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Clinical Pharmacy



   Dr Sitaram Khadka,PharmD
         Clinical Pharmacist
   Shree Birendra Hospital,Chhauni
Health Care System
Composed of physician (including other medical and dental staffs), pharmacist ,
nurse and other paramedics

Physician ;         diagnosis,    prescription, monitoring, medical care

Pharmacist;         prescription*, dispensing, counseling, monitoring,
                    pharmaceutical care

Nurse ;             administering, monitoring, nursing care

Other paramedics ; their own work

Load to physician & nurse ; high due to the system of "physicians are all in all in
hospital for the treatment of patient, with the help of nurse."

Concept of normal public/patient ; same
Perceptions of Pharmacists


   How do others see us?
”They just count a few tablets“
”They just weigh and measure things“
”A bunch of shop-keepers“
Tell me how and when to use the“
”Medicine
”Counter-prescribing“
Not really health care practitioners – they’re “
”businessmen
?”Do you need a degree to be a pharmacist“
For practising Clinical Pharmacy

•    Competence of health care practitioners
     -BPharm to Mpharm to PharmD*

    -PharmD+ Pre-registration + registration

     -Residency programs

     -Continuing Professional Development

•    Informed general public – increased expectation
Introduction; Clinical Pharmacy
Clinical pharmacy may be defined as the science and practice of rationale use of
medications, where the pharmacists are more oriented towards the patient care
rationalizing medication therapy promoting health , wellness of people.


It is the modern and extended field of pharmacy.

“ The discipline that embodies the application and development (by pharmacist) of
scientific principles of pharmacology, toxicology, therapeutics, and clinical
pharmacokinetics, pharmacoeconomics, pharmacogenomics and other allied
sciences for the care of patients”.
(Reference: American college of clinical pharmacy)
History
Until the mid 1960’s ; Traditional role.
The development of clinical pharmacy started in USA.
More clinically oriented curriculum were designed with the award of
PharmD degree.
These developments influenced the practice of pharmacy in U.K.,
Initially prescription and drug administration records were introduced followed
by an increasing pharmacy practice in hospital wards. Master degree programs
in clinical pharmacy were introduced for first time in 1976.

The progress of clinical pharmacy development remained at low profile in the
first decade after its birth in U.K. However, Nuffield report in1986 geared up the
momentum for progression of clinical pharmacy.

Until today, the clinical pharmacy practice in Nepal is in embryonic stage.
How does clinical pharmacy differ from pharmacy?


The discipline of pharmacy embraces the knowledge on
synthesis, chemistry and preparation of drugs

Clinical pharmacy is more oriented to the analysis of
population needs with regards to medicines, ways of
administration, patterns of use ,drugs effects on the
Patients,
‘the overall drug therapy management’.

The focus of attention moves from the drug to the single
patient or population receiving drugs.
Clinical Pharmacy Requirements

                       Knowledge of
                       drug therapy
      Knowledge of                    Knowledge of
     nondrug therapy                  the disease




Therapeutic                                     Knowledge of
 planning                                         laboratory
   skills                                    and diagnostic skills
                       Patient care




Drug Information                             Communication
     Skills                                     skills



                Physical         Patient
              assessment        monitoring
                 skills           skills
Level of Action of Clinical Pharmacists
Clinical pharmacy activities may influence the correct use
of medicines at three different levels:
Before the prescription
During the prescription
and
After the prescription is written.
1. Before the prescription

•   Clinical trials
•   Formularies
•   Drug information
•   Drug-related policies
2. During the prescription
•   Counselling activity

•   Clinical pharmacists can influence the attitudes and priorities of
    prescribers in their choice of correct treatments.

•   The clinical pharmacist monitors, detects and prevents the medication
    related problems

•   The clinical pharmacist pays special attention to the dosage of drugs
    which need therapeutic monitoring.

