Search

Importance Ondansetron is frequently used to treat nausea and vomiting during pregnancy. Although some studies reported important safety signals, few studies have been sufficiently large to assess rare pregnancy outcomes. Objective To study the association between ondansetron exposure during pregnancy and the risks of spontaneous abortion, stillbirth, and major congenital malformations. Design, Setting, and Participants This is a cohort study conducted in 3 countries, with a meta-analysis. Participants included women and girls aged 12 to 55 years who experienced spontaneous abortion, induced abortion, stillbirth, or live birth between April 2002 and March 2016, as recorded in administrative data from 5 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba, and Ontario), the US IBM MarketScan Research Databases, and the UK Clinical Practice Research Datalink. The statistical analysis was completed in October 2020. Exposures Exposure to ondansetron during pregnancy was compared with exposure to other commonly used antiemetics to minimize confounding by indication. Main Outcomes and Measures The primary outcome was fetal death, defined as either spontaneous abortion or stillbirth. Secondary outcomes were the 2 components of the primary outcome and major congenital malformations identified during the year after a live birth. Adjusted hazard ratios were estimated using Cox proportional hazards models with time-dependent drug exposures and were adjusted using high-dimensional propensity scores. For major congenital malformations, adjusted odds ratios were estimated from logistic models. Site-level results were pooled using random-effects meta-analysis. Sensitivity analyses considered second-line antiemetic exposure and exposure specifically during 4 to 10 weeks of gestation. Results Data from 456 963 pregnancies were included in this study of fetal death (249 787 [54.7%] in Canada, 197 913 [43.3%] in the US, and 9263 [2.0%] in the UK; maternal age, ≤24 years, 93 201 patients [20.4%]; 25-29 years, 149 117 patients [32.6%]; 30-34 years, 142 442 patients [31.2%]; and ≥35 years, 72 203 patients [15.8%]). Fetal death occurred in 12 907 (7.9%) of 163 810 pregnancies exposed to ondansetron, and 17 476 (5.7%) of 306 766 pregnancies exposed to other antiemetics. The adjusted hazard ratios were 0.91 (95% CI, 0.67-1.23) for fetal death with time-dependent ondansetron exposure during pregnancy, 0.82 (95% CI, 0.64-1.04) for spontaneous abortion, and 0.97 (95% CI, 0.79-1.20) for stillbirth. For major congenital malformations, the estimated odds ratio was 1.06 (95% CI, 0.91-1.22). Results of sensitivity analyses were generally consistent with those of the primary analyses. Conclusions and Relevance In this large, multicenter cohort study, there was no association between ondansetron exposure during pregnancy and increased risk of fetal death, spontaneous abortion, stillbirth, or major congenital malformations compared with exposure to other antiemetic drugs.

Background Opioid use has increased dramatically in North America. The safety of opioids in pregnancy is uncertain, but they are associated with several fetal abnormalities and contribute to rising rates of neonatal abstinence syndrome. We examined opioid use before and during pregnancy in a complete population-based cohort. Methods We examined opioid use in a cohort of all pregnant women in Manitoba, Canada, from 2001 to 2013. Opioid use was defined by prescriptions for opioids, converted to oral morphine equivalents (MEQ), during the 3 months before pregnancy and for each trimester. Given that the exposure per person may vary (because not all women complete all time periods), we determined a weighted number of pregnancies in each period. Results During the study period, 174 848 completed pregnancies were eligible for analysis (173 680 live births and 1168 stillbirths and intrauterine deaths), which represented a weighted value of 175 174 pregnancies. Among these pregnancies, 6.7% of the women filled opioid prescriptions in the 3 months before pregnancy. Use declined to 4.2% during the first trimester and further declined to 3.0% and 2.9% in the second and third trimesters, respectively. Over the study period, there was a modest increase in opioid use overall (from 7.3% to 7.7%). MEQ did not decline during pregnancy, and the mean MEQ increased significantly over the study period (from 284 mg to 1218 mg). Prescriptions for codeine were filled by 96.9% of the users, accounting for 66.2% of MEQ. Interpretation Although many of the women using opioids before pregnancy discontinued or reduced use of these drugs during pregnancy, the volume of opioids consumed by those who continued opioid use did not decline during pregnancy. The increasing dosage and increased use of higher-potency opioids by pregnant women highlights the need for continued evaluation of and education about the benefits and risks of this practice.

We aimed to describe medication use in pregnancies that resulted in births and abortions, as well as use after a pregnancy-related visit to characterize the receipt of medication after knowledge of pregnancy. Abortions included both spontaneous and induced abortions. Rates of medication use among women with a pregnancy outcome (2001-2013) were described using the Manitoba Population Research Data Repository at the Manitoba Centre for Health Policy. Use was determined as ≥ 1 prescription filled during pregnancies that resulted in births (livebirth/stillbirth) and abortions. Rates were calculated at any time during pregnancy and after a pregnancy-related visit. Rates were additionally characterized by risk in pregnancy using Briggs classification (2017). Of 174,848 birth pregnancies, overall 64.9% filled ≥ 1 prescription during pregnancy (a significant increase from 62.3% to 68.8% from 2001-2013, p

Background This study's objectives were to evaluate whether WCB claimants with conditions requiring certain surgical procedures are more likely to be prescribed outpatient opioids than other Manitobans and whether those prescribed opioids are more likely to still be on opioid medications 6 months post procedure. Methods We compared 7,246 WCB claims for a number of surgical procedures to 65,032 similar procedures performed in other Manitobans. Logistic regression was used to explore the association between being a WCB claimant and being prescribed opioids, while controlling for type of surgical procedure and other potential confounders. Results WCB claimants were more likely than other Manitobans to be prescribed opioids (adjusted OR 1.38; 95%CI 1.30-1.47). Amongst those prescribed opioids, the odds of being still on opioids 6 months post-procedure were not significantly elevated for WCB claimants (adjusted OR 1.09 95%CI 0.97-1.23). Conclusions WCB claimants are prescribed opioids more often than non-claimants for similar procedures. Am. J. Ind. Med. 59:257-263, 2016. © 2016 The Authors. American Journal of Industrial Medicine Published by Wiley Periodicals, Inc. Language: en

