PMY7032
Pharmaceutical
care
Part 1:
A patient-centred approach
SCHOOL OF PHARMACY
QUEEN’S UNIVERSITY BELFAST
Authors
Ms Jayne Agnew
Ms Anita Hogg
Professor Michael Scott
Reviewers
Course Management Team
Disclaimer
While every precaution has been taken in the preparation of these materials, neither Queen’s
University Belfast nor external contributors shall have any liability to any person or entity with respect
to liability, loss or damage caused or alleged to be caused directly or indirectly by the information
contained therein.
© Queen’s University Belfast 2012
Distance Learning Centre
School of Pharmacy
Queen’s University Belfast
(028) 9097 2004
http://www.qub.ac.uk/pha/
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Introduction
This module consists of 2 parts:
Part 1: A patient-centred approach
Part 2: Communicating information
The module is designed to be completed over 10 weeks
Part 1 is completed during weeks 1 – 7.
The workbook that accompanies Part 1 of this course contains a number of exercises that you will
complete in your hospital; you should discuss these with your Local Mentor in your regular meetings
and plan your ward-based activities so that you can identify suitable patients where necessary.
As you visit the wards in your hospital, collect samples of blank medication and monitoring charts and
ensure that you are familiar with the information that they contain. You should also take time to
examine the charts in use and ask your Local Mentor if there is anything that you do not understand
about the charts.
The information that is recorded on the charts will be explored in more detail as you progress through
the module.
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Table of contents
Page
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Section 1: What is pharmaceutical care?
5
Section 2: The patient journey
14
Section 3: Pharmaceutical interventions
44
Appendix 1: Medical abbreviations
55
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Section 1:
What is pharmaceutical care?
Learning outcomes
On completion of this section, you will be able to:
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Define and discuss the concepts of pharmaceutical care and medicines management
Describe deficiencies in the medicines management process
Discuss the concept of quality healthcare
Describe a model for management of patient outcomes
Topics
This section includes the following topics:
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Pharmaceutical care
Medicines management
Quality healthcare
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Pharmaceutical care
Hepler and Strand (1990) defined pharmaceutical care as:
“The responsible provision of drug therapy for the purpose of achieving
definite outcomes that improve a patient’s quality of life.”
This concept has been adopted internationally, for example, the
Pharmaceutical Society of New Zealand named their system ‘Comprehensive
Pharmaceutical Care’ (CPC). They adopted the American Pharmaceutical
Association (APA) definition of pharmaceutical care:
“A patient-centred, outcomes-orientated pharmacy practice that requires the
pharmacist to work in concert with the patient and the patient’s other health
care providers to promote health, prevent disease and to assess, monitor,
initiate and modify medication use to ensure that drug therapy regimens are
safe and effective.”
Less than optimal outcomes can result from inappropriate drug selection,
delivery, response, monitoring and/or usage.
Pharmaceutical care has emerged as a potential tool for reducing healthcare
costs by improving patient outcomes.
Healthcare is seen as a triad of structure, process and outcome, with the gap
between process and outcome being critical in the evaluation of the quality of
pharmaceutical care. Healthcare professionals must examine all three parts
of this triad to ensure that optimal care is provided.
1. Structure of care
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System characteristics (organisation, workload, access)
Provider characteristics (age, gender, training, preferences, attitudes)
Patient characteristics (age, gender, condition, severity , preferences,
attitudes)
2. Process of care
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What is actually done in giving and receiving care
Technical style (visits, referrals, test, ordering, continuity of care)
Interpersonal style (manner, counselling, communication)
3. Outcome
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Clinical end-points (symptoms and signs, laboratory values, death)
Functional status (physical, mental, social)
General well-being
Satisfaction with care
In the medical situation, a doctor can measure outcomes in terms of health
gain for a patient. It is this final stage that pharmacists have generally not
been able to do, as they do not examine patients and have no way of
knowing if the patient’s health has improved due to the action of the
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pharmacist. For this reason a modified framework was put forward by
Donabedian (RPSGB, 1992) comprising:
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Structure
Process
Output
Outcome
There may be occasions when outcome can be measured, but for the most
part a pharmacist may have to stop at the output stage in the hope that an
improved output will lead to an improved outcome. For example, in
counselling a patient on the use of medicines, the output may be improved
counselling skills while the anticipated outcome will be a patient who is better
informed.
Hepler and Strand (1990) described certain patient-orientated outcomes for
pharmaceutical care. They include:
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Curing a disease
Eliminating or reducing patient’s symptoms
Slowing or halting the disease process
Preventing a disease or symptoms
Strand et al (1991) stated three methods by which a pharmacist may achieve
these outcomes, namely:
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Identifying potential and actual drug-related problems
Resolving actual drug related problems
Preventing drug-related problems
In essence it can be seen that pharmaceutical care is fundamentally about
the safe and effective use of medicines and all of the different elements that
are necessary to achieve this goal.
In many countries, including the UK, the term “Medicines Management” has
become a synonym for pharmaceutical care and this term will be used in the
next section.
Medicines management
Pharmacy is the healthcare profession that has the responsibility for the safe,
effective and rational use of medicines. Current healthcare systems face
great challenges due to increasing numbers of adverse events, poor
adherence, increasing numbers of medication incidents and inadequate
communication across the primary/secondary interface. Furthermore,
expenditure on drugs is the second largest cost in healthcare.
The NHS plan set out the challenge to pharmacy (in the document
“Pharmacy in the Future - Implementing the NHS Plan”) to meet the changing
needs of patients. To do this, pharmacy needs to ensure that patients can get
medicines or pharmaceutical advice early, that patients get more support in
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using their medicines, and give patients the confidence that they are getting
good advice when they consult a pharmacist.
Medicines management is not a new concept. It has been defined by the
Audit Commission as:
“Encompassing the entire way that medicines are selected, procured
delivered, prescribed, administered and reviewed to optimise the contribution
that medicines make to producing informed and desired outcomes of patient
care.”
It encompasses all aspects of medicine use, from the prescribing of
medicines through the ways in which medicines are, or are not, taken by
patients.
Medicines management involves the systematic provision of medicines
therapy through a partnership of effort between patients and professionals to
deliver the best outcomes at minimal cost. The quality of use of medicines is
a key factor in achieving positive health outcomes.
Deficiencies in the medicines management process
Lack of compliance with prescribed therapy
It has been reported that up to half of all patients with long-term conditions
use their medicine in a way that is not fully effective. Poor patient compliance
with medication (for various reasons) has been recognised as a major
problem in achieving maximum benefit for patients from their prescribed
therapy.
This has significant cost implications, for example, Johnson and Bookman
(1995) estimated that $77billion of United States healthcare costs were due
to people not taking medicines as directed.
Morbidity and morality
One of the most overlooked elements in the process of
management is the appropriateness of the medicines
Inappropriate use of medicine may result from problems with
monitoring or drug administration issues. The magnitude of
related problems is significant both clinically and financially.
medication
prescribed.
prescribing,
these drug
The problem is particularly pertinent among the elderly population where the
instance of inappropriate use has been reported as ranging from 7.9% to
23.5%, hence there is clearly increased morbidity due to medicines being
used inappropriately.
Wastage of Medicines
In one Health Authority alone in the West Midlands, four tonnes of unused
patient medication were destroyed in a single year.
Medication Errors
Medication errors have been estimated to cost the NHS approximately
£500million per year in additional days spent in hospital and, worldwide,
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these account for almost 25% of all patient safety issues. Further, the Audit
Commission report “A Spoonful of Sugar” suggested that medication errors
account for about 20% of the deaths due to all types of adverse events in
hospitals.
Adverse Drug Reactions
World-wide, 3-6% of all hospital admissions are attributed to medicines. For
psychiatric patients, the figure is 12% and for the elderly can be as high as
28%. Whilst in hospital, 6-17% of all patients experience adverse drug
reactions.
Further “An Organisation with a Memory”, a report by an expert group on
learning from adverse events in the NHS, on behalf of the Department of
Health, suggested that every year nearly 10,000 people are reported to have
experienced adverse events related to medicines. In addition, in NHS
hospitals alone, adverse events in which harm is caused to patients occur in
around 10% of admissions, costing an estimated £2 billion per year in
hospital stays alone.
In response to this, the Government set a target to reduce by 90% the
number of serious errors in the use of prescribed drugs by 2005. The Clinical
Pharmacy Review stated that rational, safe and cost-effective therapy relies
on competent diagnosis and prescribing, effective evaluation of drug therapy
and patient understanding and compliance in relation to the prescribed
medication. Clinical pharmacists contribute significantly to each of these,
ensuring the quality and effectiveness of medicine use.
Primary/Secondary Care Interface Issues
Good communication by Clinical Pharmacists with clinical colleagues in both
sectors is an essential part of practice. Pharmacists have roles both as team
members and as individual practitioners, ensuring that patients benefit from
pharmaceutical care. It is recognised that communication between hospital
and the General Practitioner (GP) is essential for the continuity of care for the
patient being transferred from hospital care into the community and viceversa. Effective systems to identify and address any medication issues
occurring at admission and discharge are central to an integrated medicines
management approach. Admissions data informs diagnostic and therapeutic
decisions, whilst the discharge process must ensure effective communication
of information to the patient’s carers, GP and community pharmacist.
Continuity of pharmaceutical care can also be improved by hospital and
community pharmacists working together, as community pharmacists hold a
wealth of information about patient medication and concordance, but have
remained largely an untapped resource.
National Service Frameworks (NSF)
A number of NSFs have been published in the UK, for example, relating to
coronary heart disease, children and older people. All of these framework
documents include the requirement for appropriate medicines management.
In the case of the NSF for older people, there is clearly a significant
requirement for pharmacy input with regard to medicines management, as
emphasised by the following statements:
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“Four in five people over the age of 75 take at least one prescribed
medication, 36% take four or more medications”
“As many as 50% of older people do not take their medicines as intended.”
In addition, the frameworks deal with competencies, for example, with
respect to children there is a specific requirement for pharmacists to be a
member of the College of Pharmacy Practice Faculty of Neo-Natal and
Paediatric Pharmacy, emphasising the critical nature of medicines
management in children.