•    Community pharmacists can also make prescription decisions directly, when over
    the counter drugs are counselled.
Medication-related Problems
•   Untreated indications.
•   Improper drug selection.
•   Subtherapeutic dosage.
•   Medication Failure to receive
•   Medication Overdosage.
•    Adverse drug reactions.
•   Drug interactions.
•   Medication use without indication.
3. After the prescription

– Counselling
– Preparation of personalised formulation
– Drug use evaluation
– Outcome research
– Pharmacoeconomic studies
Functions of Clinical Pharmacists
1. Taking the medical history of the patient

2. Patient Education

3. Patient care

4. Formulation and management of drug policies

5. Drug information

6. Teaching & training to medical and paramedical staff
7.Research and development

8.Participation in drug utilization studies

9.Patient counseling

10.Therapeutic drug monitoring

11.Drug interaction surveillance

12.Adverse drug reaction reporting

13.Safe use of drugs

14.Disease management cases

15.Pharmacoeconomics
Objective

• Define clinical pharmacy
• Differentiate between traditional pharmacists role and
  Clinical Pharmacist
• Explain the qualification required for clinical pharmacists
• List the clinical pharmacists responsibility
• Describe the daily work activity of clinical pharmacists
• Define what is Therapeutic Drug Monitoring
• Discuss the different types of Therapeutic Drug
  Monitoring
Clinical pharmacy specialists
• Usually requires residency in a specialty area, in addition to a
  pharmacy practice residency

• Job functions depend on the specialty and the institution

• Usually has teaching and/or research responsibilities

• Represent pharmacy for medication use meeting/committee
  in specialty areas
Clinical Pharmacy Practice areas

                                 Investigational Drugs
   Ambulatory care
   Critical care                Pharmacoeconomics
   Drug Information             Nephrology
   Geriatrics and long –term
    care                         Obstetrics and gynecology
   Internal medicine and        Pulmonary disease
    subspecialties
   Cardiology                   Psychiatry
   Endocrinology
   Gastroenterology             Rheumatology
   Infectious disease           Nuclear pharmacy
   Neurology
                                 Pediatrics
   Nutrition Support
   ADR/DUE                      Pharmacokinetics
   Transplant                   Surgery
Various ambulatory services
 Anticoagulation Management
 Cholesterol Management
 Renal Management (CKD)
 Oncology Services
 Home Health Pharmacy Services
 Impact Pharmacy Services (Drug Conversion Program)
 Neonatal ICU
 Hypertension Management
 Integrated Coronary Vascular Disease (CVD)
 HIV/ID
 New Member Program (assist new MD in prescribing NF
  to formulary drugs)
 Heart Failure Management
 Asthma Management
Hospital pharmacist Vs
  Clinical pharmacist
The service including clinical pharmacy/clinical pharmacist

-Patients get right care from all the facets (all the drug related problems can
    easily be eliminated)

-Physicians n other health care professionals get more focused in their
own, work-load to them is low

-Patients feel more comfortable

 
   "Every drug is poison, it’s the dose that differentiate poison or drug the 
    substance is."
 
   "To kill ill by pill, not by bill"
 
   The last person to be involved in health care team with the patient;
    Pharmacist, so the system has to rely upon him/her.
The service without clinical pharmacy/clinical
                       pharmacist
-Due to high load to physicians and other health care professionals,
the quality of patient care will be low

-Most of the drug related problems cannot be easily eliminated

-Patients may not feel comfortable

   "In developing countries like Nepal; Physicians are incompetent, Nurses are careless,
    Pharmacists don’t know anything(??), System is corrupted, Public is foolish, Patient load is
    high."...Prof Furqan Hashmi

   "Medicine is for those who need them, not for those who want them."

   "If your medicine is not working it may not be your medicine, it may be you"
Medicines are Dangerous
Pharmaceutical care
• “ A practice in which a practitioner takes responsibility for a
  patient’s drug related needs and holds him or herself accountable
  for meeting these needs.”....... Linda Strand 1997

• It describes specific services & activities through which an
  individual pharmacist cooperates with patients and other health
  care professionals in designing, implementing & monitoring a
  therapeutic plan that will produce specific outcomes for the
  patient.
•   Wherein the pharmacist is engaged in;
    Drug monitoring,
    Disease monitoring,
    Drug therapy & disease management/collaborative practice

•   Pharmaceutical care is that component of pharmacy practice which entails the
    direct interaction of pharmacist with the patient for the purpose of caring for
    that patient’s drug related needs


Goal of Pharmaceutical Care
•   Goal of pharmaceutical care is to optimize the patient’s health-related quality
    of life and achieve positive clinical outcomes, within realistic economic
    expenditures
Essential Components of Pharmaceutical Care

1.Pharmacist-patient relationship
Collaborative effort between pharmacist & patient


2.Pharmacist’s workup of drug therapy (PWDT)
Provision of pharmaceutical care is centered around this,
although the methods used for this purpose may vary.
Components are:

