him q&a

II Secti'on III: Practice Lab Case Study This case is adapted from Kelly, D. L., and S. L. Pesto Causal Loop Diagrams to Facilitate Double Loop Learning ic Delivery Setting." Unpublished manuscript.

Mrs. B was a 66-year-old widow living on a fixed 11' ~~ •• '--'''- been diagnosed with high blood pressure and osteoporosi - doctor knew her well. When he selected the medication wi her high blood pressure, he took into account her age, the fazz '-_ osteoporosis, and other issues. He chose a drug that had p for patients like Mrs. B and that had minimum side effects. _ on the medication for ten years. Her insurance covered medication, except for a small out-of-pocket copayment.

The last time Mrs. B went to her local pharmacy to re tion, the pharmacist informed her that her insurance company h2.5: c==:-:.;:_ with a pharmacy benefits management (PBM) company. (The company is to perform a variety of cost-cutting services for h plans. One of these services is to decide which drugs an insuran will pay for; the PBM company's preferred-product list is known - . lary.) If Mrs. B wanted to continue to take the same medication cost her five times her usual copayment. She was quite disturbed could not afford this price increase and did not fully understan - ance company's new policy. The pharmacist offered to call Mrs. • explain the situation, and ask him whether he would change her p..,.,....:--..- to the PBM-preferred brand. When the physician was contacted aware of the PBM company's action and was not completely familiar preferred product. The pharmacist discussed Mrs. B's predicament physician and described the financial consequences of her continuing her original prescription. After this discussion with the pharmacist, - cian concluded that his only option was to approve the switch, whi - -

Mrs. B began taking the new brand of high-blood-pressure •.•.._...•...~ One week after starting on the new drug, she developed a persiste - that aggravated her osteoporosis and caused her rib pain. When the

•and pain continued for another week, Mrs. B began to take over-the- medicines for the pain. She unknowingly opened herself to a reaction ho-.".....- her blood pressure medication and the pain medication: orthostatic h,_ sion (lightheadedness when rising from a lying to an upright position morning on her way to the bathroom, she fainted, fell, and broke h She was admitted to the hospital for surgery, where she developed a tract infection. The infection spread to her repaired hip, which resulrec bloodstream infection that eventually led to her death.