Background Workers Compensation Board (WCB) recipients are a group commonly prescribed opioids. Methods We explored factors influencing post-claim opioid dose and duration by linking data from 22,451 claims with the Manitoba Center for Population Health registry. Results On average, the WCB paid for 94.55% of opioids prescribed during a claim. The amount paid for by the WCB varied significantly by total opioids prescribed. The main predictors of high opioid dosage (120 + morphine equivalents (ME)/day) during the first year post-claim (logistic regression), and of longer post-claim opioid usage (survival analysis), included opioid dosage during the final month of the claim both paid for and not paid for by the WCB. Conclusions Amongst low dose opioid claims, the WCB covers most opioids prescribed. Higher opioid dose WCB recipients are often prescribed opioids not covered by the WCB. Both opioids paid for and not paid for by the WCB are associated with post-claim opioid use. Am. J. Ind. Med. 58:650–657, 2015. © 2015 Wiley Periodicals, Inc.

Background In 2011, Manitoba implemented a province-wide program of physician detailing and free sampling for generic atorvastatin to increase use of this generic statin. We examined the impact of this unique combined program of detailing and sampling for generic atorvastatin on the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin. Methods We conducted a retrospective study of Manitoba insurance claims data for all continuously enrolled patients who filled one or more prescriptions for a statin between 2008 and 2013. Data were linked to physician-level data on the number of detailing visits and sample provision. We used interrupted time series analyses to assess policy-related changes in the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin. Results The detailing program reached 31% (651/2103) of physicians who prescribed a statin during the study period. Collectively, these physicians prescribed 61% of statins dispensed in the province. Free sample cards were provided to 61% (394/651) of the detailed physicians. The program did not change the level or trend in the overall statin use rate and the total cost of statins or increase the number of patients switching from another branded statin to generic atorvastatin. We found the program had a small impact on atorvastatin’s market share of new prescriptions, with a level increase of 2.6%. Conclusions Though physician detailers were skilled at targeting high-prescribing physicians, a combined program of detailing visits and sample provision for generic atorvastatin did not lower overall statin costs or lead to switching from branded statins to the generic. The preceding introduction of generic atorvastatin appeared sufficient to modify prescribing patterns and decrease costs.

Objective:To describe the extent of increase in use and the rate of continuation versus discontinuation of psychotropic agents before, during, and after pregnancy.Methods:Rates of psychotropic use (antidepressants, anxiolytic/sedative-hypnotics, antiepileptics, antipsychotics, lithium, stimulants) among women with a hospital-recorded pregnancy outcome were assessed using databases at the Manitoba Centre for Health Policy. Rate of use was defined as ≥1 prescription over the total number of pregnancies in the 3-12 months before pregnancy, 0-3 months before pregnancy, during pregnancy, or 3 months after pregnancy. Continued use was defined as ≥2 prescriptions with gap ≤14 days. Poisson regression was used to analyze trends.Results:Over the study period, a psychotropic drug was used before, during, or after pregnancy in 41,923 of 224,762 pregnancies. From 2001 to 2013, psychotropic use increased 1.5-fold from 11.1% to 16.2% ( p < 0.0001) in the 3-12 months before pregnancy, 1.6-fold from 6.4% to 10.5% ( p < 0.0001) in the 3 months before pregnancy, 1.8-fold from 3.3% to 6.0% ( p < 0.0001) during pregnancy, and 1.5-fold from 6.2% to 9.5% ( p < 0.0001) in the 3 months postpartum. Among the 13,579 women who received at least 1 psychotropic agent in the 3 months prior to pregnancy, 38.5% stopped the agent prior to pregnancy and only 10.3% continued use throughout pregnancy. Continued use throughout pregnancy was higher (56.9%) among the 6693 women who received at least 2 prescriptions for a psychotropic agent and were at least 80% adherent in the 3 months prior to pregnancy.Conclusion:The use of psychotropic agents increased over 12 years. The safety of continuing versus discontinuing these agents during pregnancy remains uncertain, but we observed a decrease in psychotropic drug use during the pregnancy period.

Adults with acute lymphoblastic leukemia (ALL) in first complete remission (CR1) may be treated either with ongoing systemic chemotherapy or with allogeneic hematopoietic cell transplantation (alloHCT). Despite the presence of phase III trials to support clinical decision-making, we hypothesized that physicians who treat adult ALL would demonstrate wide practice variation. Canadian hematologists who treat ALL were surveyed electronically. Overall, 69 of 173 physicians responded (40%). There was high agreement with offering alloHCT for ALL with high-risk cytogenetics or induction failure after a single chemotherapy cycle. However, only a minority of respondents felt that age >35 years was an indication for alloHCT in CR1. Almost all respondents (96%) felt that a well-matched unrelated donor was an acceptable alternative to a sibling donor. There was uncertainty about the role of cord blood (53% agree) and the utility of reduced intensity conditioning HCT (41% agree). In contrast to the results of the MRC/ECOG study, respondents considered alloHCT to be particularly helpful in high-risk patients. Consensus was lacking on the use of cord blood, RIC alloHCT, and the application of MRD. Equipoise exists on the role of alloHCT in CR1 in ALL, suggesting that further trials in this area are required.