I.Data collection;
Collect, synthesize & interpret relevant information
Patient’s demographic data: age, sex, race etc.
Pertinent medical information
Medical history (current & past)
  Family history
  Dietary history
  Medication history (prescription, OTC, allergies)
  Physical findings (weight, height, B.P)
  Lab results (serum drug levels, potassium levels, serum creatinine levels relevant
  to drug therapy)
  Patient complaints, symptoms & signs


II. Develop or identify the CORE pharmacotherapy plan

  C = condition or patient need
  O = outcome desired for that condition
  R = regimen selected to achieve that outcome
  E = evaluation parameters to assess outcome achievement
III.Identify PRIME Pharmacotherapy Problems
    This includes pharmacist's intervention

  The goal is to identify actual or potential problems that could
  compromise the desired patient outcome
  P = pharmaceutical based problems
  R = risks to patient
  I = interactions
  M = mismatch between medication & condition or patient needs
  E = efficacy
3.Documentation of pharmaceutical care
Formulate a FARM note or SOAP note to describe or document the
interventions needed or provided by pharmacist

FARM Progress Note
Description & documentation of interventions intended or provided by
pharmacist
F = Findings,
   pt-specific information—gives basis for recognition of pharmacotherapy
   problems or indication for pharmacist intervention.

A = Assessment,
    The pharmacist’s evaluation of the findings, including a statement of:
    Any additional information needed to best assess the problem to make
    recommendation
    The severity, priority or urgency of the problem
    The short term & long term goals of the intervention proposed
Short term goals: elimination of symptoms , Lowering of BP ,Management of acute
   asthma without requiring hospitalization

Long term goals:Prevent recurrence of disease,Control B.P.,Prevent progression of
   diabetes

R = Resolution, including prevention
   Observing & reassessing
   Counseling or educating the patients & care givers
   Informing the prescriber
   Making recommendation to prescriber
   Withholding medication or advising against use

M = Monitoring to assess the efficacy, safety & outcome of the intervention
   This should include
The parameters to be followed (e.g. pain, depressed mood, serum levels)
The intent of monitoring e.g. efficacy, toxicity, adverse events
How the parameters will be monitored e.g. interview patients, serum drug
level, physical examination
Frequency of monitoring—weekly or monthly
   Duration of monitoring e.g. until resolved, while on antibiotics,then monthly for
   one year
   Anticipated or desired finding e.g. no pain, healing of lesion
   Decision point to alter therapy when or if outcome is not achieved e.g. pain still
   present after 3 days, mild hypoglycemia more than 2 times a week.

SOAP Note ;
  This is used primarily by physicians,
  S=subjective findings
  O=objective findings
  A=assessment
  P=plan
Clinical skills & pharmacist’s role in
               Pharmaceutical Care
Patient assessment
Physical assessment
Barriers to adherence
Psychosocial issues

Education & counseling
Interview skills
Communication skills (e.g. empathy, listening, speaking or
writing at patient's level of understanding)
Ability to motivate & inspire
Develop & implement patient education plan based on an initial
education assessment
Identification & resolution of compliance barriers
Patient Specific Pharmacist Care Plan
Recognition, prevention & management of drug interactions
Pharmacology & therapeutics
Interpretation of lab tests
Knowledge of community resources, professional referrals
Communication & support with community medical providers


Drug Treatment Protocol
Develop & maintain (update) protocols
Follow protocols as pharmacist-clinician
Monitor,aggregate adherence to the treatment protocols e.g. drug
utilization evaluation, especially for managed care or health
system facility
Dosage adjustment
Identify patients at high risk for exaggerated or
subtherapeutic response
Apply pharmacokinetic principles to determine patient
specific dosing


Prescriptive authority
In designated practice site and positions
Effective drug           Will the patient take
                                                   Safe drug
   therapy               ?the therapy               therapy




                          Aims of
   What does the
                       Pharmaceutical
  patient view as an       Care
 improved quality of
         ?life



