Author: Jisa Elizabath Sabu
IV Year Pharm.D
Nirmala College Of Pharmacy, Muvattupuzha
Clinical pharmacy involves the activities and services of clinical pharmacists to optimize pharmaceutical care and proper use of medications for the purpose of optimal patients outcomes. Clinical pharmacy services are not limited to certain areas but applies to all medical fields such as cardiology, infectious, ambulatory care, oncology, nephrology, internal medicine also covers in-patient and out-patient services. The American College of Clinical Pharmacy (ACCP) defines clinical pharmacy as an area of pharmacy concerned with the science and practice of rational medication use. Clinical pharmacy is a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, and disease prevention. The practice of clinical pharmacy embraces the philosophy of pharmaceutical care, blending a caring orientation with specialized therapeutic knowledge, experience, and judgment to ensure optimal patient outcomes. As a discipline, clinical pharmacy also has an obligation to contribute to the generation of new knowledge that advances health and quality of life.
The goals of clinical pharmacist participation is to provide relevant information on various aspects of patients’ drug therapy, to optimise therapy- influence drug selection, monitoring & follow-up, investigate unusual drug orders or doses, to detect adverse drug reactions & drug interactions and to participate in patient discharge planning.
Drug therapy monitoring is important because the effects of a drug can vary significantly between individuals. Wherever possible, therapeutic effect should be monitored using a clinical endpoint (i.e. a measure that directly reflects how the patient feels, functions or survives). In practice, it is often not feasible to use a clinical endpoint to guide therapy, particularly for preventive treatments. The next best option is to use a surrogate endpoint: a measure that predicts whether the clinical endpoint will be achieved. For a few drugs, neither a clinical nor a surrogate endpoint is available. In these instances, if the drug has a narrow therapeutic index and there is a predictable relationship between its concentration and its effects, it may be appropriate to measure its concentration in the blood. The goal is to optimize drug therapy & patient outcomes includes activities such as medication order review, adverse drug reaction (ADR)management, clinical Review and therapeutic drug monitoring (TDM).
Medication order review – It is the review of current & recent medication orders to ensure the appropriateness of medication orders. The goal is to ensure patient receives most appropriate drug, dose & dosage form, timing of dosage & duration of therapy is optimum and drug-related problems are minimized. Medication order should be reviewed in conjunction with medication administration record, recent consultations, investigations, treatment plans and daily progress. Ensure order is appropriate- previous medications, specific conditions, age, route, dosage form, method of administration, etc. Checking for medication duplications, ADRs, interactions or incompatibilities. Adverse drug reaction monitoring – WHO defines ADR as any response to a drug which is noxious & unintended, and which occurs at doses normally used in man for prophylaxis, diagnosis or therapy of disease, or for the modification of physiological function. The goals includes detection, assessment, correlation, management, documentation & prevention of adverse reactions. Clinical Review – is the assessment of the patient for the purpose of evaluating the nature of the response to therapy and this may include the review of signs, symptoms and results of investigations. It helps to determine priorities of treatment with respect to the therapeutic outcomes desired by the patient, monitor patient’s therapy and review outcomes of treatment. Therapeutic Drug Monitoring -(TDM) is the application of pharmacology, pharmacokinetics, pathology and clinical medicine in the interpretation of measured drug concentrations in body fluids. Patients for whom TDM indicated are renal or hepatic impairment, dialysis, cardiac dysfunction, severe airway disease, geriatric patients, obstetric patients and neonates.
Ward round participation; Ward round is a visit made by a medical practitioner, alone or with a team of health professionals & medical students to hospaital in-patients at their bedside to review & follow up the progress in their health. Goals of clinical pharmacist participation is to provide relevant information on various aspects of patients’ drug therapy, optimise therapy- influence drug selection, monitor & follow up, investigate unusual drug orders or doses, detect adverse drug reactions & drug interactions and to participate in patient discharge planning. The procedure involoves pre-ward round preparation, practical tips for ward round participation, fixed time attendance, references suggestion of alternatives, intervention, new information, communication and follow-up.
Drug & poison information services; Novel psychoactive substances (NPS) can cause significant acute toxicity but usually little is known about their toxicity when they enter the recreational drug scene. Approximately 54% of countries have at least one poisons information service providing advice to healthcare professionals and/or the public on poisoning. They provide advice on recreational drug and NPS toxicity. Data are collected at population level and can be used to complement other data sources with clinical details on acute NPS toxicity and geographical/time patterns of toxicity. Like other acute NPS toxicity data, poisons centre data should be interpreted within their limitations, notably the absence of analytical confirmation and reliance on secondary reporting of clinical features. It would be possible to develop a more robust and systematic reporting system using a network of poisons information services both within and across countries that would be complimentary to other datasets on acute NPS toxicity and allow more accurate data triangulation.
