The document provides an overview of pharmaceutical care practice, emphasizing the evolution from traditional roles of pharmacists to a more patient-centered approach that focuses on optimizing medication therapy outcomes. It highlights the need for improved accountability, medication safety, and the integration of pharmacists into healthcare teams to address drug-related problems effectively. Case studies illustrate the consequences of medication errors, advocating for a shift towards clinical pharmacy services that prioritize patient care and rational drug use.

1. Pharmaceutical Care Practice: An
Overview

2. 2
DO we still need Pharmacists?
• Purchase and handling of medicines
– Non pharmacists
• Compounding role
– Pharmaceutical manufacturers
• Medicine availability
– Pharmacies vs. supermarkets and local markets
– Doctor’s office, clinic nurses

3. 3
Ask yourself: Do we still
need pharmacists?

4. • A nine-month old baby died after misplaced decimal causes 10-fold
morphine overdose
• Physician ordered Morphine .5 mg IV for post-op pain, unit secretary
does not see the decimal and transcribes the order as Morphine 5 mg IV
• Experienced nurse administered 5 mg of Morphine and repeats the dose
2 hours later
• Four hours later baby stops breathing
Washington Post, April 20, 2001
Case 1:

5. Case 2
• 44 y/o F in Florida died in an emergency department
after receiving 8,000 mg IV phenytoin instead of 800
mg
• A nurse administered overdose
– 32 vials of 50 mg / mL, 5 mL
– Required removing medication from several
automated dispensing machines
– ISMP Medication Safety Alert, March 8, 2007

6. Case 3
– An elderly Ohio woman died after she
received IV injection of potassium
phosphate that was supposed to be
administered via a feeding tube
• ISMP Medication Safety Alert, March 8, 2007

7. Case 4
• Dana Farber Cancer Institute, Boston Mass. 1995
• 39 year old female being treated for metastatic breast CA
• Cyclophosphamide ordered as: “4 gram per meter square
days 1 - 4”
– Was meant to be 1 gram / meter squared daily
• The patient received the total dose each day
– A massive overdose caused death from cardiotoxicity

8. 8
Case 5
• A 55 year old woman with chronic renal failure
and diabetes had an imaging procedure with
CT (contrast enhanced) and later developed
acute kidney injury

9. 9
Case 6
• An intern doctor in a hospital in Addis writes a
a script for 20 vials of heparin for a patient
admitted to the ER for DVT

10. What is Wrong with the Current
System? (Cont’d)
Inadequate of Accountability?
If a patient died after taking a
prescription drug that was
dispensed according to the
physician order correctly, who is
responsible?

11. Medication-
Related
Problems
Indication without
drug therapy
Drug without
indication
Improper drug
selection
Subtherapeutic
dosage
Overdosage
Drug interaction
Adverse drug
reaction
Inappropriate
laboratory
monitoring
Failure to
receive drug
Manley HM, et al. Am J
Kidney Disease 2005;
46:669-680

12. Case Study
Almaz has diabetes and a history of
arthritis.
Today, she brought a prescription
from her physician to her local
pharmacy for:
–NPH insulin injection (35 units qam)
and
–Timolol 1 drops in each eye qd for
glaucoma.

13. In the Pharmacist’s Eye
• Glaucoma - insulin dosing errors
– Hypoglycemia – may be life threatening – cause
poor compliance or failed to take it altogether
– Hyperglycemia – complications, diabetic coma risk
– Abnormal HgbA1C results – dose adjustment
issues
• Arthritis - Incorrect eye drop
– asymptomatic – risk of blindness
– difficult of using an insulin syringe

14. 14
The old
“Physicians Prescribe and Pharmacists
Dispense” model
is no longer fully appropriate to
(a) reduce drug therapy problems,
(b) ensure safety,
(c) ensure effectiveness and
(d) adherence to drug therapy.
What could be a solution?

15. 15
Pharmaceutical Care
Is the new term introduced in recent years
Adapted by WHO and in 2000 taken up by International
Pharmacy Federation
Accordingly, the policy sees the pharmacist as a member
of the healthcare team
– From medicine supply to patient care.
– From a compounder of pharmaceutical products to a provider of
services and information and
– Ultimately that of a provider of patient care.

