brief review on clinical pharmacy, drug information centre & patient safety program The lecture was presented at Al-Mahmoudiya General Hospital as part of the training course for fresh appointed pharmacist at 16/5/2023 at 11 & 15/5/2023

1. Alaa Fadhel Hassan
(MSc. Pharmacology)
Al-Mahmoudiya General Hospital

4. Basics of Clinical Pharmacy
• Qualifications
• Process of care
(Assessment of patient,
Evaluation of medication –
therapy, Development & implementation
- of a plan of care, Follow-up evaluation
& medication monitoring)
• Documentation
• Level of Action

5. Clinical Pharmacists, Qualifications
Are practitioners who provide comprehensive
medication management and related care for
patients in all health care settings.
They are licensed pharmacists with specialized
advanced education and training who
possess the clinical competencies necessary
to practice in team-based, direct patient care
environments. Accredited residency training
or equivalent post licensure experience is
required for entry into direct patient care
practice

6. Postgraduate-Residency years
Programs (PGY1 & PGY2)
PGY1
• 1 year of
clinical/academic
training &
research program
• Including all
specialities :
Medicine, Surgery,
Gynaecology &
Paediatrics
PGY2
• 1 year of specialized
clinical residency &
research in 1 these
specialities:
• Oncology and
Hematology,
Emergency, Cardiology,
Operation Room and
Surgery & Paediatrics

7. Process of Care
• Care is coordinated among providers and
across systems of care as patients transition
in and out of various settings, including:
• Assessment of the patient
• Evaluation of medication therapy
• Development and implementation of a plan
of care
• Follow-up evaluation and medication
monitoring

8. Assessment of Patient
• Reviewing the medical record using a problem-
oriented framework (interpreting & analyzing
subjective & objective information) to determine
the clinical status of the patient
• Meeting with the patient/caregivers to obtain &
document a complete medication history to
identify all of the patient’s current medications
(including regimens and administration routes),
medication-taking behaviors, adherence, allergies,
and attitudes and experiences with medications.
• Obtaining, organizing, and interpreting patient data;
and prioritizing patient problems and medication-
related needs.

9. Evaluation of Medication Therapy
• Assessing, with other members of the
health care team, the appropriateness of
current medications on the basis of
health conditions, indication, & the
therapeutic goals of each medication
• Evaluating the effectiveness, safety, and
affordability of each medication

10. Evaluation of Medication Therapy
• Assessing medication-taking behaviors
and adherence to each medication
• Identifying medication-related problems &
evaluating collaboratively with other
members of the health care team the
need for intervention patient data &
prioritizing patient problems and
medication- related needs.

11. Development and Implementation
of a Plan of Care
• Reviewing the patient’s active medical
problem list to inform & guide the
development of an individualized assessment
& plan for optimizing medication therapy
• Formulating a comprehensive medication
management assessment & plane in
collaboration with the health care team &
implementing this plan to achieve patient-
specific outcomes

12. Development and Implementation
of a Plan of Care
• Educating the patient/caregivers (both verbally
and in writing) to ensure understanding of
the care plan, to optimize adherence, & to
improve therapeutic outcomes
• Establishing patient-specific measurable
parameters & time frames for monitoring &
follow-up in collaboration with other
members of the health care team.

13. Follow-up Evaluation and
Medication Monitoring
• Coordinating with other providers to ensure
that patient follow-up & future encounters
are aligned with the patient’s medical &
medication-related needs
• Revisiting the medical record to obtain
updates on the clinical status of the patient
& then meeting with the patient/caregivers
to obtain an updated medication history to
identify, assess, and document any new
medication related needs or problems

14. Follow-up Evaluation and
Medication Monitoring
• Conducting ongoing assessments & refining
the plan of care to optimize medication
therapy & ensure that individual goals are
achieved
• Monitoring, modifying, documenting, &
managing the plan of care in collaboration
with the patient/caregivers & his/her other
health care providers.

