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Abbreviation |
Term |
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A RICH |
Agency, Reliability, Integrity, Capability, Humility |
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APC |
Australian Pharmacy Council |
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EPA |
Entrustable Professional Activity |
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ITA |
In Training Assessment Activity |
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ITP |
Intern Training Program |
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SPO |
Short Practice Observation |
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PBS |
Pharmaceutical Benefits Scheme |
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PharmBA |
Pharmacy Board of Australia |
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QCPP |
Quality Care Pharmacy Program |
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QUM |
Quality Use of Medicines |
This guide is to be used by pharmacist interns, preceptors, supervising pharmacists and Intern Training Program (ITP) providers.
This guide outlines the Entrustable Professional Activity (EPA) – Dispensing Medicines developed by the Australian Pharmacy Council (APC) for use in the assessment of pharmacist interns in Australia.
The tool is intended to assist with the assessment of an intern’s achievement of one or more of the performance outcomes listed in the Performance Outcomes Framework 2020 which accompanied the 2020 Accreditation Standards for Pharmacy Programs in Australia.
Interns will use the tool and the templates for completing the dispensing of a series of prescriptions, and discussing the technical and cognitive dimensions of these with their supervisor.
Preceptors and supervising pharmacists (collectively referred to as Supervisors) will use the tool and template for assessing the intern’s performance, providing feedback to the intern, and jointly formulating a plan for future development with the intern.
Intern Training Program providers will incorporate the tool into the Intern Portfolio, which is the compiled record of the intern’s achievements during the intern year, and which is used as the basis for determining whether the intern has achieved many of the performance outcomes. ITP providers may choose to use the assessment of this EPA as part of the formal requirement of the ITP.
Familiarity with the following documents is recommended and they should be read in conjunction with this User Guide.
This Entrustable Professional Activity (EPA) should be understood and undertaken within the overarching principles of Quality Use of Medicines (QUM) and person-centred care. In the context of this EPA, dispensing medicines includes both the cognitive and technical aspects of the process of ensuring that patients receive appropriate medications which can be used safely.
Cognitive aspects include clinical reasoning and decision-making in regard to the appropriateness of the prescribed medication, taking into account patient-specific details, co-morbidities, adverse and allergic reactions, drug interactions and contraindications, and other aspects which affect the safety and/or efficacy of a prescribed medication.
Technical aspects include accuracy and attention to detail in filling the prescription so that the patient receives the correct medication, and all legal requirements are met. Providing information to the patient regarding dispensed medications is covered in EPA 3 – Providing Counselling. It may be appropriate to carry out an assessment of EPA 1 together with EPA 3; the assessments can also be carried out independently.
Prior to commencement of this activity, it is important that consensus is reached between the intern, the preceptor, and all supervising pharmacists as to the dispensing procedure to be adopted as the standard against which intern performance is assessed. This procedure should be documented and made available to all participants, and any clarifications which are necessary should also be clearly documented. In particular it is critical that agreement is reached – and documented – about what constitutes an error.
This activity firstly requires interns to assess whether the prescription is appropriate for the patient, and then to dispense it accurately from a legal, ethical, and technical perspective. It is expected that an intern is able to articulate reasons for choosing to dispense a prescription, and also to take appropriate actions when there are risks which need to be addressed prior to dispensing. This may include gathering additional information from the patient, contacting the prescriber, or seeking other information considered necessary.
Errors are a part of professional practice, and the aim is to minimise their occurrence and maximise their detection before reaching the patient. Errors must be clearly articulated and documented in relation to the dispensing procedure against which the intern’s performance is assessed.
Interns and supervisors MUST both be clear about the details of the dispensing procedure against which the intern’s performance is compared. If no dispensing procedure is available in the workplace, suitable starting points include the Guidelines for Dispensing of Medicines prepared by the Pharmacy Board of Australia (PharmBA), resources available through the Quality Care Pharmacy Program (QCPP) and the Australian Commission on Safety and Quality in Health Care.
An ERROR results in the dispensed item(s) not being suitable to be provided to the patient. Errors are also defined with respect to the workplace documented dispensing procedure.
For this EPA, it is also important to note the definitions of a CRITICAL ERROR and NEAR MISS.
