Download Continuing Education Details - Ohio Society of Health

CONTINUING EDUCATION DETAILS
Monday, May 1, 2017
Breakdown on Biosimilars (60 minutes)
Mandy Leonard, PharmD, BCPS; System Director, Drug Use Policy and Formulary Management;
Cleveland Clinic
UAN: 0048-0000-17-008-L01-P/T
Pharmacist Learning Objectives:
– Define biosimilar drugs and the Food and Drug Administration (FDA) approval process.
– Explain regulatory issues related to biosimilars.
– Describe a formulary review process for biosimilars and formulary implementation strategies.
– Outline the financial impact of biosimilars.
Technician Learning Objectives:
– Define biosimilar drugs and the Food and Drug Administration (FDA) approval process.
– Explain regulatory issues related to biosimilars.
– Outline the financial impact of biosimilars.
Pharmacists’ Role in Population Health (30 minutes)
Rachel Chandra, PharmD; Residency Program Director; Dayton VA Medical Center
UAN: 0048-0000-17-009-L04-P/T
Pharmacist Learning Objectives:
– Discuss social determinates of health.
– Describe tools to improve population health.
Technician Learning Objectives:
– Discuss social determinates of health.
– Describe tools to improve population health.
Safety in the Era of New Diabetes Medications (60 minutes)
Diana Isaacs, PharmD, BCPS, BC-ADM, CDE; Clinical Pharmacy Specialist; Cleveland Clinic
UAN: 0048-0000-17-010-L05-P/T
Pharmacist Learning Objectives:
– Describe FDA alerts and safety updates for diabetes medications.
– Discuss cardiovascular outcomes data for diabetes medications.
– Recommend medications based on overall safety and cardiovascular risk in specific patient
populations with diabetes.
Technician Learning Objectives:
– Describe FDA alerts and safety updates for diabetes medications.
– List clinical trials reporting on cardiovascular outcomes data for diabetes medications.
Inappropriate Medication Use in the Elderly (60 minutes)
Amanda Ilenin, PharmD; Pharmacist; Dublin Methodist Hospital
Kristian Navickas, PharmD; Pharmacist; McConnell Clinic and Lab
Erica Wibberley, PharmD; Residency Program Coordinator; Marion General Hospital
UAN: 0048-0000-17-011-L05-P/T
Pharmacist Learning Objectives:
Explain physiologic changes related to medication use that occur in older adults.
Identify potentially inappropriate medication (PIM) for older adults.
– Describe the risks of using specific PIM in older adults.
– Recommend non-pharmacological and pharmacological alternatives for older adults.
Technician Learning Objectives:
– Identify potentially inappropriate medication (PIM) for older adults.
– Describe the risks of using specific PIM in older adults.
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Team Dynamics: Navigating Change and Staff Communication (60 minutes)
Sam Calabrese, BSPharm, MBA, FASHP; Associate Chief Pharmacy Officer; Cleveland Clinic
UAN: 0048-0000-17-012-L04-P/T
Pharmacist Learning Objectives:
– Describe the change management process.
– Identify strategies to manage change and transitions.
– Describe methods to maintain employee engagement during change.
Technician Learning Objectives:
– Describe the change management process.
– Identify strategies to manage change and transitions.
– Describe methods to maintain employee engagement during change.
Hypertension Controversies: SPRINTing to New Goals (60 minutes)
Diana Isaacs, PharmD, BCPS, BC-ADM, CDE; Clinical Pharmacy Specialist; Cleveland Clinic
Lauren Wolfe, PharmD; Ambulatory Care Clinical Specialist; Cleveland Clinic
UAN: 0048-0000-17-013-L01-P
Pharmacist Learning Objectives:
– Compare and contrast published guidelines for the treatment of patients with hypertension.
– Evaluate the literature utilized to determine guideline recommendations.
– Discuss the implications of the SPRINT trial in establishing blood pressure goals for different patient
populations.
– Design a patient centered therapy plan based on published guidelines and clinical trials
Institutional Medication Dispensing Categories: Medication Waste and Cost Savings Analysis (30
minutes)
Paige Garber, PharmD; PGY2 Critical Care Pharmacy Resident; UC Health - UC Medical Center
Katie McKinney, PharmD, MS, BCPS; Director of Pharmacy Services; UC Health - UC Medical Center
UAN: 0048-0000-17-014-L04-P/T
Pharmacist Learning Objectives:
– Review departmental medication dispensing category protocol development, implementation, and
ongoing quality improvement.
