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Opioid use disorder (OUD) is highly prevalent among jail and prison populations in the United States, including in Wisconsin. Medications for opioid use disorder (MOUD), including long-acting injectable naltrexone, are crucial in the treatment of OUD. These medications are especially important for individuals transitioning out of jail or prison and back into the community. Unfortunately, few individuals who were formerly incarcerated continue MOUD after reentry due to a variety of barriers. Wisconsin community pharmacists are highly accessible and uniquely positioned to provide care for this population, specifically by administering injectable naltrexone. However, community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated has not been previously explored. As a first step, this legislative and regulatory review aimed to identify Wisconsin statutes and administrative codes that may impact these services for this population. Two legal databases were searched to identify relevant Wisconsin statute and administrative code subsections. Overall, 24 statute subsections (from 7 chapters) and 31 administrative code subsections (from 12 chapters) were identified that (1) highlighted a need or potential role of community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated or (2) served as a potential barrier or facilitator to the availability, access, or use of these services. Future work should focus on helping community pharmacists leverage available resources and overcome existing legal barriers to providing or supporting MOUD services. Importantly, work should be done to ensure that individuals who were formerly incarcerated can be linked to these services upon reentry.

Background Medication prescribing and discontinuation processes are complex and involve the patient, numerous health care professionals, organizations, health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The health system also operates 15 outpatient community pharmacies. Objective The goal of this qualitative study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations, before and after CancelRx implantation. Approach Medical Assistants ( n  = 9), Community Pharmacists ( n  = 12), and Pharmacy Administrators ( n  = 3), employed by the health system were interviewed across 3-time periods between 2017 and 2018— 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and conducted a hybrid analysis with deductive content analysis following the Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductive analysis to capture additional codes and themes. Key results CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors. Conclusions This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Introduction: Community retail pharmacists are experiencing unsafe levels of stress and excessive demands within the workplace. One aspect of workload stress that has been overlooked among pharmacists is occupational fatigue. Occupational fatigue is a characteristic of excessive workload including increased work demands and reduced capacity and resources to complete the work. The goal of this study is to describe the subjective perceptions of occupational fatigue in community pharmacists by using (Aim 1) a previously developed Pharmacist Fatigue Instrument and (Aim 2) semi-structured interviews. Methods: Wisconsin community pharmacists were eligible to participate in the study and recruited via a practice-based research network. Participants were asked to complete a demographic questionnaire, a Pharmacist Fatigue Instrument, and semi-structured interview. Survey data were analyzed using descriptive statistics. Interview transcripts were analyzed using qualitative deductive content analysis. Results: Totally, 39 pharmacists participated in the study. From the Pharmacist Fatigue Instrument, 50% of the participants stated they had times where they were not able to go above and beyond standard patient care on more than half of the days they worked. A total of 30% of the participants reported that they found it necessary to take short-cuts when providing patient care on more than half of the days they worked. Pharmacist interviews were separated into overarching themes including mental fatigue, physical fatigue, active fatigue, and passive fatigue. Conclusions: The findings highlighted the pharmacists’ feelings of despair and mental fatigue, fatigue’s connectedness to interpersonal relationships, and the complex nature of pharmacy work systems. Interventions aimed at improving occupational fatigue in community pharmacies should consider key themes of fatigue that pharmacists are experiencing.

Sustaining a well-designed healthcare intervention justifies the resources allocated during its conceptualization and implementation and maximizes its clinical benefits, but staff influences on sustainment have been studied insufficiently. This study evaluates the effects of pharmacy staff (i.e., pharmacists/technicians) perceptions about the sustainability of Senior Safe , a U.S. pharmacy-based intervention to reduce older adult over-the-counter (OTC) medication misuse. Three months after introducing Senior Safe into 67 pharmacies in a large Midwestern health-system, all pharmacy staff (N = 279) received a survey invitation. Fifty-nine pharmacists and 94 technicians completed the survey. Using logistic regression modeling for the 14 belief-based survey items, and staff roles (pharmacist or technician), the final factors significantly predicting staff views that Senior Safe was sustainable were as follows: perceiving Senior Safe as well-integrated into leadership operations (OR = 5.606, < 0.001) and believing the intervention reduced OTC misuse (OR = 8.217, < 0.001). Also, technicians were more confident than pharmacists about Senior Safe's sustainment and its OTC misuse reduction success. Overall, an intervention's sustainability relies on those using it. Since the principal predictor of maintaining Senior Safe was its perceived effectiveness, increasing staff buy-in and awareness of an intervention's benefits may be central to its long-term viability. With an aging U.S. population, sustainable solutions to older adult medication misuse remain critical.

