(2) Services provided by
decentralized pharmacist
(medication therapy and patient
care)
January 7, 2017
level (3) - lecture (9)
Services provided by
decentralized
: taking
pharmacist
Medication history
Prescription monitoring
Prescribing advice
Medication errors and ADRs reporting
Therapeutic drug monitoring (TDM)
Pharmacokinetic consultation
Medicine information services
Patient education and discharge
counseling
2
Importance of
medication to patient
care
: more adeaths
Errors
each problem
year than breast
IOMcause
reports,
serious
faced
cancer
, motor
vehicle
accident, and ADIS
by
entire
health
systems
What are the
consequence
s of that ?
1,000,000 serious medication error
occur every year in
U.S. hospitals
44,000-98,000 die each year
Such error includes:
in hospital due to
Administration of wrong
medication error
drug
They occur for many reasons, including
Illegible hand writing
decimal point
Drug overdoses
Drug interaction
Developing effective
health care teams :
Role of team member:
Interprofessional or multidisciplinary
teams have demonstrate their value with
improved patient outcomes and safety
while reducing health care cost
These team can be found in various
Intensive care
setting including
Primary care
Disease-specific care setting
Critical acute care
Geriatric
End-of-life care
unit
Trauma unit
Operating room
Emergency
room
4
Pharmacist role to
provide patient care :
Pharmacist role in providing drug
therapy (to control disease, prevent
disease, slow disease progress and
cure disease) includes the following
domains
of
practice
Assure safe and effective
Assess safe and effective
Pharmacotherapy
And
Optimize therapeutic out-comes
Preparation and dispensing
Of
medication
5
Provide health care information and promote public health
Definitions :
Clinical pharmacy
Collaborative drug therapy
management (CDTM)
Pharmaceutical care
Iatrogenic injury
Interdisciplinary
Interprofessional
6
Medication and Health
History Taking :
Purpose :
To avoid many problems resulting from
incomplete or inaccurate information
on the medication history and recent
medicine that patients are taking
Such as not knowing the medication
name, dose, and use, omission of
herbal and OTC products
7
Medication and Health
History Taking :
Patient admission, discharge, or transfers
from one level of care to another are
always problem-prone points in the
medication use process (confound the
complication)
If the patients is seeing several
physicians and using several pharmacies
this confound the complication
8
Medication and Health
History Taking :
1
Bond et al. evaluated 429,827
medications error from 1,081
hospital over 1 year and
verified 17,638 fewer
medication error when
pharmacist performed
medication admission history
Medication and Health
History Taking :
In hospital setting,
pharmacist participation on
the healthcare team
averaging 386 pt lives/ y
medication admission
history in 30 hospital resulted
in 3,843 fewer deaths each
year
10
Medication and Health
History Taking :
3
A 66% reduction in adverse
drug events was seen when
pharmacists participated in
patients rounds in the
intensive care unit of a large
academic medical center
11
Medication and Health
History Taking :
The initial step in providing the
pharmaceutical care is to assess the
patient drug related needs by
gathering and analyzing patientspecific information
12
Medication and Health
History Taking :
Subjective section include information that
is given by the patient, family, caregiver, it
include
Patient
Family history
demographic
Social history
complaints/sympto
Review of system
ms
patient's thoughts
History of present
or patient
illness
perceptions of
Past medical
disease
history
Medication history
13
Medication and Health
History Taking :
The objective section includes data that
obtained from the pt and that can be
measured objectively, it includes
Vital signs
Physical findings
Laboratory test results
Serum drug concentration
Diagnostic test
14
Prescribing Advice :
face-to-face
communication
can be provided by
attending the medical
rounds
It includes
medical staff
nurse
15
Prescribing Advice :
Advice to medical staff Advice to the nursing
choice of drugs
patient drug therap
Dose and dosing
drug information
administration method
drug orders
side effects
Interactions
monitoring
requirements
16
Prescription
Monitoring :
Reviewing the contents of the prescription
for medication dosing errors,
appropriateness of administration route,
drug interactions, prescription ambiguities,
inappropriate prescribing and other potential
errors
Access to the clinical observation chart
Communication with the health care team
members
Interaction with the patient
17
Medication
reconciliation :
In 2005, the JCAHO added medication
reconciliation to its list of patient
safety goal further validating the
unique contribution of pharmacist:
Goal: accurately and completely reconcile medication
a cross the continuum of care
a process for comparing the patients
current medications with those
ordered for the patient while under
the care of the organization.
18
Medication
reconciliation :
A complete list of the patients
medications is communicated to the next
provider of service when a patient is
referred or transferred to another setting,
service, practitioner or level of care within
or outside the organization.
50% or more of all medication errors in
hospitals are due to poorly communicated
medical information
19
Clinical Services
for Out-patients
20
Clinical services :
1-Prescription monitoring
2-Patient education & counseling
3-Maintenance of PMP
21