– Analyze medication waste and cost savings trends before and after protocol implementation.
– Discuss high cost medication dispensing categories and contribution to departmental medication
waste and cost savings.
Technician Learning Objectives:
– Discuss pharmacy technician work responsibilities for continual protocol implementation.
Applying Continuous Improvement Principles to Pharmacy Practice (30 minutes)Matthew J. Hoover,
PharmD, MS, BCCCP; Pharmacy Manager; Cleveland Clinic Marymount Hospital
Jacob Zapolnik, MBA, LSSBB; Continuous Improvement Program Director; Cleveland Clinic Marymount
Hospital
UAN: 0048-0000-17-015-L04-P/T
Pharmacist Learning Objectives:
– Define the Cleveland Clinic Improvement Model (CCIM) and continuous improvement principles.
– Explain how continuous improvement can be incorporated into pharmacy practice.
– Describe successful application of the CCIM to pharmacy practice.
Technician Learning Objectives:
– Define the Cleveland Clinic Improvement Model (CCIM) and continuous improvement principles.
– Explain how continuous improvement can be incorporated into pharmacy practice.
– Describe successful application of the CCIM to pharmacy practice.
Emergent Reversal of Novel Oral Anticoagulants (30 minutes)
Alexis Luckey, PharmD, BCPS; Pharmacy Clinical Specialist, Critical Care; Cleveland Clinic Euclid Hospital
UAN: 0048-0000-17-016-L01-P/T
Pharmacist Learning Objectives:
– Describe characteristics of novel oral anticoagulants (NOACs).
– Interpret the NOACs effect on coagulation assays.
– Discuss the pharmacologic reversal of NOACs during life-threatening bleeding.
– Discuss the NOAC antidotes in the pipeline.
Technician Learning Objectives:
– Discuss the role of pharmacologic reversal of NOACs in management of patients with lifethreatening bleeding.
Expanding Critical Care Practice: An After-action Review (30 minutes)
Amanda Hansen, PharmD, MHA, FACHE; Assistant Director of Pharmacy; Cleveland Clinic
UAN: 0048-0000-17-017-L04-P/T
Pharmacist Learning Objectives:
– Describe the critical care practice model.
– Conduct an after action review.
Technician Learning Objectives:
– Review global care needs for critical care patients.
Updates in Chronic Obstructive Pulmonary Disease Maintenance Therapy (30 minutes)
Sarah Petite, PharmD, BCPS; Assistant Professor of Pharmacy Practice; University of Toledo
UAN: 0048-0000-17-018-L01-P
Pharmacist Learning Objectives:
– Review current guideline recommendations for chronic obstructive pulmonary disease (COPD)
management.
– Analyze current literature evaluating various bronchodilator treatment options for COPD.
– Apply literature to specific COPD patient cases in clinical practice.
Leadership Essentials: Utilizing Productivity Metrics to Optimize Outcomes (30 minutes)
Jonathan Williams, PharmD; Assistant Director; Cleveland Clinic
UAN: 0048-0000-17-019-L04-P/T
Pharmacist Learning Objectives:
Review the differences between internal and external benchmarking.
Describe the measurement tools for pharmacist activity.
– Discuss methods to increase the consistency and validity of pharmacist documentation in relation
to productivity.
Technician Learning Objectives:
– Review metrics associated with technical performance.
– Describe the pros and cost of different unit of service measurements.
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Tuesday, May 2, 2017
USP 797 Compliance: Common Challenges and Potential Solutions (60 minutes)
Adam W. Heiermann, PharmD; PGY1 Health-System Pharmacy Administration Resident; Cleveland Clinic
Angela Yaniv, PharmD; Assistant Director of Sterile Products; Cleveland Clinic
UAN: 0048-0000-17-020-L03-P/T
Pharmacist Learning Objectives:
– Review USP 797 requirements for sterile compounding.
– Discuss common challenges in maintaining USP 797 compliance.
– Describe strategies to maintain and improve compliance with USP 797.
Technician Learning Objectives:
– Review USP 797 requirements for sterile compounding.
– Discuss common challenges in maintaining USP 797 compliance.