Background Measuring intervention fidelity can help justify the transition of evidence-based practices into everyday community-based practices by helping identify components of the intervention supporting the intervention’s uptake. Current methods to measure fidelity include self-reported data, observational data using audio or video recordings, and in-vivo observations, but these are limited due to cost-ineffectiveness, time inefficiency, and external validity threats. Photo coding is proposed as a new, pragmatic method of observational data to measure intervention fidelity, as was used in a pharmacy system re-design intervention (Senior Safe™) to improve over-the-counter (OTC) medication safety for older adults. Methods Guided by human factors engineering principles, Senior Safe re-shelved OTC medications based on safety level, and signage was added to designate safer and high-risk products. Senior Safe was implemented by pharmacy leadership and maintained by pharmacy staff. Pharmacy leadership and researchers collaborated to take photos of Senior Safe two times (Time 1 and Time 2), at least three months apart, to examine intervention layout and medication categorization fidelity. A Layout Codebook was constructed to evaluate the conformity of signage to ergonomic principles. A Medication Categorization Codebook was designed to assess whether the signage was properly allocated to the designated products. Two research assistants and two PharmD students coded the photos. A fidelity standard of ≥ 80% concordance with intervention guidelines was used to signify high-fidelity. Results Fidelity was assessed within 67 pharmacy sites implementing Senior Safe. All sites achieved ≥ 80% fidelity concordance between Time 1 and Time 2 for the Layout Codebook. Alternatively, for the Medication Categorization Codebook, 97% of sites met high-fidelity standards during Time 1, compared to 85% of sites at Time 2, indicating statistically significant negative drift. Overall, over half of all Time 1 and Time 2 concordance rates involving the Layout and Medication Categorization Codebooks exceeded the ≥ 80% high-fidelity standard. Conclusion Measuring intervention fidelity is useful in determining whether interventions are sustained and successfully transitioned into community-based practice. Photo coding is an innovative approach to measure intervention fidelity and allows researchers to identify multiple layers of concordance and discordance to intervention guidelines. Organizations are encouraged to investigate intervention fidelity, including identifying discordance and adaptation needs.

Providing patient-centered care to manage chronic pain and opioid use disorder (OUD) is associated with improved health outcomes. However, adopting a holistic approach to providing care is often challenging in rural communities. This study aims to identify and contrast challenges to providing patient-centered care from the perspective of patients and providers. A participatory design approach was adopted to elicit the perceptions of providers and patients with lived experiences of chronic pain and/or OUD in Jefferson County, Wisconsin. Two focus groups were conducted with each stakeholder group to identify problems that participants face with respect to chronic pain management and OUD and possible solutions. Four interviews were conducted with providers experienced in chronic pain management. Analysis of focus group sessions and interviews show consensus among patients and providers that lack of behavioral health and recovery resources create barriers to effectively manage OUD and chronic pain. However, there was discordance among the two groups about other barriers such as patient and provider attitudes, tapering approach, and access to medications for OUD. This tension among patients and providers can influence patients’ retention in therapy. More efforts are needed to mitigate stigma among providers in rural communities and support psychosocial needs of patients.

Community pharmacists can play an important role in patient safety by consulting patients on over-the-counter (OTC) medications. Several OTC counseling frameworks have been integrated into pharmacy education to guide pharmacists through these consultations, but limited work has been performed to examine how these frameworks are applied in real-world settings. The objective of this study was to identify the topics discussed during over-the-counter medication consultations and explore how they align with existing counseling frameworks. Participants were recruited from 10 community pharmacies. Participants were given hypothetical symptoms and asked to select OTCs for self-treatment. The selection process and potential interactions with pharmacy staff were recorded via Tobii Pro Glasses 2. Deductive and inductive content analysis of the recordings were used to compare participant–pharmacist consultations to existing OTC counseling frameworks. In total, 144 participants completed the study, with 32 (22%) having an OTC consultation with the pharmacist. Across all consultations, eight topic categories were identified. The consultations most frequently focused on discussions of product details and did not closely align with the OTC counseling frameworks. Future work should examine if and how this discordance contributes to OTC misuse among those interacting with pharmacists and potentially adapt or develop new frameworks to further support consultations and OTC safety.

