Surya Bhatia, Scot H Simpson, Tammy BungardABSTRACT
Background
In the past decade, pharmacist practice has evolved tremendously in Canada, but the scope of practice varies substantially from one province to another.
Objective
To describe pharmacists’ scopes of practice relevant to prescribing within various jurisdictions of Canada, using the prescribing model in Alberta (authors’ province) as the reference point.
Methods
This cross-sectional survey consisted of clinical scenarios for emergency prescribing, adapting or renewing a prescription, and initial-access prescribing for a chronic disease. Pharmacists were asked about their ability to administer injections and to order or access the results of laboratory tests, as well as certification and training requirements and reimbursement models.
Results
Thirteen pharmacists representing Canadian provinces other than Alberta were surveyed in late 2015, for comparison with Alberta. With specific reference to the scenarios presented, pharmacists were able to prescribe in an emergency in 9 of the 10 provinces, renew prescriptions in all provinces, and adapt prescriptions in 6 provinces. Three provinces required that pharmacists have collaborative practice agreements identifying a specific practice area in order to initiate a prescription for a chronic disease (with 6–12 pharmacists per province having such agreements). Alberta required pharmacists to have authorization, based on a detailed application, in order to initiate any provincially regulated drug (with about 1150 pharmacists having this authorization). Pharmacists were allowed to administer vaccines in 9 provinces, and 5 provinces allowed pharmacists to administer drugs by injection. Three provinces had systems in place for pharmacists to access laboratory test results, and 2 allowed pharmacists to order laboratory tests. Five provinces had government-reimbursed programs in place for select prescribing services; however, all 9 provinces with public vaccination programs reimbursed pharmacists for this service.
Conclusions
Pharmacist prescribing differs among Canadian provinces. Although most provinces allow emergency prescribing and renewal or adaptation of prescriptions by pharmacists, only 4 provinces allow prescription initiation, with variable criteria and scope. Despite some progress to enhance patient flow through the health care system (e.g., by allowing pharmacists to extend prescriptions), further work should be pursued to harmonize clinical practices across Canada and to enable pharmacists to initiate and manage drug therapy.
KEYWORDS: pharmacist prescribing, scope of practice, disease management
RÉSUMÉ
Contexte
Au cours de la dernière décennie, la pratique des pharmaciens a énormément évolué au Canada; or, le champ de pratique est très différent d’une province à l’autre.
Objectif
Décrire les champs de pratique des pharmaciens en ce qui touche au droit de prescrire dans les différentes provinces canadiennes en utilisant le modèle de prescription en Alberta (province d’appartenance des auteurs) comme point de référence.
Méthodes
La présente enquête transversale s’appuyait sur des scénarios cliniques pour la prescription en situation d’urgence, l’ajustement ou la prolongation d’une ordonnance et la prescription initiale en cas de maladie chronique. On a demandé aux pharmaciens de parler de leur capacité d’administrer des substances injectables; de prescrire des examens de laboratoire ou d’en accéder aux résultats; des exigences en matière de certification et de formation; et des modèles de remboursement.
Résultats
Treize pharmaciens représentant les provinces canadiennes autres que l’Alberta ont été sondés à la fin de l’année 2015 pour comparer leurs champs de pratique à celui de l’Alberta. En fonction de détails précis des scénarios préétablis, les pharmaciens étaient en mesure de prescrire en situation d’urgence dans 9 des 10 provinces, de prolonger des ordonnances dans toutes les provinces et d’ajuster des ordonnances dans 6 provinces. Trois provinces exigeaient des pharmaciens qu’ils aient des ententes de pratique en collaboration spécifiant un domaine de pratique afin d’initier une thérapie médicamenteuse en cas de maladie chronique (6 à 12 pharmaciens par province possédaient de telles ententes). L’Alberta exigeait des pharmaciens qu’ils aient une autorisation en fonction d’une demande détaillée pour amorcer un traitement à l’aide d’un médicament réglementé par la province (environ 1 150 pharmaciens détenaient une telle autorisation). Les pharmaciens pouvaient administrer des vaccins dans 9 provinces et des médicaments injectables dans 5 provinces. Trois provinces possédaient des systèmes permettant aux pharmaciens de consulter les résultats d’examens de laboratoire et 2 provinces les autorisaient à prescrire de tels examens. Cinq provinces avaient en place des programmes de remboursement pour certains services de prescription; cependant, les 9 provinces dotées de programmes publics de vaccination remboursaient les pharmaciens pour ce service.