– Describe strategies to maintain and improve compliance with USP 797.
Ohio Medical Marijuana: A Multidisciplinary Perspective (60 minutes)
David Boyer, RPh; retired
Jill Beavers-Kirby, CNP, RN; Coordinator, Nurse Practitioner Programs; Mount Carmel College of Nursing
Marty Herf, JD; President and CEO; Drug-Free Solutions LLC
Michael Stanek; Vice President; Hunt Imaging LLC
UAN: 0048-0000-17-021-L01-P/T
Pharmacist Learning Objectives:
– Describe the action of marijuana in the endocannabinoid system and the subsequent therapeutic
effects.
– Discuss the current status of the rules and regulations governing the implementation of Ohio's
medical marijuana law.
– Explain the decision-making process a prescriber might go through before recommending medical
marijuana.
– Recognize workplace issues related to the use of medical marijuana on and off the job.
Technician Learning Objectives:
– Discuss the current status of the rules and regulations governing the implementation of Ohio's
medical marijuana law.
– Explain the decision-making process a prescriber might go through before recommending medical
marijuana.
– Recognize workplace issues related to the use of medical marijuana on and off the job.
USP 800: a Practical Approach to Compliance (90 minutes)
Ryan Naseman, PharmD, MS, BCPS; Assistant Director; The OSU Wexner Medical CenterMichael Storey,
PharmD, MS, BCPS; Pharmacy Manager, Inpatient Medicine; Nationwide Children's Hospital
UAN: 0048-0000-17-022-L03-P/T
Pharmacist Learning Objectives:
– Explain the need for USP 800 from an Employee Safety standpoint.
– Describe facility needs to comply with USP 800.
– Apply practice changes needed to be compliant with handling provisions of the chapter.
– Adapt the intent of the chapter to your practice setting.
Technician Learning Objectives:
– Apply practice changes needed to be compliant with handling provisions of the chapter.
– Describe facility needs to comply with USP 800.
– Apply practice changes needed to be compliant with handling provisions of the chapter.
– Adapt the intent of the chapter to your practice setting.
The Impact of a Pharmacist-managed Culture Review for Discharged ED Patients (30 minutes)
Tracey King, PharmD, MSP, BCPS; Lead Clinical Pharmacist - Emergency Medicine; Riverside Methodist
Hospital
Amy Durell, PharmD, BCPS; Clinical Pharmacist; Riverside Methodist Hospital
UAN: 0048-0000-17-023-L04-P/T
Pharmacist Learning Objectives:
– List the various responsibilities of the emergency medicine pharmacist.
– Describe the role of an emergency medicine pharmacist in managing a culture review process.
– Examine the utility of an emergency medicine pharmacist in managing the culture review process.
– Discuss the future impact of pharmacist managed culture reviews.
Technician Learning Objectives:
– Discuss the future impact of pharmacist managed culture reviews.
Optimizing the Flywheel: Funding Ambulatory Practices through a Concierge Specialty Pharmacy
Service (30 minutes)
Russell Smith, PharmD, MBA, BCPS; Director of Pharmacy; University of Toledo Medical Center
Amal Abdoney, CPhT, MPH; Transition of Care Certified Pharmacy Technician; University of Toledo
Medical Center
Cindy Puffer, RPh; Managed Care Pharmacy Operations Manager; University of Toledo Medical Center
UAN: 0048-0000-17-024-L04-P/T
Pharmacist Learning Objectives:
– Creating a business model for a concierge specialty pharmacy service.
– Discuss the role of the pharmacists.
– Discuss the barriers to a successful program.
Technician Learning Objectives:
– Discuss the financial benefits of creating a concierge specialty pharmacy service.
– Discuss the roles of technicians in a concierge specialty pharmacy service.
– Discuss the barriers to a successful program.
What to Wear? Hospital Evaluation and Operations for Hazardous Drug Handling (30 minutes)
Bridget Gegorski, PharmD; Medication Safety Officer; University Hospitals of Cleveland
Indrani Kar, PharmD; Drug Policy/Formulary Specialist; University Hospitals of Cleveland
UAN: 0048-0000-17-025-L04-P/T
Pharmacist Learning Objectives:
– Formulate an institution-specific comprehensive hazardous drug list.
– Identify methods to provide hazardous drug handling guidance to front line staff for operations.
