DRUG UTILIZATION PROCESS

● Pharmacotherapy - “Ano yung kailangan

OUTLINE niyong gawin to achieve the plan made for
the patient who has an infectious disease”
I. Drug Utilization Process ● It includes treatment planning.
a. Key points ● Pharmaceutical care
b. Categories of
Medication-related problems KEY POINTS
II. Pharmaceutical Care ● Comprises a set of functions that promote
III. Focused Area of Practice the safe, effective and economic use of
IV. Key elements of the Pharmaceutical medicines for individual patients
Care process ○ As much as possible, we should
a. Assessment recommend medications that are
b. Care Plan feasible for them, and affordable, in
c. Evaluation order for them to complete their
V. Clinical Pharmacy Functions and treatment course.
Knowledge ○ If the patient does not complete the
a. Step 1: Establishing the need treatment medication, especially with
for drug therapy antibiotics, it will lead to problems
b. Step 1.1 Relevant patient details with antibiotic resistance.
c. Step 1.2 Medication History ● Shift of the pharmacist from a
d. Step 2: Selecting the medicine product-oriented role towards direct
e. Step 2.1: Identify drug-patient engagement with patients & problems they
interactions encounter with medicines.
f. Step 2.2: Identifying ○ more engaged with the patient
drug-disease interactions ● Pharmaceutical care is a cooperative,
g. Step 2.3: Drug-drug interactions patient-centered system for achieving
h. Step 3: Administering the specific and positive patient outcomes from
medicine the responsible provision of medicines.
i. Step 3.1 Calculating the ○ Positive patient outcomes - you were
appropriate dose able to reach your treatment goal
j. Step 3.2: Selecting an which is to cure the patient and to
appropriate regimen have the least or no side effects
k. Step 4: Providing the medicine from medication
l. Step 5: Monitoring Therapy ● The three key elements of the care process
m. Step 6: Patient advice and are
education 1. Patient Assessment
n. Step 7: Evaluate effectiveness - know your patient before you
VI. Patient Information give medication (it has to be
VII. Disease Information custom fit to the patient)
VIII. Medication Information - Ex. Is your patient a child or
IX. Medication errors elderly? What is the sick?
Does he/she have
comorbidities?
2. Determining the Care Plan
- care plan - medication has
been decided on.
DRUG UTILIZATION PROCESS

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 -Questions would be: What is
the dose? How will be the
dosing regimen? Is it given
for 10 days? or 1 week?
Should you change the
medication? How will you
monitor the treatment?
- In children, you still have to
compute the dosing
3. Evaluating the outcome
- (1) Good Outcome (patient
has been cured due to
medication or antibiotic) or
(2) Bad Outcome (Patient
was not cured bc medication
did not match (treatment
failure) or toxicity
● Greatest sin by pharmacists is to
introduce another disease because of
your drug
● The ability to consult with patients is a key
process in the delivery of pharmaceutical
care and requires regular review and
development regardless of experience.
○ Always go back to the patient
○ Monitor w the patient
● KNOW THE PATIENT
● KNOW THE DISEASE
● KNOW THE DRUG
● Whenever planning for treatment or drug
regimen, you have to consider the patient.
● For example, cholera
○ you have to know the disease, then
the drug (recommend: Doxycycline).
Always Include the patient.
● If you have a patient that is 42 y.o. male,
with cholera, Doxycycline can be given, but
take note if he has a previous skin disease.
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● Or 32 y.o. female with cholera. We have to
check if Doxycycline because what if she is
pregnant? If pregnant, Doxycycline is a big
NO.
● Or 10 y.o. male, can Doxycycline be given?
Doxycycline is contraindicated in children
because of retarded bone growth.
● Medication-related problems have
brought the need for pharmacists in the
clinical setting
○ You need a pharmacist in the
healthcare team
○ You need to be the one to prevent
additional diseases because of drug
treatment
○ Drug interactions
CATEGORIES OF MEDICATION RELATED
PROBLEMS
● These are things you have to watch out for,
especially in clinical cases
Untreated indication
● Ex. wound infection in the foot, but antibiotic
was not given.
● Ex. There is a pus formation in the skin but
did not drink antibiotics. The wound has
developed, edema
Treatment without indication
● Every medicine should have a purpose
● Ex. Sipon (viral origin - viral allergic rhinitis),
but the patient is drinking Co-Amoxiclav
(antibacterial drug). Co-amoxiclav will have
no role, therefore, treatment without
indication.
