Clinical Pharmacy

PHR 405
Chapter 1: General considerations
Course Instructor:
Md. Samiul Alam Rajib
Senior Lecturer
Department of Pharmacy
BRAC University

At the beginning of the class

let us meet with Dr. Tracy
Anderson Haag, a clinical
pharmacist working in
University of Minnesota
Hospital as a Clinical
Pharmacist
And
The life of a Clinical
Pharmacist in Emergency

Clinical Pharmacy -Definition

Clinical Pharmacy is a commonly used term
in pharmacy practice and in pharmacy
literature. It is a health specialty, which
describes the activities and services of the
clinical pharmacist to develop and promote
the rational and appropriate use of medicinal
products and devices.
Clinical
functions
economic
patients.

pharmacy comprises a set of

that promote the safe, effective and
use of medicines for individual

Clinical pharmacy process requires the

application
of
specific
knowledge
of
pharmacology,
pharmacokinetics,
pharmaceutics and therapeutics to patient

Activities of Clinical
Pharmacists

The principle activities of a clinical pharmacist include:

Consulting:

Analysing

therapies,

advising

health

care

practitioners on the correctness of drug therapy and providing

pharmaceutical care to patients both at hospital and at
community level.

Selection of drugs: Defining "drug formularies" or "limited lists

of drugs" in collaboration with hospital doctors, general
practitioners and decision makers.

Drug

information:

Seeking

information

and

critically

evaluating scientific literature; organizing information services

for both the health care practitioners and the patients.

Formulation and preparation: Formulation and preparation of

medicinal

products

and

devices

according

to

acceptable

standards to meet specific patients' needs.

Drug

use

studies

and

research:

Drug

use

studies/

Activities of Clinical Pharmacists

Pharmacokinetics/ therapeutic drug monitoring:
Studying the kinetics of drugs and optimising the
dosage.
Clinical Trials: Planning, evaluating and participating
in clinical trials.
Pharmacoeconomy: Using the results of clinical
trials

and

outcome

studies

to

determine

cost-

effectiveness evaluations.
Dispensation & Administration: Dispensing and
administration of medicinal products and devices:
studying and developing systems for the dispensing
and administration of medicinal products and devices
that can guarantee a higher security in administration,

Level of Action of Clinical

Pharmacists
A. Before the prescription

Clinical trials
Clinical pharmacists are also actively involved in clinical trials at
different levels: participating in ethical committees; study monitoring;
dispensation and preparation of investigational drugs

Formularies

Drug information

Clinical pharmacists have the potential to implement and influence

drug-related policies, i.e.,
making decisions on which drugs deserve to be marketed,
which drugs should be included in national and local formularies
which prescribing policies and treatment guidelines should be
implemented..

Level of Action of Clinical

Pharmacists
2. During the prescription
Counseling activity
Clinical pharmacists can influence the attitudes and
priorities of prescribers in their choice of correct treatments.
(Video Pharmacist Vs Doctors)
The clinical pharmacist monitors, detects and prevents
harmful drug interaction, adverse reactions ad medication
errors through evaluation of prescriptions' profiles.
The clinical pharmacist pays special attention to the
dosage of drugs which need therapeutic monitoring.
Clinical pharmacists can also make prescription decisions
directly, when over the counter drugs (OTC) are counseled.

Level of Action of Clinical Pharmacists

3. After the prescription
Counseling
Preparation of personalized formulation
Drug use evaluation
Outcome research
Pharmacoeconomic studies
After the prescription is written, clinical
pharmacists play a key role in communicating
and counseling patients.
Pharmacists can improve patients'
awareness of their treatments, monitor
treatment response, check and improve
patients' compliance with their medications.
As members of a multidisciplinary team, clinical
pharmacists also provide integrated care from

How does Clinical

Pharmacy differ from
Pharmacy?
Pharmacist
Clinical Pharmacist
The discipline of
pharmacy embraces
the knowledge on
synthesis,
chemistry and
preparation of
drugs

The focus of
attention is Drug

Clinical pharmacy
is more oriented to
the analysis of
population needs
with regards to
medicines, ways of
administration,
patterns of use and
drugs effects on the
patients
The focus of
attention is patient
or population

Pharmaceutical
care

Pharmaceutical care is a co-operative,

patient- centred system for achieving
specific and positive patient outcomes
from
the
responsible
provision
of
medicines. The practice of clinical
pharmacy is an essential component in
the delivery of pharmaceutical care.
The delivery of pharmaceutical care is
dependent on the practice of clinical
pharmacy but the key feature of care is
that
the practitioner takes responsibility for
a patient's drug related needs
and is held accountable for that

Medication-related
problems

Untreated indication
Treatment without indication
Improper drug selection
Too little drug
Too much drug
Non-compliance
Adverse drug reaction
Drug interaction