Background: There has been limited research about preceptor training programs that include coaching, experiential practice or development of preceptor coaching capacity. We describe the development and evaluation of a workplace preceptor training course for pharmacists and pharmacy technicians within a large regional health authority. Methods: The instructional format was self-study readings and interactive seminars followed by structured practical experience plus feedback from a preceptor coach. During the structured practical experience, each participant served as a preceptor for a student or new staff member. Course evaluations and qualitative interviews were used to evaluate utility and perceived value among participants. Interview transcripts were analyzed using qualitative description and themes were aggregated; illustrative quotes are presented. Results: Since 2006, a total of 40 pharmacists and technicians have participated in the course and interviews were conducted with 14 of these participants. Aspects of the course that interview participants found to be particularly useful included receiving feedback from a coach, implementing a lesson plan and identifying and using different learning and teaching styles. Some participants described changes in attitudes or behaviours toward new employees or students, the use of new learning styles and changes in focus and approach to being a preceptor. Discussion: This unique course could be applied in other workplaces where pharmacy staff members help to deliver experiential education programs. The delivery format was appropriate for a mixed group of pharmacist and technician participants. Conclusion: A preceptor training course of readings, seminars and structured practical experience with feedback from a coach resulted in satisfaction with learning experiences and evidence of attitudinal and behavioural change up to 3 years after the course. Can Pharm J 2012;145:231–236.

Near misses may be early warning signals for errors. The purpose of this study was to examine the attitudes and behaviours of Manitoba hospital pharmacists and technicians toward near misses and reporting. A web-based survey of pharmacy staff at hospitals (all have non-punitive paper-based incident reporting systems) was conducted in 2009. Survey respondents were asked via a validated survey about experience with and attitudes and behaviours toward near misses. Factor analysis and Cronbach's α were used to determine internal consistency reliability. Differences between pharmacists and technicians were compared using Fisher's exact test for categorical data and t tests for survey scales. Of 37 hospitals, one large tertiary care hospital declined to participate. Of approximately 500 pharmacy staff, 122 (24%) responded. The majority (54.1%) were pharmacists, and most worked in Winnipeg (73.8%). The majority of respondents (62% overall--48% of technicians and 73% of pharmacists (p=.008)--had experienced at least one near miss within the previous three months. However, only 27% had reported a near miss with occurrence-reporting forms. There was no difference in the reporting behaviours scale (eight items, Cronbach's α=.824) between pharmacists and technicians (pharmacist score 30.9 ± 4.8, technician score 29.6 ± 6.0; p=.215). There was no difference in the attitudes scale (23 items, Cronbach's α=.873) between pharmacists and technicians (pharmacist score 81.9 ± 9.4, technician score 80.2 ± 10.6; p=.388). We observed similar behaviours and attitudes between hospital pharmacists and technicians, although reporting of near misses was low. Education of pharmacy staff and managers about near misses may help to encourage reporting.

From 1998 to 2005, nine hospital pharmacies in Winnipeg, Manitoba, Canada, had annual pharmacist vacancy rates ranging from 3.4% to 67%. Despite the implementation of very successful recruitment initiatives citywide from 2002 to 2004, most pharmacies had difficulty retaining new pharmacist recruits

Purpose. The use of sodium thiosulfate, bisphosphonates, and cinacalcet for the treatment of calciphylaxis in adults with chronic kidney disease (CKD) is discussed. Summary. Calciphylaxis, generally characterized by extraosseous calcification of soft tissues, typically occurs in patients with stage 4 or 5 CKD. Very little data are available regarding the treatment of calciphylaxis. The role of elevated calcium and phosphate concentrations and hyperparathyroidism as risk factors for calciphylaxis has led clinicians to explore therapies that modify these factors, including sodium thiosulfate, bisphosphonates, and cinacalcet. Sodium thiosulfate has been shown to produce clinical improvement of calciphylaxis lesions. Bisphosphonates have been shown to be effective in animal models of calciphylaxis, and the mechanism of action is believed to be due to inhibition of macrophages and local proinflammatory cytokines and binding to calcified vascular smooth muscle cells to inhibit further arterial calcification. Cinacalcet, a calcimimetic agent that increases the sensitivity of the calcium-sensing receptor on the parathyroid gland to calcium, is believed to decrease serum parathyroid hormone levels and stabilize calcium and phosphate concentrations. Cinacalcet has been associated with improved pain control and ulcer healing. Cases describing the use of combination therapy with cinacalcet and sodium thiosulfate for the treatment of calciphylaxis have been published, but the positive effect on wound healing is difficult to attribute to a single drug. Conclusion. Evidence for the treatment of calciphylaxis with pharmacotherapeutic interventions is limited to case reports. Further research is necessary to fully describe the optimal use of sodium thiosulfate, bisphosphonates, and cinacalcet for the treatment of calciphylaxis, including their pharmacokinetics in adults with CKD, optimal dosing strategies, and duration of therapy.

Objectives: Expenditures on antidepressants in Canada are rapidly increasing; yet few studies have analyzed the characteristics of antidepressant users. This study investigated the prevalence and incidence of antidepressant use in British Columbia over eight years. Methods: Antidepressant utilization and demographic data were assessed for the population of British Columbia from 1996 to 2004. Prescription claims were identified within the PharmaNet database for serotonin reuptake inhibitors (SSRI), tricyclics, monoamine oxidase inhibitors, bupropion (categorized separately for smoking cessation), and "novel" antidepressants, such as venlafaxine. Incident utilization (dispensed "first" antidepressant after two years without an antidepressant claim) and prevalent utilization were analyzed. All cohort members were required to have continuous registration with British Columbia medical services for at least two years before the first antidepressant claim. Results: Prevalence of antidepressant use doubled, from 34 to 72 users per 1,000 population, between 1996 and 2004. The prevalence of particular classes of antidepressants also changed over time. Prevalence of novel antidepressants and SSRIs increased, although incidence of SSRIs decreased. Prevalent and incident use of bupropion for smoking cessation peaked in 1999 but then declined. Quarterly incident antidepressant use increased in 1998 and 1999 (6.5 and 11.3 users per 1,000) but decreased through 2004 (4.2 users per 1,000). Those aged 20 to 44 years and those aged 45 to 64 years showed the greatest peak in incident antidepressant use. A socioeconomic gradient in prescribing was observed. Conclusions: Prevalent antidepressant use has increased dramatically since 1996. By contrast, incident use increased from 1998 to 1999 but then decreased through 2004. Many complex factors likely contribute to antidepressant prescribing patterns.

