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Introduction to Clinical Pharmacy– a key role for pharmacists
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.
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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
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Background - Queensland
700 km W - E 1900km N - S 1.8Million km2 4 M people in Qld Brisbane
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Queensland Brisbane
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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
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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
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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
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Perceptions of Pharmacists
How do others see us?
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“They just count a few tablets”
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“They just weigh and measure things”
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“A bunch of shop-keepers”
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“Tell me how and when to use the Medicine”
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“Counter-prescribing”
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“Not really health care practitioners – they’re
businessmen”
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“Do you need a degree to be a pharmacist?”
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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 ………………….
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Medicines are Dangerous
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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
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Effective drug therapy
Safe drug therapy Effective drug therapy Will the patient take the therapy? Aims of Pharmaceutical Care What does the patient view as an improved quality of life? Improve quality of life Economic drug therapy
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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?
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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
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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 ?
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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)
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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
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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.
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A spoonful of sugar - Audit Commission (2001)
Deaths from medicines in the UK (ICD9 & 10 data) A spoonful of sugar - Audit Commission (2001)
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So drugs are safe ………………..
Photosensitivity from Amiodarone Severe extravasation of amiodarone infusion
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NSAID or COX-2 induced peptic ulcer
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Goitre – Hypothyroidism
Secondary to Amiodarone Bleeding due to anticoagulation
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Erythemal rash from penicillin – in patient with a previous
Known allergy/ adverse drug reaction
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Necrotising fascititis – secondary to infection at site of IV injection
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Acute Liver failure from Black Cohosh - herbal medicine
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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 So 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
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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 way 1 suffers badly. Safe Medication Practice Unit
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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
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The Accident Causation Model (Adopted from Reason & Dean)
Defences Latent Conditions Error producing conditions Active Failures - Slips&lapses - Mistakes Accident So 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 conditions See next slide. Safe Medication Practice Unit
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The Medicines Management Cycle
What happens between a doctor seeing a patient and them receiving or taking their medicine ? 2 minutes discuss with neighbor
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The Medicines Management Cycle
DOCTORS Decision to prescribe Order entry Transfer information Patient Review order Monitor response Supply medicine Administer Supply information Distribute Nurses Pharmacy From Bates et al 1995
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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.
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Where do things go wrong with medicines?
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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
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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
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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
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Effective drug therapy
Safe drug therapy Effective drug therapy Aims of Pharmaceutical Care Improve quality of life Economic drug therapy
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Aims of Pharmaceutical Care
Identify actual and potential drug related problems, Resolve actual drug related problems, Prevent potential drug related problems.
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Drug therapy assessment
Six types of problems which may result in treatment failure : Inappropriate selection of medication Inappropriate formulation of medication Inappropriate administration of drug therapy Inappropriate medication-taking behaviour Inappropriate monitoring of drug therapy Inappropriate response to drug therapy
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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?
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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
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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.
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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.
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Opportunity For Error Clinical Pharmacy Role in Reducing Risks
Admission medication history Opportunity For Error Formulary Prescribing protocols Allergy check Prospective review Administration instructions Clinical pharmacy Drug distribution system
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Opportunity For Error What if we are not there!
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!
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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.
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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.
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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 ?
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To be a drug expert society needs practitioners who ……..…
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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
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Key knowledge, skills and attributes
Takes responsibility for actions; Punctual; Caring nature; Professional behaviour; Open minded; Positive attitude; Treats patients equally; Treats information confidentially;
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Key Responsibilities 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. Must ensure that their knowledge, skills and performance are of high quality, up to date, evidence based and relevant. Behave with integrity adhere to accepted standards of personal and professional conduct
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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.
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Plan for next 6 weeks Topics: Teaching and learning methods:
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
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The Beginning The End
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Any Questions?
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