16. What are Clinical Pharmacy Services?
That area of pharmacy concerned with the science and practice
of rational medication use. American College of Clinical Pharmacy
Clinical pharmacy is more oriented to the analysis of population
needs with regards to medicines, ways of administration,
patterns of use and drug effects on the patients. The focus of
attention moves from the drug to the single patient or
population receiving drugs. European Society of Clinical Pharmacy
Patient-centered services that promote the appropriate selection
and utilization of medications. Its objective is to optimize
individual therapeutic outcomes. HRSA - PSPC

17. Pharmaceutical Care
A paradigm Change
– From medicine supply to patient care.
– From a compounder of pharmaceutical
products to a provider of services and
information
– From product oriented service to patient
oriented one
– From drug product focus to patient focus
– From drug expert to drug therapy expert.

18. 18
Pharmaceutical Care
“Pharmaceutical care is
the responsible provision of drug therapy for
the purpose of achieving definite outcomes that
improve or maintain a patient’s quality of life”.
(Charles Hepler and Linda Strand, 1990)

19. Pharmaceutical Care
• Calls on pharmacists to:
– Ensure access
– Ensure access to advice
– Ensure quality drug products
– Ensure rational drug use
– Empower patients to manage their own health
and treatment

20. 20
Adopting a New Philosophy
• Providing PC means adopting a philosophy of
practice where pharmacists work with and for
the patient to optimize the outcomes of
medication therapy.
• “Drugs Don’t Have Doses-People Have
Doses !” Robert Cipole

21. Clinical Pharmacists Can
Reduce Drug Costs
University of Illinois at Chicago (2008, December 23). Clinical Pharmacists Can Reduce Drug Costs.
ScienceDaily.
For every dollar spent by hospitals or health
systems to provide clinical pharmacy services,
$4.81 was saved through lower drug costs,
reductions in adverse drug events and
medication errors and other savings.

22. 22
Global shift in the Practice of Pharmacy
• US: early 1960s: Pharm D
• US: 2000 Pharm.D mandatory for Pharmacy Schools
• Other continents:
• Asia: India: Pharm.D: 2007
• Africa: Egypt: Alexandria University
• South Africa, Zambia: baccalaureate degree +
internship in clinical areas
• UK, Australia: M.pharm (Clinical Pharmacy)

23. 23
Pharmaceutical Care in Ethiopia
• Curricular revision 2008: nationwide
• Pharmacy curriculum: more patient oriented
(4 years + 1 internship)
• FMoH: EHRIG May 2010

24. 24
PC in Ethiopia

25. Pharmaceutical Care
• Expert knowledge of therapeutics
• A good understanding of disease
process
• Knowledge of pharmaceutical products
• Drug monitoring skills
• Provision of drug information
• Communication skills

26. Pharmaceutical Care - Benefits
• Decrease medication misadventures
• Increase patient compliance to therapy
– Empowers patients to take in-charge of
their own health and treatment
• Decrease healthcare cost and demand
• Decrease morbidity of mortality
• Increase patients’ quality of life

27. Goal of Pharmacists
Clinical Training
• To make them experts in:
–identifing and solving medication
therapy problems
–becoming patient educators
–selecting the most effective therapy
–monitoring the outcome of drug
therapy

28. What is the Focus of the
New Pharmacy Curriculum?
• Clinical Application of Drug Therapy
• Treatment guideline
• Disease state knowledge
• Diagnostic procedures (to identify a drug
problem)
• Monitoring parameters (lab, physical exam,
other diagnostic tools) to follow efficacy and
safety of drug therapy.

29. Beyond Counseling
• The traditional dispensing practices
• pharmacists were simply responsible for dispensing
prescriptions accurately, as prescribed.
• pharmacists assumed responsibility for ensuring that
the right patient got the right quantity of the right
medication of the right strength at the right time.
• The pharmaceutical care model of practice
• pharmacist goes far beyond counseling to assume
responsibility for all the patient’s drug-related needs.
• Pharmacists take responsibility for ensuring the desired
outcome of the drug therapy is met.

30. Five Key Drug-Related Needs of Patients
1. Patients need every medication they are taking to
have an appropriate indication.
• If a drug does not have an appropriate indication, the drug therapy
problem “unnecessary drug therapy” will be identified.
2. Patients need their drug therapy to be effective
• When a patient’s need for medication to be effective is not met, two
possible drug therapy problems can arise. They are “wrong drug”
and “dosage too low”.
3. Patients need their drug therapy to be safe
• Not meeting a need for medication safety can result in the drug
therapy problems of “dosage too high” or “adverse drug reaction.”

