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three parts of the pharmacist patient care process (PCPP)

collaborate, communicate, document

five step process of pharmacist patient care process

1. collect

2. assess

3. plan

4. implement

5. follow-up: monitor and evaluate

SOAP

subjective, objective, assessment, plan

three part of assessment

first: state problem identified

second: list findings that support your conclusion

third: state short and long term goals

examples of short and long term goals

short: eliminate symptoms of UTI

long: cure infection

monitoring outcomes is part of

plan

checklist to ensure SOAP is being used efficiently

-all subjective and objective info is pertinent

-med-related problem list is prioritized

-assessment is clear and concise, explains thought process, answers 'why' and includes goals

-plan includes specific recommendations and monitoring parameters

who is involved in community pharmacy services

ancillary help --> technicians --> interns --> pharmacists

ancillary help

maintain stock, and medical records, type labels, count and prepare dosage units, hand deliver completed prescriptions to patients

unlicensed personnel in community settings are not allowed to

Receive verbal prescription orders Interpret or evaluate a prescription Measure, weigh, compound or mix ingredients Counsel patients Make clinical recommendations

pharmacy interns

can perform all the duties of a pharmacist but must be supervised by a pharmacist at all times

HIPPA

Health Insurance Portability and Accountability Act

pharmacists/pharmacy is a covered entity

anyone who provides treatment, payment and operations in healthcare

covered entity

A health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health information in electronic form in connection with a transaction

collect: patient profile

first and last name, address, DOB, gender, phone number/email, allergies, chronic diseases/conditions, medications, other relevant counseling information

patient profiles must be maintained for

5 years from the most recent entry

collect: insurance information

• Bank identification number: BIN #• Processor control number :PCN #• Identification number• Group codes• Medical vs. Pharmacy coverage

additional information to collect

-safety cap

-delivery services

-contact preferences

Any pharmacy in a group larger than 8 (NYS) or larger than 4 (NYC), is required

Free written and oral "translation" services

ways to receive and prescription

in person (paper), verbal, fax, electronically

required documentation for verbal prescrptions

-the date

-initals of who is receiving the call

-full signature of controlled safety

Controlled Substances Act (CSA)

Legislation in the US that defines illegal drugs and classifies them by Schedules

five schedules based on

accepted medical use

abuse potential

likelihood of causing dependence when abused

CI vs CV

CI: basically illegal drugs

-no acceptable medical use

-high potential of abuse

-lack of accepted safety for use under medical supervision

CV: low potential for abuse

limited quantities of narcotics

controlled substances: law

Must be filled within 30 days of date ordered

Cannot be filled for more than a 30-day supply

brand vs generic

generic: Same as a brand name drug in dosage, safety, strength, how it is taken, quality, performance, and intended use

contain same amount of API

two parts of preventing medication errors

technical process and clinical process

three technical ways to minimize medication errors

• "Tall Letters": mix of lower and uppercase letters.• Verify National Drug Codes (NDC#) against labels and bottles• Utilize Bar Codes

prescription label standards

1. patient name

2. drug name

3. drug strength

4. directions

use biggest font

full requirements of a label

-name and address of patient

-name and address of the owner of the pharmacy in which it was dispensed

-date compounded

-Rx number

-name of prescriber

-directions

-if generic, name of manufacturer

-name and strength of drug

these are not required by law to be on a label

refills and quantity

orange label

CONTROLLED SUBSTANCE, DANGEROUS UNLESS USED AS DIRECTED

auxiliary labels

Provide additional information, such as special instructions, warnings, or storage conditions to the patient

Drug Utilization Review (DUR)

A system of drug use review that can detect potential adverse drug interactions, drug-pregnancy conflicts, therapeutic duplication, drug-age conflicts, and so on

Internet System for Tracking Over-Prescribing -Prescription Monitoring Program (I-STOP - PMP)

required to submit controlled substance dispensing data to bureau of narcotic enforcement

FDA mandated medication guides

Addresses issues specific to a particular drugsand/or drug class

Omnibus Budget Reconciliation Act (OBRA)

A pharmacist or pharmacy intern must provide patient education (counseling) before  -Before dispensing a medication to a new patient of thepharmacy

-Before filling a new prescription for an existing patient ofthe pharmacy

-if there are new dose, strength, route, or directions

An offer to provide counseling must be made every time a patient

has a prescription refilled or has a prescription filled for a medication therapy that has been reauthorized by a prescriber

daily record

-Reports all new and refilled prescriptions dispensed

-signed by pharmacist whose initials appear on prescriptions

-must be kept for 5 years

evidence-based medicine

medical care based on the latest and most accurate clinical research

examples of primary sources

• Clinical research studies• Scientific experiments• Journal articles

examples of secondary sources

Synthesize findings from multiple primary resources: searchable databases

• Embase• PubMed (free)

tertiary sources

Include summarized information from both primary and secondary sources, typically condensed into a more digestible format

tertiary sources examples

• Textbooks• Compendia (Lexicomp, Micromedex)• Package inserts• Websites (CDC, Clinicaltrials.gov)• Other online databases (UpToDate)

Prescribing Information (PI) or United States Prescribing Information (USPI)

includes FDA approved indications, side effects, adverse reactions, contraindications, and other important information

Recommend reliable, high-quality health information geared for theaverage consumer, such as

• Health care organizations (Mayo Clinic, Cleveland Clinic)

• Disease or professional societies (American Diabetes Association)

• Consumer-specific sections from tertiary resources (Micromedex, Lexicomp)

