Pharmacy and Pharmaceutical Sciences
Hospital Pharmacy
Title slide without an image
Tutorial Series
Tutorial series learning objectives
 To understand the roles of hospital pharmacists,
including in the continuum of patient care.
 To recognise the key role of hospital pharmacists
in multidisciplinary healthcare teams.
 To further develop communication and clinical
skills in preparation to undertake hospital
placements and hospital pharmacist roles.
Learning outcomes
 To increase readiness for
– Hospital placements (PEPs)
– Pharmacist internship, and
– Post-registration employment
Tutorial overview
3 x 2-hour tutorials supported by video case vignettes,
group discussions and inter-active activities
Tutorial
Topics
#1
Performing Medication Reconciliation
Providing Medicines Information
Problem solving – IV/enteral access device implications
Communicating with other health professionals
#2
Contributing to prescribing decisions
Educating patients about medications
Supporting continuum of care
Communicating with other health professionals
#3
Monitoring drug therapy
Problem solving IV/enteral access device implications
Communicating with other health professionals
Assessment
 2-hour Objective Structured Clinical Examination (OSCE) during
the official examination period
 40% of unit mark
 Five-station OSCE covering:
– Medication reconciliation
– Communication
– Medicines information
– Extemporaneous preparation
– Documenting information on Medication chart
 Will test application of clinical and practical knowledge, and
communication skills
 Practice OSCE in the last tutorial (# 4)
Hospital tutorial # 1
 Specific learning objectives:
– To understand the process of medication reconciliation
• Taking medication histories
• Reviewing in-patient medication charts/medical records
• Documenting information on medication charts
– To understand the implications of IV/enteral access
devices on medicine administration
– To understand how to provide evidence-based
medicines information to patients and other health
professionals
– To understand how to communicate with other health
professionals and optimise medicine use and safety
Learning outcomes
 At the end of this tutorial you should be able to:
– perform medication reconciliation in a hospital setting
• take a medication history
• review a medication chart and locate information in
medical records
• record information on patient’s medication charts
– identify medication administration issues with IV/enteral
devices
– understand the pharmacist’s role in contributing to
quality use of medicines in multidisciplinary teams
Clinical
Pharmacy
Medication
Reconciliation
Patient’s hospital journey
• Emergency Department (ED), or
• Elective or ‘planned’ admission (often via preArrival
‘Admission’’ admission clinic)
• On a ward (e.g. cardiology, surgical, medical)
• +/- need for Intensive Care Unit stay
Inpatient • +/- visits/transfers to other areas/units (e.g. physiotherapy, rehabilitation)
stay
Leaving
‘Discharge’
• Home, usually with discharge medicines
dispensed in hospital pharmacy
Medication Reconciliation
 Transition points of admission or entry, discharge or exit, and transfer
between units are ‘weak links’ in the health care chain
 Medication Reconciliation process aims to:
– address communication breakdowns and system vulnerabilities at
these ‘weak links’
 Medication Reconciliation is:
– A formal, standardised process for compiling, recording and
sharing medication data between and among care providers and
the patient
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Medication Reconciliation
 Aims to:
– Prevent medicine-related safety issues
• e.g. inadvertent omission of regular medicines taken prior to
hospital admission
– Ensure Quality and Safe Use of Medicines as patients
transition between the community and hospital
• e.g. opportunity to review whether all medications are still
needed and doses are optimised
– Improve healthcare of patients
• e.g. ensure that changes made to the medication regimen in
hospital are appropriate
Medication reconciliation is a 3-step process:
1. Obtain medication history
- review multiple sources of information
2. Review medication charts
- compare medication history, medical record and medication chart
3. Resolve discrepancies through review of medical record
and discussion with healthcare team
- document in the patient’s medical record
Medication Reconciliation: On Admission
The process of comparing the patient’s pre-admission medicines
to those prescribed on the hospital medication chart
Medicine Reconciliation: On Discharge
The process of
comparing the patient’s
medication chart….
….with the discharge
prescription
Activity: 5 mins
• Getting to know some different hospital
forms (medical records) commonly used in
hospitals
– Familiarise yourself with the charts and forms in the
folder
– Consider what a pharmacist would write, and where
Medication Reconciliation is a 3-step process:
1. Obtain medication history
2. Review medication charts and medical record
3. Identify and reconcile discrepancies between the
medication history and medication chart
- discuss with healthcare team
- document in the patient’s medical record
Medication History Taking
 Pharmacists have in-depth medication knowledge, and
are trained to take more accurate and comprehensive
medication histories than other health care professionals
 Preferably within one day following admission
 Preferably face-face interview
 Other sources as appropriate
Scenario 1:
 A 66-year-old male in Emergency Department (ED) complaining of leftsided stroke symptoms
 The ED pharmacist begins the medicine reconciliation process to find
out what the patient was taking before coming into hospital
Play video
Medication History Interview
 Activity:
– Discuss strategies to use if the patient is unavailable or unable to
be interviewed? (5 minutes)
– Each group can offer suggestions in turn until all ideas are
exhausted
Medication History Interview
 If patient is unavailable for interview…
- Patient’s own medicine list
- Patient’s own medicine labels
- Carer/other family members
- Community pharmacy records
- Other healthcare professionals
- Webster packs/ Dosette boxes
- GP letter
- Hospital records from previous
admission/discharge
• Use at least two sources of information
for all medication histories
Medication History Interview
 Group Activity:
– Perform a medication history interview (15 mins)
– Form 5 groups
– In each group one student will role play patient, another one will
be the pharmacist and others will be observers
– Patient/Observers to provide feedback to the pharmacist at the
end of the interview
Medicine Reconciliation is a
3-step process:
1.
obtain medication history
2.
review medication charts and medical record
3.
