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  • January 01, 2009 2:17 PM | Brad Miller (Administrator)

    In the January WMSHP Newsletter, Brenda (Schulz) McCracken, a PGY-1 Pharmacy Resident at Spectrum Health, writes about managing hyperglycemia at her institution using basal-bolus insulin order sets.


    Importance of Inpatient Hyperglycemic Management

    Brenda J. (Schulz) McCracken, PharmD

    When insulin is ordered for a patient who has high blood glucose levels, practitioners tend to think that the patient must have a history of diabetes mellitus (DM). However, this is not necessarily true. In a study by Umpierrez et al (2002), hyperglycemia was present in 38% of patients admitted to the hospital, of which 12% had no history of DM before the admission.1 If the patients do not even have DM, why are their blood glucose levels elevated and why do practitioners bother initiating the patients on insulin therapy while in the hospital? Will high blood glucose levels for a few days really affect anything?

    It has been shown that hyperglycemia may be an independent risk factor for an increased risk of infection.2 In fact, patients with poor glucose control (at least one blood glucose value >220 mg/dL) undergoing major cardiovascular or abdominal surgery are at nearly 6 times the risk of serious postoperative nosocomial infections compared to patients with adequate blood glucose control (all blood glucose values ≤220 mg/dL).2 Hyperglycemia can also lead to increased morbidity and mortality in patients undergoing coronary artery bypass grafting and in patients with stroke.2-5

    A landmark study by Van den Berghe et al (2001) showed that maintaining controlled blood glucose levels via insulin continuous infusions significantly improved clinical outcomes among critically ill patients.6,7 This trial demonstrated a 43% reduction of intensive care unit (ICU) mortality and a 34% decrease in overall hospital mortality in patients whose average blood glucose levels were maintained at 103 mg/dL, with a target range of 80-110 mg/dL. The strict control of blood glucose was associated with fewer blood stream infections, reduced frequency of neuropathy, lower incidence of dialysis-dependent renal failure, fewer blood transfusions, and less need for mechanical ventilation. In addition, more recent studies have shown that poor blood glucose control is related to adverse outcomes, including mortality, infectious complications, longer hospital stays, and more costly care.6

    Although attention is often focused on controlling blood glucose levels in patients undergoing major surgeries and patients in the ICU, hyperglycemia is actually a major issue for all other inpatients as well. In fact, it is normal for many patients to have what is termed “stress hyperglycemia,” which is elevated blood glucose levels associated with acute illness.6 The body naturally increases blood glucose levels in response to injury, stress, certain medications, severe illness, or surgery. Even though hyperglycemia may be a natural response to illness for some patients, numerous studies have clearly shown that uncontrolled hyperglycemia negatively affects patient outcomes.2-7 As a result, tight glycemic control for all inpatients is becoming a healthcare priority and a standard of care.6 The recommended targets for blood glucose levels in hospitalized patients according to the American Diabetes Association are shown below in Table 1.9

    Table 19
    Patient Population Goal Blood Glucose Levels
    Critically ill patients As close to 110 mg/dL as possible and generally <180 mg/dL
    Non-critically ill patients Pre-meal (fasting): As close to 90-130 mg/dL as possible and generally around 110 mg/dL
    Postprandial: <180 mg/dL

    In response to research showing the significant benefits of controlling inpatient hyperglycemia, Spectrum Health has recently implemented new basal-bolus insulin order sets. In addition, all sliding scale insulin order sets have now been officially eliminated at Spectrum Health in order to provide tighter glycemic control for our patients through evidence-based medicine. Basal-bolus insulin regimens more closely mimic the body’s natural physiologic secretion of insulin (Figure 1) and provide continuous 24-hour coverage with basal insulin (i.e. insulin glargine). Also, basal-bolus regimens use a proactive rather than reactive approach to prevent future episodes of hyperglycemia. On the other hand, sliding scale regimens did not provide any insulin to patients until their blood glucose levels were already significantly elevated and the rapid-acting insulin doses often over-corrected the blood glucose level, resulting in undesirable frequent episodes of hypoglycemia.

