Effectiveness of a Medication Reconciliation Simulation in an Introductory Pharmacy Practice Experience Course

Kathy Komperda, PharmD; Kelly Lempicki, PharmD

Disclosures

Am J Pharm Educ. 2019;83(4) 

In This Article

Methods

During the 2015–2016 academic year, the medication reconciliation simulated learning exercise was incorporated in the IPPE III: Clinical course. This course is the final IPPE and emphasizes clinical practice through a combination of didactic and experiential learning opportunities. It is taught over three quarters in the third year with approximately a third of the class (about 70 students) enrolled in any given quarter.

The medication reconciliation simulated learning exercise was incorporated in the course each quarter prior to the students attending any clinical site visits. The learning exercise was based on previously published experiences in other health professional curricula and designed to fit a two-hour format.[16,17] The exercise began with a 30-minute review lecture by a pharmacy practice faculty member about how to perform medication reconciliation. This lecture was then followed by a 90-minute workshop where students worked in groups of three or four to perform a medication reconciliation. Personnel for the workshop included a simulated patient and two faculty members. This number of personnel was ideal to cover approximately five to six groups of three to four students. At the beginning of the workshop, the students were provided time (approximately 10 minutes) to individually review the patient's electronic medical record. The class then observed the faculty member who had given the lecture earlier conduct a brief patient interview with the simulated patient. The interview set the stage for a clinical scenario involving a patient recently discharged from the hospital who was meeting with the pharmacist to review her medications before seeing her doctor in the clinic. However, the faculty member did not review any specific medications during the patient interview. The role of the patient was played by an actor from the university's Clinical Skills and Simulation Center (CSC) who had experience as a standardized patient. Once the interview was completed, the student groups had approximately 40 minutes to prepare an accurate medication list, identify any discrepancies, and propose resolutions. To assist with this process, each student group was given a bag filled with the patient's medication bottles and access to the patient's electronic medical record. Anytime during the 40 minutes, each group was also able to interview the simulated patient or contact the patient's community pharmacist (portrayed by a second pharmacy practice faculty member). Each team had up to six "lifelines" represented by six index cards. Each "lifeline" represented a three-minute conversation with the patient (three cards) or the community pharmacy (three cards). Information was only provided during these lifelines if the right questions were asked by the student groups. At the end of the workshop, each student group submitted their medication list and identified discrepancies with proposed resolutions. After all groups submitted their work, the faculty member led a 20–30 minute in-class discussion reviewing the patient's accurate medication list. All medications and therapeutic topics in the patient scenario had been previously covered in the curriculum so that students could apply this knowledge as they identified the medication discrepancies and proposed appropriate resolutions.

Approximately one week after this educational intervention, students individually completed a medication reconciliation encounter with a standardized patient (SP) in the CSC. Students were allotted up to 10 minutes to review the patient's electronic medical record and then up to 15 minutes to interview the patient and review their medication bottles. Students then had up to 30 minutes to complete a post-encounter assignment documenting the patient's reconciled medication list, any discrepancies they identified, and their proposed resolutions. This SP encounter was a formative assessment where students received feedback on their performance and recommendations for improvement. This assessment counted as part of the students' score in the class; however, their score was based on whether they completed the activity, not how well it was completed. The SP encounter provided students the opportunity to individually practice the medication reconciliation process before going to their clinical sites. The same workshop and SP encounter cases were used each quarter.

A research plan was developed to evaluate the simulated learning exercise and approved as expedited by the university's institutional review board. All third-year pharmacy students enrolled in the IPPE III: Clinical course during any quarter of the 2015–2016 academic year were eligible to participate in the study. The medication reconciliation simulated learning exercise and SP encounter were required for all students since they were a course requirement; however, students' participation in the study (allowing the faculty to use their data for analysis) was voluntary. Students who enrolled and completed the study were awarded five extra credit points in the class, which accounted for less than 1% of the total course points.

In order to evaluate the simulated learning exercise described above, the students were randomized using an Excel spreadsheet into the following three groups: group A, 30-minute review lecture (same lecture as given to group B); group B, 30-minute review lecture plus a 90-minute workshop; or group C, no intervention. The simulated learning exercise previously described is what the students in group B received. Group A received only the lecture described above, and group C served as the control group to represent the course content that previous students received during their second year.

To assess the effectiveness of this educational intervention, all students completed the medication reconciliation simulation in the CSC. The post-encounter assignment, documenting the patient's reconciled medication list and identified discrepancies with proposed resolutions, was deidentified so faculty members were blinded to the student's name and group assignment. These de-identified items were then evaluated for accuracy by the investigators using a checklist (Appendix 1). The checklist was designed using a yes/no format and divided into two sections: reconciled medication list, and discrepancies and resolutions. This checklist was based on a form piloted in the IPPE III: Clinical course during the previous academic year to which minor edits were made based on user feedback before being used in this study. Students received a percent correct on each section, as well as an overall score.

Two survey instruments also were administered to all students who consented to be part of the research project. The pre-survey was administered during week 2 of the course before any of the medication reconciliation learning activities occurred. The post-intervention survey was administered electronically immediately after the students completed the SP encounter. Participation in both surveys was anonymous; however, students were tracked over time using non-personal identifiers to permit comparisons between the pre- and post-intervention surveys.

In both surveys, students were asked to indicate their level of confidence in completing 16 different activities related to medication reconciliation knowledge and skills (Appendix 2). These items were adapted from previously published quentionnares.[6,15] The confidence scale was a four-point scale including very confident, confident, unconfident, and very unconfident. On the preintervention survey, students also were asked demographic questions including age and gender, work experience in different pharmacy practice settings, and whether they performed medication reconciliation at their place of employment. On the post-intervention survey students were asked to provide feedback about the different medication reconciliation teaching strategies they experienced based on their group assignment. Students were asked to indicate their level of agreement to statements describing the different teaching strategies and SP encounter. There were also open-ended questions on the post-intervention survey for students to provide additional feedback about each of the learning experiences (lecture, workshop, or SP encounter) that were applicable to their assigned group.

So that all students ultimately had the opportunity to participate in the simulated learning exercise, students who were not originally in group B were scheduled to attend a make-up lecture and/or workshop after the SP encounter and post-intervention survey were completed. Timing of the intervention, data collection, and survey administration are summarized in Table 1.

To evaluate the primary objective, scores from the SP encounter checklists were compared between the three groups using ANOVA with additional post hoc comparisons. For the secondary objectives, survey results were analyzed using descriptive statistics and a mixed model MANOVA with post hoc comparisons to analyze the differences in pre- and post-intervention confidence levels between groups. The written comments from the post-intervention survey instrument were also reviewed and categorized into themes. Any p value <.05 was considered to be significant. All data were analyzed with IBM SPSS Statistics, version 22.0 (Armonk, NY).

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