General Discussion on Clinical Pharmacy

Development of clinical pharmacy
• Pharmacy is the science and technique of
preparing and dispensing drugs. It is
a health profession that links health
sciences with chemical sciences and aims
to ensure the safe and effective use
of pharmaceutical drugs.

CLINICAL PHARMACY
• Clinic is a facility or area where ambulatory
patients are seen for appointments and
treated by a group of physicians practicing
together and also used to indicate the
outpatient diagnostic facility operated by a
hospital
• Pharmacists, also known as chemists or
druggists, are health professionals who
practice in pharmacy, the field of health
sciences focusing on safe and effective
medication use. A pharmacist is a member of
the health care team directly involved with
patient care

• 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)
• It comprises a set of function that promote the safe,
effective and economic use of medicines for individual
patients.
• Clinical pharmacist often work in collaboration with
physicians, nurse practioners and other heathcare
professionals.

Basic component of Clinical pharmacy
• Prescribing drugs
• Adminstering drug
• Monitoring prescription
• Managing drug use
• Counselling Patient

Qualification & skill of clinical pharmacist
Most clinical pharmacists have a B.Pharm,
M.pharm and Doctor of pharmacy(pharm D)
Degree and many have completed one or more
years of
post graduate training.
Clinical Pharmacist interact directly with patient in
several different ways.They use their knowledge/
skill of medication including dosage,drug
interaction,side effect,expese and effectiveness
etc to determine if a medication plan is
appropriate for their patients.

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.

Hospital vs Clinical pharmacy
• Clinical pharmacist include hospital
pharmacist and community pharmacist.
They are the people who work in
healthcare field and have a main role in
prescription
• Hospital pharmacist are referred to those
who work in a hospital,while community
pharmacist are those who work in an
independent pharmacy.

• Clinical pharmacists participate in direct
patient care in hospitals and other
healthcare facilities, while hospital
pharmacists focus on preparing
prescriptions for patients.
• Clinical pharmacists and hospital
pharmacists are both involved in providing
medication to patients. Their scope of
duties differs, however, and clinical
pharmacists are required to complete
additional training

Job responsibilities of a clinical pharmacist
include:
• Evaluating for untreated health issues
• Performing medical tests on patients
• Ensuring patients receive the correct
medications
• Advising patients about health-related
matters
• Tracking the progress of patients

Job responsibilities of a hospital pharmacist
include:
• Preparing IV prescription medications
• Providing information to medical staff
• Ensuring the medication is safe for the
patient
• Filling out paperwork
• Monitoring and ordering inventor

• Pharmaceutical Care is the direct responsible
provision of medication related care for the
purpose of achieving definite outcomes from
the responsible provision of medicines.
• Cause the use of drug:-
-cure of the disease
-elimination or reduction of symptoms
-arrest or slowing of a disease process
-prevention of disease or symptoms

• Clinical pharmacy include all the services
performed by pharmacist practising in
hospital,community pharmacies,nursing
homes,home based care service,clinics
and any other setting where medicines are
prescribed and used.

Medicine management
Medicine management can be define as
a system of processes and behaviors
that determines how medicines are
used by the patients.

medicines management pathway
• There are nine steps and three
background processes
Steps include:-
1. Decision to Treat and Prescribe
2. Record Medicine Order
3. Review of Medicine Order
4. Issue of Medicine
5. Provision of Medicine Information

medicines management pathway
1. Distribution and Storage of Medicine
2. Administration of Medicine
3. Monitor for Response
4. Transfer of Verified Information
Background Processes include:-
1. Medicines Procurement and Materials
Management
2. Reporting and Quality Safety Audit Review
3. Communication

Goal of clinical Pharmacy
The main goal of clinical pharmacy are:
 To assist the physician in doing a better job of
prescribing and monitoring drug therapy for the
patient.
 To assist medical and Para-medical staff and
documenting medication incidents correctly
 To Promote the correct and appropriate use of
medical product and devices

Goal of clinical Pharmacy
 These activates aim at:
 Maximizing the clinical effect of medicine
 Minimizing the risk of treatment-induced
adverse events
 Minimizing the expenditures for
pharmacological treatment

Clinical Pharmacy
Requirements
Knowledge
of nondrug
therapy
Therapeutic
planning
skills
Drug
Information
Skills
Physical
assessment
skills
Patient
monitoring
skills
Communication
skills
Knowledge of
laboratory
and diagnostic
skills
Knowledge of
the disease
Knowledge of
drug therapy
Patient care

Clinical Pharmacy Requirements
Physical Assessment skills :
The clinical pharmacist assesses medication-related needs
by
 Reviewing the medical record using a problem-oriented
framework
 Meeting with the patient to obtain a complete medication
history to identify all of the patient’s current medications
 Obtaining, organizing, and interpreting patient data

Knowledge of drug therapy:
• Evaluating the effectiveness, safety, and affordability of
each medication
• Assessing medication-taking behaviors
• Identifying medication-related problems
Communication skills:
 The pharmacist should communicate with patients about
how and when they should take medication and then
verify their understanding

• Understand written information.
• Understand spoken information.
• Speak clearly so listeners can understand.
• Read and understand work-related materials
• Write clearly so other people can understand.
Laboratory and diagnostic skills:
Hospital pharmacists participate in activities that may be
considered diagnostic.

