Clinical pharmacy practice presentation ppt

Clinical Pharmacy
Practice
Dr UPPU JHANSI RANI,
PharmD

Health Care System
Composed of physician (including other medical and dental staffs), pharmacist ,
nurse and other paramedics
Physician ; diagnosis, prescription, monitoring, medical care
Pharmacist; prescription*, dispensing, counseling, monitoring,
pharmaceutical care
Nurse ; administering, monitoring, nursing care
Other paramedics ; their own work
Load to physician & nurse ; high due to the system of "physicians are all in all in
hospital for the treatment of patient, with the help of nurse."
Concept of normal public/patient ; same

Pharmaceutical care
• “ A practice in which a practitioner takes responsibility for a
patient’s drug related needs and holds him or herself accountable
for meeting these needs.”....... Linda Strand 1997
• It describes specific services & activities through which an
individual pharmacist cooperates with patients and other health
care professionals in designing, implementing & monitoring a
therapeutic plan that will produce specific outcomes for the
patient.

Aims of
Pharmaceutical
Care
Effective drug
therapy
Safe drug
therapy
Economic drug
therapy
Improve
quality of life
Will the patient take
the therapy
?
What does the
patient view as an
improved quality of
life
?

What is Clinical Pharmacy?
Clinical pharmacy may be defined as the science and practice of rationale use of
medications, where the pharmacists are more oriented towards the patient care
rationalizing medication therapy promoting health , wellness of people.
It is the modern and extended field of pharmacy.
“ The discipline that embodies the application and development (by pharmacist) of
scientific principles of pharmacology, toxicology, therapeutics, and clinical
pharmacokinetics, pharmacoeconomics, pharmacogenomics and other allied
sciences for the care of patients”.
(Reference: American college of clinical pharmacy)

Clinical Pharmacy Requirements
Knowledge of
nondrug therapy
Therapeutic
planning
skills
Drug Information
Skills
Physical
assessment
skills
Patient
monitoring
skills
Communication
skills
Knowledge of
laboratory
and diagnostic skills
Knowledge of
the disease
Knowledge of
drug therapy
Patient care

CLINICAL PHARMACIST SERVICES IN ABMH
CLINICAL PHARMACIST SERVICES IN ABMH
1. Ward round participation
2. Inventory control/stock audit
3. Crash cart audit
4. Medication errors
5. ADR Reporting.
6. Drug interactions.
7. Teaching and training to other health care
professionals
8. Patient counseling

WARD ROUND PARTICIPATION
Definition:
•The participation of the pharmacist in the ward round
along with the physician or alone on his own , to assess
the patient for drug related problems, monitoring drug
therapy for therapeutic or adverse effects and provide
drug information to the physician, patient and other
health care professionals is called as pharmacist ward
round.

WARD ROUND PARTICIPATION
• Goals and objectives:
1) Provide relevant information or various aspects of the
patient’s drug therapy such as pharmacology, kinetics, drug
available, Drug information and ADR’s.
2) Optimize therapeutic management by influencing drug
therapy selection, implementation, monitoring and follow up.
3) Detect ADRs and Drug interactions.

MEDICATION ERRORS
DEFINITION:
A Medication error is any preventable event that may cause
or lead to inappropriate medication use or patient harm while in
the control of the health care professional, patient ,or consumer.
GOAL:
To prevent and/or control potential and actual medication
errors in order to enhance patient care, Improve patient safety
and decrease liability and hospital cost.

MEDICATION ERRORS
• Causes:
1) Lack of knowledge
2) Excessive task demand
3) Lack of communication
4) Lack of patient counseling
5) Environmental factors

NCC MERP INDEX FOR CATEGORIZING ERRORS

TYPES OF MEDICATION ERROR
1. PRESCRIBING ERRORS
2. OMISSION ERRORS
3. WRONG TIME ERRORS
4. WRONG DOSAGE ERRORS
5. WRONG DOSE ERRORS
6. IMPROPER ADMINISTRATION TECHNIQUE ERRORS
7. MONITORING ERRORS
8. COMPLIANCE ERROR
9. DISPENSING ERRORS
10. WRONG DRUG PREPARATION ERROR

PRESCRIBING ERROR
• A prescribing error occurs at the time a prescriber
orders a drug for a specific patient.
• Error may include the selection of an incorrect dose,
dosage form, route of administration, length of
therapy and number of doses.
For example:
T.Eltroxin 50mg was prescribed instead of T.Eltroxin
50mcg which is appropriate to treat hypothyroidism.

