➢ Introduction to Clinical Pharmacy

➢ Concept of clinical pharmacy

➢ Functions and responsibilities of clinical pharmacist
➢ Drug therapy monitoring - medication chart review
➢ Clinical review
➢ Pharmacist intervention
➢ Ward round participation
➢ Medication history
➢ Pharmaceutical care.
Introduction to Clinical Pharmacy :
➢ Clinical pharmacy is more patient oriented health care services.
➢ Clinical pharmacy contains a set of functions that includes promoting the safe, rational
and effective use of medicines for individual patients.
➢ The clinical pharmacy practices involved specialized services which includes
pharmaceutical care of patient through complete medication history, patient profile
review, managing of adverse drug reactions, managing the drug information services and
counselling the discharge patient.
 Goal of Clinical Pharmacy:
The primary goal of clinical pharmacy is to promote the rational and
appropriate use of medicines.
These activities mainly aim at following:
• Improving the clinical effect of medicines.
• Minimizing the risk of treatment-induced adverse events.
• Minimizing the expenditures for pharmacological treatments.
Concept of clinical pharmacy :
➢ Clinical pharmacy is the growing field of pharmacy, where the clinical
pharmacists are mainly responsible for providing the services for the patient
care toward the use of medication and promote health, wellbeing and
prevention of disease.
➢ Clinical pharmacy is more patient oriented health care services. In this clinical
pharmacist associated in taking care of patient in all health care setting which
is initially began inside hospital and clinics.
➢ Clinical pharmacist often works in collaboration with physicians, physician
assistants, nurse practitioners and other healthcare professionals
Functions and responsibilities of clinical pharmacist :
Clinical pharmacists play an important role at three different levels i.e. before the
prescription, during the prescription and after writing of prescription in
promoting correct use of medicines. Following are given the key role of clinical
pharmacists at different level:
Before the Prescription:
Involved in clinical trials.
Preparation of formularies.
Drug information services.
Designing of drug-related policies.
During the Prescription:
o Involved in counselling activity.
o Involved in monitoring, detecting and preventing medication related problem.
o Clinical Pharmacist gives special attention to the dosage of drugs
which need therapeutic monitoring.
After the Prescription:
Involved in Patient Counseling.
Preparation of personalized formulation.
Involved in evaluation of use of drug.
Responsible for outcome research.
Associated in pharmacoeconomic studies.
 Functions of Clinical Pharmacist:
The principle activities of a clinical pharmacist include:

• Patient Medication History:

Patient medication history involves the collection and recording of
information past and present medications used by the patient
It is done during the patient interview and reviewing past medical records
Profile Patient Review:
In the patient profile review, the evaluation of patient and its medical chart is done by the
clinical pharmacist.
The Components of patient profile review includes the patient assessment, profile review
and medication review.
• Therapeutic Drug Monitoring (TDM):
Clinical pharmacist dealing with application of clinical
pharmacokinetic for monitoring drug efficacy and toxicities. The drugs
like gentamicin, amikacin, tobramycin, vancomycin, carbamazepine,
phenytoin, valproic acid, lithium, theophylline, cyclosporine, digoxin,
lidocaine, amitriptyline, nortriptyline and imipramine are commonly
monitored.
• Discharge Patient Counseling:
Clinical pharmacist involves in patient counseling regarding medication use at
the time of discharge.
Adverse Drug Reaction Management:
ADR management, involves the prevention, detection, management and
reporting of Adverse Drug Reactions (ADRs).
The clinical pharmacist carries out ADRs management with the help of
patient counselling, patient profile review and history of patient medication.
• Drug Information Management:
Clinical pharmacist is involved in preparation of appraisal,
collection, utilization and presentation of information relating to
drug.
Drug therapy monitoring :
➢ Monitoring of drug therapy or therapeutic drug monitoring (TDM) is a process which
involves the monitoring of the drug concentration at specific time intervals to maintain
a drug concentration in a patient's bloodstream, thereby optimizing individual dosage
regimen.
➢ TDM is mostly useful for the drugs with narrow therapeutic window, highly bound to
protein, toxic effect of metabolites and likely to interact with other drugs.
➢ Clinical pharmacist should design the patient specific drug dosage regimen to improve
the drug safety and patient outcome by considering various factors such as the
pharmacokinetic and pharmacological properties of the drugs product, rational of the
drug therapy, drug therapy in concurrent disease and other patient related factors.
➢ Measurement of drug concentration in various biological fluids such
as plasma, serum, blood or tissue to enable the monitoring of the
dosage regimen.
➢ Adjustment of dosage regimen based on the drug concentration in
biological fluid or tissue in conjugation with therapeutic responses,
sign and symptoms or other biochemical parameters.
➢ Apart from the therapeutic responses clinical pharmacist should monitor
the additional responses to the drug therapy.
➢ Maintain the records of oral and written communications with the
physician, nurses or other health practitioners regarding information of
patient specific drug therapy and health record.
Medication Chart Review
Medication chart review is the process that is conducted in systemic way
for all patients who has prescribed medicines by health care profession.
Thus, it is primary responsibility of clinical pharmacist to ensure the
correctness of medication ordering, transcribing, dispensing of
medicines, procedure and way of administration of medicines and
monitoring of medication for potential adverse effects and therapeutic
effects.
Medication chart review has been considered the activities as a starting
from activities of counselling, TDM and ADR. The main objectives of
medication chart review are to optimizing the drug therapy, improving
the health outcomes and
Reduce the medicines related problems like untreated indications,
inappropriate drug selection, drug interaction, overdose of any
medication; and any errors that may occurs while prescribing of
drug therapy and administration.
If the pharmacist found any errors or problem in medication chart
then should write annotations on the chart at appropriate place
where medication order is unclear.
➢ Clinical review :
➢ Clinical review is a systematic reviews/relevant information of all
examination done by clinical pharmacist on response and monitoring of drug
treatment and safety aspect on daily basis.
➢ The main approach of clinical review is to assess the therapeutic outcome of
the dosage regimen and its safety.
➢ It is a one of the integral parts of the medication chart review.
➢ Goals of Clinical Review:
➢ Evaluate the response and safety of drug treatment.
➢ Assess the improvement in the patient condition and the need to change in
drug therapy.
➢ Evaluate the need of therapeutic drug monitoring.
➢ Check for patient compliance to therapy.
➢ Main the good working relationship with all practitioners, other health care
staff to permit clinical review of patient, assess clinical report and for
effective communication.
➢ Identify the expert to discuss any problems and options.
MEDICATION HISTORY
➢ Patient medication history interview is a practice associated with
collection and recording of information by
reviewing/interviewing of patient related to his/her past and
present medications used.
➢ Patient medication history provides the valuable information on
the patient's allergic tendency, patient compliance and self-
medications. Such type of information of medication history
helps the pharmacist to establish with patient, commencing of
patient counselling and designing of pharmaceutical care plan.
 The goal of medication history is to acquire the information on aspects
of drug use by patients. So, such information may help pharmacist for
improvement in overall care of patient. The collected information can be
helpful to achieve following goals:
• Helps to investigate the medication discrepancies by comparing the
medication profile with the medication administration record.
• Other staff verify the collected history of patient and can provide
additional information wherever require appropriately.
• Helps to documents the allergies and drug related adverse reactions.
• Helps to evaluate rational for prescribing of drugs.
• Helps to assess indication of drug abuse.
• Helps to check the drug interactions.
• Helps to access drug administration techniques.
• Helps to examine the requirement of assistance in medication.
Importance of Accurate Medication History:

