Sample Stations - Part II (OSCE)
Format of Examination Stations - Part II (OSCE)
The Qualifying Examination - Part II consists of both interactive and non-interactive stations.
Each station will require that you complete one or more short tasks such as:
• counselling or responding to questions from a “Standardized Patient” or Standardized Client
• interacting with a “Standardized Patient” or “Standardized Client” or “Standardized Health Professional” to resolve a drug-related problem or ethical dilemma
• responding in writing to a message or request for information/advice
• screening / evaluating new prescriptions
• checking dispensed prescriptions for accuracy prior to their release
You may be required to select and justify the best therapeutic option available. For example, in a situation involving a patient’s request for assistance in selecting an appropriate nonprescription remedy for symptomatic relief, limited products will be displayed and there will be one or more appropriate and inappropriate options. Even if you believe there is a better option than those provided, you must choose the most appropriate option(s) from those available.
In any situation, you are expected to use your professional and/or ethical judgement, and act in the best interests of the patient, in order to provide good patient care. In most instances, you are required to assist the client while the client is present in the station, NOT simply refer the client to another health professional nor indicate that you will call them back later with your response.
Five station examples, which are representative of the formats for three interactive stations and two non-interactive stations, are found below.
References in Stations - Part II (OSCE)
The most current edition of the following references, or excerpts thereof, may be provided in some of the stations:
Compendium of Pharmaceuticals and Specialties (CPS), Canadian Pharmacists Association (most current or second most current edition).
Patient Self-Care (PSC), Canadian Pharmacists Association.
Herbs Everyday Reference for Health Professionals, ed. by Chandler, Canadian Pharmacists Association
Therapeutic Choices, ed. by Gray, Canadian Pharmacists Association (most current or second most current edition).
USP Dispensing Information (USP-DI):Vol. 1- Drug Information for the Health care
Professional or Vol. 2 -Advice for the Patient, Thomson Micromedex .
Handbook of Clinical Drug Data, ed. by Anderson, Knoben and Troutman, McGraw-Hill Medical.
Natural Medicines Comprehensive Database, text or website:
www.NaturalDatabase.com
Drugs in Pregnancy and Lactation, by Briggs et al, Lippincott Williams and Wilkins.
Health Canada publications
Other professional references, where appropriate.
| Reminder:
Part II (OSCE) examination is “open book”, but candidates may only use the references which are provided in the stations.
Candidates should become familiar with these (listed) references in order to use them efficiently, if provided.
Some of the written prescriptions or patient records provided in some stations may have only the drug’s trade name or generic name. (Note that trade and generic drug names are cross-referenced in the green page section near the front of the CPS.) |
Interactive Station (with a Standardized Patient) – involving a prescription medication
Video of Sample Station #1
For High-Speed Users For Modem Users
TITLE
Cancer Pain Control
OBJECTIVE
To communicate with and counsel an elderly patient on a new prescription for pain control. To recognize and address the patient’s concerns regarding pain medications
COMPETENCIES TESTED
Competency 1 Patient Care
|
Elements
|
1.1
|
Develop a trusting professional relationship with the patient. |
|
1.2 |
Gather patient information. |
|
1.3 |
Assess the health status and concerns of the patient. |
|
1.4 |
Identify the patient’s desired therapeutic outcomes. |
|
1.5 |
Identify and prioritize actual and potential drug therapy problems. |
|
1.6 |
Develop a therapeutic plan. |
|
1.7 |
Support the implementation of a therapeutic plan. |
|
1.8 |
Monitor the patient’s progress and assess therapeutic outcomes. |
Competency 5 Communication and Education
|
Element
|
5.1
|
Demonstrate effective communication skills. |
CANDIDATE’S INSTRUCTIONS:
A cancer patient who has been taking morphine sustained release tablets is experiencing increasing pain. He is now being started on morphine oral solution and has some questions and concerns about using it. Please assist him when he asks you for advice.
Time Frame: You have 7 minutes to complete this station.
Client: Standardized Patient – Ted Wheaton, male, ambulatory, approximately 70 years old.
Patient Background, Behaviour, Affect and/or Mannerisms:
An elderly patient who has been taking long-acting morphine tablets for cancer pain was recently prescribed morphine liquid for breakthrough pain. The patient is hesitant to take the morphine liquid because when he first started taking morphine tablets he was constipated and fatigued. He is seeking the pharmacist’s advice.