Medicines management in context
The UK Department of Health’s “Management of Medicines” report (2004)
summarised the key components of medicines management:
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Involving patients in the choice of treatment, respecting their views
and priorities and enabling them to take a more active role in selfmanagement
Deciding whether a medicine is needed
Selecting appropriate treatment
Providing patient-centred information
Monitoring for benefits and safety
Reviewing effectiveness of treatment
Deciding when to stop treatment
Identifying under-treated as well as over-treated
Reducing medicines wastage
Using non-pharmacological options where possible, including health
promotion advice
Developing patient-friendly ordering and collection systems
Promoting better communication between prescribers, patients,
carers and other health professionals
Making the best use of medicines – evidence based formularies and
guidelines; generic prescribing; synchronisation of quantities;
medicines no longer needed; optimisation of doses
Identifying further areas of investment in treatments to produce
improved health outcomes
Improving repeat prescribing systems
Using professionals appropriately
Managing demand.
Medicines Management is only one component of the patient care pathway
and the patient’s life, as illustrated in Figure 1, below:
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Figure 1: Medicine-taking in context
(From: ‘Management of Medicines’, Department of Health, 2004)
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Quality healthcare
The USA Office of Technology Assessment has defined quality healthcare as
being:
“The degree to which the process of care increases the probability of
outcomes desired by patients and reduces the probability of
undesired outcomes given the current state of knowledge.”
(Angaran 1991)
The desired outcomes it provides include:
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Health promotion and disease prevention
Optimal improvement in the patient’s health
Timely care
Accepted scientific principles
Informed patient co-operation and participation in the care process and
decisions
Sensitivity and concern for the patient’s welfare
Sufficient documentation to allow the continuity of care and peer
evaluation
Effective use of technology.
During the quality healthcare process it is important to realise that the
patient’s requirements will be patient specific and will change with time and
these changes should be recognised and quality care carried out accordingly.
Quality of life assessments have become popular due to the expansion of
patients’ expectations of the healthcare system, with patients now demanding
the right to have a say in their own medication choice.
The model on the next page describes the process for managing patient
outcomes in order to realise a positive contribution to health status and
quality of life.
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Model for the management of patient outcomes (Gouveia et al, 1991)
1. Patient presentation
2. History and physical examination
3. Diagnostic tests
4. Problem list developed/prioritised
5. Goals and treatment developed for each problem
5a. No intervention
6. Therapeutic plan and end points determined considering:
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Potential benefits
Safety
Relative effectiveness
Cost
7. Implementation and monitoring
7a. Non-compliance
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Adverse therapy
Therapy failure
Cost problem
8. Endpoint of therapy achieved
Physical / biological measures corrected or returned to normal
9. Positive contributions to:
 Health status – Functional status
General well-being
Patient satisfaction
 Quality of life
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Section 2:
The patient journey
Learning outcomes
On completion of this section, you will be able to:
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Discuss the concept of pharmaceutical care in relation to all aspects of the
patient journey through secondary care
Explain how in-patients are monitored throughout their stay in hospital
Make effective progress notes
Explain the concepts of compliance and concordance
Undertake effective discharge planning
Discuss the implementation of an Integrated Medicines Management service
Topics
This section includes the following topics:
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Admission
In-patient monitoring
Discharge
Pharmacist-led clinics
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1. Admission
Interface communication
The management of medicines stretches across the hospital/community
interface, becoming seamless and encompassing some or all of the following:
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Assessing and meeting pharmaceutical needs
Improving communication
Providing information
Seamless care is concerned with the transfer of patients between primary
and secondary care without loss of continuity. Specific services may vary
depending upon the drug related needs of the patient; however,
communication about the care actually delivered remains the most important
aspect of pharmaceutical care at the interface.
In 1993, the Royal Pharmaceutical Society of Great Britain’s Hospital
Pharmacist Group produced an admission and discharge checklist; one part
was produced for community pharmacists to provide to hospital pharmacists
when patients with special pharmaceutical needs are admitted to hospital,
and another part for hospital pharmacists to use when patients are
discharged. The committee identified the elderly, mentally ill and those with
comprehensive medication needs, i.e. parenteral nutrition, dialysis and cystic
fibrosis as patient groups for whom this will be important.
Details in the checklist included medication history and changes made,
allergies and adverse drug reactions, compliance and other specific
problems.
Medication history taking
On admission to hospital, a medication history aims to provide a
comprehensive and thorough review of medication that a patient has been
taking prior to and at the time of admission. An accurate medication history is
essential to alert prescribers to inappropriate therapies and adverse drug
reactions (ADRs) and to influence drug therapy decisions. The medication
history can prevent the reintroduction of a previously ineffective drug, saving
considerable time in achieving optimal drug use. It is also necessary to obtain
a full and accurate drug history on admission to ensure that all drug changes
can be recorded at discharge. If a medicine is both omitted at admission and
subsequently from the discharge prescription, general practitioners can be
led to believe that therapy has been discontinued during the hospital stay.
Failure to be notified of errors occurring in this way may well have serious
consequences for patients.
Medication histories are traditionally compiled by the admitting doctor from an
interview with the patient, previous medical notes and the GP letter of
admission. However, for a variety of reasons, this process may be
incomplete, for example:
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Most junior doctors lack experience of the wide variety of drugs
available, their side-effects and uses
The average patient is unable to recall drug names and doses
correctly and may only be able to offer a physical description of the
drug, which would be unfamiliar to a doctor
Medication may be brought into hospital in bottles labelled for
another drug in unlabelled strips of drugs or with non-specific
information
Many patients are reluctant to admit to a doctor that they have not
taken the drugs as prescribed, i.e. missed or indeed increased doses
Patients do not offer information on their use of over-the-counter
(OTC) medication along with prescribed medication.
Since the 1970s, there have been numerous studies to show that
pharmacists prepare a more accurate drug history than medical or nursing
staff and can obtain additional clinically significant information from the
interview. The clinical pharmacist can provide more than a gathering of
information on allergies and medications by using their skills to advise on:
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Previous medication that could interfere, interact or alter new drug
therapy
Admission due to drug use before or at the time of admission
Effects of drug-related problems, e.g. a side effect or inability to
swallow, on patient compliance
Significance of OTC, herbal or alternative therapies taken at home.
In addition, pharmacist drug histories improve the process of discharge
counselling from a personal knowledge of the patient and their medicines
management.
In 1998, a study at Antrim Area Hospital (in Northern Ireland) showed that in
109 medical patients, 60.5% were found to have a discrepancy in their
admission medication history when the clinical pharmacist repeated the drug
history after liaison with both the GP and the community pharmacist. Further,
a study in 2004 revealed that in a trial involving a hospital-based community
liaison pharmacist, problems were identified in 80% of the intervention
patients’ prescription charts, 49% of which related to drug omissions from
their admission history. The GP practice record was found to be the most
accurate source, whereas the GP referral letter was the least accurate source
of information. Drugs that patients brought into hospital were also an
inaccurate source. Clearly, there is an important role to be carried out by
clinical pharmacists at this point in the patient journey. Indeed, the NSF for
Older People requires that hospitals put in place systems for medication
review on admission to identify medicines-related problems.
You will learn more about the communication skills required for taking a
medication history and you will have an opportunity to practice this activity in
Part 2 of this module.
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Patients’ Own Drugs (PODs)
In the UK, patients take some £90million worth of GP prescribed medicines
with them into hospital each year, many of these medicines are not returned
when the patient is discharged. Thus, there is significant scope for
improvement in this aspect of medicines management.
The use of PODs is an important step in the removal of barriers that exist
between primary and secondary care and the use of POD schemes is an
essential component of promoting continuity of pharmaceutical care across
the primary/secondary care interface.
The benefits of the re-use of PODs have been summarised as follows (Dua
2000):
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Patient’s treatment is not interrupted when admitted to hospital
Patients can continue with their familiar medicines during their
inpatient stay and on discharge
Medication is available to aid in the taking of medication histories
Patients are less likely to be confused by brand changes
Therapy is not duplicated because hospitals do not re-supply
medicines when the patient already has a longer supply from the GP
Stopping the needless disposal of medicines brought into hospitals
that are still appropriate to the patient’s therapy
Discontinued and poor quality medicines, e.g. inappropriately stored
or expired medicines are taken from the patient, thereby removing
the risks associated with these drugs being inadvertently restarted by
the patient without the knowledge of doctors, pharmacists, etc.
Minimises the number of items to be dispensed on discharge.
An important aspect of the operation of a POD scheme is the development of
a robust POD assessment system. This aims to ensure the quality of PODs
by the implementation of an agreed procedure. Once the assessment has
been carried out, a signed consent is then obtained from the patient for the
use or destruction as appropriate of his or her own medicines.
The Audit Commission stated that medication should only be designated
unsuitable for re-use if:
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There is insufficient quality
The dosage is changed
The medicine is stopped
Use-by dates have expired
Tablets in the container are mixed
There is evidence of physical deterioration
The medicine is inadequately labelled
The container has no label or batch number.
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2. In-patient monitoring
At ward level, or during the in-patient stay phase of the patient journey, the
clinical pharmacist will carry out a range of activities as detailed below:
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Drug formulary advice
Prescription monitoring
Patient counselling
Advice on optimal drug treatment by taking therapeutic and toxic
effects of drugs, and pharmacokinetics into account
Advice on the most appropriate product and dose
Advice on adverse drug reactions
Monitoring of therapy, to include interactions and patient response to
treatment
Identification of “at risk” patients who may require more intensive
monitoring.
In monitoring patient progress and advising medical and nursing staff, the
clinical pharmacist relies extensively on information derived from a variety of
sources. These include, for example, patients’ medical notes, nursing care
notes, fluid balance and medication charts. These information sources often
contain a great deal of data, some of which may have been gathered over
several hospital admissions. Clinical pharmacists are normally allowed
unrestricted access to these sources and, in order to provide optimal patient
care, it is important that they are familiar with their structure and the types of
information contained therein.
