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Patients with stage 1 to 5 CKD and those undergoing dialysis are at extremely high risk for drug therapy problems (DTPs). 2,3 In controlled trials involving general patient populations, clinical pharmacist interventions have reduced hospital admissions, length of hospital stay, readmis sions, and emergency department visits. 4-7 The activities of pharmacists most strongly associated with improved patient outcomes include participating on rounds, interviewing patients, performing medication reconciliation, counselling patients on discharge, and conducting postdischarge followup. 5 A systematic review of 8 controlled trials involving patients with CKD showed that clinical pharmacist interventions improved management of anemia, blood pressure, and lipids, as well as calcium and phosphate parameters. 8 In this patient population, clinical pharmacists’ interventions reduced hospital admissions, length of hospital stay, and incidence of end-stage renal disease or death. 8

Background and Objective: Many Canadian hospital pharmacies are experiencing difficulties recruiting supervisory personnel. It was expected that, through a "learning-by-doing" course, pharmacy staff would learn to apply basic skills in the day-to-day supervision of pharmacy operations and human resources and to apply the principles of supervisory documentation. Methods: A supervisory skills course targeted to pharmacy staff members was developed and implemented by the pharmacy department of a large urban health region. The course was initially offered to practising pharmacy technicians. The course design emphasized a constructivist framework incorporating authentic learning and reflective practice during seminars, with experiential and self-directed learning in the workplace. Preceptors assisted learners to achieve the course goals. Learners and preceptors provided feedback about hours spent (as the course progressed) and about their satisfaction with the course itself (at the end of the course). Learners and preceptors completed a post - program evaluation 2 months after completing the course to help in the assessment of the transfer of learning (lasting impact) associated with the course. Overall performance in the course was assessed on a pass/fail basis. Results: Eighteen pharmacy technicians were admitted to the program, but one withdrew because of a job change. All learners successfully completed the course. Two months after the course, learners and preceptors described enhanced organization, time management, leadership, communication, and conflict-resolution skills on the part of learners, as well as their increased confidence, maturity, and ability to supervise staff. Learners' evaluations revealed a broadened perspective of pharmacy. The preceptors valued the enhancement of learners' skills and their increased enthusiasm. At the time of writing, 6 of the participants had secured supervisory positions. Conclusion: Creating formal instruction that engages pharmacy staff to pursue management positions is challenging. Instructional design grounded in constructivist theory and incorporating authentic learning experiences and reflection resulted in high learner satisfaction with learning outcomes. RESUME Contexte et objectif : De nombreuses pharmacies hospitalieres au Canada ont des difficultes a recruter du personnel cadre. On escomptait que, par le truchement d'un cours « pratique », les employes de la pharmacie puissent acquerir les competences de base pour la supervision au quotidien des activites de la pharmacie et des ressources humaines et qu'ils pourraient appliquer les principes de la consignation exigee par la supervision. Methodes : Un cours sur les techniques d'encadrement destine au personnel de la pharmacie a ete elabore et mis en oeuvre par le service de pharmacie d'une grande regie de la sante urbaine. Le cours a d'abord ete offert aux techniciens en pharmacie en fonction. La formule de cours mettait l'accent sur un cadre pedagogique constructiviste incorporant un apprentissage authentique et une pratique reflexive dans le cadre de seminaires, ainsi qu'un apprentissage experientiel et autodirige en milieu de travail. Des precepteurs ont aide les apprenants a atteindre les objectifs du cours. Les apprenants et les precepteurs ont fait part de leurs commentaries sur les heures consacrees a l'apprentissage (au fur et a mesure du cours) et sur la satisfaction relativement au cours (a la fin du cours). Les apprenants et les precepteurs ont rempli une evaluation deux mois apres la fin du cours pour evaluer le transfert des competences (effet durable) issues du cours. La reussite du cours a ete evaluee globalement par une note de passage ou d'echec. Resultats : Dix-huit techniciens en pharmacie ont ete admis au cours et un a abandonne a cause d'un changement d'emploi. Tous les apprenants ont reussi le cours. Deux mois apres le cours, les apprenants et les precepteurs ont decrit une amelioration des competences relatives a l'organisation, a la gestion du temps, au leadership, a la communication et a la resolution de conflits de la part des apprenants, de meme qu'une plus grande confiance, maturite et capacite a superviser le personnel. Les evaluations des apprenants ont revele une perspective elargie de la pharmacie. Les precepteurs ont apprecie l'amelioration des competences des apprenants et leur plus grand enthousiasme. Au moment d'ecrire cet article, six des participants a ce cours avaient obtenu un poste de superviseur. Conclusion : La conception d'un enseignement systematique qui eveille l'interet du personnel de la pharmacie a occuper un poste de cadre constitue un defi. Une formule d'enseignement ancree dans la theorie constructiviste et incorporant des experiences d'apprentissage authentique et la reflexion ont donne aux apprenants une grande satisfaction quant a leurs resultats pedagogiques.