When he goes to see the pharmacist (candidate) to ask for more information, he is in obvious discomfort (moving slowly and carefully) and appears somewhat anxious.
Patient Record (Profile) Information:
Patient Name: Ted Wheaton
Gender: Male
Age: 70 years old
Allergies: None known
Medical History: Prostate cancer, diagnosed 3 years ago
Medications: Sustained release morphine sulfate tablets (MS Contin) 30 mg q 12 h (prescribed 2 months ago)
Morphine oral solution 1 mg/mL, 5 mL q 4-6 h prn pain (new prescription filled yesterday)
Patient’s Opening Statement:
“Hello, I just got this new prescription for morphine liquid yesterday. I am uncertain about how to use it along with my morphine pills, and what it will do to me if I take both of them. Would you explain to me how I should take it and anything else that I should know about it?”
Other Information (patient gives this information to candidate upon request):
Social / Lifestyle:
• Non-smoker
• Moderate alcohol intake - a beer or glass of wine once or twice a week
• Lives alone in an assisted-living complex, with family support
Symptoms:
• Over the past two weeks he has experienced pain between doses of MS Contin
• Has more pain in the early evening (pain starts before the evening dose around 5:30-6 pm) and at night
• Pain often limits his ability to take his evening walks
• Has trouble sleeping because of the pain
Other:
• Has never used morphine oral solution (or any liquid medication).
• Did not start taking the liquid yesterday because he was concerned about how to take it along with the pills.
• Has a dosing cup at home for the liquid.
• Takes MS Contin 30 mg each morning and evening, and Tylenol Extra Strength in between if needed.
• Tried Tylenol extra strength (1 tablet twice daily a couple of times), but it did not help.
• Cannot remember if the doctor said anything about taking or not taking the Tylenol.
• Has occasional constipation, but not as much as when he first started taking morphine tablets. He did not know what to take for the constipation and was more concerned about taking care of the pain.
• Does not take any other medications.
STANDARDIZED PATIENT INSTRUCTIONS:
If not told by the candidate, the Standardized Patient must ask:
“Should I stop using my morphine pills and just use the liquid regularly?”
“I’m just wondering how much I could take before I go to bed?”
“Will it make me groggy (like the morphine pills did)?” OR “Will I have it with this too?” (grogginess)
By the 5-minute mark, if the candidate has not reassured the SP of the safety or benefit of taking both tablets and liquid, the SP must say:
“I’m uncertain about what it will do to me if I take both of them together.”
ASSESSOR INFORMATION (to guide scoring of candidate’s performance):
Problem Solved (full solution) if candidate:
• Explains to continue taking morphine tablets AND to take liquid morphine when pain recurs (i.e., do not stop taking morphine tablets).
• Explains dosing of the morphine liquid, including a bedtime dose.
• Explains that the patient may initially experience more drowsiness (while taking both tablets and liquid) and that it will lessen.
Solved/Marginal (partial solution) if candidate:
• Explains that both medications should be taken OR to not stop taking morphine tablets, but less thoroughly.
• Explains dosing of morphine liquid, but does not mention a bedtime dose.
• Explains that patient may experience more drowsiness (while taking both tablets and liquid), but does NOT indicate that it will lessen.
Uncertain if candidate:
• Explains to patient that both medications should be taken OR to not stop taking morphine tablets.
• Explains dosing of the morphine liquid.
• Explains that the patient may experience more drowsiness (while taking both tablets and liquid), NOT BOTH.
Unsolved if candidate:
• Suggests taking either liquid or tablets, NOT both OR suggests stopping liquid morphine OR suggests it is unsafe to take both.
• Provides incorrect dosing information (resulting in treatment failure or danger to patient).
STATION MATERIALS AND REFERENCES:
Patient Record (Profile): information as on previous page
Reference: CPS
CHECKLIST (expected candidate responses)
1. Confirms that patient takes long-acting morphine twice daily.
2. Determines that patient is experiencing pain between doses of long-acting morphine.
3. Explains that MS Contin is a long-acting pain killer and morphine liquid is short-acting/used for breakthrough pain.
4. Explains that both medications should be taken (i.e., do not stop taking morphine tablets).
5. Explains dosing of morphine liquid:
▫ 5 mL every 4 to 6 hours if needed for pain
▫ 5 mL before bedtime (to help control pain overnight)
6.Suggests talking to doctor if liquid morphine is needed often/if pain not controlled.