The clinical record
The clinical record is composed of all the various notes and records relating
to the patient; the record will come from a variety of sources, not only the
medical notes. For example, in addition to the patient’s medical record,
nursing notes will be kept at the nurses’ station and fluid balance charts and
medication records may be kept by the patient's bed. It is, therefore,
important to be aware of the extent of the clinical record and how it is
organised. In addition, the clinical pharmacist needs to be familiar with the
interpretation of the commonly used medical terminology and abbreviations.
The common medical abbreviations are provided in Appendix 1, you may
need to refer to them when reading medical notes.
Medical notes
1. Admission notes
If the patient is admitted via the Accident and Emergency (A&E) department,
then a summary of this examination is the first information seen by ward staff.
This contains patient details in addition to the reasons for admission, results
of tests performed as part of the examination (e.g. chest X-ray, peak flow
measurements) and a preliminary diagnosis.
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Upon admission to the ward, the admitting medical doctor will record the
following information as the admission note:
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the patient’s identification details
the patient’s age, sex, weight, etc.
symptoms requiring admission
previous medical history
medication taken at home
history and physical examination
differential diagnosis and/or diagnosis of present complaint
treatment plan.
2. Daily progress notes
The admission section is usually followed by notes on the patient's progress,
1
written at least daily by a Foundation doctor . Other healthcare professionals
(dieticians, physiotherapists, social workers etc.) may also record information
in this section.
The purposes of the progress notes are:
1. To improve communication among all those caring for the patient.
2. To display the assessment, problems and plans in an organized format to
facilitate the care of the patient and for use in record review and quality
control.
The progress note should express the following:
a) Are there any changes in the patient’s symptoms and complaints?
b) What is the current physical exam, are there any changes from previous
notes?
c) Report on new laboratory results and results of studies.
d) The current plan for the patient.
The content of the progress note may be described using the mnemonic
SOAP:
S - subjective data
O - objective data
A - assessment
P - plan
1 In the UK, following graduation from medical school, doctors undertake the Foundation
Programme, a 2-year, postgraduate medical training programme. They are called Foundation doctors.
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S. Subjective data
Presents a subjective assessment of the patient’s progress, for example:
Patient still has productive cough (small
amounts brown sputum) with fever + chills. No
report of headache or diarrhoea
O. Objective data
This is a record of the physical examination and includes the specific
objective and reproducible findings gathered by:
1.
2.
3.
4.
Observation of the patient
Physical examination
Laboratory results
Radiology reports
A. Assessment
This is a report on the progress for each problem, for example:
Patient still spiking temperatures with
ampicillin, symptoms unimproved.
P: Plan
This describes the plans for the care and management of each problem.
What will be done to treat the patient? It may include one or all of the
following:
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A plan for collecting further information, e.g., blood tests or X-rays.
A plan for treatment with specific procedures or medications.
A plan for educating the patient
Referral and / or consultations
Plan for follow up.
For example:
Patient to continue ampicillin, WBC ?, repeat
CXR today.
3. Results & Reports
The medical notes will contain a variety of test results and reports, for
example, haematology, biochemistry and bacteriology results or reports
relating to other diagnostic procedures such as radiology and endoscopy.
Hard copies of test results are not always available until one or two days after
the sample has been taken, however, many results may be obtained via the
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laboratory computer system on the day the sample was taken. Sometimes
laboratory results will be telephoned through to the ward when it is important
to know the result quickly. Laboratory tests will not necessarily be performed
every day, the frequency depends on the patient’s clinical condition and the
course of the disease.
Clinical laboratory tests will be covered in more detail in a later module.
Nursing notes
Nursing notes are a particularly useful source of information and are normally
found at the Nurses’ Station or Office. They contain similar data to that
recorded in the admission notes but it is often in an abbreviated form.
Headings used include:
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Reason for admission
Diagnosis
Care plan
Daily progress
Body weight
Dietary information
Additional notes and charts
Not all information is recorded in the nursing and medical notes. Additional
data includes:
Medication chart (Kardex®)
®
Located either in a Kardex system or kept by the patient's bed, medication
charts are invaluable, not only in relation to the medication that patients take,
but also with respect to the accuracy of administration. The section for prn
medications indicates the extent of their usage and can indicate if a patient
should be receiving their medication on a continuing basis (e.g. analgesic
therapy).
Medication charts normally contain the following sections:
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Regular parenteral drugs
Regular other drugs (oral, topical, rectal etc.)
PRN (when required) drugs
Single administration drugs
Fluid balance chart
These are used for patients receiving IV fluids (such as in surgery) or when
fluid restriction is important such as in congestive heart failure. Typical data
contained in this chart relates to the timing and volume of fluid administered
either parenterally or orally, and estimates of output such as urine,
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nasogastric aspirate, output from drains, vomitus and faeces. Total input and
output volumes are usually calculated for a 24 hr period.
Temperature and other vital signs chart
These charts record blood pressure, pulse and temperature and may also
contain information on the respiratory rate, oxygen saturation, bowel
movements, and summaries of fluid balance and body weight. Often body
weights are omitted, although this may reflect practical difficulties in
mobilising patients who are non-ambulatory.
Indicators of lung function
The most convenient indicator of lung function is peak flow measurements.
These are usually recorded morning and evening and, in each case,
repeated 20 minutes after administration. Accuracy of this test is technique
dependent and it is often worthwhile teaching patients how to use a peak flow
meter. In addition, the availability of extensive pulmonary function tests gives
a much more accurate diagnosis in addition to prognostic indicators.
Blood glucose/urine chart for diabetic patients
Usually kept in a chart at the patient's bed, this record provides a useful
means of monitoring glucose control and the use of insulin.
Anticoagulant therapy
Usually kept in a chart at the patient's bed, this provides a record of INR
against warfarin dose for patients who are being warfarinised.
Learning Activity:
As you visit the wards in your hospital, collect samples of blank medication
and monitoring charts and ensure that you are familiar with the information
that they contain. You should also take time to examine the charts in use and
ask your Local Mentor if there is anything that you do not understand about
the charts.
Pharmacist notes
In recent years it has become common practice for clinical pharmacists in the
UK to write in the patients' notes. If it is not practice in your hospital, it is
advisable to obtain the consent of consultant medical staff and the Director of
Pharmacy before writing in the medical notes. Some hospitals have preprinted consultation forms that may be completed by the pharmacist and
inserted into the medical record, for example, therapeutic drug monitoring or
TPN formulation pro-forma.
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Guidelines for writing in the medical notes:
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Write the date and time of making the note
Use the SOAP format
Make sure you use abbreviations appropriately
Always remember the notes are a legal document, the patient or a
legal representative may request to see them
Place your note immediately after the last note so that chronological
order is retained
Cross out a mistake with a single horizontal line and initial it; staff
must be able to read what was written and who crossed out the word
or sentence.
Always sign your note and print your name, status and extension /
bleep number.
Writing a SOAP note
In the same fashion as mentioned previously in relation to progress notes,
pharmacists should use the SOAP format:
S. Subjective data
Information based on your opinion or interpretation. It may be something that
the patient has told you, for example, relating to their medication history.
O. Objective data
Information based on fact, for example, a laboratory result or information from
the drug administration record.
A. Assessment
Your assessment of the problem as it relates to drug therapy.
P. Plan
Your recommendation, including specifics on the drug (dose, route,
frequency, interactions) and, if necessary, monitoring for efficacy and toxicity.
An example of a pharmacist’s note might be:
18 August 2011 10.35 am
Pharmacist note:
Patient complains of leg cramps. States that she
“ran out of potassium tablets 2 weeks ago”.
Potassium tablets not prescribed on drug chart
although currently receiving furosemide 40mg OM.
Recommend check K+ level & consider potassium
supplement.
J. Smith, Clinical Pharmacist, bleep 1234
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Practice points on developing your approach to clinical
records
The following guidelines are provided to help you develop your approach to
working with clinical records:
Initiating treatment
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Don't merely consider the choice and dose of medication; think of the
implications of the pharmaceutical form in which it is supplied.
Always check the diagnostic features of disease as they are useful aids
to the choice of, and anticipated response to, a particular medication
Drug therapy may have associated risk and therefore the patient's
medication should always be viewed as being potentially harmful as well
as beneficial.
Always ask yourself questions. For example: 'What effect does one drug
have on another?' 'Will the clinical status of the patient alter the way the
drug is metabolised and eliminated?' 'Will the drug therapy interfere with
the laboratory tests to give false positives or negatives?'
Think prospectively! For example: Should therapy be initiated with a
'loading' dose to give initial high blood levels, or should it be started with
a low dose and gradually increased?
Monitoring treatment
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Think retrospectively! For example: Did any dramatic or unexpected
changes occur as a result of drug therapy? Can you identify the reasons
for this and what are the implications for future practice?
Think about the use of medication given "as required". Would the patient
benefit more from medication given on a short-term regular schedule?
Combination therapies have the potential to produce a wider range of
side-effects than an equivalent dose of either single constituent.
However, in the latter case the severity of the adverse effects may be
greater than that produced by the combination.
Consider the pattern/frequency of the patient's symptoms and the
implications for the timing of drug administration.
Check that the duration of surgical antibiotic prophylaxis is appropriate.
Monitor fluid and electrolytes in post-operative patients.
Check if the drug administration schedule has been clearly stated and
adhered to.
Find out about the choice and use of dressings for wound management
on your ward. This information may not be recorded in the notes.
Changing or stopping treatment
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Try to identify the goals of therapy, when these could be thought of as
being achieved so as to allow withdrawal of medication. Knowing when to
take patients off medication is as important as knowing when to institute
therapy.
Remember to check why drug therapy has been changed and if the
change is justified.
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Pay particular attention to alterations in medication and the effects of
these changes. Using a different therapeutic approach does not
guarantee clinical improvement and you may have to explain why.
Patient Status
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Consider if a particular medication or drug combinations has the capacity
to worsen an existing clinical situation (e.g. renal function).
Check on the potential of concurrent disease to exacerbate another
condition.
Consider alternative routes of administration to oral therapy where GI
tract function may be severely reduced post-operatively.
Don't forget to change the patient back to oral therapy when GI function
returns.
Laboratory tests
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When empiric antibiotic therapy has been initiated, ensure that it is
rational and remember to follow up on bacterial sensitivity data.
