Blockchain Papers

D Davidson, Nicola Vasey, Adam Pattison Rathbone, Charlotte Lucy Richardson

Abstract Introduction Pharmacy education in the United Kingdom must adapt to produce independent prescribing pharmacists ready to join an evolving healthcare system. Current placement practices exclude approximately 21% of the population due to a lack of specific recommendations surrounding paediatric experience and knowledge within the MPharm programme.[1] In turn, students’ current experiences may be limited by lack of interaction with unique learning outcomes offered by some healthcare settings, such as paediatric hospitals.[2] To promote student exposure in an overlooked speciality, novel approaches to work-based learning can be utilised. Aim This study aimed to explore pharmacy students’ experiences of work-based learning in a paediatric hospital setting. Methods In October 2022, fourth-year MPharm students at one school of pharmacy were invited to undertake work-based learning sessions across one academic year. The sessions aimed to develop students’ paediatric consultations skills and knowledge. Sessions consisted of a briefing, ward activities, scaffolded consultations with children and carers, and debriefs with a clinical supervisor. Debriefs included students reporting clinical information, required action and learning outcomes. All debriefs provided by students were transcribed by a clinical supervisor using a spreadsheet which recorded the date, ward visited, patient details, student handover, follow-up (if required) and learning outcomes. Data was initially cleaned, quality checked, and underwent content analysis to identify patterns and key themes to describe student experiences. Results Seventy-four students took part in sessions and delivered 233 consultations covering the medical history of the patient (76%, n=177), with varied levels of completeness. Students were exposed to acute conditions (41%, n=96) and chronic conditions (33%, n=76), with 13% (n=30) still awaiting diagnosis. Forty-eight percent (n=81) of learning points related to the pathology, diagnosis and symptoms of conditions, 24% (n=41) to medicines, 15% (n=25) to patient care, 11% (n=18) to non-clinical experiences and 2% (n=4) to other outcomes. In addition to carrying out ward activities, students underwent the processing of experiences during post-session debriefs: “It’s uncomfortable seeing a child struggle to breathe” [P131]. The process of active reflection was also evidenced in debriefs: “I felt very anxious, like a tightness in the chest, to hear that a child had a short life expectancy” [P145]; “I realised they had zero cultural competence after seeing a patient from the Middle East with jaundice” [P233]. Conclusion The study demonstrates a proof of concept that students can be exposed to complex care needs and challenging consultations under indirect supervision, demonstrating the paediatric setting to be a suitable work-based learning host. However, findings are limited to a single cohort of students at a single site, meaning transferability may be limited. Future studies could focus on longitudinal educational and emotional outcomes of students by measuring clinical knowledge, competence and confidence. Utilising post-session debriefs with peers and supervisors created a space to share both pharmaceutical and emotional learning points, aiding in managing the cognitive load of students. This experience not only highlights the requirement of paediatric exposure in pharmacy education programmes to aid the students’ future practice, but the importance of supervised reflective activities following work-based learning experiences. References 1. Office for National Statistics. Ethnic group by age and sex, England and Wales: Census 2021. 2023. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/ethnicity/articles/ethnicgroupbyageandsexenglandandwales/census2021 2. Kerth J-L, van Treel L, Bosse HM. The Use of Entrustable Professional Activities in Pediatric Postgraduate Medical Education: A Systematic Review. Academic Pediatrics. 2022;22(1):21-8.