7. Asks about side effects (e.g., drowsiness, constipation).
8. Explains that:
▫ the added (liquid) morphine may cause more drowsiness
▫ drowsiness will lessen (as the body gets used to the added morphine)
9. Recommends measures to alleviate constipation: laxative or non-drug measures, e.g., increased fibre and fluid intake.
10. Determines that the patient tried Tylenol.
11. Explains/confirms appropriate use of Tylenol.
12. Explains (unsolved responses):
▫ to take either tablets OR liquid, NOT both
▫ to stop/not take liquid morphine
▫ that it is unsafe to take both
13.Explains incorrect dosing of liquid morphine (e.g., take regularly or take if Tylenol doesn’t work/delayed use of liquid morphine). (unsolved responses)
SCORES (to be based on standard scoring guidelines and Assessor Information above):
Communications
4=Acceptable
3=Acceptable/Marginal
2=Unacceptable/Marginal
1=Unacceptable |
Outcome
4=Problem Solved
3=Solved/Marginal
2=Uncertain
1=Unsolved |
Performance
4=Acceptable
3=Acceptable/Marginal
2=Unacceptable/Marginal
1=Unacceptable
Misinformation
Yes No
Risk to Patient
Yes No
|
Sample Station #2
Interactive Station (with a Standardized Patient) – involving a nonprescription medication
Video of Sample Station #2
For High-Speed Users For Modem Users
TITLE
Travellers' Diarrhea
OBJECTIVE
To interview a patient seeking assistance in selecting an appropriate nonprescription medication, to gather appropriate information, to assess the patient’s needs and to recommend appropriate drug therapy and preventive non-drug measures.
COMPETENCIES TESTED
Competency 1 Practise Pharmaceutical Care
|
Elements
|
1.1
|
Develop a trusting professional relationship with the patient. |
|
1.2 |
Gather patient information. |
|
1.4 |
Identify the patient’s desired therapeutic outcomes. |
|
1.5 |
Identify and prioritize actual and potential drug therapy problems. |
|
1.6 |
Develop a therapeutic plan. |
|
1.7 |
Support the implementation of the therapeutic plan. |
|
1.8 |
Monitor the patient’s progress and assess therapeutic outcomes. |
Competency 5 Communication and Education
|
Element
|
5.1
|
Demonstrate effective communication skills. |
CANDIDATE'S INSTRUCTIONS:
A patient is coming in to ask your advice regarding “travellers’ diarrhea”. She is leaving tomorrow for a tropical vacation. Respond as you would in practice.
Time Frame: You have 7 minutes to complete this station.
SCENARIO DESCRIPTION
Client: Standardized Patient - Amy Kletchko, female, ambulatory, 22 years old.
Patient Background, Client Behaviour, Affect and/or Mannerisms:
Ms. Kletchko is busy with last minute preparations for a vacation at a coastal resort in Cancun, Mexico where she plans to enjoy the beach and take some tours to the pyramids, as well. The day before leaving she goes to her regular pharmacy to ask about some nonprescription medication to treat “travellers’ diarrhea”, having been advised by her travelling companion, who has been in Mexico before, that there is a high risk of getting it.
When she goes in to see the pharmacist (candidate), she is pleasant, excited, and has confidence in the pharmacist.
Patient's Opening statement:
“Hi, I’m leaving tomorrow morning for a vacation in Mexico. I’d like to take something along in case I get travellers’ diarrhea. My friend gave me a bottle of Pepto Bismol tablets. Would that be a good choice for me?”
Patient Information (there is no patient record – patient gives this information to candidate on request):
Patient Name: Amy Kletchko
Gender: Female
Age: 22 years old
Allergies: Acetylsalicylic acid (ASA, Aspirin) - reaction is hives and shortness of breath
Current Medications: None
Social/Lifestyle:
• non-smoker
• moderate alcohol intake - 3 or 4 alcoholic drinks per week
History:
• Skin burns quite easily when out in the sun.
• Taking Aspirin (ASA) resulted in hives and shortness of breath.
• has a MedicAlert bracelet (for her allergy) - she doesn't always wear it.