16. Documentation, Includes
• Medication history brief summary, list of
current medications, list of allergies/adverse
events
• Active problem list with an assessment of
each problem list of current heath condition
& any additional drug related problem
• Plan of care to optimize medication therapy
& improve patient outcomes specific
medication therapy plan with dose rout
frequency & monitoring parameters
• Collaborative follow up plan

17. Documentation, Ex.

18. Documentation, Ex.

19. Drug Information Centre
Established at 2017, DIC duties include:
• Answering/responding to all request of
physicians, pharmacists & patient
whether in/outside the hospital
• Documenting all performed work via
(Drug Information Centre Request Form)
• Performing medication periodic/wall flier
• Contribution in all scientific activities held
within the hospital

21. Pharmacy & Therapeutics Committee
• Archiving all instruction associated with the pharmacy
department
• Hold monthly meeting with printed agenda discussing
the available, scarce & missed medication & medical
equipment's
• Making & updating institutional “Formulary List”, that
depend/based on safety, efficacy, quality & cost
effectiveness analysis & references such as BNF
• Maintaining reliance to the MOH “Standard treatment
Protocols” in the institution
• Evaluating & monitoring subcommittees/units as
(Antibiotic stewardship, Rational use of drugs,
Physical changes & pharmacovigilance)

22. Patient Safety
• Patient safety is an issue in all countries that
deliver health services, whether these
services are privately commissioned or
funded by the government
• Failing to adequately check the identity of a
patient or prescribing antibiotics without
regard for the patient’s underlying condition
or administering multiple drugs without
paying attention to the potential for adverse
drug reactions can lead to patient injury.

23. Patient safety, Mistake/Error
A mistake is a failure of planning (i.e. the plan
is wrong).
This can be either rule-based, when the wrong
rule is applied, or knowledge-based, when a
clinician does not take the correct course
of action. An example of a rule-based mistake
would be getting the diagnosis wrong and so
embarking on an inappropriate treatment
plan. Knowledge-based mistakes tend to
occur when health-care providers are
confronted with unfamiliar clinical situations

24. Patient Safety

25. Patient Safety

26. Patient Safety
• Patients are not only harmed by the misuse
of technology, but can also be harmed by
poor communication between different
health-care providers, or delays in receiving
treatment
• Training to become an excellent team
member starts in professional school.
Learning how to substitute roles and
appreciate the other’s perspective is central
to effective teamwork

27. Patient safety
Leaders in patient safety have defined patient
safety as follows:
“A discipline in the health-care sector that
applies safety science methods towards the
goal of achieving a trustworthy system of
health-care delivery. Patient safety is also an
attribute of health-care systems; it
minimizes the incidence and impact of, and
maximizes recovery from adverse events”

28. Patient Safety Program
• Established at 2014, duties include:

29. Patient Safety

30. Patient safety
• High alert medications: medications which
have a higher risk of causing harm when an
error occurs. They must be double checked
prior to administration by two licensed
caregivers who are authorized to administer
or dispense medications
• Limiting access to high-alert medications
• Using auxiliary labels and automated alerts
• Employing redundancies
• Improving access to information about these
drugs

31. Patient safety
• Look-alike sound-alike (LASA) Medications:
Prescribing medication errors can occur because
of similar medication names or poor handwriting
which can make many of these medications look
alike
• 1 way to differentiate two similar sounding
medications is to know the disease state that is
being treated. When transcribing a verbal order,
always read back to the prescriber what was
written or entered. Medications on the LASA lists
will be separated in clinics or on units & should
not be stocked close to each other

32. Rational use of Medications/Drugs
• Marinating institutional reliance to
medication compounding/mixing MOH
protocols for ex., chemo/biological
therapy & intravenous fluids
• Sending/sharing seasonal clinical
pharmacy-associated reports such as:
Antibiogram, antibiotic stewardship
surveillance & reports, meropenem
prescription surveillance

33. References
• Standards of Practice for Clinical Pharmacists.
Pharmacotherapy (2014), 34: 794-797.
https://doi.org/10.1002/phar.1438
• MOH, Directorate of technical affairs, , Pharmacy department.
Clinical pharmacy section. Clinical pharmacist standard of
practice, 2022.
• MOH, Directorate of technical affairs, , Pharmacy department.
Training package for newly graduated pharmacists, 2015.
• Patient Safety Curriculum Guide: Multi-professional Edition
World Health Organization 2011
• The Institute for Safe Medication Practices (ISMP)
Recommendations
https://www.ismp.org/resources?field_resource_type_target_i
d[13]=13#resources--resources_list