    Fear of hypoglycemia is the primary barrier to achieving target blood glucose levels in patients.6 Many healthcare providers are more concerned about avoiding hypoglycemia rather than detecting and controlling hyperglycemia, which is potentially the more profound threat to inpatient safety.6 Instead of reducing insulin therapy to avoid hypoglycemia, several strategies can be used to prevent it, such as increasing the frequency of blood glucose monitoring, establishing higher thresholds for withholding insulin doses, and adjusting for changes in the patient’s medical status and nutritional intake (i.e. new NPO status, interruption of TPN or IV dextrose infusions, tapering of steroid medications, etc).

    With strict hyperglycemic management and the appropriate use of insulin therapy, Spectrum Health can reduce hospital lengths of stay, decrease costs, improve therapeutic outcomes, and prevent patient mortality.



    1. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002 Mar;87(3)978-82.
    2. Pomposelli JJ, Baxter JK 3rd, Babineau TJ, Pomfret EA, Driscoll DF, Forse RA, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr. 1998 Mar-Apr;22(2):77-81.
    3. Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003 May;125(5):1007-21.
    4. Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ. 1997 May 3;314(7090):1303-6.
    5. Jorgensen H, Nakayama H, Raaschou HO, Olsen TS. Stroke in patients with diabetes. The Copenhagen Stroke Study. Stroke. 1994 Oct;25(10):1977-84.
    6. Hirsch IB, Braithwaite SS, Verderese CA. Practical management of inpatient hyperglycemia. Lakeville (CT): Hilliard; 2005.
    7. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-67.
    8. Ergun-Longmire B, Ten S, Maclaren N. Management of type-1 and type-2 diabetes in children. In: New M, editor. Pediatric endocrinology. 2005 May 5. Available from: http://www.endotext.org/pediatrics/
    9. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2005;28:S4-S36.
  • December 19, 2008 2:18 PM | Brad Miller (Administrator)

    Once again, it is time for our second session of WMSHP. I hope you all had a good holiday season. I can’t believe how quickly 2008, and my term as WMSHP President, has passed. It has been a great experience to serve you, the members of WMSHP, this past year.

    I’d like to welcome 4 new board members to the WMSHP Executive Board. Angela Green (Mercy Health Partners), Andrea Goodrich (Saint Mary’s Health Care), Kali Schulz (Ferris State University), and Bridgette Sharif (Borgess Medical Center) were all elected to the board in our general November election. Current board member, Natalie Paul (Spectrum Health) will serve as our President-Elect for 2009 and Brad Miller, also from Spectrum Health, will continue his role as WMSHP Secretary. Thanks to everyone who participated in the voting process.

    Please join us at our January meeting. Please note that the January meeting has been scheduled for January 15. John Jameson, PharmD, Professor-Pharmacy Practice, from Ferris State University will discuss “Management Problems in Diabetes.”

    Also, please see our website (www.wmshp.net) to determine if your membership is ready to expire. To do this, click on “Update Address” which you can find in the left-column, then enter your membership number. If you receive the newsletter via email, you can check your membership expiration date by clicking the link on the top of newsletter. 

  • November 01, 2008 2:19 PM | Brad Miller (Administrator)

    Remember to Vote: The ballots are out! By now, you all should have received an official WMSHP ballot in the mail. The ballot may be mailed back to Brad Miller, WMSHP Secretary, handed in to an Executive Board member, or turned in at the November WMSHP meeting in Kalamazoo. There won't be extra ballots available at the monthly meeting, so keep that in mind.

    MSHP Annual Meeting: Try to make it to the MSHP Annual Meeting being held November 14 at the Radisson Hotel in Lansing. There are a variety of topics for both Pharmacy Technicians and Pharmacists. You can register on-line at www.michiganpharmacists.org.