STANDARDIZED PATIENT INSTRUCTIONS
If the candidate does not respond to the Standardized Patient’s question about Pepto Bismol (and/or simply recommends something else), the SP must say:
"My friend gave me a bottle of Pepto Bismol to take with me. She just bought it here recently, before she went on a cruise, but she didn’t use it. I was just wondering if it would be okay to use that instead of buying something else."
ASSESSOR INFORMATION (to guide scoring of candidate’s performance)
Problem solved (full solution) if candidate:
• Asks about/confirms history of ASA allergy, including the nature of the reaction
• Recommends appropriate therapy:
▫ do NOT take Pepto Bismol - contains salicylate which may provoke allergic reaction
▫ take Imodium (loperamide) to control travellers' diarrhea
• Recommends appropriate dosage
• Recommends supportive non-drug measures for diarrhea (fluid and/or electrolyte replacement)
• Emphasizes to seek medical treatment immediately for diarrhea accompanied by fever and/or blood in feces
• Recommends preventive measures: use only bottled water for drinking water and making ice; wash with bottled water and/or peel fresh fruit and vegetables; avoid salads - unless in a hotel which follows the same precautions
Solved/Marginal (partial solution) if candidate:
• Confirms/mentions ASA allergy, but does NOT ask about the nature of the reaction
• Recommends appropriate therapy, including:
▫ do NOT take Pepto Bismol - but does NOT explain why
▫ take Imodium (loperamide) to control travellers' diarrhea
• Recommends appropriate dosage
• Does NOT recommend supportive non-drug measures for diarrhea (fluid and/or electrolyte replacement)
• Recommends seeking medical treatment if diarrhea persists or other symptoms occur (non-specific)
• Recommends drinking only bottled water (or soft drinks, etc.), but does NOT advice regarding fresh foods
Uncertain if candidate:
• Does NOT mention allergies OR does NOT relate ASA allergy to Pepto Bismol
• Recommends Imodium (loperamide) for travellers' diarrhea, without cautioning NOT to use Pepto Bismol
• Recommends seeking medical treatment/follow-up if diarrhea persists or other symptoms occur (non-specific)
• Does NOT discuss prevention
Unsolved if candidate:
• Agrees that Pepto Bismol would be appropriate OR
• Does NOT recommend medical treatment/follow-up for persistent/infectious/complicated diarrhea
STATION MATERIALS AND REFERENCES
References:
CPS
Therapeutic Choices
Nonprescription Medications:
Imodium tablets or caplets
Metamucil
Pepto Bismol tablets
Pedialyte 1L and 2L
Gastrolyte
CHECKLIST (expected responses)
1. Confirms/mentions ASA allergy.
2. Determines nature of ASA allergy/reaction.
3. Recommends: Do NOT take Pepto Bismol.
4. Explains: Pepto Bismol contains salicylate (Aspirin-like substance) and may cause an allergic reaction.
5. Recommends appropriate therapy for travellers’ diarrhea.
• Imodium (loperamide).
6. Recommends appropriate dose:
• Imodium: two capsules to start, then one capsule after each loose bowel movement, to a maximum of 8 capsules daily.
7. Recommends immediate medical attention for diarrhea accompanied by any of:
• fever,
• blood in stool,
• persistent vomiting.
8. Discusses prevention of diarrhea:
• use only bottled water for drinking water, making ice, brushing teeth,
• wash fresh fruit and vegetables using bottled water OR peel them before eating,
• avoid salads unless in a hotel which follows these same precautions.
9. Discusses supportive measures for diarrhea:
• if diarrhea lasts several days use Gastrolyte or Pedialyte to maintain electrolyte balance,
• increase fluid intake and avoid dairy products.
10. Suggests wearing a MedicAlert bracelet/tag with ASA allergy information.
SCORES (to be based on standard scoring guidelines and the Assessor Information above):
Communications
4=Acceptable
3=Acceptable/Marginal
2=Unacceptable/Marginal
1=Unacceptable |
Outcome
4=Problem Solved
3=Solved/Marginal
2=Uncertain
1=Unsolved |
Performance
4=Acceptable
3=Acceptable/Marginal
2=Unacceptable/Marginal
1=Unacceptable
Misinformation
Yes No
Risk to Patient
Yes No
|
Sample Station #3
Non-interactive Station – involving screening new prescriptions
TITLE
Screening New Prescriptions
OBJECTIVE
To effectively screen new prescriptions to identify and describe any errors, omissions or concerns.