● Root cause of Antibiotic resistance
Improper Drug Selection
● Ex. wound is caused by Staphylococcus
Aureus (beta-lactamase-producing
bacteria), but your patient is taking
Amoxicillin. S. Aureus is resistant to
Amoxicillin
● Root cause of Antibiotic resistance
● We have to choose the appropriate drug
for the disease
*Narrow spectrum
- limited species of bacteria
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*Wide spectrum
- many types of bacteria
- all bacteria can be killed
- reserved as last resort for worst-case
scenarios.
- If given when not needed, resistance may
occur.
Too little, too much drug
● Too little - underdose
○ Often experienced in children
○ In children, antibiotics are computed
based on their body weight.
● Too much - overdose
○ toxicity
Non- compliance
● Hindi natatapos yung treatment/medication
● Can be attributed to underdose
● Another cause for antibiotic resistance
○ Patient should drink the antibiotic for
10 days, but he/she only drank it for
2 days.
● Issue in tuberculosis
● TB-DOTS - Directly observed treatment
short course (6 months)
○ having 6 months supply, some tend
to sell it due to financial problems or
worse they dont drink it anymore.
Reasons for Non-compliance
● Financial problem
● Age
○ elderly - tends to be forgetful
● Side effects - such as Allergic reaction
● They have been cured already that is why
they stopped taking the medications
○ We have to educate them
Adverse Drug reaction
● Ex. The common ADR of Doxycycline is
phototoxicity
● Give them advice on the ADR of
phototoxicity (put sunblock when going out)
Drug Interaction
● Ex. Drug interaction between warfarin and
third generation cephalosporins
○ Patient with problem in clothing,
previous stroke using warfarin.
Taken with oral cephalosporin can
cause massive bleeding, because
oral cephalosporin can enhance the
bleeding from warfarin.
● When there is drug interaction you must
know the outcome of the two drugs
● Ex. Tetracycline and Antacids
○ Tetracycline will form a chelate
when given with antacids, the
antacid will interfere with
tetracycline, making it less effective
resulting in treatment failure.
○ Intervention: Give Tetracycline and
antacids 4 hours apart (depending
the which drug is more needed)
PHARMACEUTICAL CARE
● Predicated on a patient-centered approach
to identifying, preventing or resolving
medication-related problems
● Pharmacist cooperates with a patient and
other professionals in designing,
implementing, and monitoring a therapeutic
plan that will produce specific outcomes for
the patient
○ doctors and nurses
■ Nurses help pharmacists in
administration
■ Doctors - overall, especially
monitoring treatment, goals,
CAPTAIN
● To achieve this aim is to establish a
therapeutic relationship = partnership in
which the pharmacist takes responsibility for
resolving medication-related issues in line
with the patient’s wishes, expectations and
priorities
FOCUSED AREA OF PRACTICE
● Drug monitoring

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 ● Disease monitoring
○ gumagaling ba yung sakit or hindi?
○ or does a new disease develop?
○ check for comorbidities
○ Treat the patient holistically
● Drug therapy and disease
management/collaborative practice
KEY ELEMENTS OF THE PHARMACEUTICAL
CARE PROCESS
Assessment
● The main goal is to establish a full
medication history & highlight actual and
potential drug-related problems
● know the patient first
● for quick assessment: Use SAMPLE
● Ex. An infected wound on right foot
○ S - Signs and symptoms (pain,
swelling, fever)
○ A - Allergy history (Can be fatal)
○ M - Medication
○ P - Past Medical History
○ L - Last meal (help minimize gastric
irritation caused by antibiotics)
○ E - Events that lead to the problem
Care Plan
● Should clearly state the goals to optimize
care and the responsibilities of both the
pharmacist and the patient attaining the
stated goals.
● Ex. Pneumonia, the goal is to treat
pneumonia. If a patient then suffers from
difficulty in breathing one of the goals now is
to improve the airway of a patient who has
pneumonia.
○ But remember, that health is holistic
so we must also consider other
goals besides antibiotics.
○ For example, if a patient has
diarrhea that mainly causes the body
to dehydrate (lowers blood pressure,
palpitation, or fast heart rate due to
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loss of fluids), part of the care plan
should also be rehydration (Ringer's
solution, IV fluid support, and ORS)
besides the antibiotic.