    Join us at our next monthly meeting where Kevin Hess, MD will discuss "Similarities and Differences Among SSRI's for the Treatment of Depression." The meeting will be held at the Sol World Cafe inside the Radisson Plaza Hotel in Kalamazoo

  • October 01, 2008 2:20 PM | Brad Miller (Administrator)

    Important Notice - Please Read: After lengthy discussions regarding the best way to conduct WMSHP elections, the WMSHP Executive Board has decided to adopt a method of voting that is similar to the voting structure of both MSHP and MPA. The new WMSHP voting structure is also in-line with our current bylaws. Each active WMSHP member will be mailed an official ballot. The ballot may be mailed back to Brad Miller, WMSHP Secretary, handed in to an Executive Board member, or turned in at the October WMSHP meeting in Grand Rapids or the November WMSHP meeting in Kalamazoo. To eliminate the possibility of voting multiple times, there will not be extra ballots available at the monthly meetings. Please do not attempt to fax the ballots. To verify that WMSHP has your current address, log in to our website at www.wmshp.net and select "Update Address".

    We are still working on developing the best process to obtain CE and funding for our monthly meetings with the new Pharmaceutical Research and Manufacturers of America (PhRMA) guidelines. The updated code will take effect January 2009. We are still not sure how this will affect our monthly meetings, but we will be sure to let you all know as soon as possible.

    Volunteer Opportunity: The Michigan Pharmacy Week Health Fair is being held in Baldwin, MI on Saturday, October 18 from 11 a.m.-3 p.m. at St. Ann's Human Services Center on 690 9th Street. Volunteers are needed to help with medication reviews and screening activities.

    Please join us for our October meeting being held in at Tre Cugini Grand Rapids. Gregory Pratt, Emergency Preparedness Coordinator for the Michigan Pharmacists Association will be speaking on Bioterrorism.

  • September 30, 2008 2:20 PM | Brad Miller (Administrator)

    Natalie Paul received her Pharm.D. from Purdue University and completed a residency with McKesson Medication Management at Mercy Hospital and Medical Center in Chicago, IL. After completion of her residency she worked for Ferris State University as an Assistant Professor of Pharmacy Practice with a focus of Internal Medicine. Recently, Natalie has taken the role of Clinical Specialist- Staff Development and Residency Program Director of the PGY-1 Residency at Spectrum Health. She has been a member of the WMSHP board since 2005.

    Brad Miller is a clinical pharmacist in the Emergency Department at Spectrum Health's Butterworth Campus. He is a graduate of Ferris State University, and completed a pharmacy practice residency at Spectrum Health. He has served as WMSHP's Secretary since 2004, and has maintained WMSHP's website since 2003

    Andrea Goodrich is a clinical pharmacist at St. Mary's Health Care in Grand Rapids. Andrea received her B.S. in pharmacy from Ferris State University in 2001 and Pharm.D. from Midwestern University in 2006. Andrea currently works on the orthopedics/neurology unit and the Anticoagulation Management Service at St. Mary's Hospital. Other professional areas of interests include internal medicine and infectious disease/HIV medication therapy. Andrea has been a member of WMSHP since 2001 and is serving as a committee member for MPA membership committee since 2007. Andrea's professional affiliations also include ACCP, MPA, MSHP, and ASHP.

    Angela Green currently serves as the Pharmacy Education Coordinator and geriatrics specialist for Mercy Health Partners and is a residency preceptor and adjunct professor for Ferris State University. She graduated pharmacy school from Ferris State University in 2006 and completed a residency with ambulatory focus at Mercy General Health Partners in 2007. She has been an active member of WMSHP since 2007.

    Kali Schulz is a 2007 graduate of Ferris State University, College of Pharmacy. Upon graduation, she went on to complete a PGY-1 Residency at Saint Mary's Health Care in Grand Rapids. While enrolled in the PGY-1 Residency program, she also completed the Teaching and Learning Certificate Program at FSU. Schulz most recently accepted a position as an Assistant Professor of Pharmacy Practice at Ferris State University College of Pharmacy. This opportunity has allowed her to return to Saint Mary's while precepting fourth-year pharmacy students on their internal medicine clerkship. Schulz has been a member of WMSHP for two years and was the 2005 recipient of the WMSHP Scholarship. She is also an active member of ACCP and MPA.