  Improve                                        Economic drug
quality of life                                     therapy
A case
   44 year old lady with fever and green sputum and cough – no known
    previous medical history – Diagnosed with URTI, Prescribed:
       Co-Amoxiclav 1 tds
       Doxycycline 100mg D            Pharmaceutical problems
       Prednisolone 40mg D            ?Common organisms for URTI
       Theophylline 200mg bd
                                       ?History of asthma – risk vs benefit
       Omeprazole 20mg D
       Metoclopramide 10mg tds        ?Need for acid suppression
       Salbutamol 2 puff inhale prn   ?Why is she nauseous
                                       ?Benefit of brochodilation
                                       ?Does she know what to take
                                       ?Will she take it
Question?
• Think of someone in your family or a friend
  that has had something go “wrong” with their
  medicines?
  – Caused an adverse or unwanted effect ?
  – Had medicines stopped when should have
    continued?
  – Not worked?
  – What happened ?
  – Could it have been avoided ?
High Profile Examples
A patient with leukaemia received Intrathecal vincristine   •
instead of intravenously. Died beginning of February
.2001. 14th such case over the last 16 years

Patient being operated for a AAA received bupivicaine •
intravenously rather than epidurally. Patient died 3 days
.later

A 3 year old girl, who had a convulsion post flu vaccine. •
Attended hospital to get “checked out”. Received nitrous
oxide instead of oxygen in casualty
Elderly lady was prescribed Methotrexate in 1997 for her
rheumatoid arthritis. Dose increased to 17.5mg
.WEEKLY over a 6 month period

Jan 2000 patient undergoes right TKR in hospital. MTX      •
(.given as one tablet a week (only 2.5mg

.Prescription for MTX 10mg/daily written and dispensed
.30th April patient dies •
Deaths from medicines in the UK
(1999 - 2000 (ICD9 & 10 data




                (A spoonful of sugar - Audit Commission (2001
………………..So drugs are safe




Photosensitivity from   Severe extravasation of
Amiodarone              amiodarone infusion
NSAID induced peptic ulcer
Goitre – Hypothyroidism   Bleeding due to
Secondary to              anticoagulation
Amiodarone
Erythemal rash from penicillin – in patient with a previous
Known allergy/ adverse drug reaction
Necrotising fascititis – secondary to infection at site of IV injection
Acute Liver failure from Black Cohosh - herbal medicine
Human Error
                       (Mistakes, Slips, Lapses)
   Error is inevitable due to “our” limitations:
    -   limited memory capacity
    -   limited mental processing capacity
    -   negative effects of fatigue other stressors

   We all make errors all the time
   Generalised lack of awareness that causes errors
   Patients suffer adverse events much more often than previously
    realised
   Errors often NOT immediately observed

   The same error, even a minor one, can have quite different
    consequences in different circumstances.
The System:
  !Only as safe as it’s designed to be




“I assumed the brown glass
 ampoule was frusemide”
The Accident Causation Model
             (Adopted from Reason & Dean)




               Error           Active
  Latent                      Failures
             producing
Conditions                   Slips&lapses-
             conditions        Mistakes-     Accident




                                       Defences
Sources of Error
Prescribing error - selecting the wrong or inappropriate   •
drug/dose/formulation/duration etc
Communicating those instructions •

Supply error - timely; wrong drug, dose, route; expired    •
.medicines, labelling

Administration error - timing; wrong route; wrong   •
.rate/technique


.Lack of user education - actions to take •
Drug therapy assessment
Six types of problems which may result in treatment
failure
   :
 Inappropriate selection of medication.1
 Inappropriate formulation of medication.2
 Inappropriate administration of drug therapy.3
 Inappropriate medication-taking behaviour.4      1.
 Inappropriate monitoring of drug therapy.5
 Inappropriate response to drug therapy.6
Clinical Pharmacy Role in Reducing Risks
           Admission medication history
                Formulary
                     Prescribing protocols
                         Allergy check

                                Prospective review
                                   Administration instructions
                                        Clinical pharmacy
                                              Drug distribution system




Opportunity
For Error
!What if we are not there
         Admission medication history
              Formulary
                   Prescribing protocols
                       Allergy check
                              Prospective review
                               Administration instructions
                                      Clinical pharmacy

                                              Drug distribution
                                             system



Opportunity
For Error
Patient Assessment Questions

 ?Does the patient need this drug •
 ?Is this drug the most effective and safe •
 ?Is this dosage the most effective and safe •
If side effects are unavoidable does the patient need •
?additional drug therapy for these side effects
 ?Will drug administration impair safety or efficacy •
 ?Are there any drug interactions •
 ?Will the patient comply with prescribed regimen •
To be a drug expert,society needs
    practitioners who ……..…
Today’s pharmacists
Ideal Pharmacist Candidate?
•   Competent
•   Motivated/Enthusiastic
•   Teamwork spirit
•   Good communication skills
•   Responsible
•   Problem solver
•   Dedicated
The End
Any Questions?

