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Introduction to Clinical Pharmacy– a key role for pharmacists. Year 3 Peradeniya University SOP Dr Ian Coombes, Clinical senior Lecturer - School of Pharmacy.

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Presentation on theme: "Introduction to Clinical Pharmacy– a key role for pharmacists. Year 3 Peradeniya University SOP Dr Ian Coombes, Clinical senior Lecturer - School of Pharmacy."— Presentation transcript:

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 km 2 Brisbane

4 Queensland

5 Comparisons Sri Lanka ( 7 degrees N of equator )Australia (14 degrees S of equator) 66,000km27,600,000km2 (120x) 20 million people20.3 million people (=) 8.5% >65 year13.3% >65 yr (1.5 x) 3.7% GDP on healthcare9.5% 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 people3.6 hospital beds/ 1000 people New 4 year pharmacy degree4 year pharmacy degree 1000 hospital pharmacists,14,000 pharmacists, 3000 hospital Doctor order, pharmacist supplySeparation 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

18

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 ?

24

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 th 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 (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

39

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 information DistributeAdminister Monitor response Transfer information From Bates et al 1995 DOCTORS PharmacyNurses

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?

44 Comparability to Australian National Health Priority Areas In , 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 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

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. 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

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

66 Any Questions?


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