Objectives: to measure sex differences in the risk of receiving potentially inappropriate prescription drugs and to examine what are the factors that contribute to these differences. Design: a retrospective cohort study. Setting: community setting of British Columbia, Canada. Participants: residents of British Columbia aged 65 and older (n = 660,679). Measurements: we measured 2013 period prevalence of prescription dispensations satisfying the American Geriatrics Society's 2012 version of the Beers Criteria for potentially inappropriate medication use in older adults. We used logistic regressions to test for associations between this outcome and a number of clinical and socioeconomic factors. Results: a larger share of women (31%) than of men (26%) filled one or more potentially inappropriate prescription in the community. The odds of receiving potentially inappropriate prescriptions are associated with several clinical and socioeconomic factors. After controlling for those factors, community-dwelling women were at 16% higher odds of receiving a potentially inappropriate prescription than men (adjusted odds ratio = 1.16, 95% confidence interval = 1.12–1.21). Much of this sex difference stemmed from women's increased odds of receiving potentially inappropriate prescriptions for benzodiazepines and other hypnotics, for tertiary tricyclic antidepressants and for non-selective NSAIDs. Conclusion: there are significant sex differences in older adults' risk of receiving a potentially inappropriate prescription as a result of complex intersections between gender and other social constructs. Appropriate responses will therefore require changes in the information, norms and expectations of both prescribers and patients.

OBJECTIVETo review the evidence for selecting one atypical antipsychotic agent over another for management of schizophrenia.DATA SOURCESA literature search of MEDLINE (1966–June 2003), EMBASE (1998–June 2003), and the Cochrane Library was conducted using the following terms: schizophrenia, quetiapine, ziprasidone, olanzapine, aripiprazole, and risperidone. Bibliographies of relevant articles were hand-searched for additional references.STUDY SELECTION AND DATA EXTRACTIONProspective, randomized, blinded trials and meta-analyses that directly or indirectly compared ≥2 atypical antipsychotic agents in the management of schizophrenia are included in this review. Studies comparing an atypical agent with clozapine are not included.DATA SYNTHESISA small number of prospective, randomized, blinded trials that compare efficacy and tolerability of olanzapine and risperidone have been published. These trials did not reveal clinically meaningful differences in efficacy but did confirm that their adverse effect profiles are slightly different (more weight gain with olanzapine and more extrapyramidal reactions with risperidone). Direct comparisons between other atypical antipsychotics are not available. Systematic reviews (indirect comparisons) of placebo-controlled or traditional antipsychotic-controlled trials suggest similar efficacy for quetiapine, olanzapine, and risperidone when placebo is the comparator and inferior efficacy of quetiapine compared to olanzapine and risperidone when haloperidol is the comparator. The few available economic analyses are difficult to interpret in light of current practice.CONCLUSIONSAdditional randomized, blinded clinical trials directly comparing efficacy, tolerability, and cost-effectiveness are needed to confirm the proposed differences among atypical antipsychotic agents before recommendations can be made with confidence.

Background This study identifies the percentage of opioids prescribed for compensated workplace conditions in Manitoba, Canada and whether Workers Compensation Board (WCB) status is associated with higher prescription opioid doses. Methods Opioid prescriptions for WCB recipients were linked with databases housed at the Manitoba Center for Health Policy. Duration of continuous opioid prescription and morphine equivalents (ME) per day (ME/D) were calculated for individuals age 18–65. Results Over the period from 1998 to 2010, 3.8% of the total opioid dosage of medication prescribed in the study population were prescribed to WCB recipients. WCB recipients accounted for 2.1% of the individuals prescribed opioids. In adjusted analyses WCB recipients were more likely to be prescribed over 120 ME/D (OR 2.06 95% CI, 1.58–2.69). Conclusions WCB recipients account for a small, but significant amount of the total opioid prescribed in Manitoba. Manitoba's WCB population is a group at increased risk of being prescribed over 120 ME/day. Am. J. Ind. Med. 58:33–39, 2015. © 2014 The Authors. American Journal of Industrial Medicine Published by Wiley Periodicals, Inc.

Objective To evaluate the incremental increase in new onset diabetes from higher potency statins compared with lower potency statins when used for secondary prevention. Design Eight population based cohort studies and a meta-analysis. Setting Six Canadian provinces and two international databases from the UK and US. Participants 136 966 patients aged ≥40 years newly treated with statins between 1 January 1997 and 31 March 2011. Methods Within each cohort of patients newly prescribed a statin after hospitalisation for a major cardiovascular event or procedure, we performed as-treated, nested case-control analyses to compare diabetes incidence in users of higher potency statins with incidence in users of lower potency statins. Rate ratios of new diabetes events were estimated using conditional logistic regression on different lengths of exposure to higher potency versus lower potency statins; adjustment for confounding was achieved using high dimensional propensity scores. Meta-analytic methods were used to estimate overall effects across sites. Main outcome measures Hospitalisation for new onset diabetes, or a prescription for insulin or an oral antidiabetic drug. Results In the first two years of regular statin use, we observed a significant increase in the risk of new onset diabetes with higher potency statins compared with lower potency agents (rate ratio 1.15, 95% confidence interval 1.05 to 1.26). The risk increase seemed to be highest in the first four months of use (rate ratio 1.26, 1.07 to 1.47). Conclusions Higher potency statin use is associated with a moderate increase in the risk of new onset diabetes compared with lower potency statins in patients treated for secondary prevention of cardiovascular disease. Clinicians should consider this risk when prescribing higher potency statins in secondary prevention patients.