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Clinical pharmacy

  • 1. Clinical Pharmacy Dr Sitaram Khadka,PharmD Clinical Pharmacist Shree Birendra Hospital,Chhauni
  • 2. Health Care System Composed of physician (including other medical and dental staffs), pharmacist , nurse and other paramedics Physician ; diagnosis, prescription, monitoring, medical care Pharmacist; prescription*, dispensing, counseling, monitoring, pharmaceutical care Nurse ; administering, monitoring, nursing care Other paramedics ; their own work Load to physician & nurse ; high due to the system of "physicians are all in all in hospital for the treatment of patient, with the help of nurse." Concept of normal public/patient ; same
  • 3. Perceptions of Pharmacists How do others see us?
  • 4. ”They just count a few tablets“
  • 5. ”They just weigh and measure things“
  • 6. ”A bunch of shop-keepers“
  • 7. Tell me how and when to use the“ ”Medicine
  • 9. Not really health care practitioners – they’re “ ”businessmen
  • 10. ?”Do you need a degree to be a pharmacist“
  • 11. For practising Clinical Pharmacy • Competence of health care practitioners -BPharm to Mpharm to PharmD* -PharmD+ Pre-registration + registration -Residency programs -Continuing Professional Development • Informed general public – increased expectation
  • 12. Introduction; Clinical Pharmacy Clinical pharmacy may be defined as the science and practice of rationale use of medications, where the pharmacists are more oriented towards the patient care rationalizing medication therapy promoting health , wellness of people. It is the modern and extended field of pharmacy. “ The discipline that embodies the application and development (by pharmacist) of scientific principles of pharmacology, toxicology, therapeutics, and clinical pharmacokinetics, pharmacoeconomics, pharmacogenomics and other allied sciences for the care of patients”. (Reference: American college of clinical pharmacy)
  • 13. History Until the mid 1960’s ; Traditional role. The development of clinical pharmacy started in USA. More clinically oriented curriculum were designed with the award of PharmD degree. These developments influenced the practice of pharmacy in U.K., Initially prescription and drug administration records were introduced followed by an increasing pharmacy practice in hospital wards. Master degree programs in clinical pharmacy were introduced for first time in 1976. The progress of clinical pharmacy development remained at low profile in the first decade after its birth in U.K. However, Nuffield report in1986 geared up the momentum for progression of clinical pharmacy. Until today, the clinical pharmacy practice in Nepal is in embryonic stage.
  • 14. How does clinical pharmacy differ from pharmacy? The discipline of pharmacy embraces the knowledge on synthesis, chemistry and preparation of drugs Clinical pharmacy is more oriented to the analysis of population needs with regards to medicines, ways of administration, patterns of use ,drugs effects on the Patients, ‘the overall drug therapy management’. The focus of attention moves from the drug to the single patient or population receiving drugs.
  • 15. Clinical Pharmacy Requirements Knowledge of drug therapy Knowledge of Knowledge of nondrug therapy the disease Therapeutic Knowledge of planning laboratory skills and diagnostic skills Patient care Drug Information Communication Skills skills Physical Patient assessment monitoring skills skills
  • 16. Level of Action of Clinical Pharmacists Clinical pharmacy activities may influence the correct use of medicines at three different levels: Before the prescription During the prescription and After the prescription is written.
  • 17. 1. Before the prescription • Clinical trials • Formularies • Drug information • Drug-related policies
  • 18. 2. During the prescription • Counselling activity • Clinical pharmacists can influence the attitudes and priorities of prescribers in their choice of correct treatments. • The clinical pharmacist monitors, detects and prevents the medication related problems • The clinical pharmacist pays special attention to the dosage of drugs which need therapeutic monitoring. • Community pharmacists can also make prescription decisions directly, when over the counter drugs are counselled.
  • 19. Medication-related Problems • Untreated indications. • Improper drug selection. • Subtherapeutic dosage. • Medication Failure to receive • Medication Overdosage. • Adverse drug reactions. • Drug interactions. • Medication use without indication.
  • 20. 3. After the prescription – Counselling – Preparation of personalised formulation – Drug use evaluation – Outcome research – Pharmacoeconomic studies
