Clin. Pharm - Ch.1 Clinical pharmacy practice

Establish need for a drug

WHAT DUP stage:
Ensure there is an appropriate indication for each medicine and that all medical problems are addressed therapeutically. Consider deprescribing medicines that are no longer appropriate.

Select drug

WHAT DUP stage:

Select and recommend the most appropriate medicine based upon the ability to reach therapeutic goals, with consideration of patient variables, formulary status and cost of therapy

Select regimen

WHAT DUP stage:
Select the most appropriate medicines for accomplishing the desired therapeutic goals at the least cost without diminishing effectiveness or causing toxicity

Provide drug

WHAT DUP stage:
Facilitate the dispensing and supply process so that medicines are accurately prepared, dispensed in ready-to-administer form and delivered to the patient on a timely basis.

Administer drug

WHAT DUP stage:
Ensure that appropriate devices and techniques are used for medicines administration.

Monitor drug therapy

WHAT DUP stage:
Monitor medicines for effectiveness or adverse effects to determine whether to maintain, modify or discontinue.

Counsel patient

WHAT DUP stage:
Counsel and educate the patient or caregiver about the patient’s therapy to ensure proper use of medicines.

Evaluate effectiveness

WHAT DUP stage:
Evaluate the effectiveness of the patient’s medicines by reviewing all the previous steps of the DUP and taking appropriate steps to ensure that the therapeutic goals are achieved.

Clinical pharmacy

comprises a set of functions that promote the safe, effective and economic use of medicines for individual patients. It also process requires the application of specific knowledge of pharmacology, pharmacokinetics, pharmaceutics and therapeutics to patient care.

Pharmaceutical care

is a cooperative, patientcentred system for achieving specific and positive patient outcomes from the responsible provision of medicines. The practice of clinical pharmacy is an essential component in the delivery of pharmaceutical care

Medicines optimisation

aims to ensure that the right patients get the right choice of medicine at the right time. The purpose is to help patients take their medicines appropriately and, by doing so, avoid unnecessary treatment, improve safety and outcomes, and reduce wastage. Ultimately it can support patients to take greater ownership of their treatment.

• Prevention of disease or symptoms

• Arrest or slowing down of disease process

• Cure of disease

• Elimination or reduction of symptoms

• Untreated indications

• Treatment w/out indication (off-label uses)

• Improper drug selection (first gen antihistamines should not be given to elderly patients as they are prone to falls and cognitive impairment)

• Too little or too much drug (subtherapeutic and toxic doses)

• ADR (unwanted harmful effects at normal dosage)

• Drug interactions

Categroies of Medication-Related Problems

• Collecting info on med history using the most recent and accurate sources of info to create a full and current list of meds.

• Verifying this list against the hospital drug chart and ensuring that any discrepancies are identified and acted upon

• Documenting and communicating any changes, omissions, and discrepancies

Medicine Reconciliation

• Knowledge of disease, drug therapy, non-drug therapy, and laboratory & diagnostic testing

• Communication skills

• Patient monitoring

• Physical assessment

• Drug info

• Therapeutic planning

Knowledge and Skills Required in Patient Care

• Establishing the Need for Pharmaceutical Care

• Medication History

• Selecting the Medicine

• Administering the Medicine

• Providing the Medicine

• Monitoring Therapy

• Patient Advice and Education

• Evaluating EIectiveness

STEPS IN THE DELIVERY OF PHARMACEUTICAL CARE (8)

Establishing the Need for Pharmaceutical Care

WHAT STEP IN THE DELIVERY OF PHARMACEUTICAL CARE?

• Relevant patient details: age, gender, ethnic or religious bg, social history, presenting complaint, working diagnosis, previous med history, and laboratory or physical finding.

• Working diagnosis, initial diag, present working impression, admitting diag

Medication History

WHAT STEP IN THE DELIVERY OF PHARMACEUTICAL CARE?

• Part of pharm consultation that identifies and documents allergies or other serious adverse medication events, as well as information about how medicines are taken currently and have been taken in the past

Selecting the medicine

WHAT STEP IN THE DELIVERY OF PHARMACEUTICAL CARE?

ID drug-patient/disease/drug interactions

Administering the Medicine

WHAT STEP IN THE DELIVERY OF PHARMACEUTICAL CARE?

Dose, route, dosage form, documentation, and devices

Providing the Medicine

WHAT STEP IN THE DELIVERY OF PHARMACEUTICAL CARE?

• Ensuring that a prescription is legal, legible, accurate, and unambiguous.

• Contributes in large measure to the right patient receiving the right medicine at the right time

Monitoring therapy

WHAT STEP IN THE DELIVERY OF PHARMACEUTICAL CARE?

Monitoring criteria for the effectiveness of treatment and its potential adverse effects can be drawn from the characteristics of the prescribed medicines used or related to spec patient needs

Patient Advice and Education

WHAT STEP IN THE DELIVERY OF PHARMACEUTICAL CARE?

Counsel the patient or caregiver on the proper use of medicines to improve adherence and safety

Evaluating Effectiveness

WHAT STEP IN THE DELIVERY OF PHARMACEUTICAL CARE?

Practitioners delivering pharmaceutical care have a responsibility to eval effectiveness of therapy by reviewing steps 1-6