Where possible, track the efficacy of therapy using laboratory test results
or other appropriate diagnostic tests.
Think: Are there any other tests that should be performed that would elicit
important information?
Always check the sampling time for therapeutic blood level results
Pharmacokinetic considerations
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For controlled release products familiarise yourself with the release
characteristics and the duration of useful clinical effect.
Remember, changing the route of administration may have implications
for drug bioavailability, frequency of dosing and the rate of administration.
Always check for evidence of a patient's capacity to eliminate drugs.
When medication requires very careful stabilising, always check for
factors which could potentially destabilise the situation.
Consider staggering oral drug administration to prevent potential
interactions occurring in the GI tract.
Patient education
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Remember non-concordance can be the reason for therapeutic failure.
Take your own patient drug history, even if there is a record in the notes.
Patients often tell pharmacists more about their medication than they do
doctors. Address any discrepancies with the medical staff.
Think about what the patient will need to know and be able to do in order
to manage his/her medication most effectively.
Anticipate the potential problems that a patient may have in managing
therapy and act to resolve them.
Consider having written patient information available to consolidate your
verbal education and advice.
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Test yourself
You can check your understanding of this section on clinical
records by taking the online clinical records quiz.
The questions are based on the section you have just completed.
However, they do not derive verbatim from the text, but require
you to apply the general principles set out in the guidelines as
well as your own experience.
You can access the clinical records quiz via the module resources
folder on QOL.
Patient counselling
“One in five people in the UK cannot read medicine labels because the print
is too small.”
(Royal National Institute for the Blind)
A definition of counselling:
“Guiding, directing, informing, recommending, suggesting, hinting, warning”
How do we counsel patients?
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Verbal communication
Written communication
Audio-visual communication
Why do we counsel patients?
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To inform
To educate
To reinforce
To improve concordance
You will learn more about the communication skills required for counselling
patients and you will have an opportunity to practice this activity in Part 2 of
this module.
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Standards for a patient counselling service
The Antrim Area Hospital standards for patient counselling are:
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Patients or their carers should be counselled and provided with
information required for the safe and effective use of their medicines
Care should be taken to assess the wishes of the prescriber, i.e.
indication, diagnosis
Counselling should be appropriate to the needs of the individual
patients
Experienced staff ONLY should undertake medication counselling
(pre-registration students may counsel patients as part of their
training under the supervision of a clinical pharmacist)
The clinical pharmacist should assess each patient’s ability to
understand information by asking questions and should be able to
modify the approach accordingly
Counselling should take place in a suitable environment to ensure
confidentiality. If on a ward, curtains may be pulled around the bed
Information given may include verbal, written or audio-visual formats.
Information to be provided:
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The medication trade name, generic name or other descriptive name
The dose of the medication, dosage form, route of administration and
administration schedule
The intended use and expected action and what to do if the expected
action does not occur
Directions for administration and precautions to be observed during
administration, demonstration of devices
Techniques for self-monitoring of therapy
Correct storage
Discussion of possible adverse drug reactions and side-effects,
which may include:
o Steps to be taken to avoid their occurrence
o Signs and symptom of occurrence
o Effects on normal activities
o Appropriate actions if an ADR occurs
Potential drug-drug and drug-food interactions
How to obtain further supplies, amount/length of treatment, supplies
on discharge
Action to be taken in the event of a missed dose
Any other information peculiar to the specific patient or drug
Appropriate selection of any OTC preparation that may be required
Evaluation of the effectiveness of counselling by appropriate
questioning and follow-up.
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Criteria for patient selection:
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Over 65 years of age
Iatrogenic cause for admission
Known to have poor concordance with drugs
Significant change to medication during hospital stay
More than 5 regular (not PRN) drugs
Started a novel device, i.e.
o inhaler device
o insulin device
o self administration of injection
o use of oral syringes
Taking specific drugs requiring pharmaceutical care.
The importance of appropriate counselling is demonstrated below in respect
of clinical technician counselling and general counselling by pharmacists. The
data was collected during medicines management research at Antrim Area
Hospital.
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A total of 60 patients received inhaler counselling on 126 devices during
their hospital stay, an average of 2.1 devices per patient. The mean
length of time taken to deliver this counselling was 15.8 +/- 8.4 minutes.
Additional information, other than the patient information leaflet was
supplied to patients on 128 occasions. During the course of this
counselling, 41 changes to the current inhaled therapy took place, a
mean of 0.68 changes per patient.
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In terms of pharmacist counselling during this study, a total of 146
patients were counselled on a total of 525 medications whilst in hospital.
During this counselling, patients raised a total of 231 concerns regarding
their current medication.
The importance of patient counselling can be seen when it has been shown
that as many as half of all patients with long-term conditions are using
medication in a way that is not fully effective. Poor compliance with
medication has been recognised as a major problem in obtaining maximum
benefits for patients from their medicines.
Case study: The influence of structured counselling and follow-up in
the eradication of Helicobacter pylori (Al-Eidan et al, 2002)
In a study at Antrim Area Hospital, patients who had been counselled and
followed-up by a clinical pharmacist showed a statistically significant
improvement in H. pylori eradication rate (94.7% v 73.7%, P = 0.02) and
compliance (92.1% v 23.7%, P < 0.001). Of the 64 H. pylori eradicated
patients, 62 were able to eliminate their anti-secretory medication compared
with only 12 of the H. pylori persistent patients (P<0.001).
A pharmacoeconomic evaluation indicated that counselling and follow-up
reduced the direct costs of eradication by approximately £30 per patient.
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Moving from compliance to concordance
Compliance
Compliance with the prescribed instructions is a particular problem in the
elderly due to a number of factors:
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Loss of memory and/or confusion
Loss of vision
Impaired manual dexterity (e.g. arthritis sufferer)
Difficulty with mobility
Polypharmacy
Living alone
Compliance is particularly important in conditions where:
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Drug levels must be maintained (e.g. antimicrobials )
A pharmacological effect must be maintained (e.g. lowered BP)
Life-long treatment is needed (e.g. myxoedema)
Treatment is required for a particular length of time (e.g. tuberculosis)
Efficacy of a new treatment at the dose used is unpredictable.
Williams (1993) summarised the errors in drug compliance:
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Taking out of date or inappropriate drugs
Taking other people’s medication
Addition of non-prescribed medication
Poor instructions
Failure to understand instructions
Failure to appreciate the need for treatment
Fear of adverse drug reactions
Experience of adverse drug reactions
Medicines not collected from the “chemist”
Medicines allowed to run out
Poor labelling
Inappropriate container
Unpalatable medicine
Non-compliance is a complex problem and is influenced by several factors
including the patient’s personal health beliefs, the extent to which the patient
feels in control of his/her own health and the strategies which the patient
develops to cope with his/her illness.
In addition, there are strategies to aid compliance, as indicated below:
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Simplifying drug regimens
Providing suitable containers and caps, which the elderly patient is
able to open easily
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Ensuring that the containers used are labelled clearly and
unambiguously
Providing information leaflets on medicines
Patient education and counselling on their medication
Co-ordination of care
Concordance
Concordance describes a partnership approach to medicine prescribing and
taking. It is therefore different from ‘compliance’, which describes the
patient’s medicine taking in relation to the prescriber’s instructions.
Concordance recognises that people make their own decisions about
whether or not to take a prescribed treatment and acknowledges that a wellinformed patient may decide to decline treatment after hearing about the
relative benefits and risks.
Patients who have been involved in making a decision about their health are
more likely to be committed to taking their medicine. Evidence shows that
many patients wish to have more involvement than they currently do.
(Building on the Best, 2003)
Patients should be given a choice about whether they want to be involved in
their treatment decisions.
Figure 2: From compliance to concordance
2
2
From Management of Medicines (DOH 2004)
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Self-administration schemes
A central theme of the NHS plan is to empower patients to take a greater role
in managing their own care. Patients should not simply be passive recipients
of prescribing decisions by doctors. Inclusion in self-administration schemes
gives greater independence to patients and allows them to participate in their
own care and make decisions about their treatment in partnership with
clinical staff.
Self-administration schemes improve patient compliance with medication
regimens and help to prevent treatment failure. In a survey of patients with
renal failure, 18% did not comply with their medication regimen; 96% of those
who did not take their medication as recommended died or had their
transplant rejected, compared with only 18% of patients who did.
In terms of patients’ views on self-administration schemes, it has been shown
in one study that over 40% of patients felt more confident about taking their
medicines when at home, and the same number thought it had increased
their understanding – 90% of self-administering patients knew the purpose of
their medicines compared with 46% in a control group.
In addition, there are other benefits to be gained from self-administration
schemes:
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They enable the medication to do its job – patients can take
analgesics when they are in pain, sedation when they want to sleep,
and tablets that need to be taken before or after food at the correct
time
Simpler and better medicine regimens because further assessment
of the entire patient’s medication is required. Such simplification
improves compliance with the medication regime – the rate of noncompliance varies from 15% when patients are asked to take one
medicine, to 35% if more than five medicines are prescribed
It allows patients to practice taking medicines under supervision
It alerts healthcare staff to any problems the patient may experience
with medication.
In order to introduce a self-administration scheme, there is a requirement to
have in place appropriate beside lockers to store the medication, which
initially involves a capital cost. The other major consideration in relation to the
introduction of such lockers is the significant initial and, indeed, ongoing
training requirement in the use of such a system, particularly for nursing staff.
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Reflection Question 1
When considering introducing a self-administration of medicines scheme it is
necessary to liaise closely with nursing and medical staff. List possible
concerns these groups may raise and how you could respond to their
concerns.
(a) Nursing Staff
(b) Medical Staff
Original pack dispensing
On the 1st January 1999, the European Community Directive 92/27 was
incorporated into European Law. It required, among other things, that all
medicines supplied to patients must include a patient information leaflet (PIL)
in appropriate lay language and be labelled with the product’s batch number
and expiry date. This directive was one of the key drivers behind the
introduction of original pack dispensing as the packs contain the leaflet and
the expiry date. Most manufacturers supply tablets and capsules in blister
packs for 28 days treatment, rather than in bulk.