    Bridgette Sharif graduated with her Doctor of Pharmacy degree from Wayne State University in 2004 and subsequently completed a pharmacy practice residency at the University of Wisconsin Hospital and Clinics. She relocated to western Michigan in 2006 and has since been working as a clinical pharmacy specialist at Borgess Medical Center in Kalamazoo, Michigan. Her primary interest areas are cardiology and anticoagulation management. She has been a WMSHP member since 2006.

  • September 01, 2008 2:21 PM | Brad Miller (Administrator)

    Once again it is time for another fall session of WMSHP. I hope that you all had a wonderful summer and are looking forward to a great year of education and networking within WMSHP.

    During the summer the WMSHP Executive Board has been busy preparing for the year ahead. We are currently seeking nominations for Executive Board members. According to the WMSHP bylaws, only active members of WMSHP may be nominated for executive board positions. If you are interested in being a board member or know of other interested candidates, please submit their name, contact information, and a brief description of current practice and professional interests to WMSHP Secretary, Brad Miller, at email: webmaster@wmshp.net.

    Another important item to mention is the new code established by the Pharmaceutical Research and Manufacturers of America (PhRMA) to guide the interactions of pharmaceutical representatives and healthcare professionals. The new guidelines became effective July 2009 and may affect the ability of pharmaceutical companies to sponsor continuing education programs. To get an event sponsored, WMSHP may have to apply for educational grants each month. We will let you know more specific information as the effect of the new guidelines becomes clearer.

    Hope you can make it to our first meeting being held at Bravo Restaurant and Cafe in Portage (Kalamazoo). Dr. Jihad Mustapha will discuss the use of LMWH in the advanced cardiac setting.

  • April 01, 2008 2:21 PM | Brad Miller (Administrator)

    Spring has sprung! The return of Spring reminds me of our upcoming WMSHP Spring Seminar, which is scheduled for May 22, 2008 at the 28th Street Hilton in Grand Rapids. Make sure you put it on your calendar.

    Another Spring event is the selection of a recipient for the annual WMSHP scholarship. One scholarship in the amount of $1000.00 is awarded to a 3rd year pharmacy student from Ferris State University, the University of Michigan, or Wayne State University. The pharmacy student must be a native or current resident of the Western Michigan area, demonstrate involvement and/or leadership within professional organizations, and express an interest in health-system pharmacy upon graduation. The applicant must fill out an application form before the deadline of March 31. The scholarship recipient will be selected by the WMSHP board and the scholarship will be presented at the Spring Seminar.

    Hopefully many of you were able to make it to the MPA ACE meeting. A highlight for WMSHP was the recognition given to our current Past-President, Ryan Bickel. Ryan received the MPA Distinguished New Pharmacist Practitioner award. This is the 3rd year in a row that a member of WMSHP has won this award. Previous winners were Jodie Backus and Jesse Hogue. Congratulations, Ryan!

    Our next meeting will be held April 10, 2008 at Sam's Joint in Plainwell. Two area pharmacy residents will be presenting their Great Lakes Pharmacy Residency Project. Bailee Wienke is a pharmacy practice resident at Spectrum Health in Grand Rapids. Her project is entitled "Heparin Induced Thrombocytopenia in the Critically Ill: Value of the 4T Score and Compliance with Evidence-based Guidelines". Betsy Hoida is a pharmacy practice resident at Mercy General Health Partners in Muskegon. The title of Betsy's project is "A Pharmacist-Managed Medication Reconciliation Process".

  • March 01, 2008 2:21 PM | Brad Miller (Administrator)

    As in years past, our April meeting will feature continuing education presentations from 2 local pharmacy residents. It is good practice for the residents and a great way to highlight some of the remarkable and interesting projects that take place at health-systems in western Michigan. Each resident will present their major residency project. This is the same project that they will discuss at the Great Lakes Pharmacy Residency Conference at the end of April. Ten area residents submitted descriptions of their project. The WMSHP board selected projects submitted by Bailee Wienke, Pharm.D. and Betsy Hoida, Pharm.D.

    Bailee Wienke is a pharmacy practice resident at Spectrum Health in Grand Rapids. Her project is entitled "Heparin Induced Thrombocytopenia in the Critically Ill: Value of the 4T Score and Compliance with Evidence-based Guidelines".

