By: Liz Fredrickson, PharmD, BCPS; Heidi N. Anksorus, PharmD, BCPS; Alexis N. Crawford, PharmD, BCCCP, BCPS; Colleen A. Clark Dula, PharmD, BCACP; Apryl N. Peddi, PharmD, BCACP; and Jennifer N. Wisniewski, PharmD, BCPS
As pharmacists, we take an oath to “apply [our] knowledge, experience, and skills to the best of [our] ability to assure optimal outcomes for all patients.”1 Central to this promise is ensuring patient well-being, and competency in pharmacy calculations is key to medication safety and practice readiness. Unfortunately, performance in pharmacy calculations (Area 4) consistently remains the lowest among all domains on the North American Pharmacist Licensure Exam (NAPLEX), with one-third of candidates below or far below minimum competency (Figure 1).2 With the launch of the new NAPLEX blueprint, faculty may soon lose the ability to monitor this troubling trend at a time when targeted improvement is critically needed.
Figure 1. Percentage of First-time Test Takers Scoring Below or Far Below in Area 4 on the NAPLEX2
Hidden Risks in the NEW NAPLEX Framework
In recent years, the National Association of Boards of Pharmacy (NABP) has reported domain-level data to colleges and schools of pharmacy, as well as to candidates who do not pass the exam through a candidate performance report. However, on May 1, 2025, a new NAPLEX content outline was adopted that no longer includes pharmacy calculations as its own domain but instead integrates it as a subdomain under “Foundational Knowledge for Pharmacy Practice” (Domain 1).3 Deficiencies in pharmacy calculations could now be hidden by higher scores within the foundational knowledge domain. This change has implications that extend far beyond data reporting and could obscure this growing area of concern, limit the program’s ability to intervene, and be detrimental to pharmacy institutions, exam candidates, and ultimately our patients.
Impact on Colleges and Schools of Pharmacy
The 2025 ACPE Standards state that “assessment plans incorporate…standardized assessments, as required by ACPE (e.g., licensing examinations), that allow for national comparisons and college- or school-determined peer comparisons.”4 However, as pharmacy institutions look to improve instruction and student competency in pharmaceutical calculations, they are losing a key outcome measure that can guide curricular change. This change may hinder educators’ ability to correlate curricular interventions and novel instructional strategies with NAPLEX performance in this area. Ultimately, without access to a standardized, external benchmark, scholarly efforts to determine best practices in teaching and assessing pharmaceutical calculations skills may be more limited.
Impact on Exam Candidates
Annual data reported to schools from NABP on individual performance consistently demonstrate that candidates who perform poorly on pharmacy calculations are at an increased risk of failing the NAPLEX.2 However, with these recent changes, students will be unable to identify if they are underperforming in this area and focus their studying accordingly. Adverse downstream effects are also possible, including loss of residency or fellowship opportunities and delayed job starts.
Impact on Patient Care
Poor performance in pharmacy calculations can lead to failure of the licensure exam, but historically, it has been possible to pass the exam without meeting competency in this area. If national performance in pharmacy calculations continues to decline, the risk of medication errors may increase, potentially leading to patient harm. Errors of commission account for 47.6% of medication errors according to a 2019 review, in which the authors found the majority center around miscalculations or dosing errors.5 Without access to subdomain performance data, preceptors, employers, and other stakeholders won’t be able to use national performance trends to make informed decisions regarding designing competency exams or prioritizing continuing education activities.
Next Steps for Collaboration
As educators and practitioners committed to ensuring competency in pharmacy calculations, we invite our colleagues at NABP to strongly consider continued transparency in NAPLEX reporting by providing performance data specific to pharmacy calculations. Ensuring this level of detail for both institutions and candidates will enable schools and colleges of pharmacy to monitor trends, evaluate curricular effectiveness, and identify areas for instructional improvement. Ultimately, we believe this will benefit healthcare systems more broadly through improved practitioner readiness.
What techniques do you think improve skill retention and knowledge related to pharmacy calculations?
References
- Oath of a Pharmacist. American Association of Colleges of Pharmacy. Accessed May 29, 2025. https://www.aacp.org/resource/oath-pharmacist
- National Association of Boards of Pharmacy. NAPLEX calendar year reports: 2022–2024. Published January 30, 2023; January 31, 2024; January 21, 2025.
- National Association of Boards of Pharmacy. NAPLEX Content Outline. Accessed May 29, 2025. https://nabp.pharmacy/wp-content/uploads/NAPLEX-Content-Outline.pdf
- Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (“Standards 2025”). Published 2025. Accessed May 29, 2025. https://www.acpe-accredit.org/pdf/ACPEStandards2025.pdf
- Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020;54(1):74-81. doi:10.1111/medu.13821 https://asmepublications.onlinelibrary.wiley.com/doi/10.1111/medu.13821
Author Bio(s):
Liz Fredrickson is an Associate Professor of Pharmacy Practice at the Northeast Ohio Medical University College of Pharmacy. Her educational scholarship interests include the scholarship of teaching and learning and research related to compounding education. In her free time, she enjoys running, playing the guitar, and going on adventures with her husband and four children.
Heidi N. Anksorus, PharmD, BCPS, is an Associate Professor at the University of North Carolina, Eshelman School of Pharmacy. Educational scholarship interests include skill development and pedagogy (including pharmacy calculations), well-being initiatives, and collaborative learning. In her free time, Heidi enjoys spending time with her family and likes to bake, garden, and work on craft projects.
Alexis N. Crawford, PharmD, BCCCP, BCPS, is an Assistant Professor at Virginia Commonwealth University School of Pharmacy. Educational scholarship interests include scholarship of teaching and learning, work-life integration, and critical care pharmacy. In her free time, Alexis enjoys spending time with her husband and three daughters, baking, and traveling.
Colleen A. Clark Dula, PharmD, BCACP, is the Director of the Integrated Patient Care Laboratory and Associate Professor at the Ohio State University College of Pharmacy. Educational scholarship interests include teaching advancement, skills-based instruction, near-peer teaching, and student success in pharmacy calculations. In her free time, Colleen enjoys baking, reading, and traveling with her husband and two children.
Apryl N. Peddi, PharmD, BCACP, is an Assistant Professor at Virginia Commonwealth University School of Pharmacy. Educational scholarship interests include pharmacy calculations, professional identity formation, and the use of technology in pharmacy teaching and learning. In her free time, Apryl enjoys traveling with her husband and son, as well as spending time with her two large, fluffy dogs.
Jennifer N. Wisniewski, PharmD, BCPS, is an Assistant Professor at the Medical University of South Carolina College of Pharmacy. Educational scholarship interests include collaborative learning and transfer of learning. In her free time, Jennifer enjoys reading and spending time with friends and family.
Pulses is a scholarly blog supported by a team of pharmacy education scholars.
Pulses 