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Pharmacist Clinical Review Process

Author: Bidah Iqbah

Be it 10 or 2 in the night, a pharmacist will be always ready to assist you.

Medication errors and adverse events cause significant harm to patient’s health and well-being. It is estimated that the burden of adverse events of medicines is comparable to that of widespread diseases, like tuberculosis or malaria.¹ The impact of medication errors represents a burden for health systems, with the annual cost associated with medication errors estimated at USD 42 billion worldwide.² It is evident that pharmacists are essential team players in all settings who can help tackle medication errors. Their accessibility to patients allows them to interact with, counsel, and educate the patients, reinforce medication adherence, and dispel any concerns about medicines use by establishing a good relationship between them. Moreover, thanks to their expertise in medicines, pharmacists can detect potential and actual drug-related problems and suggest interventions to optimize their therapy and reduce the risk of negative outcomes. Pharmacists’ roles as part of the healthcare team allow them to significantly contribute to reducing medication-related harm.

The discovery and development of medicines revolutionized health care as they can now cure, treat and even prevent diseases that were once debilitating. Nevertheless, medicines also carry the potential for harm and can affect individuals’ health if they are taken or administered incorrectly or if their use is insufficiently monitored.²Pharmacists, due to their unique expertise in medicines, particularly in cases of polypharmacy and medication non-adherence, play a key role and, are best suited to intervene and address medication errors.  To address the numerous issue in healthcare, structured approaches have been proposed and utilized, such as medication review (MR), medicines reconciliation, and participation in multidisciplinary rounds and handover/follow-up processes. As medicines are involved in all treatment plans, it is essential that pharmacists contribute to such approaches. Irrational use of medicine leads to an increase in morbidity, mortality and health care costs.^3,4,5 Every molecule even at therapeutic doses has the capacity to cause side effects but given in combination drugs might augment or diminish the benefit of other drugs. A recent meta-analysis gave ample evidence to demonstrate that a significant proportion of ADRs resulting in burden to healthcare are preventable in nature. Similarly, almost 10% of reported adverse drug events were reported to be life-threatening in a study conducted among older persons in ambulatory care settings.⁵ These facts highlight the necessity of proper interventions to reduce patient harm and uphold medical ethics. Clinical pharmacists along with other healthcare workers should work in tandem to optimize medication treatment and bring about effective management of medicine and facilitate appropriate pharmaceutical care. Pharmacists play a vital role in providing medication reviews with the purpose of identifying any drug-related problems and recommending changes to optimize medical treatment. Taking about important services that clinical pharmacists provide, we have a prospective Drug utilization review. It involves evaluating a patient’s drug therapy before a medication is dispensed. This process allows the identification and resolution of issues before the patient actually receives the medication. DUR is an ongoing, systematic process to maintain the appropriate use of medications.⁶ It involves a  review of a patient’s medication and medical history before, during, and after dispensing in order to ensure that appropriate therapeutic decisions and positive patient outcomes are obtained. Pharmacists participating in DUR programs improve the quality of care for patients, by working to prevent the use of inappropriate drug therapy, prevent drug-related problems and improve the effectiveness of the therapy. DUR encompasses a drug review against predetermined criteria. It results in changes to drug therapy if these criteria are not met.  As a quality assurance measure, DUR programs intend to provide corrective actions. DUR programs play a key role in understanding, interpreting, evaluating, and improving the prescribing, administration and use of medications.   The results are used to ensure and encourage more efficient use of health care resources. Pharmacists play a key role in this process because of their skill and expertise in the area of medication therapy management. Pharmacists also gain a unique  opportunity to identify trends in prescribing within groups of patients.^7,8

Pharmacist Clinical Review process consists primarily of 3 steps: (1) medication reconciliation upon admission; (2) medication review, followed by a discussion between the pharmacist and caregiver; and (3) medication reconciliation upon discharge.

1) Medication reconciliation upon admission;

Medication reconciliation refers to the process of avoiding inconsistencies across transitions in care by reviewing the patient’s complete medication regimen at the time of admission, transfer, and discharge and comparing it with the new regimen that is being considered at the new setting.

