacist is bullying Aadhil but it's OK because Aadhil laughed.
                      B. The pharmacist is bullying Aadhil and this behavior is never OK.
                      C. The pharmacist is harassing Aadhil and the pharmacist’s behavior is illegal.

                      7. Two technicians, Maria and Dolores don't get along. Maria develops a sinus infection and presents a prescription to be filled late in the day when Dolores is the only technician on duty. Maria is unable to come to work for a week because of her illness, and Delores whispers to anyone who will listen that Maria had a prescription filled to treat a sexually transmitted disease. In addition to the fact that Dolores has violated HIPAA rules, what kind of behavior is this?
                      A. Harassment; Maria is a member of a protected class
                      B. Bullying; Spreading false rumors is unacceptable behavior
                      C. Neither harassment nor bullying; it's just gossip

                      8. What is the best way to combat workplace bullying effectively in healthcare?
                      A. Use a multifaceted approach that employs different strategies concurrently
                      B. Have management and supervisors develop and enforce a policy against bullying
                      C. Advise everyone in the workplace including the target to ignore the bully

                      9. It's a busy day in the pharmacy and the pharmacy’s resident bully is in great form this morning. She has called several technicians names including Dumbo, Idiot, and Sweet Cheeks. She has also made fun of one of the pharmacist’s pants, remarking on how poorly they fit him. How can the seven people who were on duty and have witnessed these attacks best address this issue?
                      A. Ignore it, because giving her any attention will increase her attacks
                      B. Use bystander intervention and ask the bully to stop the name calling
                      C. Make a note to ask the manager to refer the targets to the employee assistance program (EAP)

                      10. Janine supervises Mary, Alice, and Siobhan. Janine witnesses Mary and Alice treating Siobhan very badly at a staff meeting. They consistently mispronounce Siobhan’s name. How should Janine approach this situation after she has corrected them several times in previous meetings and also corrected the spelling of Siobhan’s name on several documents that Mary and Alice have prepared? HINT: What process has Vanderbilt university used?

                      A. Janine should meet with Mary and Alice privately and warn them that their behavior constitutes bullying and it needs to stop. She should say that she will pursue corrective and disciplinary action if the bullying behavior continues.
                      B. Janine should continue to correct Mary and Alice each and every time that they mispronounce Siobhan’s name and send any documents with misspellings back to Mary and Alice for correction. Reinforcement is the key to success!
                      C. Janine should meet with Mary, Alice, and Siobhan and try to get to the bottom of the problem. It's clear that Siobhan has done something to irritate Mary and Alice and correcting Siobhan’s behavior will fix the entire problem.

                      Pharmacy Technician Post Test (for viewing only)

                      Patient Safety: Workplace Bullying
                      Post-test
                      Learning objectives
                      After completing this continuing education activity, pharmacists and pharmacy technicians will be able to
                      1. Define workplace bullying in the healthcare setting
                      2. Explain the impact of workplace bullying on individuals, organizations, and patient care
                      3. Differentiate workplace bullying from harassment and workplace dysfunction
                      4. Describe the necessary steps to address and counteract workplace bullying
                      1. Which of the following statements correctly describes findings about bullying in pharmacies?
                      A. Researchers have a consistent definition to identify bullying in pharmacy and it includes behaviors that are mocking, taunting, or intimidating.
                      B. Leading pharmacy organizations have embraced the AMA's definition of workplace bullying and apply it consistently.
                      C. One study found several comments related to bullying, but the study wasn't designed to identify bullying and rates are probably higher.

                      2. What is the focus of the Institute for Safe Medication Practices periodic survey of health care professionals?
                      A. Disrespectful behaviors and intimidation
                      B. Causes of medication errors
                      C. Harassment as defined by the US government

                      3. Which of the following did approximately half of ISMP survey respondents report?
                      A. Respondents said that they had been pressured to accept an order or administer a drug despite safety concerns.
                      B. Respondents said they had avoided talking to a prescriber to validate an order about a safety concern more than ten times in the previous year.
                      C. Respondents said they relied on colleagues to interpret or validate an order rather than contact the prescriber.