31. Five Key Drug-Related Needs of Patients
4. Patients need to be able to comply with drug
therapy and other aspects of their care plans
• Not meeting a need for medication safety can result in
the drug therapy problem of “noncompliance” results.
5. Patients need to receive all drug therapies
necessary to resolve any untreated
indications.

32. The Pharmacotherapy Workup

33. The Pharmacotherapy Workup
• The Pharmacotherapy Workup is a logical thought
process that guides work and decisions as the clinician
assesses the patient's drug-related needs and identifies
drug therapy problems.
• The Pharmacotherapy Workup also organizes the
interventions that need to be made on the patient's
behalf.
• The Pharmacotherapy Workup establishes appropriate
parameters to evaluate at follow-up and allows the
practitioner to contribute uniquely to the patient's care.

34. The Questions, Hypotheses, and Cues of the
Pharmacotherapy Workup Are Always Generated as a
Response to Two Basic Questions
• Is the patient's problem caused by drug
therapy?
• Can the patient's problem be treated with
drug therapy?

35. Activities and Responsibilities in the Patient
Care Process
• Assessment
• Care plan
• Follow-up evaluation

36. The Pharmaceutical Care Practitioner as a Member of the Health
Care Team: Competency domains:

37. Patient-Centered Focus
• A good team's first priority must be to meet
the patient's needs.
• A team with a patient-centered focus will
consider and respect the patient's values and
preferences when making care decisions.

38. Establishment of a Common Goal
• It is critical that all team members know what
a successful outcome or goal of therapy will
be for the patient.
• If choices are to be made between competing
outcomes, the patient (or the patient's family)
must be involved.

39. Understanding of the Other Members' Roles
• Each team member must be familiar with the
professional capabilities of the other members
and must be willing to acknowledge greater
expertise and, in some instances, defer to
other team members.

40. Confidence in Other Team Members
• Confidence in other team members develops
with time and most certainly requires an
understanding of the other members' roles.
• Each member must be able to trust the work
of others. For example, a specialist practitioner
who is not confident in the care provided by
the primary care practitioner may order extra
or unnecessary tests for the patient.

41. Flexibility in Roles
• While understanding and respect for each
person's specific role is important, flexibility in
assignments is also important.
• It is undesirable for each team member to
duplicate efforts made by others, but, if
meeting the agreed upon objective calls for
changes or flexibility in roles, team members
must be prepared to act accordingly and with
respect to professional standards of practice.

42. Joint Understanding of Group Norms
• Members of successful teams will be aware of
the expectations of others in the group. These
expectations are often behavioral such as
punctuality or willingness to stay current in
one's field.

43. Mechanism for Conflict Resolution
• Every health care team will experience
instances of conflict.
• A successful health care team will identify a
specific mechanism, clearly understood by all,
for resolving conflict, through a team leader,
outside leader, or other process.

44. Development of Effective Communications
• Good health care team communication
involves at least two components: a shared
efficient and effective record keeping
mechanism, and a common vocabulary.

45. Shared Responsibility for Team Actions
• Effective team functioning can occur only if
each team member fully shares the
responsibility for those actions.
• Undertaking of such responsibility requires
confidence in the abilities of the other team
members, good communication, and
agreement upon a common goal.

46. Evaluation and Feedback
• Team design must be dynamic and open for
evaluation and revision on a continuing basis.
• A specific mechanism must be developed for
ongoing evaluation of a team's effectiveness
and redesign where needed.

47. Summary
• The three major issues in the management of
pharmaceutical services are access, quality,
and rational drug use.
• Clinical pharmacy is a type of service that
address rational drug use
• The current product focused model should be
changed to a patient focused service.
• Pharmacists are the best positioned to
promote rational drug use if properly trained.

48. Summary
• The pharmaceutical care practitioner assesses
all of a patient's medications, medical
conditions, and outcome parameters, not just
those chosen by disease state, drug action, or
quantity of medications consumed.
• The generalist identifies, resolves, and
prevents drug therapy problems up to a level
of complexity that represents a standard of
care for practice.

49. Summary
• Because no other health care practitioner focuses
attention on all of a patient's medications, your
role is both unique and important.
• A number of patient care providers manage a
portion of drug therapy for a finite amount of
time, and you must work with all of them to
create a coordinated plan for the patient's
medications in order to achieve the desired goals
of therapy in all cases.