Conclusions
Le droit de prescrire des pharmaciens varie d’une province canadienne à l’autre. Bien que la majorité des provinces permettent aux pharmaciens de prescrire en situation d’urgence et de prolonger ou d’ajuster une ordonnance, seules 4 provinces leur permettaient d’initier une thérapie médicamenteuse, et le champ et les critères encadrant cette activité étaient variables. Malgré des progrès visant à améliorer l’accès des patients aux soins et aux services de santé (notamment à l’aide de la prolongation des ordonnances par les pharmaciens), il est nécessaire d’harmoniser davantage les pratiques cliniques dans l’ensemble du Canada et de permettre aux pharmaciens d’amorcer et de gérer la pharmacothérapie.
MOTS CLÉS: droit de prescrire des pharmaciens, champ de pratique, gestion thérapeutique
In the past decade, pharmacist practice has evolved tremendously in Canada. A paradigm shift, from dispensing of drug products to provision of a service to optimize drug therapy, is under -way with different provinces adopting this change to differing degrees. Although the act of prescribing a drug is important, it is only one tool in the armamentarium to provide optimal care. The evolution of pharmacists’ scope of practice mandates progression of several key factors; to prescribe a drug, a clinician must be able to effectively monitor the therapy and hence may need to order laboratory tests and access their results, know the goals of therapy and be able to assess them, and collaborate effectively with all members of the health care team to ensure seamless care delivery. For sustainability of these pharmacist services, there must be a critical mass of pharmacy professionals capable of performing them, to enable cross-coverage and also to ensure an impact on the health care system. As well, some form of remuneration must be in place, linked to provision of the service and not the drug product, given that this service mandates a process of care that is not evident in simply dispensing a drug.
Alberta was the first province to implement prescribing regulations, and a detailed description of its prescribing model has been published.1 In brief, the Alberta College of Pharmacists adopted the philosophy that the process of pharmacist prescribing should not be limited to a list of drugs or conditions, but rather should encompass a set of skills that would be applicable to any practice area. The prescribing model contained 3 categories: emergency prescribing, adapting a prescription, and additional prescribing authorization (APA) (Table 1). Although all pharmacists listed on the provincial clinical registry may perform emergency prescribing and adapt a prescription, the privilege of APA, once granted, allows a pharmacist to independently prescribe any provincially regulated drug in a collaborative environment. To obtain APA, a pharmacist must have practised for at least 1 year before applying and must submit a formal, detailed application that undergoes peer review by individuals trained in standardized evaluation using criterion-based assessment, with established scores for success.
Table 1 The Alberta Prescribing Model and Clinical Scenarios Presented to Study Participants
In Alberta, the legislative privilege to prescribe provincially regulated drugs was granted in 2007.1 Following this milestone, the regulatory organization (the Alberta College of Pharmacists) created a model for pharmacist prescribing and a process for implementing it. The ability to access laboratory test results was established in 2006, authorization to administer drugs and blood products by injection was made available in 2008, and pharmacists were allowed to order laboratory tests starting in 2010. In addition, a compensation model for the provision of pharmacist services was negotiated between the advocacy body (the Pharmacists’ Association of Alberta, known as RxA) and Alberta Health and was launched in 2012.
Over the past decade, there has also been significant advancement in pharmacists’ practice in other provinces. However, the regulations governing a pharmacist’s ability to prescribe a drug still appear to vary for the same clinical scenario. Provinces have adopted different approvals for pharmacists to monitor therapy (e.g., ordering or accessing results of laboratory tests) and different reimbursement models for pharmacist services. To date, these practice characteristics have not been directly compared. Therefore, the purpose of this study was to describe the state of pharmacist scopes of practices within Canada, with emphasis on prescribing of drugs, using the Alberta model as the reference point.
This survey study focused on jurisdictions having a regulatory body for pharmacists; as such, pharmacists from all 10 provinces were eligible to participate, and those from the 3 territories (Yukon, Northwest Territories, and Nunavut) were ineligible. Pharmacists identified for telephone interviews had to be practising to full scope, such that they would be knowledgeable about the limits imposed by the respective regulatory bodies. The individual pharmacists surveyed were identified through the Canadian Cardiovascular Pharmacist Network (CCPN), a national group of pharmacists who are largely institution-based and who practise to full scope within the field of cardiology. Given the national representation of the CCPN and the proactive clinical practices among its members, delegates from applicable provinces were approached to either participate in the research study or to identify another pharmacist who was also practising to full scope. Given the scenarios presented and the questions posed in the survey, study participants had to have a comprehensive understanding of community-based practices; as such, many of the CCPN pharmacists who were approached recommended a community-based colleague that they knew was practising to full scope. When an interviewed pharmacist was uncertain of a specific detail, the relevant provincial regulatory body was contacted for confirmation or clarification as required. Interviews were conducted between November 30 and December 7, 2015.