Previously, prior to the introduction of original pack dispensing, there was
disparity in terms of the quantity of drugs supplied on discharge, which in
Northern Ireland had been only three days. This clearly created significant
problems at discharge with the patients having to go to their GP almost
immediately in order to get further supplies. In addition, the discharge letter
was almost invariably not available to the GP in order to assess what had
occurred during the hospital admission and to ensure that the patient would
receive the appropriate medication. Thus, the advent of original pack
dispensing not only removed/greatly reduced the problems that occurred at
discharge with regard to patient’s medication, but also led to improvements in
the process of medicines management.
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The Audit Commission stated that dispensing medicines to patients in original
packs, combined with patient bedside medicine lockers, brought the following
benefits:
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Reduced process costs as medicines are dispensed only once
Greater convenience for patients
Reduced GP workload at discharge
Reduced overall costs of medicines to the local health economy
because hospital prices are lower than those available to GP
Having been provided with 28 days supply on admission, most
patients will have at least two week supply of medicines left when
discharged, thereby allowing time for GPs to be fully informed of any
problems or changes in treatment before the patient presents for a
repeat prescription
Reduction in medicine administration error rates (from 9.7% to 2.5%
at one study site)
Hospital discharge is less likely to be delayed as medicines are
readily available at the patient’s bedside
The opportunity for greater use of patients’ own medicines
Fewer interruptions to medicine rounds while nurses find medicines
from ward stocks.
One-stop dispensing (OSD)
The aspects discussed above, namely use of PODs, bedside medication
lockers and original pack dispensing together comprise the key elements of a
re-engineered medicines management system known as one stop
dispensing. The traditional pharmacy system of dispensing separately for
admission and discharge was presenting real logistical difficulties for many
hospital pharmacies. Departments were operating at maximum capacity
which, combined with ever decreasing length of stay, increasing day surgery
as well as recruitment problems, was creating an unsafe system of work.
A multi-disciplinary approach is essential in the implementation of OSD. This
is necessary to provide persuasive argument, secure financial support and
motivate staff from different professions. The practical aspects of OSD have
been described by Burn (2002) as:
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All charts to remain on the ward at all times
Pharmacy teams are based on wards from 8.30am to 5.00pm,
Monday to Friday
No telephone calls to be made to the pharmacy from the wards
All requests for supply, advice and discharge medication to go to the
team via the bleep system
Not all charts to be seen every day
Once a week, a technician to perform an inpatient supply top up and
highlight all new items, changes in dose or new charts to be brought
to the attention of the team pharmacist
PODs to be re-used during admission and on discharge if they
comply with the assessment criteria
Items that are potentially re-useable to be held as ward stock and
available as PODs to be given as a 28-day OSD supply
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All patients to undergo a comprehensive drug history interview within
24 hours of admission (72 hours at weekend)
Discharge delays to be minimised.
Staff utilisation
In order to achieve the objectives of OSD it is important to have the right skill
mix and the role of ward-based clinical technician is critical. Burn (2002)
described the key functions of an MTO3 clinical pharmacy technician as
follows:
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Assessment of PODs
Taking drug histories
Hold the team bleep
Prioritise calls
Organise supplies
Check discharge medicines with the contents of the bedside locker
Liaise with the dispensary
Liaise with community pharmacy and GP surgeries about monitored
dosage systems or queries about medication
Counsel all patients on discharge with a basic level of information
Identify patients requiring intensive discharge advice
Complete care plans
Provide training for MTO2 technicians
Train ward staff on aspects of OSD
Role of the pharmacist
The role of the clinical pharmacist in this system is to:
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Clinically screen all prescription charts for clinical appropriateness
Clinically check all medication histories
Follow through any queries resulting from medication histories
Clinically screen all discharge medication
Liaise with the dispensary
Provide advice to medical and nursing staff
Counsel patients on discharge
Validate supply requests
Participate in consultant ward rounds as appropriate
Support the MTO3 technician as necessary
Assist in the training of pharmacy and nursing staff.
There are obviously a number of variations of skill-mix that can be put in
place, including MTO2 and indeed MTO1 pharmacy technicians. The range
of tasks may also vary to suit local circumstances, e.g. in Antrim Area
Hospital the discharge prescription is completed and signed off by the clinical
pharmacist once the consultant has confirmed discharge.
The introduction of OSD is clearly a significant exercise and takes time and
good planning involving all the key stakeholders in order to ensure its
successful implementation.
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Reflection Question 2
Document what you think are the advantages and disadvantages of a onestop dispensing system from the following perspectives:
Advantages
Disadvantages
Patient
Clinical pharmacist
Pharmacy technician (ward-based)
Nurse
Hospital doctor
General practitioner
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Expert patients
Expert patients have been defined by the UK’s Department of Health, in their
Management of Medicines report, as patients who:
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Feel confident and in control of their lives
Aim to manage their condition and its treatment in partnership with
health professionals
Communicate effectively with health professionals and are willing to
share responsibility for their treatment
Are realistic about the impact of their disease on themselves and
their family
Use their skills and knowledge to lead full lives.
In 2002, the NHS set up its Expert Patient programme, which involves lay-led
training courses in self management for people with long-term conditions.
This was predicated on an American programme entitled “Chronic Disease
Self Management System”.
It is intended that there will be disease specific modules, although the
programme is general in nature.
This quote, from a 36 year old man with kidney disease, highlights the role of
3
the expert patient :
“The doctors and nurses admit that we know more than they do, as we get
used to the disease long term.”
It can thus be seen that in terms of partnership with patients regarding
medicines and choice, it is important to recognise that there are expert
patients and, working together, the medication can be used much more
effectively.
You should now be able to complete Practice Activity 1 in your Work-based
learning portfolio.
3. Discharge
Discharge planning
“Discharge is regarded as a stage in patient care which has a period of
preparation and from which there are consequences. It cannot be viewed in
isolation from what has gone before or removed from what follows after the
event when the patient leaves the hospital.”
This definition acknowledges that the discharge plan should begin on
admission to hospital (or before if the admission is planned) and continue
seamlessly after the patient has been discharged.
3
Levenson, R. for the Task Force on Medicines Partnership
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Elements
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Patient assessment
Development of a discharge plan
Provision of services, including patient/family education and service
referrals
Follow-up evaluation.
Medication discharge education specifically for elderly patients is regarded as
an essential element of the hospital discharge process. Despite its accepted
importance there is little documentation regarding this type of patient
instruction.
It has been observed that there is often a lack of patient education and
information regarding medication, resulting in patients being discharged with
inadequate knowledge and often resulting in unsafe and ineffective selfadministration of medicines.
In 1998, RPSGB highlighted the key points necessary in terms of
communication between primary and secondary care with regard to
medicines:
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Patient’s full identification, including any temporary address
All details of drug treatment including prior to admission and
discharge medication
Any medical sundries required
Any unusual extemporaneous preparations or medication that will
continue to be supplied by the hospital
Whether the patient is at risk or requires particular attention (such as
the elderly/confused, admitted with drug-related problems, at home
with no carer/support)
Any relevant information relating to the ability of a patient to take
medication (such as literacy, language, dexterity, etc.)
Any necessity for a domiciliary visit.
There are clearly issues with regard to pharmacy staff and the services
available in respect of the number of patients being discharged. Thus, it is
important to prioritise patients in terms of pharmacy discharge service
provision.
Important factors to be considered will be as follows:
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Over 65 years of age
Patients on “specials”
Patients whose medication is changed in hospital
Patients whose medication is unlicensed or for an unlicensed
indication
Patients with a drug allergy
Patients who have suffered an adverse effect to current or previous
therapy
Patients with mental illness
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Patients receiving technically complex medication e.g. TPN.
In addition, with respect to medication changes in hospital, medical patients
have considerably more than surgical patients and therefore have the
potential to have more problems. However, evidence in the literature
indicates that there are significant problems at discharge and some examples
are highlighted below.
A study by Tierney et al (1994) showed that 17% of elderly patients
experienced problems with their medication post discharge. Cochrane et al
(1992) found that in 45 out of 50 elderly patients there was a lack of
continuity in one or more aspects between drugs taken after leaving hospital
and those provided on discharge from hospital.
Locally, two pieces of research carried out in United Hospitals Trust revealed
the following problems. In the first study, out of 95 patients discharged:
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One letter did not contain details of the patient’s name address and
date of birth
A diagnosis was not recorded in 14% of discharge summaries
158 interventions were made in relation to medication listed on the
discharge summary
Average time lapse from discharge to receipt of formal type-written
letter was 33.5 days (range 1-91).
In the second study by Bolas et al (2004) in respect of 109 medical patients
discharged, the following problems arose post-discharge:
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33% of patients had medication related problems
Discharge happened at any time of the day
Discharge prescription often incomplete or incorrect
Errors occurred when transferring details from medication records
(Kardex) onto discharge prescriptions
Dispensary under pressure to prepare the discharge rapidly, allowing
no time for a detailed check
Ward staff did not refer target groups for detailed counselling and to
receive a medicine record sheet.
Cook (1995) surveyed the opinions of primary care pharmacists. Community
pharmacists felt that discharged patients frequently ran out of medicines
before further supplies could be obtained. The majority felt that it was not
easy to identify patients who had recently been discharged from hospital and
that patients admitted to hospital presented more problems with prescriptions
than other patients. The information that they would like to receive from
hospital pharmacists included name, address, date of birth, GP, consultant,
date of discharge, diagnosis, current medication, discontinued drugs,
strength, dose, indication, brand, length of treatment, formulations, source of
problems, appliances, counselling done and required. Patients most likely to
benefit were the elderly and those on multiple drug regimens. The preferred
method of communication was either letter or patient held card.
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Locally, Brookes et al (2000) found that 66% of GPs experienced a delay in
receiving discharge information and that 77% would like information on
changes to prescribed drugs. In the same study, 87% of community
pharmacists experienced problems with recently discharged patients and
94% stated that patients came directly to them before seeing the GP after
discharge. Information that they would like to receive was similar to other
studies, i.e. changes made, duration of treatment, etc.