Evaluation
● Reviews progress against the stated patient
outcomes
● Outcomes:
○ Good Outcome- Patient gets treated
○ Bad Outcomes: Toxicity and
Treatment Failure
● Further evaluation involves monitoring
parameters.
○ For example, Vancomycin = monitor
renal function, Tetracycline= monitor
if infection heals, Diarrhea =
improved blood pressure from
cholera. Malaria, check danger
signs.
○ It is important to look out for danger
signs because it means that the drug
treatment is not working.
CLINICAL PHARMACY FUNCTIONS AND
KNOWLEDGE
Step 1: Establishing the need for drug therapy
● Establishing a diagnosis
○ Establish a diagnosis → disease is
known → become the basis for
giving a drug as a part of
management/treatment/therapy
● What is the disease?
○ Ex. Allergic rhinitis and mucus are
clear, antibiotics should not be
needed. Antibiotics should only be
given in a valid way so that patients
would not develop AR.
● Provide information to the prescriber on the
expected benefits and risks of drug therapy
○ Q: Is there a need?
■ E.g. Doctor: Need to treat an
infection of the right foot?
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 ■ Q: What drug to DISEASE INFORMATION
recommend? ● HTN x 15 years, Hypercholesterolemia x 10
■ Note: provide the drug with years, GERD x 25 years
the expected benefits and ● “ I haven’t been feeling well lately and
risk (need to inform the figured maybe my blood pressure is high.”
health care team) ● No visual disturbances, hearing problems,
● Pros and Cons headache, palpitations, chest pain, mental
● Need to gather information status change
● Shortness of breath and easy fatigability
To establish the need for drug therapy pharmacists ● Infected wound at the right foot
must know the:
● Patient information ● BP 200/120, 192/122, 192/194 → stage of
● Disease information HTN?
● Drug information ● Pulse 58, RR 24, T 38.4 C, Wt. 72, Ht. 5’
7”(BMI =___) → normal?
Step 1.1 Relevant patient details ● Fundoscopic exam: arterial tortuosity
● Age (children have lower dosage) ● Neck supple , No JVD, no bruits
● Gender (Women and children more prone ● PMI shifted laterally, s4 heard at the apex
to UTI) →?
● Ethnic or religious background (Religious ● Normal neurologic exam
beliefs; Guava or penicillin in wounds)
● Social history (STD) Disease Information (Laboratory)
● Presenting complaint (the focus of the ● Na- normal, K- normal, Cl- normal, BUN-
treatment; Fever but has an infection or normal
Harder to urinate but has STD) ● SCr- normal, Glu- normal
● Working diagnosis ● Hgb- normal, Hct- normal, Plt- normal
● Previous medical history ● AST, ALT- normal, cholesterol- normal
● Laboratory or physical findings (if in the ● HDL- low, LDL- elevated, TG- normal
hospital just like urinalysis) ● CO2- normal
○ significant or not? ● Urinalysis- negative for protein or blood
● CXR- enlarged heart, no infiltrates
PATIENT INFORMATION ● Culture of wound abscess: (+)
● Reynaldo Santos, 55-year-old, male Staphylococcus aureus
● Family history of HTN, stroke, ● C & S: S: Piperacillin-tazobactam;
hypercholesterolemia, heart attack, R-amoxiclav (in-patient setting also look at
coronary artery disease (history of CABG) culture sensitivity to give the appropriate
● Married with 4 children, grounds-keeper at antibiotic)
a ceremony ● ECG- LVH, no ST segment changes
● Smoker (1 pack/day), alcoholic -beverage ● Enlarged heart
drinker (1 can beer/day), (-) recreational ● poorly controlled HDL, LDL
drug use ● Hypertension stage 2
(alcohol and metronidazole will result in a ● Hypertension emergency
disulfiram-like reaction) ● End organ damage?
● Eat fast food for breakfast & lunch

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 MEDICATION INFORMATION
● Antibiotics have drug interactions
● Atenolol 100 mg once daily (has not taken
for over a month)
● Amlodipine 10 mg once daily (has not taken
for over a month)
● Lovastatin 20 mg once daily
● OTC famotidine prn gastric reflux ( taken
about every other day) (check for drug
interactions)
Step 1: Is there a need for a drug?