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: The Winnipeg Regional Health Authority (WRHA) implemented a medication order writing standards (MOWS) policy (including banned abbreviations) to improve patient safety. Widespread educational campaigns and direct prescriber feedback were implemented. Methods: We audited orders within the WRHA from 2005 to 2009 and surveyed all WRHA staff in 2011 about the policy and suggestions for improving education and compliance. Results: Overall, orders containing banned abbreviations, acronyms or symbols numbered 2261/8565 (26.4%) preimplementation. After WRHA-wide didactic education, the proportion declined to 1358/5461 (24.9%) ( p = 0.043) and then, with targeted prescriber feedback, to 1186/6198 (19.1%) ( p < 0.0001). A survey of 723 employees showed frequent violations of the MOWS, despite widespread knowledge of the policy. Respondents supported ongoing efforts to enforce the policy within the WRHA. Nonprescribers were significantly more likely than prescribers to agree with statements regarding enhancing compliance by defining prescriber/transcriber responsibilities and placing sanctions on noncompliant prescribers. Discussion: Education, raising general awareness and targeted feedback to prescribers alone are insufficient to ensure compliance with MOWS policies. WRHA staff supported ongoing communication, improved tools such as compliant preprinted orders and reporting and feedback about medication incidents. A surprising number of respondents supported placing sanctions on noncompliant prescribers. Conclusion: Serial audits and targeted interventions such as direct prescriber feedback improve prescription quality in inpatient hospital settings. Education plus direct prescriber feedback had a greater impact than education alone on improving compliance with a MOWS policy. Future efforts at the WRHA to improve compliance will require an expanded focus on incentives, resources and development of action plans that involve all affected staff, not just prescribers. Plans include continued advertising, MOWS summaries in all charts, all-staff education, reminders and exploration of sustainable interventions for targeted feedback for prescribers.

Background/Aims: A cost analysis of a conversion from intravenous (IV) to subcutaneous (SC) epoetin α in patients receiving chronic in-center hemodialysis (HD). Methods: This retrospective analysis compared epoetin α drug costs during a 6-month period of IV usage (July to December 2010, period 1) to a 6-month period of SC usage (July to December 2011, period 2) in four large in-center HD units. Data were collected from quarterly counts of HD patients receiving epoetin α and monthly inventory billing records. Results: 622 HD patients who received IV epoetin α (period 1) were compared to 609 HD patients who received SC epoetin α (period 2). A 12.6% decrease in dose was observed. The average weekly cost of epoetin α was USD 173.02 per patient during the IV period versus USD 151.20 per patient during the SC period. This equated to a yearly cost savings of USD 1,135 per patient with SC epoetin α. Conclusion: The switch from IV to SC epoetin α was successfully implemented in all four centers and realized significant cost savings.

Background. Psychotropic medications, in particular second-generation antipsychotics (SGAs) and benzodiazepines, have been associated with harm in elderly populations. Health agencies around the world have issued warnings about the risks of prescribing such medications to frail individuals affected by dementia and current guidelines recommend their use only in cases where the benefits clearly outweigh the risks. This study documents the use of psychotropic medications in the entire elderly population of a Canadian province in the context of current clinical guidelines for the treatment of behavioural disturbances. Methods. Prevalent and incident utilization of antipsychotics, benzodiazepines and related medications (zopiclone and zaleplon) were determined in the population of Manitobans over age 65 in the time period 1997/98 to 2008/09 fiscal years. Comparisons between patients living in the community and those living in personal care (nursing) homes (PCH) were conducted. Influence of sociodemographic characteristics on prescribing was assessed by generalized estimating equations. Non-optimal use was defined as the prescribing of high dose of antipsychotic medications and the use of combination therapy of a benzodiazepine (or zopiclone/zaleplon) with an antipsychotic. A decrease in intensity of use over time and lower proportions of patients treated with antipsychotics at high dose or in combination with benzodiazepines (or zopiclone/zaleplon) was considered a trend toward better prescribing. Multiple regression analysis determined predictors of non-optimal use in the elderly population. Results. A 20-fold greater prevalent utilization of SGAs was observed in PCH-dwelling elderly persons compared to those living in the community. In 2008/09, 27% of PCH-dwelling individuals received a prescription for an SGA. Patient characteristics, such as younger age, male gender, diagnoses of dementia (or use of an acetylcholinesterase inhibitor) or psychosis in the year prior the prescription, were predictors of non-optimal prescribing (e.g., high dose antipsychotics). During the period 2002/3 and 2007/8, amongst new users of SGAs, 10.2% received high doses. Those receiving high dose antipsychotics did not show high levels of polypharmacy. Conclusions. Despite encouraging trends, the use of psychotropic medications remains high in elderly individuals, especially in residents of nursing homes. Clinicians caring for such patients need to carefully assess risks and benefits.