Community liaison by hospital pharmacists
Analysis of the outcomes of community liaison by hospital pharmacists is
encouraging. Shaw et al (1998) found that community pharmacists in receipt
of a pharmaceutical care plan identified nine times more medication problems
than other pharmacists in discharged mental health patients. Re-admissions
were 10% in the intervention group and 26% on the control group. Binyon
(1994) liaised with both GPs and community pharmacists regarding elderly
patients’ pharmaceutical care plans. At home visits, 73% of patients showed
100% compliance and 87% showed improvement in their drug knowledge
scores. At Antrim Area Hospital, a study found that the influence of
community liaison reduced re-admission rates in elderly medical patients
from 8.8% to 6.4% over a four month study period (Brookes et al 1999). In a
further study by Bolas et al (2004), 162 patients were looked at post
discharge and it was found that the intervention group, when compared with
control patients, had a significant reduction (P< 0.005) in mismatch between
drugs prescribed at discharge and drugs taken at home, and had a greater
knowledge of their drug regimen 10-14 days after discharge (P< 0.001).
Pharmacist-generated discharge prescriptions
In relation to discharge prescriptions that are presented at the hospital
pharmacy as part of the Antrim Hospital Integrated Medicines Management
programme, a study compared the percentage of queries that arose from
both pharmacist and junior doctor generated discharge prescriptions. This
work showed that approximately a quarter of all prescriptions received by
pharmacy required some style of intervention. This is comparable to a
previous study in other UK hospitals. The intervention rate was 8.2
interventions per day. Discharge enquiries accounted for the largest
proportion of interventions (20%). This correlates with results obtained in a
previous study (18.2%). In respect of the 311 interventions recorded over the
3-month period, 82.4% were completed in less than 5 minutes, with 1.8%
taking over 15 minutes. This corresponds to a least 14 hours per month spent
on the interventions by the dispensing pharmacist. By comparison, in clinical
pharmacist prepared discharges, the error rate was less than 1%. This
difference is understandable when it is remembered that junior doctors, with
limited knowledge of medicines, carry out around 70% of all prescribing (93%
in the study above). It has been recommended that hospitals should train
doctors in the principles of drug dosing before they start prescribing. In
Antrim Hospital, a protocol has been introduced whereby clinical pharmacists
write the discharge prescription once the consultant has confirmed that the
patient is ready to go home. This protocol is shown on the following 2 pages.
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PROTOCOL FOR CLINICAL PHARMACIST TO PREPARE AND AUTHORISE
DISCHARGE LETTERS FOR GENERAL PRACTITIONERS
OBJECTIVE:
To enable Clinical Pharmacists to transcribe accurately discharge medications from the
Medicines Kardex onto a manual OR computerised discharge letter and to add the diagnosis,
procedures carried out and any review appointment(s) onto the letter from the Discharge
Summary.
PERSONNEL INVOLVED:
Clinical Pharmacists working in the Medical Directorate who have the clinical knowledge and
expertise to perform the task competently and who have been trained and assessed by the
Principal Pharmacist, Medical Directorate. The Pharmacist must have been given a copy of
the protocol and have signed to confirm that the protocol has been read and understood. The
Principal Pharmacist, Medical Directorate must keep an up to date list of Clinical Pharmacists
who have been authorised to perform this task. A copy of the protocol should be available on
each ward where the service is being provided.
SCOPE OF INFORMATION TO BE INCLUDED IN THE DISCHARGE LETTER:
The Clinical Pharmacist will ensure the following relevant information is given:1.
2.
3.
4.
5.
6.
7.
8.
9.
The correct drug and formulation,
The correct strength/dose of medicine,
The frequency of administration and where applicable, appropriate timing of doses,
route of administration,
Appropriate generic/brand name,
Appropriate pack size, e.g. insulin cartridge size,
Appropriate flavouring, e.g. nutritional products,
Administration details,
Duration of treatment and where applicable, details of supply given by hospital e.g. for
antibiotics,
10. Details of changes to medication during hospital stay.
The Clinical Pharmacist will also perform a professional check for the following:1.
2.
3.
4.
5.
6.
7.
Significant drug interactions,
Omissions, e.g. aspirin,
Duplication of pharmacologically similar drugs,
Possible drug/disease incompatibilities, e.g. renal, hepatic,
Patient allergies/sensitivities,
Removal of prn medications,
Removal of night sedation.
The Clinical Pharmacist will be authorised to transcribe and sign for all Prescription Only
Medicines (POM), Pharmacy (P) and General Sales list (GSL) Medicines with the exception
of the following categories which must have a Doctor’s signature on the Discharge Letter:1. Controlled Drugs,
2. Special/Unlicensed Drugs, Unlicensed Doses of Drugs or Licensed Drugs for an
unlicensed indication,
3. Cytotoxic Drugs (Section 8.1 in BNF).
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CRITERIA FOR COMPLETION OF DISCHARGE LETTER BY CLINICAL PHARMACISTS:
1. All medicines on the discharge letter must be prescribed on the Kardex and signed by a
Doctor.
2. A diagnosis (primary and secondary where applicable) must be available on the
Discharge Summary.
3. Procedure carried out must be available on the Discharge Summary.
4. Review appointment must be available on the Discharge Summary.
5. The Clinical Pharmacist must sign and date the discharge letter and state their status i.e.
Clinical Pharmacist.
6. The Clinical Pharmacist must ensure that the pharmacy copy of the discharge letter is
sent to Pharmacy after reviewing with the patient what items are required to be
dispensed.
7. The Clinical Pharmacist has been trained to generate computerised discharge letters.
8. The Clinical Pharmacist has sufficient clinical knowledge to assess discharge medications
and has been approved by the Principal Pharmacist, Medical Directorate.
9. All Clinical Pharmacists will be subject to regular audit.
10. All Clinical Pharmacists must have been given a copy of the protocol and have read,
understood and signed it.
11. The Clinical Pharmacist must have direct access to patient’s medical notes.
MANAGEMENT OF THE PROTOCOL:
1.
2.
3.
4.
5.
Drug and Therapeutics Committee, United Hospitals/Homefirst,
Clinical Director, Medical Directorate,
Director of Clinical Services, United Hospitals,
Chief Pharmacist,
Northern Area Prescribing Forum.
OUTCOMES OF THE PROTOCOL:
1.
2.
3.
4.
5.
6.
Accuracy of discharge letters,
GP satisfaction by provision of detailed information,
Patient satisfaction as discharge process should be speeded up,
Reduced delay in GP receiving discharge letter,
Greater skill mix,
Cost savings, e.g. only items required are dispensed.
TRAINING PROGRAMME:
There must be a verbal and written programme, followed by a supervised period of
application in practice. Assessment of training must be practical and oral testing.
AUDIT:
The Clinical Pharmacists will undergo an audit programme where 10% of their discharge
letters are assessed by a multidisciplinary team consisting of a Consultant, Pharmacist and
GP. A comparison of accuracy may be made with discharge letters by Junior Doctors
provided that the latter are anonymous.
Review Date: The Protocol must be reviewed initially after 3 months and thereafter annually.
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4. Pharmacist-led clinics
An additional service provided in some hospitals is that of specialist
pharmacist-led clinics where patients are referred by medical staff, normally
consultants, for review of aspects of drug treatment. There is considerable
variation in the extent and type of clinics among hospitals and the
development of this service depends on the availability of suitably trained
staff and the time required to run clinics. A survey of Trusts in Northern
Ireland revealed that pharmacists are providing clinics in the following areas:









Rheumatology
Diabetes
Surgery (pre-admission clinics)
Women’s Health (menopause)
Nephrology
Cardiology
Haematology
Oncology
Anticoagulation
Usually the pharmacists who run these clinics are trained and registered as
Pharmacist Prescribers and are therefore able to adjust treatment when
required. Typically clinics run once per week and are of 2 to 4 hours in
duration; activities that pharmacists carry out include:









Adjustment of drug dosages
Review and changes to drug treatment
Patient counselling, e.g. compliance, education
Patient examination
Medication history taking (pre-admission)
Prescription of treatment
Monitoring response to treatment
Management of side-effects
Referral to other healthcare professionals
Pharmacists as prescribers
The extension of prescribing rights to a wider range of health professionals in
the UK began in 1989 with the publication of the “Report of the Advisory
Group on Nurse Prescribing” (DOH 1989). This allowed district nurses and
health visitors to prescribe from a limited list of appliances, dressings, wound
care products and medicines, and by 2001 more than 22,000 district nurses
were qualified to prescribe from the list. In 2001, Ministers announced that
the formulary would be extended for nurses to include all pharmacy and
general sales list medicines and some prescription-only medicines in the 4
areas of minor illness, minor injury, palliative care and health promotion.
Since then prescribing rights have been extended to Pharmacist Prescribers
(which arose from the Crown Report in 1999). Regulations to allow
independent prescribing by pharmacists came into effect in May 2006.
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Pharmacist independent prescribers must have completed an approved
training course and may prescribe for any clinical condition, but they can only
prescribe within their professional and clinical competence.
Integrated Medicines Management
A project took place in Antrim Area Hospital in Northern Ireland during the
period 2001 – 2004 with the objective of developing an Integrated Medicines
Management (IMM) service. The process that was developed consisted of
three phases covering the main stages of a patient’s stay within hospital,
namely:



Admission
In-patient monitoring and counselling
Discharge from hospital to community.
The IMM service was delivered by five pairs of clinical pharmacists and
clinical pharmacy technicians, four pairs working in medical wards and one
pair in the surgical directorate. All members of the IMM team underwent a
programme of accelerated clinical training covering major therapeutic topics
before the start of the service. At the end of the project, the research team
were able to demonstrate considerable benefits in terms of improved
effectiveness of therapy, reduced length of stay, reduction in readmission
rates and improved patient safety, in addition to considerable economic
benefits.
Learning activities
(i) Download and read the following papers from the QUB Library electronic
journals collection:
Scullin C, Scott MG, Hogg A et al. An innovative approach to integrated
medicines management. J Eval Clin Pract. 2007; 13:781–8.
