Clinical pharmacy– a key role

1. Introduction to Clinical
Pharmacy– a key role for
pharmacists.
Year 3 Peradeniya University
SOP Dr Ian Coombes,
Clinical senior Lecturer - School of Pharmacy + Medicine,
University of Queensland, and Senior Pharmacist,
Safe Medication Practice Unit, Brisbane, Australia
Mrs Judith Coombes
Conjoint Lecturer - School of Pharmacy, University of
Queensland and Senior Education Pharmacist, Princess
Alexandra Hospital, Brisbane, Australia.

2. Content
• Introduction to Us and You
• What is clinical pharmacy and why do we need it
• Medicine management and patient journeys
• Adverse drug events – the problem
• Product versus patient focused services
• Perception of the profession
• Drivers for change –its development elsewhere
• Core practitioner skills, knowledge and attitudes,
• Plan for the next 6 weeks

3. Background - Queensland
1900km
N - S
700 km W - E
4 M people
in Qld
1.8Million
km2
Brisbane

4. Brisbane
Queenslan
d

5. Comparisons
Sri Lanka (7 degrees N of equator) Australia (14 degrees S of equator)
66,000km2 7,600,000km2 (120x)
20 million people 20.3 million people (=)
8.5% >65 year 13.3% >65 yr (1.5 x)
3.7% GDP on healthcare 9.5% GDP on healthcare (2.5x)
$160M/ yr/ on free Health $80 BN/ yr/ Health
$42 /person/year on health $3,900/person/year on health
2 hospital beds/ 1000 people 3.6 hospital beds/ 1000 people
New 4 year pharmacy degree 4 year pharmacy degree
1000 hospital pharmacists, 14,000 pharmacists, 3000 hospital
Doctor order, pharmacist supply Separation of supply from ordering

6. Judith Coombes
• University Queensland
• Pre-registration (apprenticeship year) community
• District hospital (Rockhampton) 700km N
• UK hospitals 2 years, wards and dispensary
• PAH renal specialist pharmacist
• UK MSc (Clin Pharm) DI + research pharmacist
• PAH, 700 bed teaching, Drug use evaluation
• Conjoint Lecturer U of Qld + PAH education

7. Ian Coombes
• University of London – wanted be in advertising!
• Pre-registration year - London Hospital
• Junior training – London Hospital
• Working holiday in Brisbane, 2 hospitals
• Msc in Clin Pharm, ICU, renal, cardiac jobs - UK
• Manage Clinical Services + cardiac + PAC – PAH
• Safe Medication Practice Unit
• PhD
• State wide pharmacy + prescriber education

8. Perceptions of Pharmacists
How do others see us?

9. “They just count a few tablets”

10. “They just weigh and measure things”

11. “A bunch of shop-keepers”

12. “Tell me how and when to use the Medicine”

13. “Counter-prescribing”

14. “Not really health care practitioners – they’re
businessmen”

15. “Do you need a degree to be a pharmacist?”

16. Drivers for change
• Competence of health care practitioners
- Diploma to BSc to BPharm + Pre-registration +
registration
- Continuing Professional Development.
• Re-engineering of community medicine supply
- Provided by competent practitioners
- Recognition that dispensing is a technical function
• Informed general public – increased expectation
• Realisation that ………………….

17. Medicines are Dangerous

19. 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

20. 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?

21. A case
• 44 year old lady with fever and green sputum
and cough – no known previous medical history
– Diagnosed with upper resp. tract infection
• Prescribed:
– Co-Amoxiclav 1 tds
– Doxycycline 100mg D
– Prednisolone 40mg D
– Theophylline 200mg bd
– Omeprazole 20mg D
– Metoclopramide 10mg tds
– Salbutamol 2 puff inhale prn
Pharmaceutical problems
Common organisms for URTI?
Need for atypical organism ?
History of asthma – risk vs benefit?
History asthma – risk vs benefit
Need for acid suppression?
Why is she nauseous ?
Benefit of brochodilation?
Does she know what to take?
Will she take it?

22. Why did you choose to do this
course?
What do you envisage doing when
you become a pharmacist?
2 minutes talk to your neighbour and
then feedback

23. Question?
• Think of someone in your family or a friend
that has had something go “wrong” with their
medicines?
– Caused an adverse or unwanted effect ?
– Had medicines stopped when should have
continued?
– Not worked?
– What happened ?
– Could it have been avoided ?