Using Alberta’s prescribing model, we developed 4 practical case scenarios, which underwent face validity testing by 3 independent Alberta pharmacists, reflecting each element of the model (Table 1). The scenarios were designed to minimize any clinical concerns or questions and thus focused solely on the act of prescribing. Responses to the scenarios for each element of the Alberta prescribing model were collated to compare and contrast pharmacist services across the country. For each scenario, it was assumed that the pharmacist had the appropriate knowledge, skills, and infrastructure to perform the service at the highest level that the jurisdiction’s scope would allow. Participants were asked also to describe the training and certification programs required to enable prescribing, whether they were able to order or access the results of laboratory tests, and whether they could administer injections (and to describe the training required to do so). The complete survey is available upon request to the corresponding author. Ethics approval was received from the Health Research Ethics Board of the University of Alberta Hospital (protocol 00059315).
A total of 13 pharmacists representing the 9 Canadian provinces other than Alberta were interviewed; the authors supplied information pertinent to Alberta. Most of the pharmacists interviewed (n = 8) were non–CCPN delegates with practices in community pharmacies. For 4 provinces, 2 pharmacists were interviewed together at their request.
Each province has adopted a different model for pharmacist prescribing (Table 2). Pharmacists in 4 provinces (Alberta, Saskatchewan, Manitoba, New Brunswick) could initiate therapy for a chronic disease, although the criteria under which they could do so differed across the provinces. Conversely, almost all provinces had regulations allowing pharmacists to “adapt/renew/extend” prescriptions to enable continuity of care and facilitate smoother transition through the health care system. In doing so, these provinces enabled all pharmacists on their respective registries to perform this level of prescribing.
Table 2 Prescriptive Pharmacist Services as Depicted by Scenarios in Survey*
Outside of the scenarios presented, respondents from many provinces reported prescribing for minor ailments as the most common form of independent prescribing. Quebec, Prince Edward Island, Newfoundland and Labrador, Nova Scotia, and New Brunswick all had regulations allowing pharmacists to prescribe for a list of minor ailments, leaving the specific pharmacologic therapy to the pharmacist’s discretion. Although the lists of conditions were very similar among the provinces where pharmacists were allowed to prescribe for minor ailments, Saskatchewan and Manitoba each had a list of drugs that could be selected for the specified conditions.
The majority of provinces had similar definitions for emergency prescribing and renewing a prescription and enabled pharmacists to perform these functions (Table 1). In most provinces, pharmacists could renew a prescription for up to 90–100 days or no longer than what was previously prescribed; Ontario was the exception, allowing prescriptions to be extended up to 6 months. In British Columbia, pharmacists were able to renew any schedule 1 drug (except for psychiatric medications, unless the pharmacist was working as part of a multidisciplinary team), provided the drug was a long-term medication with no changes in the previous 6 months.
All provinces had regulations in place allowing pharmacists to adapt prescriptions, yet adapting a prescription was found to be the most heterogeneous area of prescribing, with differing provincial definitions. According to the scenario presented, all pharmacists in 6 of the 10 provinces (Alberta, Ontario, Quebec, Prince Edward Island, Nova Scotia, New Brunswick) were able to reduce the dosage independently, whereas those in Saskatchewan and Manitoba could adapt the dose if a collaborative practice agreement (CPA) with a physician was in place. Pharmacists in British Columbia and in Newfoundland and Labrador were unable to adapt the scenario prescription.