    Betsy Hoida is a pharmacy practice resident at Mercy General Health Partners in Muskegon. The title of Betsy's project is "A Pharmacist-Managed Medication Reconciliation Process".

    Our next meeting will be held March 13, 2008 at Pietro's Italian Restaurant in Grand Rapids. Tracey Mersfelder, Pharm.D., BCPS will be discussing therapy for neuropathic pain.

    With spring right around the corner, don't forget about our annual WMSHP Spring Seminar scheduled for May 22. More information will be sent out in the future.

  • February 01, 2008 2:22 PM | Brad Miller (Administrator)

    Well, I guess we can say that winter is finally here. I hope you are all staying warm and safe on those icy Michigan roads. The results are in from our membership survey regarding the ACPE guidelines for standards for commercial support. The majority of our membership wish to continue with our current format of dinner and a live CE presentation. To accomplish this it is likely that the average meeting time will lengthen by about a half-hour.

    As the WMSHP representative, I attended my first MSHP board meeting and committee day on January 17. MSHP has been working hard on the 2nd version of Changing Perceptions, a promotional brochure aimed at accurately presenting what clinical activities pharmacists do. Changing Perceptions is used to promote the profession of pharmacy to state and federal legislators as well as the general public. The initial version of Changing Perceptions is still available in pdf form on the MSHP website at http://www.michiganpharmacists.org/pharm_prof/changing_perceptions.htm.

    The new version will be available sometime in the next few months. I encourage all of you to get involved and join a MSHP committee. What a great way to positively affect our profession and network with other pharmacists from across the state of Michigan.

    Don't forget to attend the 2008 MPA Annual Convention and Exposition February 29-March 2 in Dearborn. Registration information can be found on MPA's website at www.michiganpharmacists.org .

    Coming soon: Please note that our next meeting will be held on February 21, 2008 at the Sol World Cafe in Kalamazoo. Dr. Kahn Nedd will be discussing the use of beta blockers in hypertension.

  • January 31, 2008 2:22 PM | Brad Miller (Administrator)

    In the February WMSHP Newsletter, Chelsey Skiba, a Ferris State University Pharm.D. Candidate, writes of the benefits of pharmacists performing medication reconciliation.


    Are pharmacists more effective at promoting patient safety by performing medication reconciliation compared to other healthcare professionals?

    Evidence Based Answer
    Evidence suggests that pharmacists do promote patient safety by performing medication reconciliation more effectively than other health care professionals (Strength of Recommendation [SOR]: C-, based on six pilot studies). Pharmacists performed more complete medication histories by identifying a higher average of home mediations per patient than other health care professionals (SOR: C-, based on four pilot studies). Pharmacists identified more discrepancies between home medication orders and medication histories than nurses (SOR: C-, based on two pilot studies).

    Evidence Summary
    An accurate and complete medication history is important because if it is incorrect it can lead to inappropriate drug treatment. According to a pilot study carried out by Nester and Hale, patients who had a pharmacist take their medication histories rather than a nurse received a significantly larger fraction of clinical interventions (34% vs. 16%, p<0.001). It was also found that nurses had significantly fewer patients noted as taking a herbal/nonprescription medication than the pharmacists (70% vs. 98%, p<0.001). Patients' community pharmacies were also contacted significantly more often by pharmacists than by nurses for clarification (24% vs. 4%, p<0.001).1 Nester concluded that pharmacists are more effective at taking medication histories than nurses, but a small sample size and representation are limitations to this study.