– Illustrate the need for multidisciplinary engagement in creating policy.
Technician Learning Objectives:
– Formulate an institution-specific comprehensive hazardous drug list.
– Identify methods to provide hazardous drug handling guidance to front line staff for operations.
– Illustrate the need for multidisciplinary engagement in creating policy.
Meeting the New Antimicrobial Stewardship Standard (30 minutes)
Brittany N. Bates, PharmD, BCPS; Clinical Pharmacist; Lima Memorial Hospital
UAN: 0048-0000-17-026-L04-P
Pharmacist Learning Objectives:
– Review the Joint Commission Antimicrobial Stewardship Standard.
– Provide examples of how to meet the standard with limited resources.
Reaching the Homebound: Strategies for Pharmacist Interventions in Post-acute Care (30 minutes)
Eileen Hendrickson, RPh, PharmD, MBA; Director of Pharmacy; Cleveland Clinic Home Care Services
UAN: 0048-0000-17-027-L04-P/T
Pharmacist Learning Objectives:
– Describe pharmacist roles in post-acute care.
– Identify opportunities to utilize technology to reach home bound patients.
– Evaluate the value of pharmacist services in post-acute care.
Technician Learning Objectives:
– Describe opportunities for pharmacy technicians in post-acute care.
Assessing and Reducing Readmissions Associated with Outpatient Parenteral Antimicrobial Therapy
(30 minutes)
Elizabeth Stacy, PharmD; PGY2 Internal Medicine Pharmacy Resident; UC Health - UC Medical Center
UAN: 0048-0000-17-028-L04-P/T
Pharmacist Learning Objectives:
– Explain literature supporting outpatient parenteral antimicrobial therapy (OPAT) and
recommendations for best practices.
– Review outcomes of patients in an OPAT discharge program at an academic medical center.
– Identify process improvement strategies to reduce OPAT-related readmissions.
Technician Learning Objectives:
– Discuss adverse effects that may be associated with OPAT readmission (see PTCE Blueprint 1.5).
Bridging the Generation Gap: Teaching and Learning across Generations (30 minutes)
Ashley Ramp, PharmD, MEd; Pharmacy Resident; Cleveland Clinic
UAN: 0048-0000-17-029-L04-P/T
Pharmacist Learning Objectives:
– Define the four different generations in the workplace in 2016.
– Summarize the differences and similarities while evaluating the motivations and hurdles to each of
the four generations in the workplace today.
– Interpret different scenarios and individual reactions within the construct described in #1-2.
– Effectively evaluate and support coworkers and employees across all generations.
Technician Learning Objectives:
– Define the 4 different generations in the workplace in 2016.
– Summarize the differences and similarities while evaluating the motivations and hurdles to each of
the four generations in the workplace today.
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Interpret different scenarios and individual reactions within the construct described in #1-2.
Effectively evaluate and support coworkers and employees across all generations.
Developing a Process to Communicate Medication Inventory Needs across a Health-system (30
minutes)
Jason Milner, PharmD; System Director of Pharmacy Integration; Cleveland Clinic
Matthew J. Hoover, PharmD, MS, BCCCP; Pharmacy Manager; Cleveland Clinic Marymount Hospital
UAN: 0048-0000-17-030-L04-P/T
Pharmacist Learning Objectives:
– Describe medication inventory needs across a health system.
– Identify operational and regulatory barriers to moving medication inventory across a health
system.
– List ways to evaluate successful medication inventory movement across a health system.
Technician Learning Objectives:
– Describe medication inventory needs across a health system.
– Identify operational and regulatory barriers to moving medication inventory across a health
system.
– List ways to evaluate successful medication inventory movement across a health system.
Hedging the Opioid Epidemic: Ketamine for Acute Pain (30 minutes)
Caitlin Pfaff, PharmD, BCPS; Emergency Medicine Clinical Pharmacy Specialist; UC Health - West Chester
Hospital
Rachel Wilde, PharmD; PGY1 Pharmacy Resident; UC Health - West Chester Hospital
UAN: 0048-0000-17-031-L04-P/T
Pharmacist Learning Objectives:
– Describe local and national trends in opioid use and abuse.
– Review ketamine pharmacology and pharmacokinetics.
– Identify dosing strategies for ketamine in acute pain.
– Review results of a community hospital experience with low-dose ketamine for acute pain.