Monitoring patient compliance; Patient compliance is paramount in the effectiveness of therapeutic regimens. Without compliance therapeutic goals cannot be achieved, resulting in poorer patient outcomes. The social and psychological factors thought to influence compliance are identified as knowledge and understanding including communication, quality of the interaction including the patient-provider relationship and patient satisfaction, social isolation and social support including the effect of the family, health beliefs and attitudes-health belief model variables, and factors associated with the illness and the treatment including the duration and the complexity of the regimen. Noncompliance is a significant problem and a major challenge for the healthcare team. Practical advice is offered for nurses and other health care professionals to increase patient compliance with therapeutic regimens. These include factors involved in the patient-provider relationship, communication skills and information-giving, and the mobilization of existing social support networks. Management of compliance at the different stages of clinical trials is necessary; at trial design, compliance should be taken into account in sample size calculations; during the conduct of a trial, compliance should be monitored in order to safeguard the power of the study; and in interpretation of trial results, compliance data are helpful both in order to avoid erroneous conclusions and to enrich the value of the data. Compliance should be measured in all limbs of randomized trials, including the placebo limb, without breaking trial blinding.
Detection of medication errors; American Society of Health System Pharmacists(ASHP) defines medication error as – “Any preventable event that may cause or lead to inappropriate medication use or harm while the medication is in the control of healthcare professional, patient or consumer. Medication errors have important implications for patient safety, and their identification is a main target in improving clinical practice errors, in order to prevent adverse events. Error detection is the first crucial step. Approaches to this are likely to be different in research and routine care, and the most suitable must be chosen according to the setting. The major methods for detecting medication errors and associated adverse drug-related events are chart review, computerized monitoring, administrative databases, and claims data, using direct observation, incident reporting, and patient monitoring. All of these methods have both advantages and limitations. Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of a culture of safe practice. Combining and comparing data from various and encourages the diffusion of a culture of safe practice sources increases the reliability of the system. Error prevention can be planned by means of retroactive and proactive tools, such as audit and Failure Mode, Effect, and Criticality Analysis (FMECA). Audit is also an educational activity, which promotes high-quality care; it should be carried out regularly. In an audit cycle we can compare what is actually done against reference standards and put in place corrective actions to improve the performances of individuals and systems. 6. Patient safety must be the first aim in every setting, in order to build safer systems, learning from errors and reducing the human and fiscal costs. The types of errors include prescription centered, dispensing centered and administration centered. Prescription centered involves wrong time, wrong dose, wrong dosage from wrong direction, serious drug interactions and illegible handwriting. Dispensing centered includes errors of commission, ie dispensing wrong medicine, wrong quantity, SALA errors, wrong mixing or compounding, dispensing expired items, charging higher prices, etc and Errors of omission ,ie failure to give proper directions to the patient or failure to alert the patient, failure to identify possible interactions or contraindications, etc. Administration centered includes patient centered and nurse centered. Therefore to prevent medication errors; Patient education, Prior authorization Electronic technology such as bar coding, electronic prescription record, e-prescribing, electronic DUR Automated medication dispensing and Internal quality control programmes are necessary.
Drug Therapy Review -Medication history review refers to the process by which a pharmacist interviews a patient’s medication regimen to ensure that patient receives effective, safe and cost-effective treatment. It can be undertaken any time during patient’s admission, pre-wards, ward rounds or day of admission. Also includes collection and interpretation of potent information,assessment of therapeutic goals, identification of drug related problems, individualising medication regimen,monitoring treatment outcomes medication chart endorsement and information sources can be the patient , family or care-giver.
Pharmacist Intervention; is the action by a pharmacist that directly results in a change in patient management or therapy. Pharmacists impact outcomes by ensuring each patient gets the right drug, in the right dose, at the right time. To do so, pharmacists intervene when patients experience medication-related gaps in care, attempting to Educate patients about drugs and disease states. Medication non-adherence: Is a patient taking their medication as prescribed by their physician? If not, pharmacists can intervene to identify it. Interventions by the pharmacists have always been considered as a valuable input by the health care community in the patient care process by reducing the medication errors, rationalizing the therapy and reducing the cost of therapy.
From all the above discussed activities, without standardized and validated instruments specifics to assess the performance of the clinical pharmacist, it is hard to establish the main clinical activities performed by pharmacists in their pharmaceutical practice environments and to propose training actions to improve professional practice. Despite the large number of instruments available and considered validated by the authors, it is questioned to what extent the validity indicators presented in the different studies really show the validation status.
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