Therapeutic Planning skills

 therapeutic planning may incorporate :-
• patient education,
• dietary adjustment,
• an exercise program,
• drug therapy,
• And the participation of nursing and others health
professionals.
• Therapeutic plans are important in the management of
complex or chronic illnesses.

Level of Action of Clinical Pharmacists
Before prescription
During prescription
After prescription

Before the
prescription
•
Clinical trials
Formularies
Drug information
Drug-related policies
•
•
•

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(MRP)
•
•
•
•
•
•
•
•
Untreated indications.
Improper Drug selection.
Subtherapeutic Dosage.
Medication Failure to Receive
Medication Overdosage.
Adverse drug reactions.
Drug Interactions.
Medication use without
indication.

Prevention of MRP
Communicate
with healthcare
provider
Designate a
medication
manager
Keep a
medication list
Consult with
doctor or
pharmacist
Use common
sense when
using
medication
Obtain a refills in
timely manner

After the prescription
Counselling
Preparation of personalised
formulation
Drug use evaluation
Pharmacoeconomic studies
Outcome research

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.

Patient consultation
• Consultation is the act of seeking
assistance from another physicians or
health care professionals for diagnostic
studies, therapeutic interventions, or other
services that may benefit the patient.

Role of pharmacist in consultation
• Reorganization of the pharmacist's activities may
improve pharmaceutical consultations.
• The potential determinants of personal consultation
show that 52% of participants trusted pharmacist
and 55% considered the pharmacist as a friend%
agreed about full investigation. .

METHOD OF CONSULTATION
WWHAM
ASMETHOD
ENCORE

Consultation Process: WWHAM
• W= Who is it?
• W= What are the symptoms?
• H= How long has it going on?
• A= action taken?
• M= Medicine being taken?

Consultation Process: ASMETHOD
• A= Age of the patient?
• S= Self or someone else?
• M= Medicine has taken?
• E= Exactly what do you mean?
• T= Time of symptoms?
• H= History of diseases?
• O= Other symptoms?
• D= Doing anything for cure?

Consultation Process: ENCORE
• E= Evaluate the symptoms its onset
recurrence and duration?
• N= No medication is always and option?
• C= Care when dealing with specific patient
group?
• O= Observe the patient for sign of systemic
disturbance ?
• R= Refer when in doubt?
• E= Explain any course of action
recommended?

Role of Clinical Pharmacist
Step:1. Stabilizing the need for the drug therapy
Step:1.1 Relevant Patient Details
Step:1.2 Medication History

Step:1. Stabilizing the need for the drug therapy
The pharmacist often one provides information to
the independent prescribe on the expected
benefits and risk of drug therapy by evaluating
both the evidence base and individual patient
factor. The evidence for one specific mode of
therapy may not be conclusive. In this
circumstances, the pharmacist will need to call on
their understanding of the principles of
Pharmaceutical science and on clinical experience
to provide the best advice possible.

Step:1.1 Relevant Patient Details
Without background information of the patient
health and social circumstances it is difficult to
establish the existence of all potential for medical
related problems.So the following requirements
are need to be fulfilled:
Factor Implications
Age The very young and the very old are most at risk of
medication-related problems. A patient's age may indicate
their likely ability to metabolise and excrete medicines and
have implications for step 2 of the drug use process
Gender This may alter the choice of the therapy for certain
indications. I t may also prompt consideration of the
potential for pregnancy or breast feeding

Factors Implications
Ethnic or
Religious
Background
Racially determined predispositions to intolerance or
ineffectiveness should be considered with certain classes
of medicines, for example, ACE inhibitors in Afro-Caribbean
people. Formulations may be problematic for other groups, for
example, those based on blood products for Jehovah's
Witnesses or porcine-derived products for Jewish patients
Social History This may impact on ability to manage medicines and influence
pharmaceutical care needs, for example, living alone or in a
care home or availability of nursing, social or informal carers

Factor Implications
Presenting
complain
Symptoms the patient describes and the signs identified by the doctor on
examination. Pharmacists should consider whether these might be
attributable to the adverse effects of prescribed or purchased medicines
Working
Diagnosis
This should enable the pharmacist to identify the classes of medicines that
would be anticipated on the prescription based on current evidence
Previous Medical
History
Understanding the patient's other medical conditions and their history helps
ensure that management of the current problem does not compromise a
prior condition and guides the selection of appropriate therapy by identifying
potential contraindications
Laboratory or
Physical Findings
The focus should be on findings that may affect therapy, such as : renal
function,liver function, full blood count, blood pressure, cardiac rhythm.
Results may convey a need for dosage adjustment or presence of an
adverse reaction