Technician Learning Objectives:
– Describe local and national trends in opioid use and abuse.
– Review results of a community hospital experience with low-dose ketamine for acute pain.
Rotation Revamp: Advancing Pharmacy Practice Experiences (60 minutes)
Laura J. Nice, BS, PharmD Candidate; Student Pharmacist; Northeast Ohio Medical University
Jennifer M. Toth,BS, BA, PharmD Candidate; Student Pharmacist; Northeast Ohio Medical University
Tyler A. Vest, PharmD; PGY1 Pharmacy Resident; University of North Carolina Medical Center
Dale English, PharmD, FASHP; Associate Dean of Student Affairs; Sullivan University
UAN: 0048-0000-17-032-L04-P/T
Pharmacist Learning Objectives:
– Describe student pharmacist involvement in Practice Advancement Initiative (PAI) and how this can
be applied to IPPE/APPE rotations.
– Illustrate activities students can engage in on rotation that would be beneficial to student
pharmacists, preceptors, and experiential sites.
– Explain processes for implementation of IPPE/APPE rotation objectives that align with PAI that are
beneficial to student pharmacists, preceptors.
– Provide an outline for goals and objectives that allow for meaningful experiential education
experiences that advance PAI.
Technician Learning Objectives:
– Describe the role of the pharmacy technician in experiential education.
– Explain the benefits in actively engaging pharmacy technicians in experiential education.
Diversion Monitoring and Non-controlled Medications (30 minutes)
Tyler O. Tomasek, PharmD, BCPS; Interim Pharmacy Manager; Cleveland Clinic South Pointe Hospital
Brett L. Rodgers, BA, CPhT; Pharmacy Department Analyst; Cleveland Clinic Marymount Hospital
UAN: 0048-0000-17-033-L04-P/T
Pharmacist Learning Objectives:
– Describe common methods used to monitor for drug diversion.
– Discuss challenges associated with identifying non-controlled drug diversion.
– Revise current monitoring practices to include surveillance of non-controlled medications at-risk for
diversion.
Technician Learning Objectives:
– Describe common methods used to monitor for drug diversion.
– Discuss challenges associated with identifying non-controlled drug diversion.
Contingency Planning: What is Your Nightmare? (30 minutes)
Elizabeth Dallman, PharmD; PGY1 Health-System Pharmacy Administration Resident; OhioHealth
Riverside Methodist Hospital
Kellie L. Evans, PharmD; PGY2 Health-System Pharmacy Administration Resident; OhioHealth Grant
Medical Center
Harrison Jozefczyk, PharmD; PGY1 Health-System Pharmacy Administration Resident; OhioHealth Grant
Medical Center
Maggie K. Sherry, PharmD; PGY2 Health-System Pharmacy Administration Resident; OhioHealth
Riverside Methodist Hospital
Nicholas L. Manion, PharmD; PGY2 Health-System Pharmacy Administration Resident; OhioHealth
Riverside Methodist Hospital
UAN: 0048-0000-17-034-L04-P/T
Pharmacist Learning Objectives:
– Define contingency planning and its importance to an organization.
– Describe the process used to identify, assess, and prioritize the pharmacy service line areas of risk
at OhioHealth.
– Explain lessons learned through this project that could be applied to other facilities.
Technician Learning Objectives:
– Define contingency planning and its importance to an organization.
– Describe the process used to identify, assess, and prioritize the pharmacy service line areas of risk
at OhioHealth.
– Explain lessons learned through this project that could be applied to other facilities.
A High-pressure Situation: Decompressing the Evidence Regarding Management of Traumatic Brain
Injury (60 minutes)
Dan James, PharmD; PGY1 Pharmacy Resident; OhioHealth Grant Medical Center
Taylor Roberson, PharmD; PGY2 Emergency Medicine Pharmacy Resident; OhioHealth Grant Medical
Center
Daniel Dybdahl, PharmD; PGY1 Pharmacy Resident; OhioHealth Grant Medical Center
UAN: 0048-0000-17-035-L01-P
Pharmacist Learning Objectives:
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Describe the pathophysiology of traumatic brain injury (TBI) in relation to its resulting
complications.
Evaluate common agents used for appropriately managing severe TBI in adults.
Discuss the current evidence regarding treatment modalities surrounding severe TBI.