Identify and reconcile discrepancies between the medication
history and medication chart
- discuss with healthcare team
- document in the patient’s medical record
Inpatient Medication Chart
 Important, yet complex multipage document
 Provides information on:
–
–
–
–
–
Patient’s demographics including
age and possibly weight
All medicines prescribed by the
hospital doctors
Administration times of medicines by
nursing staff, and their initials
Reasons for medicine nonadministration
Allergies
 Used by many members of the
health care team, including
pharmacists
Inpatient Medication Chart
 Pharmacist’s role:
– Daily (Mon-Fri) review to ensure correct medicines are
prescribed (reconcile medication history information with
medication chart)
– Consider appropriateness of prescribed drugs
– Check doses, administration routes and timing, drug-drug and
drug-disease interactions
Play video
Medication Reconciliation is a 3-step process:
1.
Obtain medication history
2.
Review medication charts and medical record
3.
Identify and reconcile discrepancies between the medication
history and medication chart
- discuss with healthcare team
- document in the patient’s medical record
Use of Medical Records
 Access them for comprehensive patient information
AND
 Document Medication Reconciliation activities in
them
– If no discrepancies identified, eg:
 All meds prescribed correctly
OR
– If discrepancies identified and action taken, eg:
 Regular meds omitted - Xalatan eye drops 1 bd
 Contacted [resident] & recommended to prescribe Xalatan
 Annotate with your name, signature, profession (‘pharmacy’) and
contact details such as a pager number
Medicines
Information
Medicines Information:
Role of Clinical Pharmacists
 Steps in providing medicines information:
– Determine primary question and required timeframe for response
– Develop search strategy
– Access relevant information
– Critically appraise information
– Respond within agreed timeframe
Access relevant information
 Which references to use and when?
– Standard Texts:
• dosing, indications, drug interactions, compatibility, common
ADRs
– Literature search:
• investigational drugs, off-label use for marketed drugs, rare
ADRs
– Time may be limited on the wards
• May need to enlist assistance from Medicines
Information Centre/Pharmacist
Play Video
Activity: 15 mins
 You are reviewing a medication chart for Mr
John Brown on your ward.
 The nurse asks for your advice about how to
give the regimen via a nasogastric tube.
– Diltiazem CD 240mg capsule
– Asasantin capsules (Aspirin 25 mg tablet
inside a capsule containing 200 mg SR
dipyridamole beads)
– MS Contin (morphine SR) tablets 30 mg
– Efexor XR (venlafaxine) capsules
– Omeprazole 20mg tablet
Activity: 15 mins
– Form 5 groups
– Access the relevant information and formulate a response
– For medications that can be given as prescribed, endorse the
orders so as to ensure the doses are given correctly
– For medication orders that need to be changed, determine what
you would recommend the doctor prescribe so that the regimen
can be given via the NG tube
– In each group one student will role play nurse, another one will be
the pharmacist and others will be observers
– Nurse/Observers to provide feedback to the pharmacist at the end
of the medicines information session
35
Answers
– None of them should be crushed to administer via the NG tube
• Diltiazem CD, MS Contin (morphine SR), Efexor XR (venlafaxine)
capsules and Asasantin capsules are slow release products.
– Diltiazem should be switched to 60mg tablets and given ‘qid’
– MS Contin could be switched to morphine solution (and given 4
hourly) or MS Contin granules could be used, as long as they were not
crushed.
– Efexor capsules can be opened and the beads can be administered
down the NG tube, but might stick to plastic tube. The beads should
not be crushed. Preferable to switch to alternative SSRI or with-hold in
the short-term.
36
Answers (contd)
– Asasantin capsules can be opened and the 25mg aspirin tablet
crushed and the granules carefully mixed with water, but not crushed,
then administered down the tube. Alternatively, aspirin could be given
as a dispersible tablet, then the standard release dipyridamole tablets
can be crushed and made into a slurry. In this case an equivalent
daily dose would need to be administered four times daily.
– Omeprazole should not be crushed due to the enteric coating. The
tablets (not capsules) can be dispersed in water, but not crushed.
– Remember to use oral syringes, not intravenous syringes, to deliver
the medications via the tube.
37
Play Video
Compulsory Homework:
National Inpatient Medication Chart online training course
 Go to:
http://nps.lamsinternational.com/moodle/course/category.p
hp?id=40
 Takes 1.5 - 2 hours
 Print a record of your course completion certificate
and scores
 Bring completion certificate to Tutorial 2 or 3
References
 SHPA Standards of Practice for Clinical Pharmacy
 Clinical Skills for Pharmacists, A Patient-Focused Approach
(Tietze, J, ed 3)
 Pharmacy Practice Experiences – A Students Handbook
(Setlak, P)
 Hospital Pharmacy (Stephens, M ed 2)
 Medication Review: A Process Guide for Pharmacists (Chen,
T et al, ed 2)
 Australian Medicines Information Training Workbook (ed 1)