Components of Clinical Pharmacy

Prescribing

Good Reads:
Gennaro AR Remington
Encyclopedia of Clinical Pharmacy…Dipiro.
Roger Walker.
Four components of Clinical Pharmacy.

Prescribing drugs.

Administering drugs.

Documenting.

Communication/counseling
Prescribing drugs
To authorize by means of a written order the supply
of a medicine.
issued by a prescriber.

involves decision making.

Historically, preserved for medical/dental/veterinary

training.

Now prescribing rights have been extended to

 Component parts of a prescription
PATIENT full name and address of the patient.
INFORMATION patient’s age, weight, or body surface area.

DATE date is important in establishing the medication record to a pharmacist in filling

prescriptions for controlled substances.

Rx SYMBOL OR symbol is representative of both the prescription and the pharmacy itself.
SUPERSCRIPTION
INSCRIPTION MEDICATION PRESCRIBED.
name, dosages, and quantities of the prescribed ingredients.
medications may be prescribed under their trademarked name or by generic names.
Pharmacist can provide substitution of an equivalent product If permitted by the
prescribing physician or by state law.

SUBSCRIPTION DISPENSING DIRECTIONS TO PHARMACIST.

serves merely to designate the dosage form (eg, tablets, capsules, inhaler, transdermal
patch) and the number of dosage units to be supplied.

SIGNATURA DIRECTIONS FOR PATIENT.

include best time to take the medication, importance of adhering to the prescribed
dosage schedule, what to do if a dose is missed, the permitted use of the medication
with respect to food/drink.
 Rational/Effective Prescribing
Rational Prescribing requires that patients receive medications.

appropriate to their clinical needs.

in doses that meet their own individual requirements

for an adequate period of time.

at the lowest cost to them and their community.

(WHO)
 Inappropriate/Irrational prescribing
• Result in serious morbidity/mortality.

• waste of resources.
– antimicrobial resistance (Antibiotics).

• Polypharmacy, interacting medicines.

• Continuing to prescribe for a longer period than necessary.

• Prescribing too low a dose of a medicine.

• Prescribing without taking account of the patient's wishes.

 Four aims of Prescriber
• Maximise effectiveness
• Minimise risks
• Minimise costs
• Respect the patient's choices.

Drug Selecting STEPS/criteria

• Safety.
• Tolerability
• Effectiveness.
• Price.
• Simplicity.
Preskorn, S.H., 1994. Antidepressant drug selection: criteria and options. J. Clin. Psychiatr. 55 (Suppl A), 6–22;
• Principles of biomedical ethics….
Barber, N., 1995. What constitutes good prescribing? Br. Med. J. 310, 923–925

1) respect for autonomy Confidentiality and consent

Medication being taken by a patient and his illness is a private matter
It is essential that patient understands their diagnosis, the
benefit/rationale of the proposed treatment and the associated
risks/consequences.
prescriber needs to determine if the patient has the competency to make
decisions for themselves.

2) Non-maleficence Prescribers…..review both the potential positive effects and the negative
not knowingly causing effects of treatment.
harm to the patient.

3) Beneficence Beneficence is referred to both physical and psychological benefits of

actions

4) Justice and veracity ensure that all patients have the same opportunity for good health.
 UK Model:….History
• 1986, prescribing had been the sole domain of doctors, dentists and
veterinarians.
• 1990s, to include nonmedical prescribers (pharmacists, nurses and
optometrists).
Independent Prescribing. Supplementary prescribing
prescribing by a practitioner (doctor, dentist, partnership between an independent
pharmacist) prescriber (doctor or dentist) and a
supplementary prescriber (nurse, pharmacist,
chiropodists/podiatrists, physiotherapists,
radiographers and
optometrists)

responsible/accountable for the assessment to implement an agreed patient-specific

of patients with Undiagnosed/diagnosed clinical management plan with the patient's
conditions. agreement.
Independent prescriber, undertakes the requires information to be shared and
initial assessment of the patient, determines recorded in a common patient file.
the diagnosis and the initial treatment Plan.
The Health and Social Care Act 2001 allowed pharmacists and other
HCP’s to prescribe.

2003, ……..allowing pharmacists to qualify as supplementary

prescribers.
DH, 2005. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4110032.

2006……pharmacists became independent prescribers.

Able to prescribe any licensed medicine except

Controlled Drugs and unlicensed medicines.

In the UK suitably qualified pharmacists can prescribe as either

supplementary or independent prescribers.

(Miscellaneous Amendments) Order of May 2006.(UK).

 Role of Pharmacist in Prescribing.
provide necessary information/guidance.
advise the prescriber of drug sensitivities the patient
may have………….(ADRs).
suggest alternative drug products.
keep appropriate records on the health status and
medication history of his/her patients.
Accountability as a Prescriber.
Prescribers are accountable both
legally/professionally.
The legal responsibility lies with whom signed the
prescription.
Competence and competency
• knowledge, skills and attributes required to undertake an activity.

Consultation/Skills
Skills needed
Interpersonal skills: ability to communicate/relationships with patients.
Reasoning skills: ability to gather appropriate information,
interpret the information.
apply information for both in diagnosis and management

Practical skills: ability to perform physical examinations and use clinical instruments
Calgary Cambridge framework for prescribing
consultation
Initiating the Greet the patient and confirm his/her identity.
session introduce yourself and gain consent.
Take into account both the patient and prescriber's needs.
Gathering explore the problem from both the patient/prescriber's perspective.
information Explore patient's ideas/concerns/expectations and experience of his/her
condition and effect on his/her life.
Physical Obtain the patient's consent for any examination.
examination
Explanation Negotiating the plan of action with the patient, assess the patient's prior
and planning knowledge.