COMPETENCIES TESTED
Competency 1 Patient Care
|
Element
|
1.5
|
Identify and prioritize actual and potential drug therapy problems. |
Competency 3 Ethical, Legal and Professional Responsibilities
|
Element
|
3.1
|
Apply legal and ethical requirements including federal and provincial/territorial legislation, policies, by-laws and standards. |
CANDIDATE’S INSTRUCTIONS:
1. Before you enter the station:
• Take one Candidate Answer Sheet from the folder marked “For Candidates Only”, on the door or wall outside the station. (Do NOT take anything from any other folder.)
• Attach one bar code label to the Candidate Answer Sheet in the space indicated.
2. When the start buzzer sounds:
• Enter the station and begin immediately.
• Find the CPS and written prescriptions on the desk/table.
3. Do the exercise:
• There are five (5) WRITTEN PRESCRIPTIONS to be assessed. They are taped to the desk/table.
• Some of the written prescriptions have ONE OR MORE problems to be resolved before they can be processed and filled by a pharmacy technician.
For each WRITTEN PRESCRIPTION:
1. Determine if it is ready to be processed and filled by a pharmacy technician.
2. If there is no problem to be resolved before processing or filling the prescription, fill in the bubble beside ”No problem – may be processed and filled as written”.3.If there are any problem(s) that need to be resolved, fill in the bubble beside “Problem(s)” and clearly describe the PROBLEM(S) in the space provided. |
4. When the final buzzer sounds:
• Stop writing immediately.
• Turn your completed Candidate Answer Sheet over (answer side down) on the desk/table, to be collected by examination staff.
• Proceed to the next station, taking your notebook (with bar codes) with you.
Time Frame: You have 7 minutes to complete this station.
Important:
• Do not mark the reference materials or written prescriptions in any way.• Do not write over any bubbles on the Candidate Answer Sheet as it will render the sheet invalid. |
WRITTEN PRESCRIPTIONS (not provided here in full but would show the following problems)
Rx 1 Paroxetine (Paxil) 20mg - mitte: 4 weeks
Answer: Problem.
Description: no dosing information.
Rx 2 Acyclovir (Zovirax) ointment - apply 4-6 times daily to affected area, for shingles; mitte 30 g
Answer: Problem.
Description: inappropriate route of administration.
Rx 3 Diltiazem (Cardizem) 30 mg qid x 1 month for angina
Answer: No problem – may be processed as written.
Rx 4 Amoxicillin (Amoxil) 250 mg, cap i tid x 7 days for Jamie, Celine and Dalia
Answer: Problem.
Description: prescription for more than one person on one order is unacceptable/illegal.
Rx 5 Cefuroxime (Ceftin) - i bid x 7 days
Answer: Problem.
Description: no strength specified.
CANDIDATE ANSWER SHEET FORMAT
| Rx1 |
.Paxil 20mg - mitte: 4 weeks |
| . |
 No problem - may be processed as written
 Problem(s) - describe PROBLEM (S) clearly:
Incomplete dose information
|
SCORING INFORMATION:
Solved Fully if 5/5 correct
Solved Marginally if 3/5 or 4/5 correct
Uncertain if 2/5 correct
Unsolved if 0/5 or 1/5 correct
STATION MATERIALS AND REFERENCES
CPS
Printed prescriptions (five)
Sample Station #4
Non-interactive Station – involving checking dispensed prescriptions
TITLE
Checking Dispensed Prescriptions
OBJECTIVE
To check dispensed medications and identify any corrections that must be made before the medications can be released.
COMPETENCIES TESTED
Competency 6 Drug Distribution
| Elements |
6.1 |
Apply relevant knowledge in the performance of tasks related to drug distribution. |
| o |
6.2 |
Demonstrate the ability to supervise drug distribution. |
Competency 7 Understanding Management Principles
| Element |
7.1 |
Supervise personnel such that delegated functions are carried out to meet accepted standards. |
CANDIDATE’S INSTRUCTIONS:
1. Before you enter the station:
• Take one Candidate Answer Sheet from the folder marked “For Candidates Only”, on the door or wall outside the station. (Do NOT take anything from any other folder.)
• Attach one bar code label to the Candidate Answer Sheet in the space indicated.
2. When the buzzer sounds:
• Enter the station and begin immediately.
• Find the CPS, dispensed medications and corresponding written prescriptions on the desk / table.