Objective To quantify an association between acute kidney injury and use of high potency statins versus low potency statins. Design Retrospective observational analysis of administrative databases, using nine population based cohort studies and meta-analysis. We performed as treated analyses in each database with a nested case-control design. Rate ratios for different durations of current and past statin exposure to high potency or low potency statins were estimated using conditional logistic regression. Ratios were adjusted for confounding by high dimensional propensity scores. Meta-analytic methods estimated overall effects across participating sites. Setting Seven Canadian provinces and two databases in the United Kingdom and the United States. Participants 2 067 639 patients aged 40 years or older and newly treated with statins between 1 January 1997 and 30 April 2008. Each person hospitalized for acute kidney injury was matched with ten controls. Intervention A dispensing event was new if no cholesterol lowering drug or niacin prescription was dispensed in the previous year. High potency statin treatment was defined as ≥10 mg rosuvastatin, ≥20 mg atorvastatin, and ≥40 mg simvastatin; all other statin treatments were defined as low potency. Statin potency groups were further divided into cohorts with or without chronic kidney disease. Main outcome measure Relative hospitalization rates for acute kidney injury. Results Of more than two million statin users (2 008 003 with non-chronic kidney disease; 59 636 with chronic kidney disease), patients with similar propensity scores were comparable on measured characteristics. Within 120 days of current treatment, there were 4691 hospitalizations for acute kidney injury in patients with non-chronic kidney injury, and 1896 hospitalizations in those with chronic kidney injury. In patients with non-chronic kidney disease, current users of high potency statins were 34% more likely to be hospitalized with acute kidney injury within 120 days after starting treatment (fixed effect rate ratio 1.34, 95% confidence interval 1.25 to 1.43). Users of high potency statins with chronic kidney disease did not have as large an increase in admission rate (1.10, 0.99 to 1.23). χ2 tests for heterogeneity confirmed that the observed association was robust across participating sites. Conclusions Use of high potency statins is associated with an increased rate of diagnosis for acute kidney injury in hospital admissions compared with low potency statins. The effect seems to be strongest in the first 120 days after initiation of statin treatment.

Background Recent evidence suggests that proton pump inhibitors (PPIs) might be linked with adverse cardiac events, but a causal relationship is unproven. Methods We applied the self-matched case series method to two studies using population-based health care data from Ontario, Canada between 1996 and 2008. The first included subjects aged 66 years or older hospitalized for acute myocardial infarction within 12 weeks following initiation of PPI, while the second included subjects hospitalized for heart failure. In both studies we designated the primary risk interval as the initial 4 weeks of therapy and the control interval as the final 4 weeks. To test the specificity of our findings we examined use of histamine H2 receptor antagonists and benzodiazepines, drugs with no plausible causal link to adverse cardiac events. Results During the 13-year study period, we identified 5550 hospital admissions for acute myocardial infarction and 6003 admissions for heart failure within 12 weeks of commencing PPI therapy. In the main analyses, we found that initiation of a PPI was associated with a higher risk of acute myocardial infarction (odds ratio 1.8; 95% confidence interval 1.7 to 1.9) and heart failure (odds ratio 1.8; 95% confidence interval 1.7 to 1.9). However, secondary analyses revealed similar risk estimates histamine H2 receptor antagonists and benzodiazepines, drugs with no known or suspected association with adverse cardiac events. Conclusion PPIs are associated with a short-term risk of adverse cardiac events, but similar associations are seen with other drugs exhibiting no known cardiac toxicity. Collectively these observations suggest that the association between PPIs and adverse cardiac events does not represent reflect cause-and-effect.

Interest in optimizing iron management in the treatment of anemia of CKD is growing due to concerns that high doses of ESAs may have deleterious effects and the high cost of ESAs in comparison to iron therapy. International guidelines have defined iron targets for this patient population, but there are some unanswered questions with respect to long-term use of iron, such as the maximum TSAT or ferritin concentration and concerns with oxidative stress. Large head-to-head safety studies of the different i.v. iron preparations have not been performed to date and current safety data rely on small studies and spontaneous adverse event reporting. Interprofessional management of anemia, including iron therapy, has shown beneficial effects and should be encouraged.

Providing a safe work environment is an important goal for any hospital pharmacy department. Historically, great care has been exercised in the receipt, storage, preparation, distribution, administration, and disposal of cytotoxic drugs. Although other drugs have been acknowledged as potentially hazardous, most facilities do not have processes to identify and ensure their safe and consistent handling. Existing medication and chemical safety programs have limitations in their applicability to hospital pharmacy practice. For example, the Workplace Hazardous Material Information System excludes prescription drugs. The US National Institute for Occupational Safety and Health (NIOSH) recommends full handling precautions for all hazardous drugs. However, in a busy, diverse hospital pharmacy practice, application of such procedures may be impractical. The Canadian Society of Hospital Pharmacists (CSHP), in its “Hazardous Pharmaceuticals (Including Cytotoxic Drugs): Guidelines for Handling and Disposal”, provides information about general issues related to handling hazardous products, but greater detail (for example, a list of specific drugs considered hazardous) was required to develop procedures for use by front-line staff. The Winnipeg Regional Health Authority (WRHA) is a publicly funded organization that delivers acute, long-term, and community health services in Winnipeg, Manitoba (population catchment 800 000). The WRHA Pharmacy Program has a staff of approximately 150 full-time equivalent pharmacists and 150 full-time equivalent pharmacy technicians. Staff members of the WRHA Pharmacy Program deliver and manage pharmacy care at 8 facilities totalling about 2000 beds and provide selected pharmacy services for WRHA-affiliated clinics, personal care homes, and community health agencies. The WRHA has a single formulary for all acute care facilities. This article describes the development and implementation of the Safe Handling of Hazardous Drugs Program within the WRHA Pharmacy Program. The purpose of this project was to develop practical guidelines for the safe handling of all potentially hazardous drugs. In 2007, the WRHA introduced a new policy for handling parenteral cytotoxic drugs, which was applicable to all regional staff. However, information was lacking about the safe handling of cytotoxic drugs administered by other routes and handling of potentially hazardous non-cytotoxic drugs; therefore, the WRHA Pharmacy Program struck a Hazardous Drugs Task Force. The regional Nursing Leadership Council was invited to participate in this task force, to help in developing safe handling processes for hazardous drugs that would also be applicable to nursing staff, but the Council chose not to participate; instead, they focused on implementation and education related to the new policy for cytotoxic drugs. Therefore, the task force worked on processes for the safe handling of hazardous drugs within the pharmacy, with the understanding that other health care disciplines would be included later, at a time of their choosing.

