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Presenations on clinical pharmacy patient caring
1. Clinical Pharmacy
(Patient Care)
By L.T.M. Muungo, PhD,By L.T.M. Muungo, PhD,
Pharmaceutist,Pharmaceutist,
Department of Pharmacy, UNZA,Department of Pharmacy, UNZA,
Zambia
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 such as biomedical care, Rehabilitatory care etc
However, work load could be attributed to physician & nurse to be 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
11. For practising Clinical Pharmacy
(American system)
• Competence of health care practitioners
-BPharm to MClinPharm 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?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
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
16. Level of Action of Clinical Pharmacists
Clinical pharmacy activities may influence the correct use
of medicines at three different levels:
Before the prescriptionBefore the prescription
During the prescriptionDuring the prescription
and
After the prescription is written.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 PharmacistsFunctions 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
Ambulatory care
Critical care
Drug Information
Geriatrics and long –term
care
Internal medicine and
subspecialties
Cardiology
Endocrinology
Gastroenterology
Infectious disease
Neurology
Nutrition Support
ADR/DUE
Transplant
Investigational Drugs
Pharmacoeconomics
Nephrology
Obstetrics and gynecology
Pulmonary disease
Psychiatry
Rheumatology
Nuclear pharmacy
Pediatrics
Pharmacokinetics
Surgery
27. Various ambulatory servicesVarious 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
29. The service including clinical pharmacy/clinical pharmacistThe 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/clinicalThe service without clinical pharmacy/clinical
pharmacistpharmacist
-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 most developing countries like Nepal and similar ones; Physicians are mostly incompetent from
their training pathways, Nurses are likely to be careless, Pharmacists don’t know anything through
their compromised training packages, health systems mostly are corrupted, Public health
knowledge is very scanty and generic in nature and most cases patient load is unproportionally
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 CareGoal 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 such as 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 NoteFARM 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
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 based skills
Physical assessment
Barriers to adherence
Psychosocial issues
Education & counseling based skills
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 based skills
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 based skills
Develop & maintain (update) protocols
Follow protocols as clinical 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 based skills
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
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
Prednisolone 40mg D
Theophylline 200mg bd
Omeprazole 20mg D
Metoclopramide 10mg tds
Salbutamol 2 puff inhale prn
Pharmaceutical problems
Common organisms for URTI?
History of asthma – risk vs benefit?
Need for acid suppression?
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
Amiodarone
Severe extravasation of
amiodarone infusion
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
Generalized 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. “I assumed the brown glass
ampoule was frusemide”
The System:
Only as safe as it’s designed to be!
58. The Accident Causation Model
(Adopted from Reason & Dean)
Active
Failures
-Slips&lapses
-Mistakes
Error
producing
conditions Accident
Defences
Latent
Conditions
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:
1.Inappropriate selection of medication
2.Inappropriate formulation of medication
3.Inappropriate administration of drug therapy
1.4.Inappropriate medication-taking behaviour
5.Inappropriate monitoring of drug therapy
6.Inappropriate response to drug therapy
63. Patient Assessment QuestionsPatient 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 ……..…
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!)
Things still do look alike.
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.