3. Do the exercise:
• There are four (4) DISPENSED MEDICATIONS to be assessed. The corresponding written prescriptions are taped to the desk/table.
• Some of the medications have ONE OR MORE problems to be corrected before releasing them to the patients.
For each DISPENSED MEDICATION:
1. Determine if it is ready to be released to a patient.
2. If it is ready to be released, fill in the bubble beside “No correction(s) required – may be released as filled.”
3. If any correction(s) are required, fill in the bubble beside “Correction(s) required” and clearly specify the necessary CORRECTION(S) in the space provided on the answer sheet.
NOTE: If there is a problem, clearly specify the CORRECTION(S), not the problem.
|
4. When the final buzzer sounds:
• Stop writing immediately.
• Turn your completed Candidate Answer Sheet over (answer side down) on the desk/table, to be collected by examination staff.
• Proceed to the next station, taking your notebook (with bar codes) with you.
Time Frame: You have 7 minutes to complete this station.
Important:
• You are not to physically correct any problem. Only record the necessary correction(s) in the space provided on the Candidate Answer Sheet.
• The prescriptions are correctly written and any therapeutic problems have been resolved.
• The omission of auxiliary labels is not to be considered a problem.
• Do not write over any bubbles on the exam paper as it will render the exam sheet invalid.
• Do not mark the product labels, reference materials, or written prescriptions in any way. |
WRITTEN PRESCRIPTIONS (only one example is provided; there will be four prescriptions in total):
Written Rx1
DISPENSED MEDICATIONS (only one example is provided; there will be
four dispensed medications in total):
Dispensed Rx1 Label
CANDIDATE ANSWER SHEET FORMAT:
Sample Answer Format
| Rx1 |
. |
| . |
No corrections required - may be released as filled
Correction(s) required - specify CORRECTION(S) clearly:
Patient name on label should be "Veda Simmonds"
|
NOTE: An answer that states “Wrong patient name" would be incorrect as it does not specify the actual correction. (It only describes the problem.)
SCORING INFORMATION:
Solved Fully if 4/4 correct
Solved Marginally if 3/4 correct
Uncertain if 2/4 correct
Unsolved if 1/4 or 0/4 correct
STATION MATERIALS AND REFERENCES:
CPS
Written prescriptions (four)
Corresponding Dispensed Prescriptions (four)
Stock bottles
Sample Station #5
Interactive Station (with a Standardized Health Professional)
TITLE
Warfarin / Carbamazepine Interaction
OBJECTIVE
To identify and explain a drug/drug interaction problem and recommend an appropriate solution.
COMPETENCIES TESTED
Competency 1 Patient Care
| Elements |
1.5 |
Identify and prioritize actual and potential drug therapy problems. |
| o0 |
1.6 |
Develop a therapeutic plan. |
| o0 |
1.8 |
Monitor the patient’s progress and assess therapeutic outcomes. |
Competency 4 Drug, Therapeutic and Practice Information
| Element |
4.3 |
Retrieve information from relevant sources |
Competency 5 Communicate and Educate Effectively
| Elements |
5.1 |
Demonstrate effective communication skills. |
| o0 |
5.1 |
Demonstrate comprehension and fluency in English or French. |
| o0 |
5.2 |
Demonstrate sensitivity, respect and empathy when communicating with diverse groups or individuals. |
CANDIDATE'S INSTRUCTIONS:
You are working in a pharmacy in a medical clinic. A physician is waiting in the pharmacy to give you a new written prescription for one of her patients.
• Attach one bar code label to the new prescription form – in the space indicated.
• You may use the blank space beside the prescription for making rough notes.
• The patient record is on the desk/table, for your reference.
Your tasks are to:
1. Review the prescription for any drug related problem(s).
2. You may speak with the physician if:
a. you need more information
b. you wish to discuss the patient’s therapy
3. You must speak directly to the physician to:
a. identify and explain any drug related problem(s)
b. recommend an appropriate solution to the problem(s)
4. If no change is necessary, fill in the bubble beside “Fill as written”
OR
5. If a change of therapy is recommended:
a. fill in the bubble beside “change or clarify..”
b. specify an appropriate drug and/or other option/s
c. document any change(s) on the prescription review form
When you have finished (or when the final buzzer sounds), give this prescription form to the assessor for scoring.
|
Note: You are NOT required to dispense the prescription or counsel the patient.