25. Medical/medication errors in the UK
• Adverse events occur in 10% of admissions
• An estimated 850,000 adverse events a year
• Adverse events cost approximately £2 billion/yr
• The NHS pays £400 million clinical negligence
• Medication errors accounts for around a quarter
of the incidents which threaten patient safety
The Chief Medical Officer
An Organisation with a Memory
Department of Health (2000)

26. High Profile Examples
• A patient with leukaemia received Intrathecal vincristine
instead of intravenously. Died beginning of February
2001. 14th such case over the last 16 years.
• Patient being operated for a AAA received bupivicaine
intravenously rather than epidurally. Patient died 3 days
later.
• A 3 year old girl, who had a convulsion post flu vaccine.
Attended hospital to get “checked out”. Received nitrous
oxide instead of oxygen in casualty

27. High Profile Cases (Cont.)
• Elderly lady prescribed Methotrexate in 1997 for her
rheumatoid arthritis. Dose increased to 17.5mg
WEEKLY over a 6 month period.
• Jan 2000 patient undergoes right TKR in hospital. MTX
given as one tablet a week (only 2.5mg).
• 6th April 2000 patient asks GP to reduce number of
tablets “as in hospital”.
• Prescription for MTX 10mg/daily written and dispensed.
• 30th April patient dies.

28. Deaths from medicines in the UK
1999 - 2000 (ICD9 & 10 data)
A spoonful of sugar - Audit Commission (2001)

29. So drugs are safe ………………..
Photosensitivity from
Amiodarone
Severe extravasation of
amiodarone infusion

30. NSAID or COX-2 induced peptic ulcer

31. Goitre – Hypothyroidism
Secondary to Amiodarone
Bleeding due to
anticoagulation

32. Erythemal rash from penicillin – in patient with a previous
Known allergy/ adverse drug reaction

33. Necrotising fascititis – secondary to infection at site of IV injection

34. Acute Liver failure from Black Cohosh - herbal medicine

35. Human Error
(Mistakes, Slips, Lapses)
• Error is inevitable due to “our” limitations:
- limited memory capacity
- limited mental processing capacity
- negative effects of fatigue other stressors
• We all make errors all the time
• Generalised lack of awareness that errors occur
• Patients suffer adverse events much more often
than previously realised
• Errors often NOT immediately observed

36. The same error, even a minor
one, can have quite different
consequences in different
circumstances.

37. “I assumed the brown glass
ampoule was frusemide”
(ICU RN after injecting 10mg
adrenaline)
The System:
Only as safe as it’s designed to be!

38. The Accident Causation Model
(Adopted from Reason & Dean)
Active
Failures
- Slips&lapses
- Mistakes
Error
producing
conditions Accident
Defences
Latent
Conditions

40. The Medicines Management Cycle
• What happens between a doctor seeing a
patient and them receiving or taking their
medicine ?
• 2 minutes discuss with neighbor

41. The Medicines Management Cycle
Decision to
prescribe
Patient
Order entry
Review order
Supply medicine
Supply
informationDistribute
Administer
Monitor
response
Transfer
information
From Bates et al 1995
DOCTORSDOCTORS
PharmacyPharmacy
NursesNurses

42. Sources of Error
• Prescribing error - selecting the wrong or
inappropriate drug/dose/formulation/duration etc
• Communicating those instructions
• Supply error - timely; wrong drug, dose, route;
expired medicines, labelling.
• Administration error - timing; wrong route; wrong
rate/technique.
• Lack of user education - actions to take.

43. Where do things go wrong with medicines?
Errors
Frequency
(literature) %
Frequency
(600 bed
Hospital)
Drug Related
admissions
5 – 20 % of unplanned
admissions
4 – 15 patients /
day
Prescribing
errors
2.5 –10 % of orders 40 – 160 orders
in error/ day
Dispensing
errors
0.01 – 0.05 % of items 1-5 leave the
pharmacy/ week
Administration
errors
5- 15% of doses 40 – 100 doses/
day
Discharge
prescribing
5 –17% of items for
discharge
20 –70 items in
error/ day

44. Comparability to Australian National
Health Priority Areas
In 2000-01, hospital admissions
– Angina: 88,500
– Myocardial infarction: 37,500
– Asthma: 49,000
– Diabetes: 46,000
– Adverse Drug Events: 140,000

45. Reducing the risk of adverse
events
• Always
– include a detailed drug history in the consultation
• Only
– use drug treatment when there is a clear indication
• Stop
– drugs that are no longer necessary
• Check
– dose and response, especially in the young, elderly
and those with renal, hepatic or cardiac disease

46. 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

47. Aims of
Pharmaceutical
Care
Effective drug
therapy
Safe drug
therapy
Economic drug
therapy
Improve
quality of life

48. Aims of Pharmaceutical Care
• Identify actual and potential drug related
problems,
• Resolve actual drug related problems,
• Prevent potential drug related problems.