● Yes, the patient still needs an antibiotic for
the infected wound on his right foot.
○ Proceed to Step 2
● Make sure all medications are for a
specific purpose
○ Atenolol and Amlodipine
hypertension
○ Lovastatin - Hypercholesterolemia
○ Famotidine - GERD
● Make sure all diseases are well addressed
● In this step, you will be able to determine if
treatment is needed and what treatment you
should give.
○ If treatment is not needed, then
remove
● There are some instances where the
sickness (ex. the infected wound on the
right foot - resolved) was already cured after
evaluation but was still prescribed
antibiotics. You can eliminate it in this step.
Step 1.2 Medication History
● Allergies (more careful in choosing
antibiotics)
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○ Inquire for allergies which can
change the choice of drugs
● Adverse medication events
(life-threatening events in penicillin)
○ You should be knowledgeable about
the drug you are recommending to
prevent adverse medication
events and drug interaction
(inquire in the medication history
step)
● Identifies prescribing errors of omission
or transcription (check if there are too
many medications that are not needed)
○ STOP ORDER- Hospital pharmacy
practice term that means to stop all
medications for 1 week so that the
doctor can review the medications
that are only needed by the patient.
■ Doctors review the
medication; e.g. if all the
medication has indications,
and if one does not have
medication, then you should
stop it.
■ Depends on the hospital
practice
-
○ Reviewing the transcription
● Important step before proceeding to the
next step
● SAMPLE in step 1.2
○ A - Allergies
○ M - Medication history
○ P - Comorbidities
Step 2: Selecting the medicine
● Clinical and cost-effective selection of
medicine in the context of individual patient
care
● “Is it appropriate for my patient?” How will
we select?
● Identify drug-patient, drug-disease, and
drug-drug interactions which are prioritized
according to the likelihood of occurrence
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● Selecting the drug and custom fitting it to adverse effects (e.g,
your patient nephrotoxic) of the
● Ex: An elderly patient who presented with drug during the
hospital-acquired pneumonia (HAP). treatment. Your role
○ Patient: elderly does not end with
○ Disease: HAP the doctor’s
○ Drug: decision of
■ Need a drug? Yes treatment,
■ What drug? (You have to be especially with
knowledgeable about the possible adverse
disease such as knowing the events.
first line of treatment for ■ Ex. Piperacillin Tazobactam
HAP) - may be safe for the
■ Know also the causative elderly, but prone to
agent aspiration pneumonia;
■ Ex. Co-amoxiclav - Is it ■ Have to consider the efficacy,
appropriate for the elderly, for the safety, and the cost.
HAP? - Not appropriate for ■ Also drug-drug interactions,
HAP, since HAP causative like chlorthalidone (a
agents are either thiazide diuretic) may
pseudomonas, proteus increase the nephrotoxicity of
mirabilis, and Klebsiella. gentamicin.
(Proceed to another drug)
■ Ex. Gentamicin - another Step 2.1: Identify drug-patient interactions
group of antibiotics under ● Age group or gender
aminoglycosides. It is ● Allergy, previous adverse drug reactions
effective in HAP, but it is (e.g. Stevens-Johnson syndrome, Reye’s
nephrotoxic. Thus, it may syndrome)
not be appropriate for ○ If there is a lot of allergic reaction,
elderlies since they may CHANGE THE MEDICATION
have compromised renal ○ Stevens-Johnson syndrome -
function (weak renal known for sulfa containing drugs like
clearance) - need to check Co-Tri
for it. ○ Reye’s syndrome is common with
● In some situations, Aspirin medication
the drug’s benefits ● Abnormal hepatic or renal function
may outweigh the ○ understand the pharmacokinetic
adverse effects (need characteristics of the drug
to weigh its pros and ○ these are the two organs involved in
cons) your drug’s excretion or elimination
● If the doctor wants to ○ Will the elimination of the drug be
risk it, then you have affected by kidney or renal
to monitor the patient function?
and the possible

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 ■ Is the drug excreted in the
kidneys?
■ For ex. Aminoglycosides are
excreted by the kidneys. You
have to assess first how is
the renal function of the
patient. If the renal function is
not good, you might
somehow hesitate in giving
aminoglycosides
Step 2.2: Identifying drug-disease interactions
● Medicine has the potential to make a
pre-existing condition worse
● Older patients - several chronic illnesses
and the likelihood of exposure to
polypharmacy.
