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11/2/2000

Texas Society Launches Exchange Program with Mexican Pharmacists

Nancy Tarleton Landis

The Texas Society of Health-System Pharmacists (TSHP) is engaged in a program with Mexican pharmacists that is heightening awareness of practice issues on both sides of the border. TSHP's council on professional affairs developed an exchange program—a sort of mini-residency—in which pharmacists from Mexico work alongside their counterparts in Texas health systems.

The program description speaks of "learn[ing] innovative and creative pharmaceutical care from each other." TSHP leaders were excited about the opportunity to help bring Mexican pharmacy closer to the level of practice in the United States, but TSHP's first experience with a Mexican pharmacist proved enlightening for the hosts as well as the guest.

Seeds of the program. Lourdes Cuellar, immediate past president of TSHP, explained the events that led to Rafael Carballo's six-week rotation at Metropolitan Methodist and Northeast Methodist Hospitals in San Antonio. Cuellar, who is Director of Pharmacy and Ancillary Services at The Institute for Rehabilitation and Research in Houston, had attended an annual scientific conference of Mexican pharmacists for several years and received inquiries about institutional pharmacy.

In Mexico, said Cuellar, most pharmacists are employed by the pharmaceutical industry. As a rule, "They don't have pharmacists per se in their pharmacies. In hospitals in Mexico, a lot of what we know as pharmacy practice is done by physicians." Probably the biggest obstacle to bringing practice in Mexico in line with that in the United States and Canada, she said, is that Mexico has three universities that offer degrees in pharmaceutical sciences but have totally different curricula. "There is no standardization within the country."

However, she continued, many students in these programs are aware of pharmacy practice outside Mexico and want to spend their time with patients, not in laboratories. A presentation Cuellar gave in Mexico on the role of pharmacists in U.S. health systems led to e-mail correspondence with the Mexican pharmacists, a letter from Mexico's minister of health endorsing an exchange program in health-system pharmacy, and, eventually, the TSHP professional affairs council's proposal for objectives and a curriculum.

The first exchange. Agatha Nolen, Director of Pharmacy at Metropolitan Methodist and Northeast Methodist Hospitals, and Linn Danielski, Manager of Pharmacy Purchasing at Baptist Medical Center, both in San Antonio, cochair the professional affairs council. Nolen's health system hosted Carballo, the first Mexican pharmacist to participate. After working in industry, as an inspector for the government, and most recently in hospital pharmacy, Carballo had been appointed director of pharmacy at a new 1080-bed government hospital being built in Mexico City.

During his time at the San Antonio hospital last spring, Carballo had to forgo many options of the mini-residency and zero in on the basics of drug distribution and physician–pharmacist communication at a large hospital. Although TSHP's plan is for a six-month program with two-week rotations at various practice sites, Carballo could spend only six weeks before returning to Mexico for a presentation to the government on what he had learned.

A safe system without computers? Carballo studied the pharmacy process from order entry to delivery of drug to the patient, learning all he could along the way about pharmacists' relationships with physicians and nurses. Creating a process that incorporated quality assurance—for a hospital lacking a computer system—was his goal.

Nolen, accustomed to a highly sophisticated computer system, said she "pulled out old files to help him create a system that would have some sense of safety. We tried to think through the process and how you keep manual records, how nurses note orders, how medication administration records get generated....He tried to design a system so that the nurses could get their job done correctly. It was almost as if he was saying, 'The pharmacy is going to be a given; we're just going to set it up correctly. Where we really need to concentrate our efforts is with the administration of drugs by nurses.'"

Control that stops at the pharmacy door. Grounded in industry, where every process is highly controlled, Carballo was concerned about the relative lack of control in hospitals, especially once a drug leaves the pharmacy. Through his eyes, Nolen saw her health system in a new light. "For example," she said, "we have a lot of geriatric patients, and we don't always provide liquid formulations for patients who may have difficulty swallowing. Our nurses crush all the tablets to put down tubes. Rafael was amazed at nurses taking five or six drugs and crushing them all into the same mortar without consideration of the mixture or the cleanliness of the product—especially out in the hallway on med carts." Also, because the hospital has "the luxury of automation," including a computerized patient record and a central pharmacy robot, he was surprised that [bedside] bar-code medication scanning had not been implemented, Nolen said.

"When Rafael said, Do you know what the nurses are doing? and then told me from his perspective, my eyes were opened. We tend to focus on pharmacy issues, spending huge amounts of time looking at our processes and trying to eliminate defects when we probably have not given more than a glance to the processes occurring on the floor—why our processes don't work for nursing. For example, maybe the medication room on the nursing unit isn't set up appropriately, but most pharmacists would not be involved in the construction plans for setting one up. Once the drug leaves our doorway, we're no longer in charge. I thought, I've got to change that.

"This experience put in perspective that I really need to devote my efforts to things like promoting double-checking the wristband, computerized checks to ensure that this is the right dose for that time....It's absolutely critical to know what the patient got when, but we accept that doses don't always get charted. I've refocused my efforts on trying to influence more what goes on on the floors. We've made few attempts, for example, to find out why we get so many returned drugs. Obviously, there are parts of the medication delivery process that are not working for our nurses and our patients....Without this experience, I could have continued down the same road I have for 20 years and not gotten energized to become more involved. This philosophical change has at least as much value as any technical knowledge we could gain from the exchange."

Future exchanges. The second Mexican pharmacist scheduled to participate, Beatriz Espinosa, began her immersion in Texas pharmacy at TSHP's annual seminar earlier this year. Espinosa was to begin her mini-residency in November, based primarily in El Paso and focusing on clinical activities and physician–pharmacist collaboration. She planned to spend time at the regional poison control center and, as Carballo did in San Antonio, to attend local pharmacists' meetings to learn the value of professional organizations in career development.

Nolen said TSHP wants to get feedback from two or three exchange pharmacists on whether the program meets their needs. Then, she said, TSHP might approach the Mexican consulate about sponsoring exchanges on a regular basis.

Cuellar and Nolen would like the program to develop to the point that they can send some Texas pharmacists to Mexico. Also, said Cuellar, "It would be great if we could get other border states to do this."