Background: The renal dosing directive of the Winnipeg Regional Health Authority Pharmacy Program outlines an auditable pharmacy service whereby pharmacists are required to perform documentation (i.e., document their rationale) only if they do not adjust the dose of any medications listed in the directive. Objective: To compare the suitability of manual orders (hard copy) and reports from the pharmacy information system (computer-generated) for determining pharmacists’ compliance with the renal dosing directive; to measure compliance with the renal dosing directive; and to determine pharmacists’ opinions about audit programs. Methods: A retrospective audit was used to compare 400 manual orders with the corresponding orders in reports from the pharmacy information system, to determine compliance with the renal dosing directive. An e-mail survey was performed to gather pharmacists’ opinions about audit programs. Results: Of the 400 orders evaluated, 86 (22%) required consideration of a dose adjustment. Of these, 78 (91%) showed that dosing followed the guidelines for renal dysfunction in standard pharmacy references. Six (7%) of 86 manual orders and 8 (9%) of 86 pharmacy information system orders were not compliant with the renal dosing directive (i.e., no dosage adjustment and no documentation of rationale). Of 77 pharmacists approached, 34 (44%) completed the survey. Most respondents (31/34 [91%]) agreed that auditing is beneficial to patients, and the same number (31/34 [91%]) agreed that auditing provides important information to the pharmacy program. Only 17 (50%) were aware of medications listed in the renal dosing directive, and 14 (41%) felt that they had received sufficient education about pharmacy directives. Most respondents (29/34 [85%]) agreed that audits would reveal areas for improvement, and all (34/34 [100%]) would comply with any changes required to facilitate performance of an audit if such changes did not increase workload. Conclusions: Similar results were obtained with the 2 auditing methods used for this study (manual orders and reports from the pharmacy information system). However, pharmacists’ current use of electronic documentation limits the feasibility of pharmacy information system audits. Survey respondents claimed that they were not familiar with the renal dosing directive, but they did agree that auditing clinical services is beneficial. RESUME Contexte : La directive sur l’ajustement posologique chez les insuffisants renaux du Programme de pharmacie de la Regie regionale de la sante de Winnipeg dec rit un service de pharmacie verifiable sel on le quel les pharmaciens sont tenus de consigner les motifs seulement s’ils n’ajustent pas la posologie des medicaments enumeres dans la directive. Objectif : Comparer la pertinence des ordonnances manuelles (version papier) et des rapports generes par le systeme informatique de la pharmacie (version electronique) pour determiner la conformite a la directive sur l’ajustement posologique chez les insuffisants renaux de la part des pharmaciens; mesurer le degre de conformite a cette directive; et obtenir l’opinion des pharmaciens quant aux programmes de verification. Methodes : On a mene une verification retrospective pour comparer 400 ordonnances manuelles aux ordonnances correspondantes dans les rapports du systeme informatique de la pharmacie, afin de determiner la conformite a la directive sur l’ajustement posologique chez les insuffisants renaux. Un sondage par courriel a ete envoye aux pharmaciens pour obtenir leur opinion sur des programmes de verification. Resultats : Des 400 ordonnances evaluees, 86 (22 %) requeraient la prise en consideration d’un ajustement posologique. De celles-ci, 78 (91 %) se sont averees conformes aux lignes directrices sur l’ajustement posologique en cas d’insuffisance renale dans les ouvrages de reference standards de pharmacie. Six (7 %) des 86 ordonnances manuelles et 8 (9 %) des 86 ordonnances saisies par le systeme informatique de la pharmacie n’etaient pas conformes a la directive (c.-a-d. aucun ajustement posologique et aucune consignation des motifs). Des 77 pharmaciens qui ont recu le sondage, 34 (44 %) y ont repondu. La plupart des repondants (31/34 [91 %]) etaient d’accord pour dire que la verification est avantageuse pour les patients et la meme proportion (31/34 [91 %]) l’etait aussi pour dire que la verification procure des renseignements utiles pour le programme de pharmacie. Seulement 17 (50 %) pharmaciens etaient au courant de la liste des medicaments de la directive et 14 (41 %) estimaient qu’ils avaient recu une formation suffisante sur les directives pharmaceutiques. La plupart des repondants (29/34 [85 %]) ont affirme que les verifications permettraient de cerner des points a ameliorer et tous (34/34 [100 %]) ont dit qu’ils se conformeraient a tout changement necessaire a la tenue d’une verification, pourvu que cela n’entraine pas d’augmentation de la charge de travail. Conclusions : Des resultats similaires ont ete obtenus a partir des deux methodes de verification utilisees dans cette etude (ordonnances manuelles et rapports du systeme informatique de la pharmacie). En revanche, l’utilisation actuelle de la consignation electronique par les pharmaciens limite la faisabilite des verifications des systems informatiques de pharmacie. Les repondants au sondage ont affirme ne pas etre familiers avec la directive sur l’ajustement posologique chez les insuffisants renaux, mais que la verification des services cliniques est avantageuse.

Publication bias is the preferential publication of research with positive results, and is a threat to the validity of medical literature. Preliminary evidence suggests that research in blood and marrow transplantation (BMT) lacks publication bias. We evaluated publication bias at an international conference, the 2006 Center for International Blood and Marrow Transplant Research (CIBMTR)/American Society for Blood and Marrow Transplantation (ASBMT) “tandem” meeting. All abstracts were categorized by type of research, funding status, number of centers, sample size, and direction of the results. Publication status was then determined for the abstracts by searching PubMed. Of 501 abstracts, 217 (43%) were later published as complete manuscripts. Abstracts with positive results were more likely to be published than those with negative or unstated results (P = .001). Furthermore, positive studies were published in journals with a mean impact factor of 6.92, whereas journals in which negative/unstated studies were published had an impact factor of only 4.30 (P = .02). We conclude that publication bias exists in the BMT literature. Full publication of research, regardless of direction of results, should be encouraged and the BMT community should be aware of the existence of publication bias.