During transition of care continuity and coordination of care is of paramount importance. This requires timely and effective communication between different healthcare providers. Poor communication has been associated with poor patient outcome and medication errors⁹ and this is one instance where the process of medication reconciliation guarantees that rational medication is prescribed. The medicines that the patient should be prescribed match those that are prescribed. By performing reconciliation at transfer of care, a comprehensive medication list can be made continuously available and adapted to the current clinical requirements^{11,12,13,14,15}. This comprehensive medication list also serves as the starting point for medication review¹⁶. Clinical pharmacists can detect potentially inappropriate medication by carrying out medication review.  These Inappropriateness can take the form of wrong dose, frequency, route of administration or duration of therapy, potential drug–drug or drug–disease interaction, over- prescribing, under-prescribing, and misprescribing of drugs or the omission of treatment or prevention¹⁵.

A thorough screening of all the medication by the clinical pharmacist is an important part of a shared decision-making process between physicians and pharmacists¹⁶. Several methods to screen for inappropriate prescribing is now available, one such example is the  Medication Appropriateness Index (MAI)^17,18. This is a Screening Tool to spot potentially inappropriate Prescriptions in  Older Persons.^16,19 The complete process of medication reconciliation and review is a good example of the services a clinical pharmacist can provide. Clinical pharmacy services aim to provide optimum patient care with effective medication therapy that promotes health, well-being, and disease prevention²⁰. However, the establishment of these clinical pharmacy services is not without some difficulties.

2) The Medication Review Process

Medication review involves an evaluation of all of the patient’s medicines with the aim of optimising the quality use of medicines. A proper medication review should  result in the identification of any actual or potential medication-related problems and give recommendations to optimize their use.

The medication screening can be done by a clinical pharmacist. The review of  areas like medication history, the current and previous prescription, drug related problems  that occurred in the past, medical history and diagnosis and information about the current admission, including diagnosis and laboratory results is also of great importance.

The purpose of carrying out medication review is to improve the quality, safety and appropriate use of medicines. ²¹

3) Medication Reconciliation upon Discharge Upon discharge

Medication reconciliation at discharge intends to reconcile the medications the patient was taking prior to admission and those that were initiated at the hospital, with the medications they should take post-discharge. This is done to ensure that all discrepancies are resolved prior to discharge.

The clinical pharmacist should review the discharge medication list and compare it with the medications given upon admission. Unintended discrepancies between the different sources should be discussed with the prescriber and changes should be made accordingly. Clinical pharmacists should also discuss the discharge medication with the patient or caregiver before discharge. Emphasize any changes in the medications. In addition, necessary counseling should also be provided for all new drugs they would be taking, including their appropriate use, administration, adverse drug reactions, or possible important interactions with food or other drugs.

A special focus should also be placed on effective communication within each of these steps.A way to improve communication in multidisciplinary meetings involving clinical pharmacists. This gives an opportunity to address medication-related issues on a regular basis. Another strategy that has been proven to be successful is the presence of pharmacists in ward rounds in order to provide immediate pharmacological support.

An important barrier when it comes to implementing a thorough medication reconciliation is the time required to perform this task. Obtaining the best possible medication history requires trained staff and time.²¹

Conclusions

Implementing clinical pharmacy services should be considered in every hospital. All these clinical pharmacy services can only be effective if the treating physician utilizes the results to optimize patient treatment. Therefore, we have a responsibility to create awareness on the potential role of clinical pharmacy for their patients.

Healthcare providers should receive intensive training and should acknowledge each others’ roles in the optimization of patient’s healthcare. Interdisciplinary and seamless healthcare can be facilitated by the creation of structured patient files that are securely accessible to professionals.

Irrational use of medications has and will lead to a plethora of drug related problems. To identify and prevent any unnecessary patient harm services provided by clinical pharmacists is essential.They work in collaboration with other healthcare professionals to optimize medication treatment. As part of this, pharmacists have a critical role in providing medication reviews to identify drug-related problems and recommend changes to optimize patient care.²² This can be conducted at different levels from prescription review, to full clinical medication reviews. The clinical pharmacists have a responsibility to  assess the treatment in the context of the patient’s conditions and symptoms.^23,24 In the hospital setting, the clinical pharmacist has access to all necessary patient data, can interview the patient themselves as and when needed and discuss any discrepancies and recommendations with the physician. Hence, we can safely say that the pharmacist clinical review process plays a crucial role in patient’s welfare and must strive forward to tackle any barriers towards the implementation of these processes.

Reference:

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