It is considered to be a CRITICAL ERROR if the error made by the intern is not detected by the intern but is only detected on subsequent checking.
It is considered to be a NEAR MISS if the error made by the intern is detected by the intern, prior to any subsequent checking.
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EPA Title |
Dispensing medicines |
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Specifications and limitations |
Outcome: Medications are safely, accurately, and appropriately dispensed to the correct patient, according to name, brand, strength, quantity, and formulation, with accurate directions on the label; dispensing reflects the intentions of the prescriber. Specifications: Prescription is checked for legality, validity, and completeness according to all relevant jurisdictional requirements. Clinical appropriateness and safety of the prescribed medication for the specific patient is checked and confirmed; any changes are clearly documented. Clarification is sought and documented where necessary. Prescription details are accurately entered into dispensing system. Appropriate product is selected from stock. All required labels are attached appropriately to the product. Prescription paperwork is assembled correctly. Checks are carried out at appropriate stages of the process. Products and paperwork are stored appropriately prior to collection. Patient receives correct medications and associated paperwork. Limitations: None |
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Potential risks in case of failure |
Inappropriate and/or inaccurate dispensing may lead to individual patient harm and/or harm to the health and safety of the public. |
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Performance outcomes |
3.14: dispensing medicines safely and accurately in accordance with current legislation, scope of practice, PharmBA Guidelines, and other relevant jurisdictional requirements to optimise patient outcomes. 4.2: identifying and acknowledging professional limitations and seeking appropriate support where necessary, including additional professional education and/or referral of patients to other health care professionals. 5.3: recognising and responding to the inherent complexity, ambiguity, and uncertainty of contemporary and future professional practice. |
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Required knowledge, skills, attitudes, and experiences (A RICH) |
Knowledge of legal requirements for prescriptions (C) Knowledge of scheduling of medicines (C) Knowledge of pharmacology, medical chemistry, pharmacotherapeutics, pharmacodynamics, pharmacokinetics, formulations (C) Communication skills (C) Attention to detail (R) Person-centred approach (I) Awareness of personal limitations (H) Willingness to seek assistance (H) |
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Information sources to assess progress and ground an entrustment decision |
Dispensing log Critical error and near miss log Short practice observations (SPO) Reflection on performance by intern1 Entrustment discussions |
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Entrustment/supervision level expected at which stage of training |
Level 2 or 3 on entry to intern year Level 4 by end of intern year; may be entrusted earlier |
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Time period to expiration if not practiced |
Not applicable to intern year. |
1 A template provided as part of the In Training Assessment (ITA) activity - Reflection is a useful resource for this reflection
Two primary types of information should be gathered to allow assessment of the intern’s capacity to carry out this EPA. These are the logs of prescriptions dispensed by the intern (Dispensing, and Critical error and near miss logs), and Short Practice Observations (SPOs). The former are intended to provide evidence that the intern is capable of consistently carrying out the process, whereas the latter are designed to focus in more detail on the cognitive elements, particularly the intern’s clinical reasoning and decision making.
Information for these two sources are considered to be complementary, and both are important elements of the overall demonstration of the intern’s performance.
Note: In professional practice, pharmacists often employ non-pharmacists to carry out some of the technical aspects of dispensing, with the pharmacists more involved in the cognitive aspects, and final checking. However, during the intern year, it is considered appropriate for interns to be engaged in all parts of the process in order for them to develop an understanding of the risks and potential errors that can arise during the process. All interns should therefore be provided with sufficient training opportunities to complete the dispensing process from beginning to end in order to allow them to develop both their own expertise, and the capacity to oversee the process when carried out by others under their supervision.
These logs are primarily designed to provide evidence of the intern’s capacity to carry out the technical aspects of dispensing medicines with consistent accuracy. The log specifically requires interns to complete a minimum of 10 prescriptions in each of 6 categories, with a focus on ensuring that the medication is dispensed and supplied to the patient without error. Examples of relevant categories are listed below, but other categories may be relevant to a particular workplace, and preceptors and interns should discuss which categories are of relevance to their situation.
Interns should complete the Dispensing log immediately after dispensing a relevant prescription, and ask their supervisor to sign that it has been checked. Space is provided on the form if you wish to attach a duplicate dispensing label.