Models of pharmacy practice are currently the focus of considerable attention within the North American pharmacy profession. In Canada, through the “Blueprint for Pharmacy” initiative, a vision and implementation plan for pharmacy practice in Canada have been established and endorsed by all pharmacy organizations. Three key objectives of the Blueprint are to incorporate technology, to enhance training and utilization of pharmacists and technicians, and to enhance accountability to patients. If pharmacists are to assume greater responsibility and accountability for management of medication therapy, they will need to spend more time performing direct patient care and less time performing technical drug distribution activities. These plans for the profession of pharmacy, when viewed in aggregate, call for transformative change (whereby the culture of pharmacy is changed), rather than transitional change (whereby only a process is changed). However, there is debate in the literature regarding the best approach for initiating and sustaining transformational change initiatives within organizations. This article describes the process followed and lessons learned during a Blueprint-associated transformative change initiative: organizational restructuring and implementation of a new pharmacy practice model within a large health authority.

Background: To create a checklist of the tasks that a pharmacist must perform during medication order review in the hospital setting and to evaluate the utility of and pharmacists' satisfaction with the checklist. Methods: An evidence-based checklist for medication order review was developed, with items related to order urgency, verification of patients' identity, therapeutic review, and actionable items. Pharmacists were educated about the checklist, and it was made available at 2 community hospitals in an urban setting. Pharmacists completed a nonvalidated satisfaction survey and participated in focus groups or interviews within 3 months after implementation of the checklist. Qualitative descriptive theory was used to identify themes within the data. Near-miss occurrence reports for the 3 months before and after implementation of the checklist were quantified. Results: Of 16 pharmacists who were involved in the implementation phase, 14 participated in focus groups or an interview, and 11 responded to the survey. All respondents felt that the primary role of the checklist was for training. They felt that the checklist could be useful when reviewing high-alert or unfamiliar medications or therapy for patients with complex medications. The checklist was most helpful when it was used as a reminder, on an as-needed basis. Nine (82%) of the 11 survey respondents indicated that the checklist standardized the process of medication order review, the same number felt that it prevented accidental omission of critical checks, and 8 (73%) felt that it improved patient safety. Education was necessary to reinforce the purpose of the checklist and its self-check nature. There was no difference in the number of near misses in the pharmacy between the 3-month periods before and after implementation of the checklist. Conclusion: Pharmacists participating in the study felt that a checklist for medication order review had a role in training new pharmacists and standardizing processes. RESUME Contexte : Creer une liste de controle des tâches que doit executer un pharmacien dans le cadre de la validation des ordonnances de medicaments en milieu hospitalier et evaluer l'utilite de cette liste ainsi que le niveau de satisfaction du pharmacien. Methodes : Une liste de controle factuelle pour la validation des ordonnances de medicaments comportant des elements lies au niveau d'urgence de l'ordonnance, a la verification de l'identite des patients, a l'examen therapeutique et aux questions decisionnelles a ete developpee. Les pharmaciens ont ete formes a l'utilisation de cette liste qui a ete mise en oeuvre dans deux hopitaux communautaires en milieu urbain. Ils ont par la suite repondu a un sondage non valide sur leur satisfaction a l'egard de cet outil et participe a des groupes de discussion ou a des entrevues au cours des trois mois suivant la mise en oeuvre de la liste de controle. On a eu recours a une theorie descriptive qualitative pour regrouper les donnees par themes. On a quantifie les declarations de quasi-accidents de medication pendant les trois mois precedant et suivant la mise en oeuvre de la liste de controle. Resultats : Des 16 pharmaciens qui ont utilise la liste de controle, 14 ont participe aux groupes de discussion ou a une entrevue et 11 ont repondu au sondage. Tous les repondants etaient d'avis que la liste de controle servait tout d'abord a des fins de formation. Ils estimaient que cette liste pouvait etre utile lors de la validation des ordonnances de medicaments ou de traitements sous haute vigilance ou inusites chez des patients sous pharmacotherapie complexe. Elle s'est revelee tres utile comme aidememoire, au besoin. Neuf (82 %) des 11 sondes ont declare que la liste de controle avait standardise le processus de validation des ordonnances de medicaments, le meme nombre estimait qu'elle avait prevenu l'omission accidentelle de verifications essentielles et huit (73 %) repondants etaient d'avis qu'elle avait ameliore la securite des patients. Il a ete necessaire de sensibiliser davantage les pharmaciens a la raison d'etre de la liste de controle et a son aspect d'autocontrole. On n'a observe aucun changement dans le nombre de quasi-accidents de medication dans la pharmacie par suite de la mise en oeuvre de la liste de controle. Conclusion : Les pharmaciens qui ont participe a cette etude estimaient qu'une liste de controle pour la validation des ordonnances de medicaments jouait un role dans la formation des nouveaux pharmaciens et dans la standardisation des processus.

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.

It is well documented that clinical pharmacists who provide pharmaceutical care reduce the frequency of drug-related problems (DRPs) and that optimization of drug therapy in this way may influence health expenses, patients’ quality of life, and mortality rates.[1][1],[2][2] It is common for

The purpose of this study was to describe attitudes and behaviours of pharmacy staff toward near misses through a survey and interviews. Themes of an acknowledgment of pharmacy process changes resulting from near miss reporting, feelings of personal responsibility, minimizing the importance of reporting near misses, and a need for further education were evident in both the survey and qualitative discussions. This survey is useful to inform educational efforts and to encourage near miss reporting.