Hundreds of drug interactions have been documented; few are clinically significant enough to be

contraindicated or require a change in dosage

pharmacokinetics

the effect the body has on the drug as it travels through the absorption, distribution, metabolism, and excretion (ADME) processes

Pharmacokinetic interactions occur when one drug alters the

ADME processes of another drug

Absorption from the gastrointestinal (GI) tract may be influenced by:

• Agents that bind drugs• Agents that increase/ decrease GI motility• Change in gastric pH• Drugs that alter the p-glycoprotein and organicanion transporters in the intestine

Distribution can be altered by drugs that

compete for binding sites on plasma proteins

Agents can change the size of the physical compartment in which

another drug distributes

Highly protein-bound drugs can be displaced from binding sites on albumin,leading to

increased drug concentration in the blood

excretion

removal of a drug from the body

Excretion of drugs by the kidney can be changed by drugs that

reduce renal blood flow or inhibit specific renal transport mechanisms

Drugs that alter urinary pH can alter the ionization state of drugs that are weak acids or weak bases, leading to

changes in renal tubular reabsorption

metabolism

the process of converting a drug into a form that can be excreted

most pharmacokinetic drug interactions occur during

metabolism

metabolism: Enzyme-catalyzed transformation reactions occur in

intestine and liver

The metabolism of drugs may beaffected by other agents thatinfluence the hepatic drug-metabolizing enzymes, especially

cytochrome P450 isoenzymes

More than 50 CYP enzymes havebeen identified and the most clinically important are

CYP2C9, CYP2C19, CYP2D6, and CYP3A4

enzyme inducers

decrease the concentration of substrate drugs --> more enzymes

enzyme inhibitors

increase the concentration of the substrate drugs --> cause less functional enzymes and/or decrease in rate of drug metabolism

pharmacodynamics

the effect or change the drug has on some type of organism (such as the human body)

pharmacokinetics vs pharmacodynamics

Pharmacokinetics: What the BODY does on the drug

(movement of drug through body)

Pharmacodynamics: What the DRUG does on the body

pharmacodynamic interactions

additive, synergistic, antagonistic, potentiation

antagonism

interactions based on opposing actions or effects

additive effects

the algebraic summing of the effects of two drugs

synergism

when the result of the interaction is greater than the sum of the drugs used alone

potentiation

When one drug's effect is increased by another agent that has no such effect

pharmacotherapy

Area of pharmacy practice that ensures the safe, appropriate, and economical use of medications

Newly approved medications should be used only if

there are clear advantages over older medications

A medication should not begiven by injection (IV, IM, SQ) when

giving it by mouth would be just as effective and safe.

avoid the "prescribing cascade"

treating side effects as a new disease

Before medications are used, these interventions should be made

lifestyle modifications or non-pharmacologic interventions

three primary components of a drug therapy problem

 Undesirable event or risk of an eventexperienced by the patient

 The drug therapy associated with theproblem

 The relationship that exists between the undesirable patient event and the drug therapy

contraindicated

should not be used because it may be harmful to the person

Joint Commission

an independent, not-for-profit organization that evaluates and accredits healthcare organizations

-maintains standards of healthcare

-"checks-up" on facility

-publishes yearly patient safety goals

centralized vs decentralized pharmacies

CareSatellitePediatricSatelliteCentral Centralized One pharmacy that serves the entirehospital Decentralized One central pharmacy and Many "satellite" pharmacies Located near patient units

pharmacy and therapeutics committee (in hospital)

-chaired by a physician

-make important decisions/changes for the hospital formularies, policiesand procedures

role of pharmacist on medical team

-order, writing, medication reconciliation

-collab on medication therapy managment

-hospital initiatives

medication reconciliation

Process of identifying the most accurate list of all medications apatient is taking Includes name, dosage, frequency, and route

medication reconciliation involves comparing the patient's current list of medications against

the physician's admission, transfer, and/or discharge orders

responsible for as many as 50% of all medication errors and up to20% of adverse drug events in the hospital

poor communication of medical information

steps in the medication order process

ordering (clinician) --> transcribing (not necessary for electronic) --> verifying and dispensing --> administration (nurse)

CPOE

computerized physician order entry

the order is entered into

patient profile

when there is a problem with orders, the

prescriber must be contacted

though administration of meds is a nursing responsibility, it becomes important to the pharmacist when

we are monitoring levels of specific medications

medication error

Any preventable adverse drug event involving inappropriate medication use by a patient or health care professional; it may or may not cause the patient harm.

prohibited abbreviations: U

unit

prohibited abbreviations: IU

international unit

prohibited abbreviations: QD and QOD

daily and every other day

prohibited abbreviations: .X and X.0 mg

0.X mg and X mg

prohibited abbreviations: MS, MS04 and MgS04

morphine sulfate and magnesium sulfate

medical record

-Chart/file created for newly admitted hospital (inpatient) or clinic (outpatient/ambulatory) patients

-Serves as a legal document that documents the course of treatment

disadvantages of electronic medical records (EMR)

Cost of system implementationTransitions in care- from different health systemsTrainingPower outage/technical issuesSecurity/risk for data breach“Cut and paste” errors

RHIO - regional health information organization

Group of organizations that share healthcare-related information Allow healthcare provides greater patient access to information generated atother facilities

healthix

Largest public HIE (health info exchnage) serving NYC and Long Island

retention of Medical Records in NY forHospitals

Must be retained in their original or legally reproduced form for: A period of 6 years from the date of discharge Obstetrical records and children's records for at least 6 years or until thechild is age 21, whichever is longer At least 6 years after death