Pharmacists in Alberta, Saskatchewan, Manitoba, and New Brunswick could initiate a prescription, with differing criteria. Saskatchewan, Manitoba, and New Brunswick pharmacists were able to initiate prescriptions if they worked in a specific practice area and had a CPA in place with the physician(s) or institution. Provinces mandating these agreements had differing requirements in terms of their submission to the provincial pharmacy regulatory body. In Saskatchewan, it was estimated that 12 pharmacists had a CPA in place (a situation also known as Level 2 prescribing), and these pharmacists were restricted to prescribing drugs on a list contained within the submission. In Manitoba, 6 pharmacists had been designated as Extended Practice Pharmacists by the provincial college. In order to apply, Manitoba pharmacists had to gain specific certification in the identified practice area, have experience (ranging from 1000 to 5000 h), and be working within a collaborative practice. In New Brunswick, 11 pharmacists had CPAs in place with specified physicians, who had to submit a letter of collaboration allowing the pharmacist to order, manage, and modify drug therapy. In Alberta, once APA is granted, the pharmacist can prescribe in any area of practice, based on the presumption that they have the skill set to do so. An estimated 1150 pharmacists in Alberta had APA at the time of our survey. Although Quebec pharmacists were unable to initiate a new prescription in the scenario presented, they could adjust doses to reach a therapeutic target and were allowed to prescribe a new dose to meet the target. The other provinces (British Columbia, Ontario, Prince Edward Island, Newfoundland and Labrador, Nova Scotia) had no provisions in place to enable pharmacists to initiate a prescription for chronic diseases.
Although legislation in the majority of provinces allows access to laboratory test results, the surveyed pharmacists from 5 provinces (Manitoba, Prince Edward Island, Newfoundland and Labrador, New Brunswick, Nova Scotia) reported technical difficulties in implementing such access for all community pharmacists. At the time of the survey, pharmacists from Alberta, Saskatchewan, and Quebec were able to access laboratory results. In terms of ordering laboratory tests, Manitoba, New Brunswick, and Prince Edward Island had legislation enabling pharmacists to do so, but only pharmacists in Alberta and Quebec were performing this function.
All provinces that enabled pharmacists to administer injections required the pharmacists to take a locally approved injection-training course before receiving certification. Nine provinces allowed pharmacists to administer vaccinations, with Ontario pharmacists being restricted to the influenza vaccine only (Table 3). Quebec regulations did not allow pharmacists to administer injections, unless for demonstration purposes. In addition to vaccines, pharmacists certified in Alberta, Manitoba, Prince Edward Island, Newfoundland and Labrador, and Nova Scotia were allowed to administer drugs by injection. New Brunswick had legislation allowing pharmacists to administer drugs by injection; however, the framework for implementation was not yet complete.
Table 3 Reimbursement for Prescribing Services and Administration of Injections by Pharmacists
All provinces that enabled pharmacists to administer publicly funded vaccines had a reimbursement model in place (Table 3). In contrast, only 5 provinces (British Columbia, Alberta, Saskatchewan, Quebec, Nova Scotia) offered provincial coverage for the service of prescribing drugs (emergency prescribing or extending/adapting a prescription) and carried specific criteria as to who would be eligible for coverage. Within the realm of extended CPAs (in Saskatchewan, Manitoba, and New Brunswick) or APA in Alberta (e.g., initial-access prescribing for a chronic disease), Alberta was the only province to have a funding model in place for this service.
Although on the surface it appears that pharmacist practice is similar across the provinces, exploration of specific case scenarios revealed wide variation. Similarities across most provinces were evident in emergency prescribing, extension of prescriptions, and the more technical elements of “adapting” a prescription that benefit patient flow through the health care system (e.g., completing information that is overtly missing from a prescription or correcting an obvious prescription error, changing the dose or dosage form on the basis of product availability from the manufacturer). In contrast, the services of adapting a prescription on the basis of clinical assessment (e.g., organ function or to meet a clinical end point) and initiating a prescription for a chronic disease were more variable and restrictive among Canadian provinces. Outside of the scenarios presented in the survey, there were 7 provinces (Saskatchewan, Manitoba, Quebec, Prince Edward Island, Newfoundland and Labrador, Nova Scotia, and New Brunswick) that enabled pharmacists to prescribe from a defined list of minor ailments.