Allow the patient time to consider the information provided.

Patients should have the opportunity to ask questions, raise doubts

Consider patient's beliefs, culture, abilities and lifestyle into account.

for example fasting during Ramadan.
Closing the patient should be able to identify unexpected outcomes/treatment failure.
session
Issues the prescriber should reflect upon before prescribing a medicine

What is the drug used for? Indications, Does first line mean first choice?

How effective is the drug? good evidence for efficacy?

How does it compare with existing drugs?

How safe is the drug? published comparative safety data?

clinically important drug interactions?

monitoring requirements?

patients in whom it is contraindicated?

Does the drug provide value evidence of cost-effectiveness compared to
for money? other available interventions?

What is its place in therapy? What advantages are there?

Are the benefits worth the cost?

Communicating risks/benefits of treatment
• Communicate risks/benefits in terms the patient can
understand.

• side effects Vs benefits of treatment.

• An informed patient is more likely to be concordant

with treatment.

• patients' is determined by patient’s emotions, beliefs

and values, not facts.
 Non-Adherence

• Effect of not taking the treatment needs to be told

to the patient.

• Patient's previous experience of medicines

associated side effects should be explored.

• Identify patient’s barriers to adherence.

• Medication/prescription review
Structured, critical examination of a patient's medicines.
A medication review can be from a simple review of the prescription to an in-depth
clinical medication review.
Review should be carried out by a competent health care professional.
Potential benefits of MR
Improves the current/future management of the patient's
medical condition.
• Develop an understanding between the patient and the
HCP.
Improves health outcomes/reduces adverse events.
Provides an opportunity to the patients to be actively
involved in their care/treatment.
Reduces unwanted/unused medicines.
 Factors that influence prescribers

Colleagues HCP’s rely on advice from trusted colleagues as a key source of information.

Pharmaceu has an important influence on prescribing decisions.

tical Promotion of medicines to the prescriber and patient groups
industry Pharmaceutical representatives provide new information to prescribers. but information
presented is not without bias and rarely provides any objective discussion.
Pharmaceutical industry spends millions on advertising, company sponsored information
from medical journals ,sponsorship to attend conferences.
The intensity of marketing activities are an important influence on
prescribing by health care professionals.
Strategies to improve prescribing
managerial and process orientated supportive and educationally orientated

Local and national guidelines implementation of evidence-based interventions

Provision of comparative (benchmarking) Interpersonal influence, through trusted
information colleagues or opinion leaders

Managerial approaches to influence prescribing

Formularies Prescribers are encouraged or required to adhere/helps consistency of prescribing.
can help contain costs.
these are the medicines stocked in the pharmacy.
Local and useful tools to guide and support prescribers in choosing which medicines they should
national prescribe.
guidelines.
systematically developed evidence based statements to assist clinicians in making
decisions.
Local guidelines are often developed to provide a local context and of national guidance.
 Electronic prescribing
• e-prescriptions to minimize medication errors.

• numerous large hospitals now require physicians to

enter orders directly into at a computer.

• These orders are screened for potential errors and

sent directly to the pharmacy for processing.

• This practice now has been implemented in retail

pharmacies.
 Advantages of E-Prescribing
Reducing/eliminating the errors.

prescribers receives prompts drug-specific dosing

information.

Information from the patient’s medical record can be linked

with information from the patient’s prescription records.

refill requests can be expedited.

computers facilitate data exchange between the physician

and pharmacist.
PROCESSING THE PRESCRIPTION ORDER
RECEIVING THE patient present the prescription order directly to the pharmacist.
PRESCRIPTION Gathering of essential disease and drug information from the patient.
Obtain the correct name, address, and other patient information.
Complete a brief health and medication history to establish patient’s
database.
READING/ Pharmacist should determine the compatibility of the newly prescribed
CHECKING THE medication with previous drugs.
PRESCRIPTION Consider drug–food or drug-disease interactions of drug allergy.
Consult with the prescriber to determine best therapeutic alternative.
A pharmacist should never guess at the meaning of an indistinct word or
unrecognized abbreviation.
Look alike or sound alike drugs are a potential source for errors.
Failure to specify the desired strength of a medication or its dosage form,
must be corrected.
Dose frequency must be checked for safety and efficacy.
Physicians’ Desk AMA Drug Evaluations,Handbook of Clinical Drug Data, Pharmacist’s Drug Handbook, and Pediatric
Dosage Handbook
NUMBERING To determine the appropriate refill frequency, patient compliance.
AND DATING
PREPARING when substitution is permitted, the pharmacist should select manufacturer’s
THE product on the basis of his knowledge of the quality, effectiveness, and cost.
PRESCRIPTION
PATIENT What did the doctor tell you to expect from the medication?
COUNSELING ensure that the patient knows how to use the medication properly.
labeling instructions.
information on the drug, dosage form, route of administration, any special
directions for use, common side effects/interactions and therapeutic,
contraindications , techniques for self-monitoring drug therapy, proper storage,
prescription refill information, and action to be taken in the
event of a missed dose.
Record/maintain patient profiles of the patient’s disease states, known
allergies, and drug sensitivities.
Drug Information for the Health Care Professional Vol II, Advice for the Patient (drug information in lay language)

RECORDING record of the prescriptions dispensed is maintained in the pharmacy through

AND FILING the use of computer and hard copy prescription files.
to access a patient’s records and refill a prescription previously dispensed.
• Thank U