DISPENSING ERROR
• Dispensing errors occur at any stage of the dispensing
process, from the receipt of the prescription in the pharmacy
to the supply of a dispensed medicine to a patient.
• Classification of dispensing errors:
Incorrect drug
Incorrect strength
Incorrect dosage form
Dose added
Missing doses.

OMISSION ERROR
• Failure to administer an ordered dose to a
patient in a hospital before the next
scheduled dose is considered as an omission
error.

WRONG TIME ERRORS
• Administration of a drug outside a predefined
time interval from its scheduled
administration time.
• Administering doses too early or too late may
effect the drug serum levels and consequently
the efficacy of the drug.

WRONG DOSAGE FORM ERRORS
• Dose administered or dispensed in a different form
from the ordered by the prescriber are classified as
wrong dosage form errors.
• For example:
Tobramycin 80mg for every 8hrs ordered to be given
intravenously instead of inhalation.

WRONG DOSE ERROR
• It occurs when a patient is given a dose that is greater(over
dose) or less than the actual dose.
For example:
A 80 year old male patient is a k/c/o CKD and HTN whose
creatinine clearance was found to be 18.7ml/min though
according to crcl Inj.Meropenem 0.5g Bd should be prescribed
but in this patient Meropenem 1.5gm BD was prescribed.

WRONG DRUG PREPARATION ERRORS
• Drugs requiring reconstitution, dilution, special
preparation prior to dispensing or administration of
drug.
• But fail to do such type of procedure leads to wrong
drug preparation error.
• Eg:
Cephalexin oral suspension with an incorrect of
water

WRONG ADMINISTRATION TECHNIQUE ERRORS
• Doses that are administered using an
inappropriate procedure or incorrect
technique are categorized as wrong
administration technique.
Eg:
Instilling the eye drops in the wrong eye.

MEDICATION ERRORS
Reducing errors:
1)Patient communication
2)Intra professional communication
3)Education and training
4)Electronic prescribing
5)Ensuring a safe dispensing procedure.

ADVERSE DRUG REACTION
• Definition: The WHO defines an ADR as
follows
A drug related event that is noxious and
unintended and occurs at normal doses used
in humans for prophylaxis, diagnosis or
therapy of disease or for the modification of
physiological function.

OBJECTIVES OF ADR MONITORING
Why ADRs should be monitored?
1.To detect the nature and frequency of ADRs including periodic
reevaluation of risk-benefit ratio of medicinal products
2.To provide the updated drug safety information to health care
professionals.
3.To identify the risk factors that may predispose, induce or
influence the development , severity and incidence of adverse
reactions.

CLASSIFICATION OF ADR
Depending on
Onset of event: Acute(<60min), Sub acute (1-24hrs) and latent
(<2days).
Type of reaction:
Type A (Augmented) : Insulin induced hypoglycemia
Type B (Bizarre) : Penicillin induced anaphylaxis
Type C (Chronic) : Paracetamol induced hepatotoxicity
Type D (Delayed). : Antipsychotic induced tardive
dyskinesia
Severity : Minor, Moderate, severe.

HOW TO ASSESS ADRs?
• ADRs can be assessed by causality assessment probability
scales.
 WHO probability scale
 Naranjo algorithm

REPORTING ADR
A. What to report
 Report serious , non -serious, known or unknown, frequent or
rare adverse drug reactions due to medicines, vaccines and
herbal products.
B. Who can report:
 All health care professionals
C. Where to report:
 Duly filled form can be send to nearest ADR monitoring Centre
or directly to National coordination Centre
 Call on help line 1800 180 3024 to report ADRs
 Mail to pvpi@ipc.india.net

REPORTED ADVERSE DRUG REACTIONS
• Telmisartan induced hyperkalemia
• Ramipril induced dry cough
• Loperamide induced angioedema
• Feropenem induced maculopapular rashes
• Sulfasalazine induced DRESS syndrome
• Heparin induced Hyponatremia
• Metformin induced Acute gastroenteritis
• Steroids induced leucocytosis
• Premetrexed induced acute kidney injury

Case study for Adverse drug reaction
assessment.
• A 75 year old female patient was admitted on 16/6/2017 with the chief
complaints of rashes, itching and restlessness. She is a k/c/o of venous
ulcer, HTN. She recently had venous ulcer surgery on may 24 . She was
prescribed with T.feropenem 200mg BD as a part of treatment for one
week. After the third dose patient had complaint of itching, rashes all over
the neck and after next dose patient had rashes all over the body and
came to hospital. And diagnosed as drug induced maculopapular rashes
all over the body. Doctor has prescribed Inj.Avil 2 ml, Inj.Hydrocortisone
100mg stat and feropenem was withdrawn.
• Assess the causality of this reaction by using WHO probability scale and
Naranjo’s algorithm.