The scenario specific to initiating a new medication for a chronic disease (asthma) identified 3 provinces (Saskatchewan, Manitoba, and New Brunswick) requiring CPAs; in addition, Alberta pharmacists to whom APA has been granted may perform this service. Although CPAs enable pharmacists to proactively manage drug therapy, they pose barriers to the health care system, overall. These agreements are specific to defined disease areas, with one province (Saskatchewan) setting out a list of associated drugs for these defined areas. With new medications constantly coming to market, the list of drugs may quickly become outdated. With limitations on practice areas, pharmacists may not be able to prescribe medications that are related to the particular disease trajectory yet fall within a separate practice area (e.g., for patients with diabetes, prescribing may be limited to hypoglycemic agents, with no allowance for prescribing dyslipidemic agents). Moreover, with a CPA the pharmacist is performing a delegated function of another health care provider and is thus limited to prescribing only for patients under that physician’s care. This poses many challenges in a free-standing community pharmacy that serves patients under the care of many physicians. Importantly, if the physician revokes the CPA, the pharmacist can no longer provide the level of care that patients may have come to expect. Given the uniqueness of these types of agreements, only a minority (< 1%) of pharmacists in these provinces pursue them. The low uptake for this level of prescribing makes it problematic to ensure that the majority of patients within each province benefit from this care. To be sustainable, the service must be reproducible and ultimately must affect the care of enough patients to warrant funding. Proceeding with variable models across the country is, in many ways, a disadvantage to the profession of pharmacy and ultimately may leave the general public unaware of what a pharmacist may or may not be able to do.
Similar to the situation for prescribing, the administration by injection of vaccines (9 provinces) and drugs (5 provinces) has evolved in most provinces. Conceptually, if a pharmacist is certified to administer an injection, it might be inferred that the service would not be affected by whether the product injected was a vaccine or a drug product. All provinces allowing injections require pharmacists to complete a certification course. In British Columbia, Alberta, Manitoba, Ontario, Newfoundland and Labrador, and Nova Scotia (where Dalhousie University also serves Prince Edward Island and New Brunswick), this training has been integrated into the undergraduate curriculum, enabling all undergraduates to be certified or to apply for injection certification upon graduation. While it is feasible to integrate the knowledge required for the technical skill of administering injections into the undergraduate program, developing a program that will train and equip students to prescribe by the time of graduation may be more challenging. Indeed, it is logical to assume that more practice-based learning (in the form of clinical hours) must be provided to ensure that graduates are capable of performing all prescriptive services. As the profession evolves to provide more clinical-based services, the experiential aspect of undergraduate programs must reflect these changes.
For pharmacists to optimize drug therapy by prescribing medications, a sustainable infrastructure that enables reimbursement as well as access to patient-specific information (laboratory test results, diagnoses) must be in place. Most provinces either are working toward (Manitoba, Prince Edward Island, Newfoundland and Labrador, New Brunswick, Nova Scotia) or have enabled (Alberta, Saskatchewan, Quebec) community pharmacist access to laboratory results, and a minority of pharmacists are now ordering laboratory tests (Alberta, Quebec). In terms of reimbursement, all provinces where pharmacists perform publicly mandated vaccine administration had government funding for this service. In contrast, 5 provinces (British Columbia, Alberta, Saskatchewan, Quebec, Nova Scotia) had some form of reimbursement for the act of prescribing a drug. Pharmacists from the majority of provinces with prescribing reimbursement systems in place expressed concern about the lack of incentive to prescribe, because the time and documentation required to perform this function were prohibitive given the monetary amount provided.
This study had some limitations. By design, we selected clinical scenarios that were common in community practice; however, we quickly learned that our survey did not fully capture the various definitions of prescribing across the provinces. Seven provinces had a minor-ailment category for prescribing, which was not captured in the scenarios, yet this type of prescribing is a major component of pharmacist prescribing in these provinces. Furthermore, we learned of the heterogeneity across provinces with regard to “adaptation”. Our scenario suggested a need to adjust on the basis of renal dysfunction, as opposed to dealing with issues of product availability, errors in the prescription, etc.; as such, we acknowledge that our scenario may have underrepresented what pharmacists in a particular province could do within this category of prescribing. By using a specific clinical scenario, we were able to identify exactly what pharmacists in each province could do in terms of adapting prescriptions—whether it be the strength of the medication or dosage formulation, the duration of therapy, or therapeutic substitutions—which offered a tangible comparison among the provinces. Second, the results may have underestimated the reimbursement provided by provincial governments. Pharmacists in many provinces are reimbursed for medication management or medication review, which is defined differently across the provinces and may not encompass prescribing.9 Within this study, however, we specifically chose to link reimbursement to the prescribing function, so a review of other reimbursement options was beyond the scope of the study. Third, although we chose to focus on the opinions of pharmacists practising to full scope, we fully acknowledge that many other factors may influence the integration of new roles as pharmacist scopes of practice within Canada evolve, for example, variations in the provincial legislation that regulates pharmacist activities, infrastructure support to perform these activities, and settings (hospital, community, etc.). A focused examination of the different regulatory environments across the provinces would add an important perspective to this issue, but was beyond the scope of the current study.