Time Frame: You have 7 minutes to complete this station.
SCENARIO DESCRIPTION
Client: Standardized Physician - Dr. Jean Gaucher
Background:
Earlier in the day Dr. Gaucher wrote a new prescription for one of her patients. (See candidate answer sheet for actual prescription). The physician is waiting in the pharmacy if the pharmacist (candidate) needs to speak to the physician about the new prescription. The candidate may ask the physician questions if the candidate identifies any drug related problems with the prescription. The physician will respond as appropriate.
Patient Record (Profile) Information (see below):
Patient Name: Chris Langley
Gender: Male
Age: 55 years old
Weight: 80 kg (180 lbs)
Medical History: Deep vein thrombosis (DVT) – diagnosed 5 weeks ago
Trigeminal neuralgia – newly diagnosed
Allergies: None known
Current Medications: Warfarin 5 mg daily – started 5 weeks ago in hospital.
Physician's Opening statement: “Hello, I’m Dr. Gaucher. I’ll be here if you need to speak with me about Chris Langley’s prescription.”
Other information (Physician gives this information to candidate upon request):
Symptoms:
• Patient has pain in face (trigeminal neuralgia).
Other:
• Patient had a leg injury playing recreational floor hockey, followed by deep vein thrombosis in the left leg. He will be on warfarin for several more months...depending on resolution of symptoms (pain, edema).
• Patient was in hospital for one week following the DVT.
• Dr. Gaucher will be seeing him again in one month. His INR has been quite stable at 2.5 and was last checked just a few days ago. Dr. Gaucher is agreeable to ordering (at the candidate’s suggestion) more frequent lab work.
STANDARDIZED PHYSICIAN INSTRUCTIONS:
When the candidate consults with the Standardized Health Professional (SHP), the SHP replies as follows.
If the candidate recommends a change without identifying the problem, the SHP must ask:
“What is the problem?”
If the candidate identifies the problem but does not explain it, the SHP must ask:
“Do you know how the interaction works – can you give me a bit more information?”
Following discussion of the problem, if the candidate has not yet offered a recommendation, the SHP must ask:
“What would you suggest to resolve the problem?”
If the candidate wants to change the Tegretol to a different drug, the SHP must say:
“I have had a lot of success with carbamazepine in trigeminal neuralgia...so I prefer to use it. Do you have any other suggestions?”
If the candidate discourages use of carbamazepine and warfarin concurrently or still wants to change the Tegretol to an alternate drug, the SHP must say:
“I’ll take that under advisement and note your concern here, but for now I want him on both.”
If the candidate recommends more frequent monitoring as a general precaution, without identifying or explaining the interaction, the SHP must ask:
“What do you think the results would show?”
If the candidate identifies the problem and suggests monitoring INR as before, without discussing frequency, the SHP must say:
“He’s going for monthly blood work so will have another test in about 3 or 4 weeks.”
ASSESSOR INFORMATION (to guide scoring of candidate's performance):
Problem Solved (full solution) if candidate:
• Identifies the drug-related problem: carbamazepine – warfarin drug interaction.
• Explains the mechanism of the interaction: carbamazepine induces warfarin metabolism/cytochrome P450 enzymes.
• Explains probable outcome of the interaction: expect a decreased INR/decreased anticoagulant effect.
• Recommends to fill as written/use of both carbamazepine as ordered AND to monitor INR more frequently – OR to change to another acceptable drug, e.g. gabapentin.
• Mentions that, when taking both medications, warfarin dose may need to be increased (to maintain a therapeutic INR).
Solved/Marginal (partial solution) if candidate:
• Identifies the drug-related problem: carbamazepine – warfarin drug interaction.
• Explains either the mechanism of action OR probable outcome (NOT both) – provides scant information.
• Recommends to fill as written/use of both carbamazepine as ordered AND to monitor INR more frequently – OR to change to another acceptable drug, e.g., gabapentin.
• Explains that warfarin dose may need to be adjusted, but does not specify that it may need to be increased.
Uncertain if candidate:
• Identifies the drug-related problem: carbamazepine – warfarin drug interaction.
• Does not explain either the mechanism of the interaction or the probable outcome OR explanation is unclear.
• Recommends NOT using carbamazepine and warfarin together but does NOT suggest a solution.
• Recommends increased INR monitoring.
Unsolved if candidate:
• Does NOT identify the carbamazepine – warfarin drug interaction.
