Presentation on theme: "Introduction to Clinical Pharmacy– a key role for pharmacists"— Presentation transcript:
1 Introduction to Clinical Pharmacy– a key role for pharmacists Introduction to Clinical Pharmacy– a key role for pharmacists. Year 3 Peradeniya University SOPDr Ian Coombes,Clinical senior Lecturer - School of Pharmacy + Medicine, University of Queensland, and Senior Pharmacist, Safe Medication Practice Unit, Brisbane, AustraliaMrs Judith CoombesConjoint 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 itMedicine management and patient journeysAdverse drug events – the problemProduct versus patient focused servicesPerception of the professionDrivers for change –its development elsewhereCore practitioner skills, knowledge and attitudes,Plan for the next 6 weeks
3 Background - Queensland 700 km W - E1900kmN - S1.8Millionkm24 M peoplein QldBrisbane
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 health2 hospital beds/ 1000 people3.6 hospital beds/ 1000 peopleNew 4 year pharmacy degree4 year pharmacy degree1000 hospital pharmacists,14,000 pharmacists, 3000 hospitalDoctor order, pharmacist supplySeparation of supply from ordering
6 Judith Coombes University Queensland Pre-registration (apprenticeship year) communityDistrict hospital (Rockhampton) 700km NUK hospitals 2 years, wards and dispensaryPAH renal specialist pharmacistUK MSc (Clin Pharm) DI + research pharmacistPAH, 700 bed teaching, Drug use evaluationConjoint Lecturer U of Qld + PAH education
7 Ian Coombes University of London – wanted be in advertising! Pre-registration year - London HospitalJunior training – London HospitalWorking holiday in Brisbane, 2 hospitalsMsc in Clin Pharm, ICU, renal, cardiac jobs - UKManage Clinical Services + cardiac + PAC – PAHSafe Medication Practice UnitPhDState wide pharmacy + prescriber education
8 Perceptions of Pharmacists How do others see us?
16 Drivers for changeCompetence 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 functionInformed general public – increased expectationRealisation that ………………….
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 Effective drug therapy Safe drug therapyEffective drug therapyWill the patient take the therapy?Aims of Pharmaceutical CareWhat does the patient view as an improved quality of life?Improve quality of lifeEconomic drug therapy
21 A case44 year old lady with fever and green sputum and cough – no known previous medical history – Diagnosed with upper resp. tract infectionPrescribed:Co-Amoxiclav 1 tdsDoxycycline 100mg DPrednisolone 40mg DTheophylline 200mg bdOmeprazole 20mg DMetoclopramide 10mg tdsSalbutamol 2 puff inhale prnPharmaceutical problemsCommon organisms for URTI?Need for atypical organism ?History of asthma – risk vs benefit?History asthma – risk vs benefitNeed 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 admissionsAn estimated 850,000 adverse events a yearAdverse events cost approximately £2 billion/yrThe NHS pays £400 million clinical negligenceMedication errors accounts for around a quarter of the incidents which threaten patient safetyThe Chief Medical OfficerAn Organisation with a MemoryDepartment of Health (2000)
26 High Profile ExamplesA 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 A spoonful of sugar - Audit Commission (2001) Deaths from medicines in the UK (ICD9 & 10 data)A spoonful of sugar - Audit Commission (2001)
29 So drugs are safe ……………….. Photosensitivity from AmiodaroneSevere extravasation of amiodarone infusion
31 Goitre – Hypothyroidism Secondary to AmiodaroneBleeding 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 capacitylimited mental processing capacitynegative effects of fatigue other stressorsWe all make errors all the timeGeneralised lack of awareness that errors occurPatients suffer adverse events much more often than previously realisedErrors often NOT immediately observedSo these people – your predecessors PERCEIVED that they wouldn’t have any problems. Doctors don’t go out there, thinking that they will make mistakes.These are some of the reasons why…(points on slide - just need to raise awareness!)Safe Medication Practice Unit
36 The same error, even a minor one, can have quite different consequences in different circumstances. For every 100 errors, 90 will survive unharmed.Use speeding example… you speed along coronation drive and don’t get any problems… however occasionally you do have an accident.9 in 100 who could go either way1 suffers badly.Safe Medication Practice Unit
37 The System: Only as safe as it’s designed to be! “I assumed the brown glass ampoule was frusemide” (ICU RN after injecting 10mg adrenaline)Things still do look alike.Safe Medication Practice Unit
38 The Accident Causation Model (Adopted from Reason & Dean) DefencesLatentConditionsErrorproducingconditionsActiveFailures- Slips&lapses- MistakesAccidentSo thinking back to example (white ants)When things do go wrong, there are several contributing factors.Active failures:Don’t always blame the person who makes the error.Error producing conditions:Start thinking about what has led to the error.Go and watch how nurses administer drugs... Understand how many other factors there are that the nurses have to cope with.Latent conditionsSee next slide.Safe Medication Practice Unit
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 DOCTORSDecision toprescribeOrder entryTransferinformationPatientReview orderMonitorresponseSupply medicineAdministerSupplyinformationDistributeNursesPharmacyFrom Bates et al 1995
42 Sources of ErrorPrescribing error - selecting the wrong or inappropriate drug/dose/formulation/duration etcCommunicating those instructionsSupply error - timely; wrong drug, dose, route; expired medicines, labelling.Administration error - timing; wrong route; wrong rate/technique.Lack of user education - actions to take.
44 Comparability to Australian National Health Priority Areas In , hospital admissionsAngina: 88,500Myocardial infarction: 37,500Asthma: 49,000Diabetes: 46,000Adverse Drug Events: 140,000
45 Reducing the risk of adverse events Alwaysinclude a detailed drug history in the consultationOnlyuse drug treatment when there is a clear indicationStopdrugs that are no longer necessaryCheckdose 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 Effective drug therapy Safe drug therapyEffective drug therapyAims of Pharmaceutical CareImprove quality of lifeEconomic drug therapy
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:Inappropriate selection of medicationInappropriate formulation of medicationInappropriate administration of drug therapyInappropriate medication-taking behaviourInappropriate monitoring of drug therapyInappropriate response to drug therapy
50 Pharmaceutical care planning Process of workcollect relevant patient informationassess informationidentify problemsstate desired outcomesprioritise problemsdevelop an action plan for each problemwas 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 :- 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 Opportunity For Error Clinical Pharmacy Role in Reducing Risks Admission medication historyOpportunityFor ErrorFormularyPrescribing protocolsAllergy checkProspective reviewAdministration instructionsClinical pharmacyDrug distribution system
55 Opportunity For Error What if we are not there! FormularyPrescribing protocolsProspective reviewClinical pharmacyAdmission medication historyAllergy checkDrug distributionsystemAdapted by P.Thornton from J. Reason, 9/01OpportunityFor ErrorAdministration instructionsWhat 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 toxicityThe 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 baseChemistry,Pharmaceutics,Pharmacology,Therapeutics,Law, Ethics, Professional conduct.Skills baseProblem 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 Takes responsibility for actions;Punctual;Caring nature;Professional behaviour;Open minded;Positive attitude;Treats patients equally;Treats information confidentially;
62 Key ResponsibilitiesAct 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 careProvide information which can be understood.Must ensure that their knowledge, skills and performance are of high quality, up to date, evidence based and relevant.Behave with integrityadhere 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: Teaching and learning methods: Abbreviations,Evidence based medicineMedication history taking, confirmation, reconciliationEffective communication with other clinical staffTherapeutic – c-vasc, respiratory, renal, neurology (pain) , gastroTeaching and learning methods:Didactic, set some tasks, feedback go through in tutorials