The role of the pharmacist has changed significantly throughout the nation, from solely dispensing drug products to enabling smoother transitions through the health care system with emergency prescribing, prescription extensions, and some forms of prescription adaptation, but there is still a vast degree of variation among the provinces. We identified 4 provinces where pharmacists can initiate therapy for a chronic disease, as well as 3 provinces mandating CPAs, for which there has been limited uptake (6–12 pharmacists per province). Alberta has taken the broadest approach to pharmacist prescribing, through APA, which emphasizes the process of prescribing without limiting the process to specific diseases or drugs, and this province has experienced good uptake of this option (1150 pharmacists). With pharmacy schools across the nation having to provide a standardized level of education, practising pharmacists ought to be enabled to deliver a standardized level of patient care services. The variation in pharmacist prescribing observed in this study is limiting for the profession of pharmacy in many ways, and the next step as a nation may be to work toward harmonizing pharmacists’ authority to provide prescriptive services.
1 Yuksel N, Eberhart G, Bungard TJ. Prescribing by pharmacists in Alberta. Am J Health Syst Pharm. 2008;65(22):2126–32.
2 Amendment to orientation guide – medication management (adapting a prescription). Vancouver (BC): College of Pharmacists of British Columbia; 2008 [revised 2001 Feb, 2016 Apr; cited 2016 Apr 28]. Available from: http://library.bcpharmacists.org/6_Resources/6-2_PPP/1017-PPP58_OrientationGuide.pdf
3 Guidelines for prescribing minor ailments and patient self-care prescribing. Saskatoon (SK): University of Saskatchewan, medSask; [updated 2016 Mar; cited 2016 Apr 28]. Available from: http://medsask.usask.ca/professional/guidelines/
4 Expanded scope of practice. Winnipeg (MB): College of Pharmacists of Manitoba; 2010 [cited 2016 Apr 28]. Available from: http://mpha.in1touch.org/site/expandedscopeofpractice?nav=practice
5 Practice directive prescribing of drugs by pharmacists. Cornwall (PE): Prince Edward Island College of Pharmacists; 2014 [cited 2016 Apr 28]. Available from: http://pei.in1touch.org/uploaded/web/PEI%20Proposed%20Standards%20for%20Prescribing%20final%20draft.pdf
6 Prescribing by pharmacists. St John’s (NL): Newfoundland and Labrador Pharmacy Board; 2015 [cited 2016 Apr 28]. Available from: www.nlpb.ca/media/SOPP-Prescribing-by-Pharmacists-Aug2015-revFeb2016.pdf
7 Assessing and prescribing for minor ailments. Dartmouth (NS): Pharmacy Association of Nova Scotia; [cited 2016 Apr 28]. Available from: https://pans.ns.ca/public/pharmacy-services/assessing-prescribing-minor-ailments
8 Minor ailment assessments. Fredericton (NB): New Brunswick Pharmacists’ Association; [cited 2016 Apr 28]. Available from: http://nbpharma.ca/minor-ailment-assessments
9 Pammett R, Jorgenson D. Eligibility requirements for community pharmacy medication review services in Canada. Can Pharm J. 2014;147(1):20–4.
Competing interests: Tammy Bungard has received speaker’s honoraria from Bayer and Bristol-Myers Squibb, as well as unrestricted research grants from Bristol-Myers Squibb-Pfizer, and Bayer for work outside the topic of this article. Surya Bhatia and Scot Simpson have nothing to disclose. ( Return to Text )
Funding: None received. ( Return to Text )
The authors gratefully acknowledge the following pharmacists who completed the survey: Elaine Lum and Joan Cote (British Columbia), Bill Semchuk and Lindsay Richels (Saskatchewan), Peter Thompson and Nicole Nakatsu (Manitoba), John Papastergio (Ontario), Denis Brouillette (Quebec), Stephanie Young (Newfoundland and Labrador), Doug Doucette (New Brunswick), Andrea Kent (Nova Scotia), and Paul Jenkins and Crystal MacEachern (Prince Edward Island).
Canadian Journal of Hospital Pharmacy, VOLUME 70, NUMBER 5, September-October 2017