Step 2.3: Drug-drug interactions
● Pharmacokinetic DI
○ absorption (alteration of pH)
■ Ex. Aspirin is a weak acid
(in an acidic medium), if you
alter the pH, the drug
becomes more nonionized.
It can be absorbed.
■ If you make it basic, weak
acid becomes ionized. There
could be no absorption = no
bioavailability = drug
ineffective
○ Distribution (competition in the
plasma. protein-binding and free)
■ Ex. Warfarin and
Tolbutimide. Warfarin - blood flow = excretion rate is
plasma protein (Inert) (effect
= 40%). Tolbutamide has a
higher affinity for plasma
protein. Magiging 80% free of
Warfarin, the effect would
increase.
■ Free is the one causing the
effect
○ Metabolism
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■ be familiar with inducers and
enzyme inhibitors
■ Ex. Rifampicin (anti TB
drug) which is an inducer,
what would happen to the
effect of the second drug? -
drug will have a shorter
half-life bc if given w an
enzyme inducer,
metabolism is rapid,
efficacy shortened or
worse it will not reach the
therapeutic level.
■ If enzyme inhibitor, Ex.
Trimethoprim (antibiotic). If
you give another drug, the
second drug will not be
metabolized immediately =
longer stay in the
bloodstream = risk of
toxicity
○ Excretion (competition for the
transporter)
■ Ex. Penicillin and
Probenecid. Penicillin has a
longer stay in the
bloodstream bc the excretion
was affected bc of the
competition for the
transporter. Increase the
risk of adverse effect
(allergy). Probenecid got the
transporter.
■ NSAIDS - decrease renal
slowed down = second drug
will stay longer = increase
risk of toxicity
● Pharmacodynamic DI
○ 1 + 1 = 2 (Addition)
○ 1 + 0 = 2 (Potentiation) - the other
drug have no inert activity but the
other drug has enhance its effect
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 ○ 1 + 1 = 0 (Antagonism) -
combination of the drugs are
ineffective. Treatment failure
○ 1 + 1 = 3 (Synergism)
● Special care for drugs with a narrow TI
Step 3: Administering the medicine
● Ex. Elderly with Hospital Acquired
Pneumonia
○ Medication: Gentamicin
○ Cockcroft-Gault formula - used in
computing renal clearance of
aminoglycosides
○ Whenever you give a drug you are
guided by the Therapeutic window
■ Plasma concentration limit of
the drug in the bloodstream
■ The drug should fall in the
MEC- minimum effect in
concentration and the MTC-
minimum toxic concentration
■ If the drug has a narrow
therapeutic window make
sure that it is of the right
concentration
● Ex. 8(MEC)-10(MTC)
mc/mL therapeutic
window. Below 8 it is
ineffective, if it is
more than 10 can
cause toxicity
■ Renal clearance is important
to know what dose to give to
this patient with this type of
renal function, with the right
dose that falls in the
therapeutic window
● Consider ADME
● Dose (very crucial)
○ especially in special populations
○ elderly - consider the renal function
(dose adjustments)
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○ children - based on the body weight
(Antibiotics are usually given in
mg/kg/day)
● Route of Administration
● Oral
○ It is safer but have a lot of
irregularities
○ The absorption of the drug given by
the oral route may be altered with
full stomach
Ex. Tetracycline when taken with milk can reduce
the absorption of tetracycline
● Transdermal Administration.
● Rectal Administration.
● Vaginal Administration.
● Storing medication
● Dosage form
○ Sustained release tablet
○ Parenteral
■ Ex. Gentamicin
■ Route of administration: IV
■ Dosage form: Parenteral
○ Inhalational
○ Antibiotics
○ Topical Antibiotic (For skin)
○ Oral antibiotic
○ IV antibiotic
○ Instillation.
○ Injection.