DRUG INTERACTIONS
• An interaction is said to occur when the effects of one drug
are changed by the presence of other drug, herb, food, drink.
• An interaction occurs when pharmacokinetics or
pharmacodynamics of drug changed.
• Types:
1) Drug-Drug interactions
2) Herbal- Drug interactions
3) Food-Drug interactions
4) Drink –Drug interactions
5) Pharmacogenetic interactions

RISK FACTORS
• Poly pharmacy
• Multiple prescribers
• Multiple pharmacies
• Genetic make up
• Specific population like females, elderly, obese,
transplant recipient, critically ill patients.
• Specific illness like hepatic disease and renal
impairment.
• Narrow therapeutic index drugs.

Mechanisms
 Pharmacokinetics:
• Absorption interactions
• Distribution interactions
• Metabolism interactions
• Excretion interactions
 Pharmacodynamics:
• Synergistic interactions
• Antagonistic interactions

SEVERE DRUG INTERACTIONS
 Aspirin <-> Torsemide
 Tramadol<-> Linizolid
 Aspirin<-> Glimipizide/metformin
 Tramadol<-> Ondansetron
 Rifampin<-> Tacrolimus
 Spironolactone<-> Ramipril
 Furosemide<->Amikacin

Case study
Chief complaints: A 73 year old male patient admitted on 23/06/2017 came with
complaints of breathlessness, fever , cough and generalized weakness.
Past history: Renal allograft recipient in 2011 june , HTN
Diagnosed as TB since 15 days on AKT 4.
Drug History: T.Tacrolimus 65 mg BD, T.Prednisolone 7.5mg OD.
Lab reports: Sr.creatinine: 2.0mg/dl, BUN: 45mg/dl on 6/5/2017
sr.creatinine: 4.8mg/dl, BUN: 68mg/dl on 23/6/2017
sr.creatinine: 6.8mg/dl, BUN: 75mg/dl on 26/7/2017
Current medications: cap. Rifampin 450mg OD , Isoniazid 300mg OD, pyrazinamide
750mg, Ethambutol Hcl 800mg OD, T.levofloxacin 500mg BD, T.Bendon 10mg OD,
Syp.Ascoryl, Neb with Duolin and budecort 4 th hrly.
Follow up: RFT levels were raised .
Rifampin has stopped on 27/6/2107 and added T.levofloxacin 500mg BD

STOCK AUDIT/INVENTORY CONTROL
WHY INVENTORY CONTROL IS IMPORTANT FOR PHARMACY?
Stock control requires effective guidelines which contains SOP
for stock ordering, receiving, storage, dispensing and disposal.
A good stock ordering system work towards preventing the
pharmacy from being over and under stock.
In a over stocked pharmacy has a risk of medicines expiring,
high inventory cost and limited storage space.
As under stocked pharmacy cannot fulfill the need of the
community.

CRASH CART AUDITING
Why crash cart is needed?
A crash cart is a mobile cart cart stocked with emergency
medical equipment's.
The function of crash cart is to provide a mobile station within
the hospital that contains everything needed to treat a life
threatening conditions.
A well organized crash cart can serve a lot of time and
confusion during an emergency. Which in turn serve much life. It
was developed for ready for situations.

MAINTENANCE
 Crash cart should be checked daily and monthly against check
list to ensure that they are fully stocked at all times.
 When an item from crash cart used , it should be replaced
immediately after the emergency.
 A daily check includes ensuring that the crash cart has all the
necessary supplies in the proper place and all its electronic
equipment is fully charged
 A monthly check would include checking drug expiration date
as well as sterilization dates for endotracheal tubes if they are
reused.

PATIENT COUNSELING
• Patient counseling is defined as providing medication
information orally or written form to the patient or his
representatives.
like on directions of use, advice on side effects, precautions ,
storage, diet and life style changes

Educate other health care professionals
 Identify the educational needs of the health care
professionals.
 Establish rapport with other health care professionals.
 Communicate recommendations or relevant information to
health care professionals in a manner appropriate to their
training, skills and needs.
 Provide back ground information and primary literature to
other health care professionals as needed.

Clinical pharmacy practice presentation ppt

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