    In a pilot study performed by Gleason et al, pharmacists conducted medication histories and reconciled the information received with the patients chart history, which was first obtained by doctors and nurses. When a medication discrepancy was noted between the two histories the pharmacist would alert the doctor and if the doctor acted on the discrepancy it was defined as an error and was then accessed for its potential to have caused patient harm. Physicians adhered to pharmacists suggestions about the discrepancies the bulk of the time (n = 69/97 or 71%). Complete omission of a drug that a patient was on prior to hospitalization was the discrepancy requiring intervention most frequently (n= 41/97 or 42%). The authors then used the National Coordinating Council for Medication Error Reporting and Prevention's (NCCMERP) 9-point rating scale to determine potential patient harm if the intervention had not been made in the first 24-48 hours of admission. They noted 38/69 (55%) of the discrepancies fell into the least likely to cause harm category (A-C). On the contrary, if 15/69 (22%) of the discrepancies had not been intervened by a pharmacist the patient outcome could have resulted in harm (categories E & F).2 Gleason concluded that medication reconciliation by a pharmacist may have prevented patient harm, but this is up to interpretation due to the descriptive nature of their statistics. Lessard et al performed a similar study to describe medication discrepancies in senior patients and found that the majority (57%) of the discrepancies noted were omissions also. They used a modified version of the NCCMERP and found that a portion (25.8%) of the discrepancies fell into the category that could have necessitated monitoring and/or intervention to prevent harm (category D).3

    A pilot study completed in a hospital's inpatient behavioral health unit comparing nurse and pharmacist obtained medication histories found that pharmacists identified a significantly higher average number of medications per patient than nurses (5.3 vs. 4.0, p<0.05).4 A pilot study carried out in a hospital Emergency Department (ED) had 252 patients complete medication histories by an ED provider and then by a pharmacist. ED providers only identified 817 home medications from the same patients that pharmacists identified 1096 home medications.5 Another study in the ED compared the effect a pharmacist had on a hospitals medication reconciliation form that was usually filled out by a nurse and found that pharmacists had significantly less errors upon completion of the form than the nurses (3% vs. 59%, p = 0.001). The nurses also recorded significantly less allergy documentation than the pharmacists (79% vs. 100%, p = 0.001).6

    Author Comments
    The 2008 National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) necessitate that "medications are accurately and completely reconciled across the continuum of care." JCAHO rational stated that medication reconciliation is "essential in the reduction of transition related adverse drug effects."7 Although JCAHO does not recommend a specific health care professional be responsible for medication reconciliation the American Pharmacists Association recommends that "pharmacists be responsible for reconciling medication use when patients move between practice settings within the continuum of care".8 The American Society of Health-Systems Pharmacists set a goal for their 2015 initiative for pharmacists to be "involved in managing the acquisition, upon admission, of medication histories for the majority of inpatients with complex and high-risk medications in 75% of hospitals".9


    1. Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Ann J Health-Syst Pharm. 2002;59(22):2221-25.
    2. Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitilzed patients. Am J Health-Syst Pharm. 2004;61(16):1689-95.
    3. Lessard S, DeYoung J, Vazzana N. Medication discrepancies affecting senior patients at hospital admissions. Am J Health-Syst Pharm. 2006;63(8):740-3.
    4. Lizer MH, Brackbill ML. Medication history reconciliation by pharmacists in an inpatient behavioral health unit. Am J Health-Syst Pharm. 2007;64(10):1087-91.
    5. Carter MK, Allin DM, Scott LA, Grauer D. Pharmacist-acquired medication histories in a university hospital emergency department. 2006;63(24):2500-2503.
    6. Hayes BD, Donovan JL, Smith BS, Hartman CA. Pharmacist-conducted medication reconciliation in an emergency department. 2007;64(16):1720-3.
    7. Joint Commission on Accrediation of Healthcare Organizations. 2008 National Patient Safety Goals.http://www.jointcommission.org/NR/rdonlyres/82B717D8-B16A-4442-AD00-CE3188C2F00A/0/08_HAP_NPSGs_Master.pdf (accessed 2007 Sept 24).
    8. American Pharmacists Association. Final Report of the 2007 APhA House of Delegates.http://www.pharmacist.com/AM/Template.cfm?Section=Search1&section=About_APhA1&template=/CM/ContentDisplay.cfm&ContentFileID=3311 (accessed 2007 Sept 24).
    9. American Society of Health-Systems Pharmacists. 2015 Health-System Pharmacy Initiative. http://www.ashp.org/s_ashp/docs/files/2015_Goals_Status_0307.pdf 
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