Burnett KM, Scott MG, Fleming GF, Clark CM, McElnay JC. Effects of an
integrated medicines management program on medication appropriateness
in hospitalized patients. Am J Health-Syst Pharm. 2009; 66:854-9
(ii) You will find a series of downloadable audio files in the ‘Additional
resources’ folder on the module web page. The files contain supplementary
material relating to the Integrated Medicines Management project.
You should download and listen to the recordings.
Note – the files are mp3 files and can be downloaded and listened to on your
computer or they can be transferred to any device that plays mp3 files.
(iii) You should now be able to complete Practice Activity 2 in your Workbased learning portfolio.
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Section 3:
Pharmaceutical interventions
Learning outcomes
On completion of this section, you will be able to:




Implement a methodical approach to making interventions
Screen patients efficiently and effectively for medication problems
Develop a pharmaceutical care plan
Implement systems for recording interventions
Topics
This section includes the following topics:





© QUB
Screening patients for medication problems
Pharmaceutical care plans
Participation in ward rounds
Medication history review
Recording interventions
Page 44
Introduction
One of the difficulties faced by new clinical pharmacists is to know when and
how they should intervene in a patient’s treatment. To make an effective
contribution to the clinical team, pharmacists must do more than respond to
questions. In order to take a proactive approach, they must be aware of the
stages in the treatment process where their expertise may be of value and
the risk factors that may cause problems with therapy.
Opportunities for pharmaceutical intervention
A methodical approach to making interventions should be adopted, including:




Screening for potential medication problems
Preparation of patient profiles
Giving advice/making one or more interventions
Monitoring outcomes
The opportunities to apply your pharmaceutical knowledge and skills at each
stage of clinical treatment are summarised in the following table:
CASE
PROGRESSION
PHARMACIST
KNOWLEDGE
APPLICATION
PHARMACIST
SKILL
APPLICATION
Presenting complaint
 Non-drug related
 Drug related
Inappropriate therapy?
Non-compliance?
Adverse drug reaction?
Drug interaction?
Drug History taking
Cause assessment
Acute therapy
Protocols
Options (advantages vs.
disadvantages)
Endpoints
Treatment
recommendation
Treatment evaluation
Diagnostic and
laboratory tests
Influence of drugs
Tests involving drugs
Drug interference in tests
Result interpretation
Result evaluation
Drug therapy
Protocols
Options (advantages vs.
disadvantages)
Endpoints
Treatment
recommendation
Treatment evaluation
Pharmaceutical care
Reasons for therapy
Treatment regimen
Methods of administration
Side effects
Drug-specific advice
Patient counselling
Communication skills
Discharge
Drug-specific advice
Patient counselling
Communication skills
Diagnosis
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Screening patients for medication problems
Every patient should be assessed for medication problems; however, it is
unnecessary for pharmacists to intervene in the treatment of every patient.
Patients should be screened for risk factors relating to their therapy (e.g.
drugs with a narrow therapeutic index) or their condition (e.g. impaired renal
or hepatic function). Patients must therefore be screened in a systematic
manner in order to identify those who will benefit from the pharmacist’s
intervention. Screening of drug therapy can be undertaken either from the
drug charts or from the clinical records.
1. Screening patients using drug charts
Drug charts are quick to access and although they do not give a full picture,
they do provide the opportunity to identify drugs with potential adverse
reactions or interactions, as well as inappropriate formulations, presentations,
dosages or dose intervals. The latter may be apparent from the basic patient
data available on the prescription sheet (gender, age, drug sensitivities).
From the drugs prescribed, assumptions may be made about certain clinical
conditions (e.g. lactulose plus neomycin may indicate hepatic
encephalopathy).
Adverse drug reactions may arise from the natural pharmacological action of
the drug (Type 1) or as an idiosyncratic effect (Type 2). One of the skills of
the clinical pharmacist is to determine which potential adverse drug reactions
or interactions are of clinical rather than academic significance.
You should now be able to complete Practice Activity 3 in your Work-based
learning portfolio.
2. Screening patients using clinical records
More detailed screening can be undertaken by using the clinical records. To
extract the relevant information from clinical records, clinical pharmacists
must be familiar with the various records that are available and the
terminology used. Having completed Section 2, you have already had some
experience of using clinical records. In this section you will develop a more
structured approach to screening clinical records.
Pharmaceutical Care Plan
You will find it helpful to use a standard “Pharmaceutical Care Plan” when
monitoring clinical records.
An example of a Pharmaceutical Care Plan is provided in the following
pages.
When completing the Pharmaceutical Care Plan, it is advisable to adopt a
standardised approach, as follows:
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Page 1: Identifying problems




Record the patient’s identification data and relevant drug and medical
history details.
List the patient’s medication history on admission.
List medical or pharmaceutical problems in chronological order.
Number the problems so that they can be linked to specific drugs.
Page 2: Assessing problems and measuring outcomes




List the patient’s problems
Record and evaluate the various therapeutic options that you can
think of.
Indicate any outcome measures that you wish to monitor along with
the reason and frequency.
Record the date of completion when a problem has been resolved.
Page 3: Recording data


Record the patient’s daily drug prescription, cross-referencing with
the problem list.
Record laboratory results and any investigation or drug level results
as appropriate.
Learning activity
1. Familiarise yourself with the Pharmaceutical Care Plan on the following
pages, taking note of the various sections and how they are linked.
2. Download a blank Pharmaceutical Care Plan form from the resources
folder for this module and use it to monitor the progress of an acutely ill
patient who has been prescribed more than five medications.
3. Discuss your completed Pharmaceutical Care Plan with your local
mentor.
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Sample Pharmaceutical Care Plan
Patient Initials: SF
Ward 22
Age
Student:
Allergies/ Drug
Intolerance
58
Impairments:
Visual
Auditory
Mobility
Dexterity
Speech
Literary
Hospital No: MH520521
Height
Weight 70kg
Gender F
Other
Consultant: CPT
Penicillin
Date Admitted: 10/7/11
Date Discharge/ Died/ Transferred:
17/7/11
Prob.
No
Drug treatment on Admission
1.
Phenytoin 400mg daily
Learning None 
Presenting Complaint
Acute upper (R) quadrant abdominal pain
Working Diagnosis
Cholecystitis
Relevant Medical History
Epilepsy 12 yrs
Previous episodes of colicky pain over 3
yr period
Smoker 20/day
Relevant Past Drug History
OTC Preparations
Date
No.
Problem List (Medical or Pharmaceutical)
10/7/11
10/7/11
10/7/11
11/7/11
11/7/11
11/7/11
11/7/11
11/7/11
12/7/11
12/7/11
1
2
3
4
5
6
7
8
9
10
Epilepsy
Cholecystitis
Allergic to penicillin
Raised LFTs
 WCC
Pyrexia
Nil orally – parenteral phenytoin/ intravenous fluids
Non-ambulatory
Surgical antibiotic prophylaxis
Analgesia – morphine
Outcome Measurement
Prob.
No
Problem Assessment
Therapeutic Options & Evaluation
Action
Purpose
Frequency
e.g. Ascites – on diuretics
e.g. Give spironolactone – discuss
Give Loop diuretic - discuss
e.g. Monitor K+
e.g. To prevent
Hyperkalaemia
e.g. alternate
days
Epilepsy – nil orally
Intravenous phenytoin
Max rate 50mg/min
To prevent hypotension
Daily
12/7/11
Dose 100mg IV tid
To prevent phenytoin
toxicity
Daily
12/7/11
Dilute in 50-100mls normal saline
Max conc 10mg/ml
Daily
12/7/11
In line filter 0.22- 0.5 micron
To prevent infusion of
precipitate
Daily
12/7/11
Date
1
Date
done
2
Cholecystitis
Cholecystectomy
3
Penicillin allergy – on
cefuroxime
Possibility of cephalosporin allergy
Monitor for signs of allergy
To prevent anaphylaxis
Daily
11/7/11
4
Raised LFTs
Risk of phenytoin toxicity 
11/7/11
Give cefuroxime 750mg IV – one dose at
theatre and two doses post op
Give 2.5L fluids / day – 1L normal saline +
1.5L dextrose 5% + 60mmol KCl
To prevent phenytoin
toxicity
To prevent unnecessary use
of antibiotics
To prevent fluid and
electrolyte disturbances
Alternate
days
Cholecystectomy –
prophylactic antibiotics
Nil orally – requiring
intravenous fluids
Monitor LFTs
If signs of toxicity monitor phenytoin level
Discontinue antibiotics after 3 doses if no
sign of infection (monitor WCC and temp)
Monitor U+E
Monitor fluid balance
Daily
12/7/11
8
Patient non-ambulatory
Give enoxaparin
Enoxaparin 20mg SC
To prevent DVT
Daily
12/7/11
10
Analgesia - morphine
Constipation
Monitor patient’s bowel movements
Laxative
To prevent constipation
Daily
12/7/11
5+6+9
7
12/7/11
DATE
Problem
No
Investigations/
Drugs
Normal range
Comments
11/7/11
12/7/11
13/7/11
14/7/11
15/7/11
16/7/11
17/7/11
Dose & route
9
1
Phenytoin
200mg tid po
Cefuroxime
Phenytoin
Picolax
Atropine
750mg tid IV
200mg bd IV
2 stat po
600mcg po
10mg IM 4
hrly
Restarted on
discharge



10
Co-codamol
8/500mg
2 QID po
Na+
K+
Urea
Creatinine
Alb
Tbil
Alp
Ast
GGT
Amylase
135-145
3.5-5.2
2.5-7.5
55-125
35-50
3-17
30-95
17-45
10-45
35-95
142
5.0
4.2
90
35
28
115
25
30
1100
WCC
4-11
11.5
5











Morphine sulphate
4
4
4
4



10
7


Started on
discharge
144
4.4
4.2
148
2.9
5.0
146
3.7
4.7
39
20
92
40
45
430
12.2
147
3.3
5.1
39
20
88
40
45
150
10.9
10.1
No
growth
Bile sample
7
7
Input
Output
1600
450
2000
1750
2000
2000
2000
2550
2000
4700
2000
1900
2000
1550
6
Temp
38.5
38.4
37.6
37
37
37
37
Participation in ward rounds
Ward rounds often involve several members of the healthcare team and are usually
led by a consultant or other senior clinician. The ward round provides an opportunity
for the clinical pharmacist to provide information and advice regarding optimisation of
drug therapy for individual patients.