• Incorrectly explains the interaction (e.g. carbamazepine inhibits warfarin metabolism or results in increased INR or enhanced anticoagulation), leading to potential risk.
• Does NOT recommend increased INR monitoring.
• Recommends unacceptable solution (i.e. change to phenytoin, with or without monitoring; stop warfarin; decrease dose of warfarin).
STATION MATERIALS AND REFERENCES:
Patient record (profile): - see below
Reference: CPS
PATIENT RECORD
PATIENT: LANGLEY, Chris
ADDRESS: 731 3rd, City, Province
PHONE: 775-9990
AGE: 55 years old
SEX: Male
ALLERGIES: None known
COMMENTS: Deep vein thrombosis - diagnosed 5 weeks ago
PHYSICIAN: Dr. J. Gaucher
ADDRESS: 1655 West Broadway, City, Province
PHONE: 879-8874
|
Rx
#
|
Medications - Directions
|
Qty
|
Physician
|
Repeats
Authorized
|
Repeats Remaining
|
|
2
|
Warfarin (Coumadin) 5 mg
1 tablet daily
|
60
|
J. Gaucher |
0
|
0
|
|
1
|
Amoxicillin (Amoxil) 250 mg
1 cap tid x 7 days
|
21
|
J. Gaucher |
0
|
0
|
|
Dispensing Intervals
|
|
Original
|
Refill
Frequency
|
Last
Filled
|
|
4 weeks ago
|
q60 days
|
4 weeks ago
|
|
2 months ago
|
o
|
2 months ago
|
EXAMINATION MASTER
Please do not mark in any way.
|
|
CHECKLIST (expected responses)
1. Determines (from patient record) that patient is currently taking warfarin.
Identifies and explains:
2. Drug interaction between warfarin and carbamazepine.
3. Carbamazepine increases the metabolism of warfarin / induces cytochrome P450 enzymes.
4. Carbamazepine - warfarin interaction results in decreased INR / decreased anticoagulant effect.
5. Warfarin dose may need to be increased (to maintain a therapeutic INR).
6. Recommends acceptable solution (one of the following):
• Continue carbamazepine as ordered (fill as written) and monitor INR more frequently
OR
• Change carbamazepine to other acceptable drug therapy
▫ Neurontin (gabapentin)
▫ Depakene (valproic acid)
▫ Rivotril (clonazepam)
7. Gives incorrect explanation OR recommends unacceptable solution (Incorrect
response):
• Carbamazepine decreases metabolism of warfarin OR increases INR
• Warfarin doses may have to be decreased
• Continue monitoring INR monthly (no increased frequency)
• Change to phenytoin (with or without monitoring)
• Discontinue warfarin
8. Correctly documents consultation / outcome on prescription / answer sheet.
9. Indicates "Fill as written" WITHOUT advising to monitor INR more frequently. (Incorrect response)
SCORES (to be based on standard scoring guidelines and Assessor Information above)
Communications
4=Acceptable
3=Acceptable/Marginal
2=Unacceptable/Marginal
1=Unacceptable |
Outcome
4=Problem Solved
3=Solved/Marginal
2=Uncertain
1=Unsolved
Risk to Patient
Yes No
|
Performance
4=Acceptable
3=Acceptable/Marginal
2=Unacceptable/Marginal
1=Unacceptable
Misinformation
Yes No
|
CHECKLIST (expected responses)
Applies legal / ethical principles:
1. Refuses to provide or confirm any drug information including name, purpose or side effects of drug.
Explains requirements and how to comply with them:
2. Explains patient confidentiality requirements/bylaws – cannot give this information without proper authorization.
3. Explains conditions under which information can be given:
• written consent from patient
• court order
4. Suggests inappropriate conditions under which information can be given: (uncertain)
• contact the prescriber
• obtain patient's verbal consent
5. Provides drug name or side effects or confirms drug information. (incorrect response)
Communications
4=Acceptable
3=Acceptable/Marginal
2=Unacceptable/Marginal
1=Unacceptable |
Outcome
4=Problem Solved
3=Solved/Marginal
2=Uncertain
1=Unsolved
Risk to Patient
Yes No
|
Performance
4=Acceptable
3=Acceptable/Marginal
2=Unacceptable/Marginal
1=Unacceptable
Misinformation
Yes No
|
Top of Page