  • 21. Functions of Clinical Pharmacists 1. Taking the medical history of the patient 2. Patient Education 3. Patient care 4. Formulation and management of drug policies 5. Drug information 6. Teaching & training to medical and paramedical staff
  • 22. 7.Research and development 8.Participation in drug utilization studies 9.Patient counseling 10.Therapeutic drug monitoring 11.Drug interaction surveillance 12.Adverse drug reaction reporting 13.Safe use of drugs 14.Disease management cases 15.Pharmacoeconomics
  • 23. Objective • Define clinical pharmacy • Differentiate between traditional pharmacists role and Clinical Pharmacist • Explain the qualification required for clinical pharmacists • List the clinical pharmacists responsibility • Describe the daily work activity of clinical pharmacists • Define what is Therapeutic Drug Monitoring • Discuss the different types of Therapeutic Drug Monitoring
  • 24.
  • 25. Clinical pharmacy specialists • Usually requires residency in a specialty area, in addition to a pharmacy practice residency • Job functions depend on the specialty and the institution • Usually has teaching and/or research responsibilities • Represent pharmacy for medication use meeting/committee in specialty areas
  • 26. Clinical Pharmacy Practice areas  Investigational Drugs  Ambulatory care  Critical care  Pharmacoeconomics  Drug Information  Nephrology  Geriatrics and long –term care  Obstetrics and gynecology  Internal medicine and  Pulmonary disease subspecialties  Cardiology  Psychiatry  Endocrinology  Gastroenterology  Rheumatology  Infectious disease  Nuclear pharmacy  Neurology  Pediatrics  Nutrition Support  ADR/DUE  Pharmacokinetics  Transplant  Surgery
  • 27. Various ambulatory services  Anticoagulation Management  Cholesterol Management  Renal Management (CKD)  Oncology Services  Home Health Pharmacy Services  Impact Pharmacy Services (Drug Conversion Program)  Neonatal ICU  Hypertension Management  Integrated Coronary Vascular Disease (CVD)  HIV/ID  New Member Program (assist new MD in prescribing NF to formulary drugs)  Heart Failure Management  Asthma Management
  • 28. Hospital pharmacist Vs Clinical pharmacist
  • 29. The service including clinical pharmacy/clinical pharmacist -Patients get right care from all the facets (all the drug related problems can easily be eliminated) -Physicians n other health care professionals get more focused in their own, work-load to them is low -Patients feel more comfortable    "Every drug is poison, it’s the dose that differentiate poison or drug the  substance is."    "To kill ill by pill, not by bill"    The last person to be involved in health care team with the patient; Pharmacist, so the system has to rely upon him/her.
  • 30. The service without clinical pharmacy/clinical pharmacist -Due to high load to physicians and other health care professionals, the quality of patient care will be low -Most of the drug related problems cannot be easily eliminated -Patients may not feel comfortable  "In developing countries like Nepal; Physicians are incompetent, Nurses are careless, Pharmacists don’t know anything(??), System is corrupted, Public is foolish, Patient load is high."...Prof Furqan Hashmi  "Medicine is for those who need them, not for those who want them."  "If your medicine is not working it may not be your medicine, it may be you"
  • 32. Pharmaceutical care • “ A practice in which a practitioner takes responsibility for a patient’s drug related needs and holds him or herself accountable for meeting these needs.”....... Linda Strand 1997 • It describes specific services & activities through which an individual pharmacist cooperates with patients and other health care professionals in designing, implementing & monitoring a therapeutic plan that will produce specific outcomes for the patient.
  • 33. Wherein the pharmacist is engaged in; Drug monitoring, Disease monitoring, Drug therapy & disease management/collaborative practice • Pharmaceutical care is that component of pharmacy practice which entails the direct interaction of pharmacist with the patient for the purpose of caring for that patient’s drug related needs Goal of Pharmaceutical Care • Goal of pharmaceutical care is to optimize the patient’s health-related quality of life and achieve positive clinical outcomes, within realistic economic expenditures
  • 34. Essential Components of Pharmaceutical Care 1.Pharmacist-patient relationship Collaborative effort between pharmacist & patient 2.Pharmacist’s workup of drug therapy (PWDT) Provision of pharmaceutical care is centered around this, although the methods used for this purpose may vary. Components are: I.Data collection; Collect, synthesize & interpret relevant information Patient’s demographic data: age, sex, race etc. Pertinent medical information