Background: Few studies have evaluated drug-related problems in patients undergoing elective total hip or knee arthroplasty. Objective: To quantify, for patients undergoing elective total joint arthroplasty, drug-related problems arising from medication orders written before or immediately after the surgery. The primary outcome was the proportion of patients with at least one drug-related problem. The secondary outcomes were the total number and descriptions of these problems, according to the patient’s age and the category, type, and severity of the drug-related problem. Methods: From among patients who underwent elective total joint arthroplasty in a large Canadian regional health authority in 2005, 150 were randomly selected for this chart audit. Patients were included if they had been taking more than one medication before surgery. The charts were examined for drug-related problems, which were categorized according to whether the problem involved a prescription for a home medication, an order for a postoperative medication, or a potential indication for drug therapy. The problems were further described by type and potential severity. Results: Of the 146 patients whose charts were available, 116 (79.5%) had at least one drug-related problem, with a mean of 1.88 drug-related problems per patient. Of the 146 patients, 88 (60.3%) had at least one drug-related problem involving a home medication, 34 (23.3%) had problems related to postoperative orders, and 37 (25.3%) had problems related to a potential indication. The mean number of drug-related problems per patient was 2.03 for those 65 years of age or older and 1.56 for those younger than 65 years (p = 0.09); however, more of the older patients experienced at least one drug-related problem related to home medications (67% [67/100] versus 46% [21/46], p = 0.02). The most common types of problems were medication omissions, illegible drug orders, inappropriate dose or frequency, and drug–allergy interactions. Of the 275 drug-related problems identified, 147 (53.5%) were deemed potentially harmful, 78 (28.4%) required monitoring, and 50 (18.2%) were considered not harmful. Conclusions: In this study, patients who underwent total joint arthroplasty experienced many drug-related problems. Pharmacists may have opportunities to optimize patient care by identifying, resolving, and preventing drug-related problems in this patient population. RESUME Contexte : Un nombre limite d’etudes ont evalue les problemes relies a la pharmacotherapie chez les patients devant subir une arthroplastie par prothese totale de la hanche ou du genou. Objectif : Quantifier, chez les patients devant subir une arthroplastie par prothese totale non urgente, les problemes relies a la pharmacotherapie decoulant des ordonnances de medicaments redigees avant ou immediatement apres l’intervention. Le principal parametre d’evaluation etait la proportion de patients presentant au moins un probleme relie a la pharmacotherapie. Les parametres d’evaluation secondaires etaient le nombre total de ces problemes et leurs descriptions, en fonction de l’âge du patient ainsi que de la categorie, du type et de la gravite du probleme relie a la pharmacotherapie. Methodes : Parmi les patients qui avaient subi une arthroplastie par prothese totale non urgente au sein d’une importante regie regionale de la sante canadienne en 2005, 150 ont ete choisis au hasard pour cet audit sur dossiers medicaux. Les patients etaient retenus aux fins de l’audit s’ils avaient pris plus d’un medicament avant l’intervention. Les dossiers medicaux ont ete analyses a la recherche de problemes relies a la pharmacotherapie classes selon que le probleme impliquait une ordonnance pour un medicament pris a la maison, une ordonnance pour un medicament postoperatoire, ou une indication potentielle pour une pharmacotherapie. Les problemes ont ete classes plus finement par type et par gravite potentielle. Resultats : Des 146 patients dont les dossiers medicaux etaient disponibles, 116 (79,5 %) presentaient au moins un probleme relie a la pharmacotherapie, pour une moyenne de 1,88 probleme relie a la pharmacotherapie par patient. Des 146 patients, 88 (60,3 %) presentaient au moins un probleme relie a la pharmacotherapie impliquant un medicament pris a la maison, 34 (23,3 %) presentaient des problemes relies aux ordonnances postoperatoires, et 37 (25,3 %) presentaient des problemes relies a une indication potentielle. Le nombre moyen de problemes relies a la pharmacotherapie par patient etait de 2,03 pour les patients de 65 ans ou plus, et de 1,56 pour les patients de moins de 65 ans (p = 0,09); cependant, un plus grand nombre de patients plus âges ont presente au moins un probleme relie a la pharmacotherapie impliquant un medicament pris a la maison (67 % [67/100] contre 46 % [21/46], p = 0,02). Les types de problemes les plus courants etaient les omissions de medicaments, les ordonnances illisibles, les doses ou les frequences d’administration inappropriees et les interactions medicament-allergie. Des 275 problemes relies a la pharmacotherapie recenses, 147 (53,5 %) ont ete juges potentiellement nocifs, 78 (28,4 %) ont necessite une surveillance, et 50 (18,2 %) ont ete juges non nocifs. Conclusions : Les patients qui ont subi une arthroplastie par prothese totale dans le cadre de cette etude presentaient de nombreux problemes relies a la pharmacotherapie. Les pharmaciens pourraient avoir des occasions d’optimiser les soins aux patients s’ils sont en mesure de reperer, de resoudre et de prevenir les problemes relies a la pharmacotherapie dans cette population de patients.