Medication-related
problems
Clinical guidance on medicines adherence

emphasizes the importance of patient

involvement in decisions about medicines.
Recommendations include that health care
professionals should:
adapt their consultation style to the needs of
individual patients
consider any factors which may affect
patients involvement in the consultation
establish the most effective way of
communicating with each patient
encourage patients to ask about their
condition and treatment
be aware that consultation skills can be

Medication
reconciliation
Lets watch a movie and make
some ideas about Medication
reconciliation

Medication reconciliation
Medication reconciliation has been defined as:
Collecting information on medication history
using the most recent and accurate sources
of information to create a full, and current,
list of medicines.
Verifying this list against the hospital drug
chart and ensuring that any discrepancies
are identified and acted upon;
Documenting and communicating any
changes, omissions or discrepancies.
This process requires the name of medicines,
dosage, frequency and route of
administration to be established for all
medicines taken prior to admission.
The information collected as part of
medicines reconciliation is a pre-requisite

Key elements of the care

process
Element

Assessm
ent

Care
plan

Evaluati
on

Purpose

The main goal is to establish a

full medication history and
highlight actual and potential
drug-related problems
This should clearly state the
goals to optimize care and the
responsibilities of both the
pharmacist and the patient in
attaining the stated goals
This reviews progress against
the stated patient outcomes

Key elements of the care

process

Lets watch a video clip

to see how a good
pharmacist actually
perform a patient
counseling and find out
the key element of care
process

Consultation process
Descriptions of
pharmaceutical consultation
have been confined largely to the use of
mnemonics such as WWHAM, AS METTHOD and
ENCORE.
These approaches provide the pharmacist with a
rigid structure to use when questioning patients
about their symptoms but, although useful, serve
to make the symptom or disease the focus of the
consultation rather than the patient.
Research into patients' perceptions of their
illness and treatment has demonstrated that they
are more likely to adhere to their medication
regimen, and be more satisfied with the
consultation, if their views about illness and
treatment have been taken into account and the

Mnemonics used in the

pharmacy consultation process
WWHAM
Who is it for?
What are the symptoms?
How long has it been going on?
Action taken?
Medicines taken?
AS METTHOD
Age of the patient?
Self or for someone else?
Medicines being taken?
Exactly what do you mean (by the symptom)?
Time and duration of the symptom.
Taken any action (medicine or seen the doctor)?
History of any disease?
Other symptoms?
Doing anything to alleviate or worsen the
symptom?

Mnemonics used in the

pharmacy consultation
process

ENCORE
Evaluate the symptom, its onset, recurrence
and duration.
No medication is always an option.
Care when dealing with specific patient
groups, notably the elderly, the young, nursing
mothers, pregnant women, those receiving
specific medication such as methotrexate and
anticoagulants, and those with particular
disease, for example, renal impairment.
Observe the patient for signs of systemic
disturbance and ask about presence of fever,
loss of weight and any accompanying
physiological disturbance.
Refer when in doubt.
Explain any course of action recommended.

Home assignment
Please watch Video 5 and Video
6 and determine which
Mnemonic has been used to
for the counseling.

Pharmaceutical
consultation
Undertaking a pharmaceutical consultation can
Undertaking a pharmaceutical consultation can
be considered as

phases,

each

a series of four interlinked

with

goal

and

set

of

competencies (Table 1).

For effective consultation, the practitioner also
needs

to

draw

upon

range

of

communication behaviors (Table: 3)

The ability to consult with patients is a key
process in the delivery of pharmaceutical care
and consequently requires

regular review and

development, regardless of experience.

Table 1: Pharmaceutical
consultation
process
Element
Goal
Examples of associated
competencies
Introduction

Building a therapeutic
relationship
Invites patient to discuss
medication or healthrelated issue

Discusses structure and purpose of

consultation
Negotiates shared agenda

Data collection
and
problem
identification

Identifying the patient's

medication-related needs

Takes a full medication history

Establishes patient's understanding
of their illness
Establishes patient's understanding
of the prescribed treatment
Identifies and prioritizes patient's
pharmaceutical problems

Actions and
solutions

Establishing an
acceptable
management plan with
the patient

Involves patient in designing

management plan.
Tailors information to address
patient's perception of illness and
treatment
Checks patient's understanding
Refers appropriately

Closure

Negotiating safety
netting
strategies with the
patient

Provides information to guide action

when patient experiences problems
with
management plan

Table 2: Key post-consultation

questions
Do I know more now about the patient?
Was I curious?
Did I really listen?
Did I find out what really mattered to them?
Did I explore their beliefs and expectations?
Did I identify the patient's main medication-related
problems?
Did I use their thoughts when I started explaining?
Did I share the treatment options with them?
Did I help my patient to reach a decision?
Did I check that they understood what I said?
Did we agree?
Was I friendly?

Table 3: Consultation
behaviors
Active listening
Appropriate use of open and closed questions
Respect patient
Avoid jargon
Demonstrate empathy
Deal sensitively with potentially embarrassing
or sensitive issues