  • 35. Medical history (current & past) Family history Dietary history Medication history (prescription, OTC, allergies) Physical findings (weight, height, B.P) Lab results (serum drug levels, potassium levels, serum creatinine levels relevant to drug therapy) Patient complaints, symptoms & signs II. Develop or identify the CORE pharmacotherapy plan C = condition or patient need O = outcome desired for that condition R = regimen selected to achieve that outcome E = evaluation parameters to assess outcome achievement
  • 36. III.Identify PRIME Pharmacotherapy Problems This includes pharmacist's intervention The goal is to identify actual or potential problems that could compromise the desired patient outcome P = pharmaceutical based problems R = risks to patient I = interactions M = mismatch between medication & condition or patient needs E = efficacy
  • 37. 3.Documentation of pharmaceutical care Formulate a FARM note or SOAP note to describe or document the interventions needed or provided by pharmacist FARM Progress Note Description & documentation of interventions intended or provided by pharmacist F = Findings, pt-specific information—gives basis for recognition of pharmacotherapy problems or indication for pharmacist intervention. A = Assessment, The pharmacist’s evaluation of the findings, including a statement of: Any additional information needed to best assess the problem to make recommendation The severity, priority or urgency of the problem The short term & long term goals of the intervention proposed
  • 38. Short term goals: elimination of symptoms , Lowering of BP ,Management of acute asthma without requiring hospitalization Long term goals:Prevent recurrence of disease,Control B.P.,Prevent progression of diabetes R = Resolution, including prevention Observing & reassessing Counseling or educating the patients & care givers Informing the prescriber Making recommendation to prescriber Withholding medication or advising against use M = Monitoring to assess the efficacy, safety & outcome of the intervention This should include The parameters to be followed (e.g. pain, depressed mood, serum levels) The intent of monitoring e.g. efficacy, toxicity, adverse events How the parameters will be monitored e.g. interview patients, serum drug level, physical examination
  • 39. Frequency of monitoring—weekly or monthly Duration of monitoring e.g. until resolved, while on antibiotics,then monthly for one year Anticipated or desired finding e.g. no pain, healing of lesion Decision point to alter therapy when or if outcome is not achieved e.g. pain still present after 3 days, mild hypoglycemia more than 2 times a week. SOAP Note ; This is used primarily by physicians, S=subjective findings O=objective findings A=assessment P=plan
  • 40. Clinical skills & pharmacist’s role in Pharmaceutical Care Patient assessment Physical assessment Barriers to adherence Psychosocial issues Education & counseling Interview skills Communication skills (e.g. empathy, listening, speaking or writing at patient's level of understanding) Ability to motivate & inspire Develop & implement patient education plan based on an initial education assessment Identification & resolution of compliance barriers
  • 41. Patient Specific Pharmacist Care Plan Recognition, prevention & management of drug interactions Pharmacology & therapeutics Interpretation of lab tests Knowledge of community resources, professional referrals Communication & support with community medical providers Drug Treatment Protocol Develop & maintain (update) protocols Follow protocols as pharmacist-clinician Monitor,aggregate adherence to the treatment protocols e.g. drug utilization evaluation, especially for managed care or health system facility
  • 42. Dosage adjustment Identify patients at high risk for exaggerated or subtherapeutic response Apply pharmacokinetic principles to determine patient specific dosing Prescriptive authority In designated practice site and positions
  • 43. Effective drug Will the patient take Safe drug therapy ?the therapy therapy Aims of What does the Pharmaceutical patient view as an Care improved quality of ?life Improve Economic drug quality of life therapy
  • 44. A case  44 year old lady with fever and green sputum and cough – no known previous medical history – Diagnosed with URTI, Prescribed:  Co-Amoxiclav 1 tds  Doxycycline 100mg D Pharmaceutical problems  Prednisolone 40mg D ?Common organisms for URTI  Theophylline 200mg bd ?History of asthma – risk vs benefit  Omeprazole 20mg D  Metoclopramide 10mg tds ?Need for acid suppression  Salbutamol 2 puff inhale prn ?Why is she nauseous ?Benefit of brochodilation ?Does she know what to take ?Will she take it
  • 45. Question? • Think of someone in your family or a friend that has had something go “wrong” with their medicines? – Caused an adverse or unwanted effect ? – Had medicines stopped when should have continued? – Not worked? – What happened ? – Could it have been avoided ?