49. Drug therapy assessment
Six types of problems which may result in
treatment failure:
1. Inappropriate selection of medication
2. Inappropriate formulation of medication
3. Inappropriate administration of drug therapy
4. Inappropriate medication-taking behaviour
5. Inappropriate monitoring of drug therapy
6. Inappropriate response to drug therapy

50. Pharmaceutical care planning
Process of work
– collect relevant patient information
– assess information
– identify problems
– state desired outcomes
– prioritise problems
– develop an action plan for each problem
– was desired outcome achieved?

51. Pharmaceutical Care Activities (1)
• Patient Consultation - discuss expectations
and concerns,
• Pharmacist’s assessment - identify current
or potential drug therapy problems,
• Creation of a care plan - establish goals of
therapy, action to be taken and outcomes to
be monitored.
• Communication of that plan eg Dr, nurse
other pharmacist, patient, carer

52. Pharmaceutical Care Activities (2)
• Patient education and/or referral –
• provide individualised, current information
about drug therapy and how to use;
Demonstrate special techniques; refer to
doctor or other HCP.
• Patient monitoring and follow-up –
• are the goals being met.

53. Refocusing the profession because :-
1. Problems caused by drug use in society,
2. Business orientated approaches place the
product before the patient,
Pharmaceutical care is :-
• a patient-centred approach (not drug-centred),
• a process of managing drug-related problems,
• Where pharmacists take responsibility for
provision of drug therapy.

54. Formulary
Prescribing protocols
Prospective review
Clinical pharmacy
Admission medication history
Allergy check
Drug distribution system
Opportunity
For Error
Administration instructions
Clinical Pharmacy Role in Reducing Risks

55. Formulary
Prescribing protocols
Prospective review
Clinical pharmacy
Admission medication history
Allergy check
Drug distribution
system
Adapted by P.Thornton from J. Reason, 9/01
Opportunity
For Error
Administration instructions
What if we are not there!

56. Outcomes of Pharmaceutical
Care(1)
• The patient receives effective drug therapy
- based on the evidence of current medical
literature (Evidence based Medicine).
• The patient receives safe therapy - based
on a knowledge of their individual clinical
circumstances.

57. Outcomes of Pharmaceutical
Care(2)
• The patient receives the most economic
therapy - not compromising efficacy or
toxicity
• The patient receives drug therapy desired
to improve their quality of life.

58. Patient Assessment Questions
• Does the patient need this drug ?
• Is this drug the most effective and safe ?
• Is this dosage the most effective and safe ?
• If side effects are unavoidable does the patient
need additional drug therapy for these side effects?
• Will drug administration impair safety or efficacy ?
• Are there any drug interactions ?
• Will the patient comply with prescribed regimen ?

59. To be a drug expert society needs
practitioners who ……..…

60. Key knowledge, skills and
attributesKnowledge base
• Chemistry,
• Pharmaceutics,
• Pharmacology,
• Therapeutics,
• Law, Ethics, Professional conduct.
Skills base
• Problem solvers,
• Make decisions,
• Good communication + Effective consultation process,
• Gather information,
• Calculate doses,
• Offer advice that’s timely and accurate (Pts, Dr’s and Nurses),
• Dispense medicines,
• Monitor and follow up

61. Key knowledge, skills and
attributes
Attributes
• Takes responsibility for actions;
• Punctual;
• Caring nature;
• Professional behaviour;
• Open minded;
• Positive attitude;
• Treats patients equally;
• Treats information confidentially;

62. Key Responsibilities
1. Act in the interest of patients and seek to provide the
best possible health care for the community.
– Treat all with courtesy, respect and confidentiality.
– Respect patients’ rights to participate in decisions about their
care
– Provide information which can be understood.
1. Must ensure that their knowledge, skills and
performance are of high quality, up to date, evidence
based and relevant.
2. Behave with integrity
– adhere to accepted standards of personal and professional
conduct

63. Summary
• Drugs are beneficial but can also cause harm.
• Society needs a gatekeeper who manages the
use of drugs.
• Pharmacists must adopt a patient focused
approach to identifying and resolving drug
related issues.
• The consultation process and effective
communication lies at the heart of achieving
this.

64. Plan for next 6 weeks
• Topics:
– Abbreviations,
– Evidence based medicine
– Medication history taking, confirmation, reconciliation
– Effective communication with other clinical staff
– Therapeutic – c-vasc, respiratory, renal, neurology (pain) ,
gastro
• Teaching and learning methods:
– Didactic, set some tasks, feedback go through in tutorials

65. The End

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