Step:1.2 Medication History
A medication history is the part of a pharmaceutical consultation that identifies
and documents allergies or other serious adverse medication events, as
well as information about how medicines are taken currently and have been
taken in the past. It is the starting point for medicines reconciliation and
medication review.
Discrepancies between the history recorded by the medical team and that
which the pharmacist elicits fall into two categories:
1. Intentional (where the medical team has made a decision to alter the
regimen) or
2. Unintentional (where a complete record was not obtained).
Discrepancies should be clarified by the prescriber or referred to a more senior
pharmacist.

Key Components of Medication History:
1. Introduce yourself to the patient and explain the purpose of
theconsultation.
2. Identify any allergies or serious adverse reactions and record these on the
prescription chart, care notes or patient medication record.
3. Ascertain information about prescribed and non-prescribed treatments
from:
 the patient's recall
 medicines in the patient's possession
 referral letter (usually from the patient's primary care doctor)
 copy of prescriptions issued or a repeat prescription list
 medical notes
 contact with the appropriate community pharmacist or primary care
doctor.
4. Ensure the following are recorded:
 generic name of medicine (unless specific brand is required)
 dose
 frequency
 duration of therapy.

Key Components of Medication History:
5. Ensure items such as inhalers, eye drops, topical medicines, herbal and
homeopathic remedies are included, as patients often do not consider these as
medicines.
6. Ascertain the patient's medication-taking behavior.
7. Consider practical issues such as swallowing difficulties, ability to read labels
and written information, container preferences, ordering or supply problems.
8. Document the history in an appropriate format.
9. Note any discrepancies between this history and that recorded by other health
care professionals.
10. Ascertain if these discrepancies are intentional (from patient, nursing staff,
medical staff or medical notes).
11. Communicate non-intentional discrepancies to the prescriber.
12. Document any other important medication-related information in an appropriate
manner, for example, implications of chronic renal failure, dialysis, long-term steroid
treatment.

A) Identify drug patient interaction
 Contraindication, drug related to age and
gender.
 Identifies previous ADR allergy.
 Abnormal renal and hepatic function.
 Patient preference to certain treatment.
Route of administration.
Step:2-Seleciton of medicine

B) Identify drug disease interaction

Elder patient :Drug therapy is essential when
caring for elderly patients, but clearly it is a double-
edged sword. Elderly patients are at high risk of
having drug interactions, but the prevalence of these
interactions is not well documented. Several types of
interactions exist: drug–drug, drug–disease, drug–
food, drug–alcohol, drug–herbal products, and drug–
nutritional status.

C) Identify drug-drug interaction.
When two drugs interact, the overall effect of one or both of the drugs may be
greater than desired .
Example: Certain antacids can prevent certain medicine(such as antibiotics, blood-
thinners and heart medications) from being absorbed into the blood stream.

Step-3: Administering medicine
A. Pharmacokinetic factor
i. Rate and extent of drug absorption
ii. Drug distribution
iii. Plasma protein binding
iv. Metabolism
v. Excretion
B. Pharmacodynamics factor
i. Receptor binding
ii. Enzyme

Continued…
C. Factors affecting bioavailability
Physicochemical Factor
• Surface area
• Particle size
• Dissolution rate
• Disintegration
time
• PH
Physiological Factor
• Small intestine
• GI motility
• Gastric emptying
time

D. Calculating dose of a
drug
on the basis of body

E. Selection of appropriate regimen
Simple regimen
• Short term or long
term
• Increased
duration
• Decrease
frequency of drug
administration
• Oral route is more
Complicated Regimen
• For short half-life
• Short therapeutic
index

Step:4- Providing Medicine
• Prescription should be legal, legible and
accurate
• Right medicine for right patient at right
time
• Screening the prescription
• Continued the availability and supply of
medicine
• Risk related to providing medicine
• Proper labeling with clear dosage
instruction

Step:5- Monitoring Therapy
• Effectiveness of therapy
• Identification of potential ADR
• Required more care in low TI Drug
Example:
Digoxin, Phenytoin, Theophylline
• Anticoagulant
Example: Warfarin

Step:6- Patient Advice and Education
• Provide accurate and reliable information
• Convey the benefits and risk of therapy
• Patient reminder chart
• Ask any question they may have
• Provide info. Throughout the hospital and
during discharge
Step:7- Evaluating Effectiveness

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 ?

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

General Discussion on Clinical Pharmacy

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General Discussion on Clinical Pharmacy