Moyosore Taiwo, Adebanjo Olowu, Yusuf Olanlokun, Ojo Timothy

As healthcare systems globally transition toward patient-centered and decentralized care models, the role of pharmacists has evolved from traditional dispensing functions to more autonomous, clinically integrated responsibilities. This paradigm shift, driven by the need for efficiency, accessibility, and personalized care, positions pharmacists as critical stakeholders in therapeutic decision-making, especially within primary and community-based health systems. In decentralized healthcare structures, such as those found in integrated care networks and rural outreach programs, pharmacists are increasingly responsible for clinical judgment, medication optimization, patient education, and adverse drug reaction monitoring—functions traditionally reserved for physicians. This study explores the extent and determinants of clinical decision-making autonomy among pharmacists within decentralized healthcare models. It examines how organizational structure, regulatory frameworks, risk management policies, and interprofessional collaboration impact pharmacists’ ability to make independent clinical decisions. Particular attention is paid to the balance between autonomy and accountability, highlighting potential risks such as therapeutic errors and liability concerns, alongside opportunities for improving medication adherence and reducing hospital readmissions. Using a mixed-methods approach involving policy analysis, structured interviews, and clinical case reviews, the study uncovers significant variation in autonomy across regions and care settings. It proposes a framework for risk-informed autonomy, whereby pharmacists operate with expanded clinical responsibility under well-defined governance and support systems. Ultimately, this research underscores the importance of redefining pharmacists’ roles in modern health systems and offers strategic recommendations for empowering them within decentralized models without compromising patient safety or care quality.

Pedro Armando, Sonia Andrea Naeko Uema, Elena María Vega

Argentina is a federal republic with approximately 44 million people, divided into 23 provinces and an autonomous city, Buenos Aires. The health system is segmented into public, social security and private subsystems. The social security and private sectors cover more than 60% of the population. Total health expenditure in 2017 was 9.4% of gross domestic product. Primary health care (PHC) was considered as the principal strategy for universal coverage policy for health system reform in Latin America at the end of 20th century. The most remarkable characteristics of the Argentinian health system are its fragmentation and disorganization. An increase of public sector demands, due to a socioeconomic crisis, led to the subsequent collapse of the system, caused primarily by a sustained lack of investment. First care level decentralization to the Integral Health Service Delivery Networks (IHSDN) becomes the cornerstone of a PHC-based system. Pharmacists and community pharmacies are not formally mentioned in PHC policies or IHSDN. However, pharmacies are recognized as healthcare establishments as part of the first care level. Community pharmacists are the only health care professional whose profit comes from the margin on product sales. Contracts with social security and private insurances provide small margins which reduce the viability of community pharmacies. There is a preference by community pharmacies to diversify product sales instead of providing professional services. This is driven by marketing and economic pressures rather than patient care and health policies. Dispensing is the main professional activity followed by management of minor illness and associated product recommendations. Currently, there are no national practice guidelines or standard operating procedures for the provision of pharmaceutical services and there is no nationally agreed portfolio of services. National pharmacy organizations appear to have no official strategic statements or plans which would guide community pharmacies. There are some isolated experiences in community pharmacies and in public first care level pharmacies that demonstrate the possibilities and opportunities for implementing pharmaceutical services under the PHC approach. There is a real lack of integration of community pharmacies and pharmacists in the healthcare system.