  • 46.
  • 47. High Profile Examples A patient with leukaemia received Intrathecal vincristine • instead of intravenously. Died beginning of February .2001. 14th such case over the last 16 years Patient being operated for a AAA received bupivicaine • intravenously rather than epidurally. Patient died 3 days .later A 3 year old girl, who had a convulsion post flu vaccine. • Attended hospital to get “checked out”. Received nitrous oxide instead of oxygen in casualty
  • 48. Elderly lady was prescribed Methotrexate in 1997 for her rheumatoid arthritis. Dose increased to 17.5mg .WEEKLY over a 6 month period Jan 2000 patient undergoes right TKR in hospital. MTX • (.given as one tablet a week (only 2.5mg .Prescription for MTX 10mg/daily written and dispensed .30th April patient dies •
  • 49. Deaths from medicines in the UK (1999 - 2000 (ICD9 & 10 data (A spoonful of sugar - Audit Commission (2001
  • 50. ………………..So drugs are safe Photosensitivity from Severe extravasation of Amiodarone amiodarone infusion
  • 52. Goitre – Hypothyroidism Bleeding due to Secondary to anticoagulation Amiodarone
  • 53. Erythemal rash from penicillin – in patient with a previous Known allergy/ adverse drug reaction
  • 54. Necrotising fascititis – secondary to infection at site of IV injection
  • 55. Acute Liver failure from Black Cohosh - herbal medicine
  • 56. Human Error (Mistakes, Slips, Lapses)  Error is inevitable due to “our” limitations: - limited memory capacity - limited mental processing capacity - negative effects of fatigue other stressors  We all make errors all the time  Generalised lack of awareness that causes errors  Patients suffer adverse events much more often than previously realised  Errors often NOT immediately observed  The same error, even a minor one, can have quite different consequences in different circumstances.
  • 57. The System: !Only as safe as it’s designed to be “I assumed the brown glass ampoule was frusemide”
  • 58. The Accident Causation Model (Adopted from Reason & Dean) Error Active Latent Failures producing Conditions Slips&lapses- conditions Mistakes- Accident Defences
  • 59. Sources of Error Prescribing error - selecting the wrong or inappropriate • drug/dose/formulation/duration etc Communicating those instructions • Supply error - timely; wrong drug, dose, route; expired • .medicines, labelling Administration error - timing; wrong route; wrong • .rate/technique .Lack of user education - actions to take •
  • 60. Drug therapy assessment Six types of problems which may result in treatment failure : Inappropriate selection of medication.1 Inappropriate formulation of medication.2 Inappropriate administration of drug therapy.3 Inappropriate medication-taking behaviour.4 1. Inappropriate monitoring of drug therapy.5 Inappropriate response to drug therapy.6
  • 61. Clinical Pharmacy Role in Reducing Risks Admission medication history Formulary Prescribing protocols Allergy check Prospective review Administration instructions Clinical pharmacy Drug distribution system Opportunity For Error
  • 62. !What if we are not there Admission medication history Formulary Prescribing protocols Allergy check Prospective review Administration instructions Clinical pharmacy Drug distribution system Opportunity For Error
  • 63. Patient Assessment Questions ?Does the patient need this drug • ?Is this drug the most effective and safe • ?Is this dosage the most effective and safe • If side effects are unavoidable does the patient need • ?additional drug therapy for these side effects ?Will drug administration impair safety or efficacy • ?Are there any drug interactions • ?Will the patient comply with prescribed regimen •
  • 64. To be a drug expert,society needs practitioners who ……..…
  • 65.
  • 66.
  • 68. Ideal Pharmacist Candidate? • Competent • Motivated/Enthusiastic • Teamwork spirit • Good communication skills • Responsible • Problem solver • Dedicated

Editor's Notes

  1. Safe Medication Practice Unit So these people – your predecessors PERCEIVED that they wouldn’t have any problems. Doctors don’t go out there, thinking that they will make mistakes . These are some of the reasons why…(points on slide - just need to raise awareness !)
  2. Safe Medication Practice Unit Things still do look alike .
  3. Safe Medication Practice Unit So thinking back to example (white ants ) When things do go wrong, there are several contributing factors . Active failures : Don’t always blame the person who makes the error . Error producing conditions : Start thinking about what has led to the error . Go and watch how nurses administer drugs... Understand how many other factors there are that the nurses have to cope with . Latent conditions See next slide .