For each category, the 10 prescriptions should be completed consecutively without error; critical errors and near misses should be documented in the Critical error and near miss log. If a critical error occurs, the count restarts; near misses do not require the restart of the count. A near miss is an error which is detected by the intern; an error is one which is detected by an individual after the intern has completed the dispensing process.
Space is provided on the logs for recording of intern reflection on the task, and supervisor feedback on intern performance. This space can also be used to record discussion about the cognitive aspects of the task – for example the supervisor may ask the intern to describe the thinking behind their evaluation of the prescription and the decisions that were made about it. These written observations and reflections are intended to supplement the information gained as a result of an SPO and entrustment discussion – see next section.
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Table 1: Possible categories of prescription for the dispensing log
While this is to some extent dependent on the specific workplace, the following list indicates types of critical errors/near misses which may be relevant and important. Other types are also possible.
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Table 2: Examples of critical errors and near misses
The purpose of the short practice observation (SPO) is to focus on both the cognitive and technical aspects of dispensing a particular prescription. It involves a supervisor observing the intern while dispensing a prescription from beginning to end, and may involve discussion with the intern to establish the intern’s clinical reasoning when deciding that the prescription is legal, valid, appropriate, and safe for the patient. Experienced non-pharmacist dispensary staff should also be involved as observers where possible, in order to gather the perspectives of a diverse group of observers.
A minimum of 6 SPOs is considered appropriate for assessing the performance of the intern on this EPA in order to cover the 6 categories of prescriptions for the dispensing log. Clearly, an intern is likely to be observed regularly while dispensing prescriptions, but an SPO is a formal point where the intern and observers are advised that a more formal evaluation is to occur. It is most appropriately carried out as part of the dispensing and error log activity, but it may occur at other times. It may be scheduled when initial assessment of the prescription needs consultation with a prescriber or gathering of other relevant information.
Ideally, SPOs should be spaced throughout the period of supervised practice to allow for observation of improvements in performance, and an SPO should be scheduled for each category of prescription chosen for the dispensing log activity. It is not intended that SPOs be carried out in clusters or close together in time, but regularly spaced and scheduled at times when an intern is considered to have improved since a previous SPO. At the end of each SPO, an entrustment discussion (see below) should occur between the intern and the observers.
The entrustment discussion is intended to provide additional evidence to support (or not) a decision that an intern can be entrusted to perform the EPA with greater autonomy, that is less supervision. Using the four-step framework, the preceptor should require the intern to:
Ad hoc entrustment discussions can be held at any stage of the intern year and should form part of the overall evidence on which a summative entrustment decision is based. An ad hoc entrustment decision should form part of any formal SPO, and the outcomes recorded (a template is provided). The aim should be to give the intern a clear idea of where performance has been strong and where further improvement is necessary.
When either the intern or preceptor considers that the intern may be ready for assessment, a summative entrustment discussion may be held. At this discussion, evidence from previous activities, feedback and discussions should be reviewed, and the preceptor should ask additional questions until such time as a decision in favour of entrustment to perform the activity with greater autonomy (decreasing supervision) can be justified.
For level 4 entrustment, following a summative entrustment discussion, and based on available evidence, the preceptor will need to answer the questions:
If the answers to both questions are YES, a level 4 entrustment decision may be appropriate. It is critical to note, however, that even when an intern has been deemed entrustable at level 4, the Pharmacy Board requirements for supervision while the intern is provisionally registered still apply. In addition, at least one pharmacist with general registration must be physically present on the premises in accordance with legal requirements under the Health Practitioner Regulation National Law.
From a practical perspective, within the individual workplace, supervisors may identify that an intern is entrustable at level 4 but should still ensure that their work is adequately checked. This may entail allowing the intern to carry out the activity independently but putting measures in place to require an independent verification of accuracy and appropriateness. As an example, an intern may carry out the dispensing process (EPA 1) with little supervision, but a final check is carried out by a generally registered pharmacist before supplying to the patient. Supervisors will need to balance the level of supervision that is required by the intern with the professional responsibility of the supervisor to ensure accountability and patient safety.
As part of the final submission by preceptors to ITP providers at the end of the supervised practice period, ITP providers should consider including a declaration by the preceptor as to the level of entrustment given to the intern for this EPA at the time of the final declaration.