Khaled Al–Surimi

We are pleased to publish the second issue of the Global Journal on Quality and Safety in Healthcare (JQSH). In this issue, we would like to discuss the similarities and differences between research and quality improvement (QI) projects in health care. Imagine you are working in a hospital or a department within a hospital and you want to improve an aspect of health-care quality and safety by focusing on the issue of medication errors. Given that situation, you decide to implement a “zero harm” rule because of medication errors. The question is will this be a QI or a research project? In another example, you are a resident working in an oncology department and you noticed that most patients receiving certain chemotherapeutic agents had neuropathy complications, so you decided to collaborate with the physical therapist on a project to compare patients who received chemotherapy drugs and exercise with those who did not exercise. Again, the question is will this be a research project or a QI project? Regardless of the answer, it is important to implement the project systematically. If your project is focused on QI, then you should consult the QI specialists in your hospital who can help you to use the appropriate QI methodology, which includes Plan, Do, Study, Act (PDSA) cycles. If your project qualifies as research, then you should consult a research methodologist and biostatistician regarding study design, sample size, and others and work with the institutional review board (IRB) to provide guidance and templates.Many health professionals do not know how a research project differs from a QI project and when they complement each other.[1–3] Our traditional thinking is that quality and safety improvement in health care as well as the effectiveness of an intervention can only be studied in the form of a traditional scientific research project, as it has its own well-established rigorous approach. We may be ignorant or unaware of how to use the QI scientific approach to study the performance of a health-care system.[4,5] The problem lies within our frame of thinking because we are prioritizing the proof of effectiveness over bringing about and sustaining improvement. We use the results of pre-assessment and post-assessment research as the gold standard for evidence-based policy and practice, whereas in reality, sustaining the improvement is continuous and more dynamic.[1,6]Research projects are question-driven and focus on providing proof of effectiveness. The main purpose of research is to generate new generalizable knowledge about a particular subject to a study population, where the study results often end up published in academic journals. In this case, researchers must follow a strict study protocol approved by the IRB, including obtaining the consent from study participants before starting the project and report any deviation from the protocol to the IRB, if needed.[7–9] However, QI projects are data-driven and focus on showing sustained improvement to a specific process and system or outcomes within a health-care organization using, if possible, the research evidence generated as the basis for developing the improvement interventions.[10] A QI project does not aim to generate new knowledge as a research project does, rather, it generates several learning lessons as to what actually works and does not work and why. A QI project produces empirical evidence to benefit other organizations within a similar context and setting, which are interested in replicating the change to improve a process or system using the rapid PDSA cycle approach.[11] Through cycles of testing, we learn what is going to improve and why, without the need to generalize the results to another context, as research projects usually aim to do. Also in QI projects, the measurement framework is not about pre and post. It is about continually measuring the metric of interest that you want to improve and coming up with not just one intervention but multiple interventions based on learning from prior PDSA cycles. At the end, you reach the point of realizing sustained improvement through a series of interventions that were informed by testing in the actual system that you want to improve. The PDSA cycle is repeated, and new changes are made to continue to improve a process and, ultimately, the outcome. The essential measurements included in a QI project are process measures, outcomes measures, and balancing measures, which are used to show that the improvement occurs over time. Data from QI activities are usually aggregated and presented in run/control charts, histograms, and line graphs, whereas data from research are analyzed using statistical tests such as t-test, chi-square test, and regression analysis, and then aggregated and presented in appropriate tables and/or graphs.Typically, QI results are shared within the organization and might be implemented in other departments. The lessons learned from QI activities can be published; however, it must be clear to the readers that the project was for QI, not traditional research. Although a QI project does not require IRB approval, some organizations have QI committees that approve and coordinate QI project activities, and some organizations require articles to be approved before submitting for publication.In summary, the sustained improvement realized in a QI project can be complemented and validated with a thorough research-based assessment of effectiveness.[12] We should not consider the proof of effectiveness the same as the proof of sustained improvement, but they both are very important. I would like to emphasize that both research and QI projects use scientific and systematic approaches, albeit different, but both methods are scientific and rigorous in their own ways. The aims, methods, and outcomes in research and QI projects are quite different. Hence, understanding the differences and similarities between research and QI projects will help to determine the right approach when designing and implementing the right project for the right purpose using the right method. Table 1 is a snapshot comparison between QI and research with more focus on the project's aim and method aspects.In research projects, we can be guided by asking the following: Do we have a clear question to be investigated and answered?What do we hope to accomplish by answering the question?What is currently known about the topic?What are the risks and benefits for patients involved with the study of this topic?What type of study design will be used (observational vs. experimental)?How will the data be analyzed and presented (statistical tests, P-values, etc.)?In QI projects, we can ask the following: What is the magnitude of the quality problem based on available data?What types of quality tools have been used to measure and assess the problem?What is the measurement plan to be used during implementation of the project?What types of changes/interventions will be tested during the PDSA cycles?Has the proposed change/intervention been used in other health-care settings or reported in the literature?Will the results of this project directly improve patient-care outcomes or processes?Is the organization's management supportive of the project and willing to dedicate employee's time and supplies to do the project?What is the sustainability plan for the results?