• Helps in the prevention of prescription errors and subsequent risks to the

patients.

• Helpful in finding of drug related pathology and any clinical signs

due to results of drug therapy.
• Considering all accurate medication history information, it helps to
establish better care plan for the patients.
PHARMACIST INTERVENTION :
➢ Pharmacist intervention covers wide range of medication related issues.
➢ There is necessary of pharmacist intervention to detect any problem with the medication
therapy.
➢ In patient care services, there recognizes various untreated health issues and this can be
resolved by choosing appropriate therapeutic regimen.
➢ Pharmacists follow the progress of therapeutic outcome.
➢ Pharmacist involved in the review of prescription and if needed suggest the appropriate
therapeutic regimen to improve the safety, efficacy as well as cost of medications.
➢ Method of pharmacist intervention considered has great inputs in the patient care system.
➢ In this, the pharmacist role is to reduce the medication errors, justifying the use of
therapeutic regimen in particular patient and reducing the cost of medications.
 Importance of Pharmacist Intervention:

Medication errors may cause the consequences which may

range from minor to seriousness and sometimes may require
hospitalization or death of patient. Pharmacist intervention
may reduce to this happen. Following are some objectives of
pharmacist intervention.
• To review the prescription order before dispensing of the drugs.
• To prevent the development of complication and morbidity.
• To improve the patient compliance.
• To reduce the cost and improve the effectiveness of medications .
 Ward Round Participation :Ward round is nothing but the routine
rounds by the health care provider to meet/visit the patient for normal
check up on daily basis to check the progress of health of patients.
Mostly physician is the leading person along with their team who may be
assistant, nurse and pharmacist in the ward round to observe the patient
condition and routine checkup and decide further therapeutic regimen for
their patient.
Goals and Objectives of the Ward Round Participation:
• Monitor the patient's condition and take immediate decision on medication to
improve the patient condition and avoid death.
• To check the case history of patients and accordingly change the approaches of
treatments.
• To ensure the safe and cost-effective treatment plan for the patients.
 ➢ PHARMACEUTICAL CARE
➢ Pharmaceutical care is a practice of pharmacist to contribute to
optimize the rational therapy towards improvement in the health status
of patients. The major goal and output of the pharmaceutical care are,
elimination/prevention of the disease symptoms, cure or slowing of
disease condition.
➢ Functions of Pharmaceutical Care Plan:
➢ Following are the three main functions of pharmaceutical care plan:
➢ Identification of actual and potential drug-related problems in patient.
➢ Resolve the patient's actual drug-related problems.
➢ Prevention of the patient's potential drug-related problems.
 Development of Pharmaceutical Care Plan:
Following are some steps involved in formation of pharmaceutical
care plan:
• Creation of comprehensive database for respective patient.
• Evaluate the actual and potential drug-related problems.
• Establish therapeutic goals.
• Specify the parameters for the monitoring with end points and frequency.
• Documentation of the progress of the patient health status towards
therapeutic goals.