Review the TBI pharmacotherapy recommendations as outlined in the 2016 Brain Trauma
Foundation guidelines and 2015 ACS TQIP guidelines.
There Is No “I” in Preceptors: a Team-based Student Precepting Approach (30 minutes)
Abbi Smith, PharmD, BCPS; Pharmacy Manager; Cleveland Clinic Euclid Hospital
UAN: 0048-0000-17-036-L04-P/T
Pharmacist Learning Objectives:
– Evaluate how a team-based approach to precepting can quickly give new preceptors added skills
and confidence in precepting.
Technician Learning Objectives:
– Assess how a team-based approach to precepting can also be applied to technician students, and
be beneficial for pharmacy team engagement.
More BUCK for your BANG! How Value-Based Purchasing and HCAHPS Affects Hospital Repayment (30
minutes)
Adam Ingram, PharmD; PGY1 Pharmacy Resident; MetroHealth Medical Center
Katie McKinney, PharmD, MS, BCPS; Director of Pharmacy Services; UC Health - UC Medical Center
UAN: 0048-0000-17-037-L04-P/T
Pharmacist Learning Objectives:
– Compare the current structure of Medicare reimbursement to historical reimbursement models.
– Describe the concept of performance based redistribution.
– Interpret scores from HCAHPS reports.
– Summarize the time-line for performance standards and incentive payment redistribution.
Technician Learning Objectives:
– Compare the current structure of Medicare reimbursement to historical reimbursement models.
– Describe the concept of performance based redistribution.
– Interpret scores from HCAHPS reports.
– Summarize the time-line for performance standards and incentive payment redistribution.
Initiation of Pharmacy Virtual Visits for Heart Failure Mediation Education Follow-up Post Discharge
(30 minutes)
Daniel Lewis, PharmD, BCPS; Pharmacy Manager; Cleveland Clinic
Ramone Boyd, PharmD; Lead Pharmacist; Cleveland Clinic
UAN: 0048-0000-17-038-L01-P/T
Pharmacist Learning Objectives:
– Describe Pharmacy Telehealth/virtual visits.
– Explain patient population selection.
– Show workflow process.
– Summarize the current state of program.
Technician Learning Objectives:
– Describe pharmacy technician role in medication histories as related to assisting with Virtual Visits.
– Discuss opportunities for technicians in future state assisting with patients who have medication
access challenges.
Improving Community Health with Increasing Vaccination Rates: it’s Worth a Shot! (30 minutes)
Christine Bosler Walton, PharmD; PGY1 Pharmacy Resident; OhioHealth Doctors Hospital
Megan Keller, PharmD, BCACP, CDE; Director, Clinical Pharmacy Services; OhioHealth Doctors Hospital
Family Practice
UAN: 0048-0000-17-039-L01-P/T
Pharmacist Learning Objectives:
– Illustrate application of vaccine tracking into workflow.
– Summarize state vaccine tracker program.
– Recommend appropriate therapy based upon clinic chart review.
Technician Learning Objectives:
– Summarize state vaccine tracker program.
– Identify appropriate vaccine product.
– Recall appropriate vaccine storage and preparation.
An Update and Review of Ohio Pharmacy Laws and Rules (60 minutes)
Sheri Ann Zapadka, RPh, Compliance Specialist, State of Ohio Board of Pharmacy
UAN: 0048-0000-17-040-L03-P/T
Pharmacist Learning Objectives:
– Discuss pending legislative initiatives and their impact on pharmacy practice.
– Review recent changes to Ohio laws and rules and their impact on institutional care.
– Analyze pharmacy consult agreement rules and their impact on pharmacy practice.
– Identify common gaps observed in institutional compounding.
– Illustrate appropriate methods for drug destruction and record keeping.
– Evaluate office practices for personally furnished dangerous drugs.
– Examine methods to identify diversion in the health care setting.
Technician Learning Objectives:
– Discuss pending legislative initiatives and their impact on pharmacy practice.
– Review recent changes to Ohio laws and rules and their impact on institutional care.
– Analyze pharmacy consult agreement rules and their impact on pharmacy practice.
– Identify common gaps observed in institutional compounding.
– Illustrate appropriate methods for drug destruction and record keeping.
– Evaluate office practices for personally furnished dangerous drugs.
– Examine methods to identify diversion in the health care setting.