Attendance at ward rounds can be a daunting prospect for the new clinical
pharmacist as this does not normally form part of their undergraduate training,
however, confidence will grow with experience. The key to becoming an effective
member of the clinical team is in adequate preparation for the ward round. This
requires you to have a current knowledge of the patient, their drug treatment, their
progress and any problems that have occurred. The process of screening patients for
intervention, particularly using clinical records, will help you to prepare for the ward
round. In addition, you should ensure that you are familiar with the indications,
dosages, side effects and interactions of the drugs that you expect to encounter on
the round.
Learning activity
You will gain valuable experience by participating in multidisciplinary ward rounds. If
you do not attend a regular ward round, you should discuss attendance with your
local mentor and try to start attending a regular ward round. You may wish to start by
accompanying your local mentor to a ward round until you are confident enough to
participate on your own.
Medication history review
The goal of the medication history interview is to obtain information on drug use that
may assist in the overall care of the patient. Medication histories are usually obtained
from the patient or a relative/carer on admission to hospital; however, these
medication histories are often incomplete and may fail to detect problems that the
patient has in relation to their medication. Other potential sources are the patient’s
own drugs if they are available, and the patient’s GP and community pharmacist. If
the patient’s community pharmacist is contacted, the patient must use this community
pharmacist for the majority of their pharmaceutical needs. GP and community
pharmacy records can be used to assess concordance if the quantity and date of
dispensing are obtained.
The medication history interview provides an ideal opportunity for clinical pharmacists
to fully exploit their expertise as “medication managers”. During the interview it should
be possible for pharmacists to utilise their broad knowledge of a wide range of drugs
and dose forms, and their uses, to build up a comprehensive medication history. In
particular, the history should include prescription and non-prescription medications,
the use of complementary medicines, adverse reactions to any of these medications,
factors influencing compliance, drug allergies and other relevant factors. No other
health professional should be able to undertake this task as competently as a
pharmacist.
You will learn more about the communication skills required for taking a medication
history and you will have an opportunity to practice this activity later in this module.
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Recording interventions
It is essential for clinical and management purposes to record all clinical pharmacy
interventions and their outcomes. The form below is an example of a form that may
be used to record interventions, or your hospital may have its own form. In this form,
the appropriate number is circled under each heading and further details can be
added in the ‘Details’ box. Alternatively, electronic recording may be done using a
hand-held PDA or barcode reader.
Patient Initials
CLINICAL PHARMACY
ADVICE/INTERVENTION RECORD
PHARMACIST
WARD
ENQUIRER
1.
2.
3.
4.
5.
Hospital Number
Pharmacist
Doctor
Nurse
Patient
Other (specify)
TREATMENT STAGE
1. Started
2. Not commenced
3. Information only
ROUND
Y/N
PROBLEM CLASSIFICATION
1. Prescription unacceptable
2. Availability problem
3. Non policy/Non
formulary
4. Administration
5. Dose
6. Frequency
7. Route of administration
8. Duration of treatment
9. Pharmacokinetics/T.D.M
10. A.D.R
11. Drug choice
12. Drug allergy
13. Potential interaction
14. Other (specify)
DATE
OUTCOME OF INTERVENTION
1. Accepted, treatment
changed
2. Legitimate, treatment
unchanged
3. Rejected
4. Information only
5. C.S.M Notification
6. Patient Counselling
7. Drug history recorded
8. Unknown
9. Other (specify)
DETAILS
Intervention monitoring forms may be used to record the details of each intervention
and to compile statistical data which can be used to demonstrate clinical pharmacists’
impact on individual patient care. The data can be analysed easily by transferring the
figures to a computer-based spreadsheet or database. Compilation of accurate
4
statistical data requires accurate data recording – Boardman and Fitzpatrick (2001)
4
Boardman H and Fitzpatrick R (2001) Self-reported clinical pharmacist interventions underestimate their
input to patient care. Pharmacy World and Science 23(2):55-59
© QUB
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undertook an analysis of self-reported clinical pharmacist interventions and found that
interventions represented 68% of pharmacist activities on the wards, however, less
than one third of the interventions were actually recorded.
The effectiveness of clinical pharmacist interventions with respect to patient care has
been documented in the literature utilising various grading systems to rate the
significance of the intervention on patient care.
One example is the use of a six point grading system as devised by Eadon (1992)
and detailed below:
Intervention Type
Grade
Intervention which is detrimental to the patient’s
well-being
1
Intervention which is of no significance to patient
care
2
Intervention which is significant but does not
lead to an improvement in patient care
3
Intervention is significant and results is an
improvement in patient care
4
Intervention is very significant and prevents a
major organ failure or adverse reaction of similar
importance
5
Intervention is potentially life-saving
6
This system has been used in studies at the Antrim Area Hospital in Northern Ireland.
In the initial pilot work it was found that 65% of interventions were graded 4 and
above, with 18% being very significant (i.e. grade 5) and 0.2% potentially life-saving
(i.e. grade 6).
In the later Integrated Medicines Management Project, the intervention grading data
were as follows:
Grade 2
2%
Grade 3
21%
Grade 4
75%
Grade 5
2%
Thus, a similar pattern was seen.
Therapeutic drug monitoring
Therapeutic drug monitoring involves the measurement of drug levels and the
application of pharmacokinetic principles and pharmacodynamic factors to optimise
drug therapy in an individual. The clinical pharmacist has an important input into
therapeutic drug monitoring, from ensuring correct sampling to interpretation of
results. Therapeutic drug monitoring is offered as an option in the year 2 course
“PMY7035 Therapeutics for clinical pharmacists 2”.
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Ethics and confidentiality
The NHS Confidentiality Code of Practice, published in 2003, is a guide to required
practice for those who work within or under contract to NHS organisations concerning
confidentiality and patients' consent to use their health records. It states that a duty of
confidence arises when one person discloses information to another (e.g. patient to
clinician) in circumstances where it is reasonable to expect that the information will be
held in confidence.
Patients entrust us with, or allow us to gather, sensitive information relating to their
health and other matters as part of their seeking treatment. They do so in confidence
and they have the legitimate expectation that staff will respect their privacy and act
appropriately. In some circumstances patients may lack the competence to extend
this trust, or may be unconscious, but this does not diminish the duty of confidence.
This is essential if the legal requirements are to be met and the trust of patients is to
be retained. A key guiding principle is that a patient’s health records are made by the
health service to support that patient’s healthcare.
One consequence of this is that information that can identify individual patients, must
not be used or disclosed for purposes other than healthcare without the individual’s
explicit consent, some other legal basis, or where there is a robust public interest or
legal justification to do so. In contrast, anonymised information is not confidential and
may be used with relatively few constraints.
In addition, there are ethical requirements to be considered, and statements in the
General Pharmaceutical Council’s Code of Ethics require the pharmacist to respect
the confidentiality of information acquired in the course of professional practice
relating to a patient and the patient's family.
Confidentiality should be strictly observed, particularly by clinical pharmacists who
have access to personal medical and social information. Any breach of confidentiality
could have serious consequences for the individual responsible who may face
disciplinary procedures. Local clinical pharmacy development may also be threatened
if consultants lose confidence in the integrity of pharmacists.
Patient advice
Advice to patients, either in response to questions or as part of counselling, may raise
ethical considerations. In giving advice, pharmacists should be aware of the doctor patient relationship. Information provided should of course be accurate, but
pharmacists should avoid causing undue alarm by going into unnecessary detail
about side effects or possible adverse drug reactions. Clinical pharmacists should be
familiar with the local terminology used for sensitive conditions (e.g. CA for cancer).
You should now be able to complete Practice Activity 4 in your Work-based learning
portfolio.
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Appendix 1: Medical abbreviations
Abbreviation
Meaning

diagnosis
no, none
abdomen
accident and emergency or air entry
atrial fibrillation
bowel movement
blood pressure
bowel sounds
carcinoma
coronary artery bypass graft
congestive heart failure
central nervous system
complains of
consolidation
crepitations (fine crackling sound heard on inspiration – sign
of fluid on lungs)
cerebrovascular accident
cardiovascular system
chest X-ray
dextrose (5%) in water
drug history
diabetes mellitus
electrocardiogram
erythrocyte sedimentation rate
full blood picture
family history
gastrointestinal tract
genitourinary system
history of
history of presenting complaint
heart rate
heart sounds
first and second heart sounds, nil else (normal – no heart
murmurs)
international normalised ratio
jugular venous pressure
left
liver function tests
liver kidney kidney spleen
lower lobe (of lung)
myocardial infarction
nothing abnormal detected
naso-gastric (usually aspirate)
on examination
peak expiratory flow rates or peak flows
pupils equal reactive to light and accomodation
pulmonary function tests
past medical history
paroxysmal nocturnal dyspnoea
o
Abd
A/E
AF
BM
BP
BS
Ca
CABG
CHF
CNS
C/O
Cons
Creps
CVA
CVS
CXR
D5W
DH
DM
ECG
ESR
FBP
FH
GIT
GUS
H/O
HPC
HR
HS
I+II+0
INR
JVP
L
LFTs
LKKS
LL
MI
NAD
NG
O/E
PEFR
PERLA
PFTs
PMH
PND
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PNS
PUD
PVC
R
R=L
RF
ROS
RR
RS
SB
S/B
SBP
SH
SOB
SR
ST
TG
TIA
TOP
U&E
U/S
w/e
WCC or WBC
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peripheral nervous system
peptic ulcer disease
pulmonary vascular congestion
right
same on both sides
rheumatic fever
review of systems
respiratory rate
respiratory system
sinus bradycardia
seen by
systolic blood pressure
social history
shortness of breath
sinus rhythm
sinus tachycardia
triglycerides
transient ischaemic attack
termination of pregnancy
urine and electrolytes
ultra-sound
weekend
white cell count or white blood cells
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