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.

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

Background - Queensland

1900km N - S

700 km W - E

4 M people in Qld

1.8Million km2

Brisbane

Brisbane

Queensland

ComparisonsSri 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

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

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

Perceptions of Pharmacists

How do others see us?

“They just count a few tablets”

“They just weigh and measure things”

“A bunch of shop-keepers”

“Tell me how and when to use the Medicine”

“Counter-prescribing”

“Not really health care practitioners – they’rebusinessmen”

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

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 ………………….

Medicines are Dangerous

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

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?

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?

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

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 ?

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 safetyThe Chief Medical Officer

An Organisation with a Memory Department of Health (2000)

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

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.

Deaths from medicines in the UK1999 - 2000 (ICD9 & 10 data)

A spoonful of sugar - Audit Commission (2001)

So drugs are safe ………………..

Photosensitivity from Amiodarone

Severe extravasation of amiodarone infusion

NSAID or COX-2 induced peptic ulcer

Goitre – HypothyroidismSecondary to Amiodarone

Bleeding due to anticoagulation

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

Necrotising fascititis – secondary to infection at site of IV injection

Acute Liver failure from Black Cohosh - herbal medicine

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

The same error, even a minor one, can have quite different

consequences in different circumstances.

“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!

The Accident Causation Model(Adopted from Reason & Dean)

Active Failures

- Slips&lapses- Mistakes

Errorproducingconditions Accident

Defences

Latent Conditions

The Medicines Management Cycle

• What happens between a doctor seeing a patient and them receiving or taking their medicine ?

• 2 minutes discuss with neighbor

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

PharmacyPharmacyNursesNurses

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.

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

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

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

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

Aims of Pharmaceutical

Care

Effective drug therapy

Safe drug therapy

Economic drug therapy

Improve quality of life

Aims of Pharmaceutical Care

• Identify actual and potential drug related problems,

• Resolve actual drug related problems,

• Prevent potential drug related problems.

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

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?

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

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.

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.

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

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!

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.

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.

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 ?

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

Key knowledge, skills and attributes

Knowledge 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

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;

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.

2. Must ensure that their knowledge, skills and performance are of high quality, up to date, evidence based and relevant.

3. Behave with integrity– adhere to accepted standards of personal and professional

conduct

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.

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

The End

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