● Documentation (special instructions/info
for nurses or carers)
○ To document the administration
○ Usually in medical chart
○ To make sure that the drug is being
given
○ Instruction:
○ It should be taken before
meals
○ It should be strictly given
every 8 hours
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 ○ 8 hours and 3 times a day is
different
● Devices (spacers, infusion pumps)
MEDICATION ERRORS
● Wrong drug error
○ Right drug to the right patient
● Extra dose error
○ Wrong dosage
● Omission error
○ Drug not given
● Wrong dose or wrong strength error-
○ Problem in transcription
○ telephone orders
○ Ex. .10mg - might be read as 10 mg
in the transcription. To correct it,
write it as 0.10mg to avoid
misunderstanding
● Wrong route error
○ Dapat IV pero nabigay oral
● Wrong time error
○ Should be given 3 times a day but
only given 2 times a day
● Wrong dosage form error
○ Dapat Sustained release tablet pero
nabigay immediate release tablet
○ Dapat inhalational pero tablet
binigay
● Therapeutic duplication, incomplete drug
order, vague order
○ Ex. TMP-SMX, Cotrimoxazole -
same drug
○ vague order - not legible prescription
or phone order (connectivity/signal
problems)
Step 3.1 Calculating the appropriate dose
● Dosage adjustments for patients with
impaired renal function
● Pediatric doses
● Loading dose, maintenance dose, creatinine
clearance
● dose should be precise
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Step 3.2: Selecting an appropriate regimen
● Guided by the duration of action of drugs
○ Long D.O.A. - OD (once a day)
■ e.g. aminoglycosides
(gentamicin)
○ Short D.O.A - TID (3x a day)
■ e.g. amoxicillin
● Oral vs intravenous
● Frequency and compliance
○ Patients should always be reminded
when to take their medications. e.g.
Antiretrovirals have a specific time to
take.
○ Remember the dose, dosage form,
route of administration, and duration.
Also, think about the prescription.
○ Ex. Amoxicillin 500 mg /cap. Sig.
Take 1 cap 3x a day for 7 days
Step 4: Providing the medicine
● Ensure a prescription is legal, legible,
accurate, and unambiguous
○ it should be properly prescribed, with
clear writing. if unambiguous, call
the physician to confirm.
● Delivering the right medicine to the right
person with the right dose at the right time
○ Nurses always ask the patient's
name and check if it is the right
medicine for the patient.
● Special care for medicines with similar
names and packaging, similar patient
names, or supplying several family
members at the same time.
○ Look out for S.A.L.A.D. (Sound Alike
Look Alike Drugs). More S.A.L.A.D.
can be found in ismp.org
■ Ex. Metronidazole and
mebendazole
○ Also treat family members or
couples if a patient has an endemic
disease or STD.
○ A need for dispensing skills
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Step 5: Monitoring Therapy
● Is the treatment effective? Are there no
adverse effects (is it safe)?
○ Ex: Is the fever gone? Are the
symptoms improving?
○ If there's pneumonia, did the
breathing improve? Is the phlegm
excreted reduced?
○ If it's a wound infection, is the pus
gone? Is the inflammation reduced?
And has the fever gone?
○ If it's cholera, does diarrhea still
happen often or not?
○ It's important to understand the drug
■ Can the drug cause an
allergic reaction?
■ Ex. If the patient is unfamiliar
with his/her allergies like
penicillin, conduct a skin
sensitivity test (intradermal,
get a lump from the skin and
after a few minutes, check if
there's a wheel formation or
redness, it means that the
patient is allergic to the
antibiotic)
● Close monitoring especially drugs with a
narrow therapeutic index
○ Aminoglycosides, there are more
benefits than risks of adverse drug
events. If there is ADE, there are
two things to decide on;
■ Stop the drug and change it
■ Alter/Reduce the dose
● Monitoring anticoagulant therapy
Step 6: Patient advice and education
● Benefits and risks of therapy and the
consequences of not taking the medicine
○ Drug knowledge and familiarization
are needed
● In a manner that the patient can understand
(layman terms)
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● Information is provided at the same time or
as soon as possible after the prescribing
decision
○ Ex. Outpatient, 3 days intravenous in
the hospital then antibiotic treatment
orally will continue at home, this is
where the pharmacist comes in
and explains the antibiotic
treatment.
■ The pharmacist would inform
patients about ADE. ADE
can be allergies, if the patient
knows this, they will have an
urgency to go back to the
doctor and realize that it can
be a history of the patient.
● Encourage patients to read leaflets and ask
questions
○ Close communication between
pharmacist and patient
○ Interactive session, so feedback is
also required
Step 7: Evaluate effectiveness
● Did we reach the expected outcome?
● If not, review steps 1-6
References:
Notes from Synch and Asynch Discussions
of Doc Tanodra
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