2. The pharmacy services can be broadly classified as
clinical, hospital and community pharmacy services based
on the point of service.
The clinical pharmacy servicesare rendered in a clinic for
inpatients and OPD patients.
The inpatient services comprise of entire patient careand
supplies regarding the aspects involving drugs.
For example the activities like ward rounds ,safety,drug
information services, poison centre, pharmacovigilance
services, development and management of hospital
formulary, patient counseling and education along with
discharge medication.
3. Ward round participation
Ward rounds are the routine clinical roundswhere
the healthcare providers visit the patients in the
ward to assess the progress of the health
condition of the inpatients.
The doctor led ward rounds comprises of the unit
of medicine or any other specialty where in
professor,associate professors, assistant
professors, senior residents, postgraduates and
interns along with pharmacists and nurses observe
the patient's condition nda assess to decide further
therapeutics for the patients.
4. The goal of the ward round is to closely monitor the
patient's condition and take immediate intervention
to improve the patient condition and avoid death.
The doctors are visiting all the patients admitted in
their unit in an order beginning from intensive care
unit.
Here also there is documented case reports to
remind the case history of the patients who quickly
updates and is able to change the strategies of
treatments.
5. The ward team comprises of doctors,
nurses and pharmacists who work in a
team with a common objective to ensure
safe, effective, economic and patient
friendly treatment with knowledge inputs
of each professional practice.
6. The pharmacist being an expert in the matters of drug
should be available for the ward round team to decide
upon the matters of dosage regimens, formulary
interpretations, ADR monitoring, Drug-drug interactions,
Drug-food interactions and drug and poison information
services.
The availability of pharmaceutical services definitely
enhances accuracy of treatment, patient safety and
efficacy.
7. The pharmacist in ward round should take to 2 times one with the
doctors and another one with himself alone.
In the first ward round he follows the treatment given and checks the
formulary for the dose prescribed.
Further he may also critically think any possible risk to the patients due
to drug administered he will alert the team and prevents the further
causality that would have occurred due to non-viability of clinical
pharmacy services.
In the 2nd round the pharmacist targets the patients prior to discharge
and advice the patients regarding discharged medication practice in the
rounds. He also motivates to knowledge diet and exercise required for
disease management for a patient to be discharged.
8. The withdrawal of pharmacists from the ward rounds
will be a great loss for the clinical team and the
patients. The medication errors, incorrect dosage can
bring down the therapeutic outcomes in a negative
perspectives.
It is well established that the expectations from the
patients does not stop at the clinical cure but for a
cost effective economic expenses with improved
quality of life.
The gaps in the knowledge of healthcare practice in
disease management can be fulfilled by a qualified
pharmacist in a hospital.
9. Drug therapy monitoring, also known as Therapeutic
Drug Monitoring (TDM), is a means of monitoringdrug
levels in the blood.
Therapeutic drug monitoring (TDM) refers to the
measurement and interpretation of principally blood or
plasma drug concentration measurements with the
purpose of optimising a patients drug therapy and
clinical outcome while minimising the risk of drug-
induced toxicity.
TDM involves tailoring a dose regimen to an individual
patient by maintaining the plasma or blood
concentration within a particular range.
10. • To attain desired pharmacological effect of the drug.
• To reach the maximal effect in shortest possible time.
• To decrease the risk of toxicity.
• With a narrow therapeutic index.
• Which are highly protein bound.
• Which are liable to interact.
• In which the metabolite might be toxic.
11. MEDICATION CHART REVIEW
•It is a fundamental responsibility of a
pharmacist to ensure the appropriateness of
medication orders.
•It serves as starting point for other clinical
pharmacy activities ( medication counselling,
TDM, DI, and ADR).
•Organising information according to medical
problems ( example disease) helps breakdown a
complex situation into its individual parts.
12. GOALS:
1. To optimise the patients drug therapy.
2.To prevent or minimise drug related
problems/medication errors.
PROCEDURE:
√ The patients medical record should be reviewed in
conjugation with the medication administration
record.
√ Recent consultations, treatment plans and daily
progress should be taken into account when
determining the appropriateness of current
medication orders and planning each patient’s care.
√ All current and recent medication orders should be
reviewed.
13. 1.
2.
3.
4.
c)
Checking that medication order is written in accordance
with legal and local requirements.
Ensuring that the medication order is comprehensible and
unambiguous, that appropriate terminology is used and that
drug name are not abbreviated. Annotate the chart to
provide clarification as required.
Detecting orders for medication to which the patient may be
hypersensitive/intolerant.
Ensuring that medication order is appropriate with respect
to:
a) The patient’s previous medication order.
b) Patient’s specific considerations e.g disease state,
pregnancy.
Drug dose and dosage schedule, especially with respect
to age, renal function, liver function.
d) Route, dosage form and method of administration.
14. 5.Checking complete drug profile for medication
duplication,interactions or incompatibilities.
6.Ensuring that administration times are appropriate e.g.
with respect to food,other drugs and procedures.
7. Checking the medication administration record to
ensure that all ordered have been administered.
1.Ensuring that the drug administration order clearly indicates
the time at which drug administration is to commence.
2.Special considerations should be given especially in short
course
therapy as in antibiotics and analgesics.
1. Ensuring that the order is cancelled in all sections of
medication administration record when the drug therapy is
intended to cease.
2. If appropriate follow up of any non-formulary drug orders,
recommending a formulary equivalent if required.
15. 1.Ensuring appropriate therapy monitoring is
implemented.
2.Ensuring that all necessary medication is ordered.
E.g. premedication, prophylaxis.
1. Reviewing medication for cost effectiveness.
2. Identification of drug related problems.
• Untreated indication.
• Inappropriate drug selection.
• Adverse drug reaction.
• Failure to receive drug.
• Drug interactions.
• Drug use without indication.
• Overdosage.
16. Medication chart Endorsement
Another important goal of treatment chart review is to
minimise the risk of medication errors that might
occur at the level of prescribing and / or drug
administration.
A medication error is any preventable error that may
lead to inappropriate medication use or patient harm.
To prevent potential morbidity and mortality
associated with these errors, pharmacists should
systematically review the medication chart and write
annotations on the chart where the medication orders
are unclear.
17. CLINICAL REVIEW
• Clinical review is one of the integral components of
medication review and should preferably be performed
on a daily basis. It is the review of the patients’progress
for the purpose of assessing the therapeutic outcome.
The therapeutic goal for the specific disease should be
clearly identified before the review.
:
The primary aims of the clinical review areto:
• Assess the response to drug treatment.
• Evaluate the safety of the treatment regimen.
• Assess the progress of the disease and the need forany
change in therapy.
• Assess the need for monitoring, if any. Assessthe
convenience of therapy(to improve compliance).
18. 1. G. Parthasarathi, Karin Nyfort Hansen, Milap C Nahata.
A textbook of clinical pharmacy practice Essential
concepts and skills. Universities Press. 2nd edition.
2. A Text book of Pharmacy Practice by the author Sourabh
Kosey Nirali Prakashan. Page No.17.1-17.16
3. A Text book of Pharmacy Practice by the author Dr.
Sachin V. Tembhurne, Dr. Ashwini R. Madgulkar, Dr.
Virendra S. Ligade Nirali Prakashan. Page No.17.1-17.12
4. www.google.com
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