                      4. A competent floating pharmacist is occasionally assigned to a store where a technician consistently calls out, “How many times do I have to tell you this? You've worked here before! You should know where these things are!” every time he asks her a question. Which of the following might the staff experience when observing this behavior?
                      A. Decreased absenteeism
                      B. Diminished morale
                      C. Relief that they are not targets

                      5. A prescriber who works in a hospital is notorious for his disrespectful treatment of nurses and pharmacists. He frequently scolds nurses if they call to clarify orders, and he often hangs up by slamming the phone in pharmacists’ ears. Which of the following potential negative patient outcomes have studies associated with this type of behavior?
                      A. Higher medication error rates and increased infections
                      B. Increased rates of falls and hip fracture
                      C. Strained employee relations reducing collaboration

                      6. Aadhil is a practicing Muslim who steps away from the work site to pray a couple of times a day. He's also a new father and has been up all night. He mentions this fact to his coworkers during the morning huddle, and asks for their support during the day. The pharmacist on duty finds that Aadhil has made two mistakes in filling a physician's order within the first three hours of work. He calls out, “Hey Aadhil, maybe next time you go to pray you could pray for better accuracy!” Aahil laughs uncomfortably. How would you classify this behavior?
                      A. The pharmacist is bullying Aadhil but it's OK because Aadhil laughed.
                      B. The pharmacist is bullying Aadhil and this behavior is never OK.
                      C. The pharmacist is harassing Aadhil and the pharmacist’s behavior is illegal.

                      7. Two technicians, Maria and Dolores don't get along. Maria develops a sinus infection and presents a prescription to be filled late in the day when Dolores is the only technician on duty. Maria is unable to come to work for a week because of her illness, and Delores whispers to anyone who will listen that Maria had a prescription filled to treat a sexually transmitted disease. In addition to the fact that Dolores has violated HIPAA rules, what kind of behavior is this?
                      A. Harassment; Maria is a member of a protected class
                      B. Bullying; Spreading false rumors is unacceptable behavior
                      C. Neither harassment nor bullying; it's just gossip

                      8. What is the best way to combat workplace bullying effectively in healthcare?
                      A. Use a multifaceted approach that employs different strategies concurrently
                      B. Have management and supervisors develop and enforce a policy against bullying
                      C. Advise everyone in the workplace including the target to ignore the bully

                      9. It's a busy day in the pharmacy and the pharmacy’s resident bully is in great form this morning. She has called several technicians names including Dumbo, Idiot, and Sweet Cheeks. She has also made fun of one of the pharmacist’s pants, remarking on how poorly they fit him. How can the seven people who were on duty and have witnessed these attacks best address this issue?
                      A. Ignore it, because giving her any attention will increase her attacks
                      B. Use bystander intervention and ask the bully to stop the name calling
                      C. Make a note to ask the manager to refer the targets to the employee assistance program (EAP)

                      10. Janine supervises Mary, Alice, and Siobhan. Janine witnesses Mary and Alice treating Siobhan very badly at a staff meeting. They consistently mispronounce Siobhan’s name. How should Janine approach this situation after she has corrected them several times in previous meetings and also corrected the spelling of Siobhan’s name on several documents that Mary and Alice have prepared? HINT: What process has Vanderbilt university used?

                      A. Janine should meet with Mary and Alice privately and warn them that their behavior constitutes bullying and it needs to stop. She should say that she will pursue corrective and disciplinary action if the bullying behavior continues.
                      B. Janine should continue to correct Mary and Alice each and every time that they mispronounce Siobhan’s name and send any documents with misspellings back to Mary and Alice for correction. Reinforcement is the key to success!
                      C. Janine should meet with Mary, Alice, and Siobhan and try to get to the bottom of the problem. It's clear that Siobhan has done something to irritate Mary and Alice and correcting Siobhan’s behavior will fix the entire problem.

                      References

                      Full List of References

                      References

                         
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                        18. Medscape: Medscape Access. Medscape.com. Published 2023. Accessed August 9, 2023. https://www.medscape.com/slideshow/2022-physicians-misbehaving-6015583?icd=login_success_email_match_norm#13
                        19. Staff B. Customer Harassment, Bullying Affecting Pharmacists’ Ability to Do Their Jobs. www.uspharmacist.com. https://www.uspharmacist.com/article/customer-harassment-bullying-affecting-pharmacists-ability-to-do-their-jobs
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                        27. Koelmeyer S. An elbow in the waist: What is and isn’t bullying in the workplace. SmartCompany. Published May 20, 2019. Accessed August 3, 2023. https://www.smartcompany.com.au/business-advice/legal/bullying-workplace/
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