Clinical pharmacy

compiled for lecture note B.Pharm viii semester(final semester)

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”

8. “Counter-prescribing”

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?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 prescription Before the prescription
During the prescription During 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

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

28. Hospital pharmacist Vs
Clinical pharmacist

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/clinical The 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 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"

31. Medicines are Dangerous

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
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
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. Aims of
Pharmaceutical
Care
Effective drug
therapy
Safe drug
therapy
Economic drug
therapy
Improve
quality of life
Will the patient take
the therapy?
What does the
patient view as an
improved quality of
life?

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 ?

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

51. NSAID induced peptic ulcer

52. Goitre – Hypothyroidism
Secondary to
Amiodarone
Bleeding due to
anticoagulation

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. “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

61. Formulary
Prescribing protocols
Prospective review
Clinical pharmacy
Admission medication history
Allergy check
Drug distribution system
Opportunity
For Error
Administration instructions
Clinical Pharmacy Role in Reducing Risks

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

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 ……..…

67. Today’s pharmacists

68. Ideal Pharmacist Candidate?
•Competent
•Motivated/Enthusiastic
•Teamwork spirit
•Good communication skills
•Responsible
•Problem solver
•Dedicated

69. The End

70. Any Questions?