Background Prescription opioid misuse is a serious national crisis; in 2018 the top drugs involved in prescription overdose deaths included pain medications (opioids), benzodiazepines, and stimulants. Health information technology (health IT) provides a means to address this crisis through technologies that streamline the prescribing and discontinuation process. CancelRx is a health IT function that communicates when medications, such as controlled substances, are discontinued at the clinic and therefore should not be filled at the pharmacy. Prior to CancelRx, the communication of discontinued medications was a manual process, requiring the patient or a clinic staff member to personally contact the pharmacy to inform them of the change. The objective of this study was to assess how controlled substance medication discontinuations were communicated over time, before and after the implementation of CancelRx. Methods Secondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation. The study utilized an interrupted time series analysis (ITSA) to capture the percentage of controlled substance medications that were discontinued in the clinic’s electronic health record and discontinued in the pharmacy’s dispensing software. The ITSA plotted the percentage of successful discontinuation messages over time, particularly after the health system’s implementation of CancelRx, a novel technology. Results After CancelRx implementation there was an immediate (change = 77.7 percentage point) and significant (p < 0.001) increase in the number of controlled substance medications that were successfully discontinued at the pharmacy after being discontinued in the clinic. This change was sustained in the year following CancelRx (slope = 0.03 pp, 95% CI − 0.050 to 0.110) and did not revert to pre-CancelRx levels. The health IT functionality was able to effectively complete discontinuation tasks and potentially reduce workload for clinic staff. Conclusions Overall, this study demonstrates the role that technology can play in promoting communication between clinics and pharmacies, especially when medications such as controlled substances are discontinued.

The increase in people with complex chronic health conditions is stressing the US health care delivery system. Community pharmacies play a role in ensuring patients' safe medication use for chronic care management (CCM), but their efforts are undermined by volatile work demands and other system barriers. Medication safety in community pharmacies is a multidimensional issue shaped by the work system and interactions among pharmacists, primary care providers, and patients. The objective is to create and evaluate a system of CCM that supports safe medication use. The CCM system design will focus on creating and evaluating a Medication Safety Map (MedSafeMap) for patients with complex chronic health conditions. This study has three aims: (1) identify and define community pharmacy work system design requirements for safe medication practices, enabling resilient performance; (2) design and develop MedSafeMap, a feasible and sustainable solution, to facilitate safe medication practices through resilient performance; and (3) implement MedSafeMap in community pharmacies and pilot-test its impact on pharmacy staff attitudes, behaviors, and performance. This study will leverage participatory design and human factors engineering methods throughout the 3 aims. For aim 1, four rounds of qualitative observations within 6 pharmacy sites will be conducted to parse areas MedSafeMap could address. Two rounds of interviews with pharmacists and technicians from each of the sites will be used to expand upon areas of interest identified during the observations. Observational and interview data will be used to construct functional resonance analysis method models and resilience narratives to map both risks and best practices within the system based on daily workplace factors. For aim 2, focus groups with pharmacist and technician stakeholders will be guided by participatory stakeholder engagement to inform prototyping for MedSafeMap. Simulation-based research involving standardized patients in CCM scenarios will be used to test and refine MedSafeMap components. Finally, for aim 3, MedSafeMap will be implemented in pharmacies. Observations using the work observation method by activity timing (WOMBAT) for the time and motion study will aid in understanding how MedSafeMap impacts pharmacy staff workflow. We will assess adoption challenges and resilience-focused attitudes, behaviors, and performance to support CCM. As of August 2025, all 6 pharmacy sites have been recruited. Three of the 4 rounds of observations, 2 rounds of interviews with 12 pharmacists and 12 technicians from the study sites, and the 6 focus groups have been conducted. Preparations for the simulations are ongoing. MedSafeMap is an innovative approach that will guide pharmacists and technicians in safely providing care to patients with complex chronic health conditions. It will help them navigate the complex tasks and communications between the pharmacy, patient, and primary care provider arising with this type of complex care. DERR1-10.2196/69011.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is estimated to be the leading cause of death in the next 15 years. Patients with COPD suffer from persistent chronic cough, sputum production and exacerbations leading to deteriorating lung function, worsening quality of life and loss of independence. While evidence-based interventions exist to improve the well-being of patients with COPD, incorporation of these interventions into routine clinical care is challenging. Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) is a team-based, coordinated care transitions service integrating evidence-based interventions for COPD management within the patient care delivery model to reduce readmissions. This evaluation considers the process of scaling the COPD CARE service across medical facilities using an implementation package designed for service expansion. The implementation package was developed at the United States Veterans Health Administration and implemented at two medical centres. Core dissemination and implementation science methods were applied to guide design and delivery of the implementation package.The aims of this evaluation were to (1) evaluate the impact of the implementation package on use of evidence-based interventions for COPD management and (2) explore clinician perceptions of the implementation package. This prospective mixed-methods quality improvement project included two Plan Do Check Act (PDCA) cycles conducted over a 24-month period. Electronic health record data demonstrated significant improvements in the count of evidence-based interventions incorporated into routine clinical care after training completion (p<0.001), offering preliminary effectiveness of the package to improve uptake of best practices for COPD management. Clinician perceptions of the implementation package, measured by questionnaire at multiple time points, demonstrated significant improvements for all scales at the end of the final PDCA cycle. Clinicians described the implementation package as positively impacting clinician confidence, interprofessional collaboration and patient care delivery.