Introduction to Clinical Pharmacy– a key role for pharmacists. Year 3 Peradeniya University SOP

1. Introduction to Clinical Pharmacy– a key role for pharmacists.Year 3 Peradeniya University SOP Dr Ian Coombes, Clinical senior Lecturer - School of Pharmacy + Medicine, University of Queensland, and Senior Pharmacist, Safe Medication Practice Unit, Brisbane, Australia Mrs Judith Coombes Conjoint Lecturer - School of Pharmacy, University of Queensland and Senior Education Pharmacist, Princess Alexandra Hospital, Brisbane, Australia.

2. Content • Introduction to Us and You • What is clinical pharmacy and why do we need it • Medicine management and patient journeys • Adverse drug events – the problem • Product versus patient focused services • Perception of the profession • Drivers for change –its development elsewhere • Core practitioner skills, knowledge and attitudes, • Plan for the next 6 weeks

3. Background - Queensland 700 km W - E 1900km N - S 1.8Million km2 4 M people in Qld Brisbane

4. Queensland Brisbane

5. Comparisons

6. Judith Coombes • University Queensland • Pre-registration (apprenticeship year) community • District hospital (Rockhampton) 700km N • UK hospitals 2 years, wards and dispensary • PAH renal specialist pharmacist • UK MSc (Clin Pharm) DI + research pharmacist • PAH, 700 bed teaching, Drug use evaluation • Conjoint Lecturer U of Qld + PAH education

7. Ian Coombes • University of London – wanted be in advertising! • Pre-registration year - London Hospital • Junior training – London Hospital • Working holiday in Brisbane, 2 hospitals • Msc in Clin Pharm, ICU, renal, cardiac jobs - UK • Manage Clinical Services + cardiac + PAC – PAH • Safe Medication Practice Unit • PhD • State wide pharmacy + prescriber education

8. Perceptions of Pharmacists How do others see us?

9. “They just count a few tablets”

10. “They just weigh and measure things”

11. “A bunch of shop-keepers”

12. “Tell me how and when to use the Medicine”

13. “Counter-prescribing”

14. “Not really health care practitioners – they’re businessmen”

15. “Do you need a degree to be a pharmacist?”

16. Drivers for change • Competence of health care practitioners - Diploma to BSc to BPharm + Pre-registration + registration - Continuing Professional Development. • Re-engineering of community medicine supply - Provided by competent practitioners - Recognition that dispensing is a technical function • Informed general public – increased expectation • Realisation that ………………….

17. Medicines are Dangerous

19. Pharmaceutical Care “ A practice in which a practitioner takes responsibility for a patient’s drug related needs and holds him or herself accountable for meeting these needs.” Linda Strand 1997

20. Will the patient take the therapy? What does the patient view as an improved quality of life? Safe drug therapy Effective drug therapy Aims of Pharmaceutical Care Economic drug therapy Improve quality of life

21. A case • 44 year old lady with fever and green sputum and cough – no known previous medical history – Diagnosed with upper resp. tract infection • Prescribed: • Co-Amoxiclav 1 tds • Doxycycline 100mg D • Prednisolone 40mg D • Theophylline 200mg bd • Omeprazole 20mg D • Metoclopramide 10mg tds • Salbutamol 2 puff inhale prn Pharmaceutical problems Common organisms for URTI? Need for atypical organism ? History of asthma – risk vs benefit? History asthma – risk vs benefit Need for acid suppression? Why is she nauseous ? Benefit of brochodilation? Does she know what to take? Will she take it?

22. Why did you choose to do this course? What do you envisage doing when you become a pharmacist? 2 minutes talk to your neighbour and then feedback

23. Question? • Think of someone in your family or a friend that has had something go “wrong” with their medicines? • Caused an adverse or unwanted effect ? • Had medicines stopped when should have continued? • Not worked? • What happened ? • Could it have been avoided ?

25. Medical/medication errors in the UK • Adverse events occur in 10% of admissions • An estimated 850,000 adverse events a year • Adverse events cost approximately £2 billion/yr • The NHS pays £400 million clinical negligence • Medication errors accounts for around a quarter of the incidents which threaten patient safety • The Chief Medical Officer • An Organisation with a Memory • Department of Health (2000)

26. High Profile Examples • A patient with leukaemia received Intrathecal vincristine instead of intravenously. Died beginning of February 2001. 14th such case over the last 16 years. • Patient being operated for a AAA received bupivicaine intravenously rather than epidurally. Patient died 3 days later. • A 3 year old girl, who had a convulsion post flu vaccine. Attended hospital to get “checked out”. Received nitrous oxide instead of oxygen in casualty

27. High Profile Cases (Cont.) • Elderly lady prescribed Methotrexate in 1997 for her rheumatoid arthritis. Dose increased to 17.5mg WEEKLY over a 6 month period. • Jan 2000 patient undergoes right TKR in hospital. MTX given as one tablet a week (only 2.5mg). • 6th April 2000 patient asks GP to reduce number of tablets “as in hospital”. • Prescription for MTX 10mg/daily written and dispensed. • 30th April patient dies.

28. Deaths from medicines in the UK1999 - 2000 (ICD9 & 10 data) A spoonful of sugar - Audit Commission (2001)

29. So drugs are safe ……………….. Photosensitivity from Amiodarone Severe extravasation of amiodarone infusion

30. NSAID or COX-2 induced peptic ulcer

31. Goitre – Hypothyroidism Secondary to Amiodarone Bleeding due to anticoagulation

32. Erythemal rash from penicillin – in patient with a previous Known allergy/ adverse drug reaction

33. Necrotising fascititis – secondary to infection at site of IV injection

34. Acute Liver failure from Black Cohosh - herbal medicine

35. Human Error(Mistakes, Slips, Lapses) • Error is inevitable due to “our” limitations: • limited memory capacity • limited mental processing capacity • negative effects of fatigue other stressors • We all make errors all the time • Generalised lack of awareness that errors occur • Patients suffer adverse events much more often than previously realised • Errors often NOT immediately observed

36. The same error, even a minor one, can have quite different consequences in different circumstances.

37. The System: Only as safe as it’s designed to be! “I assumed the brown glass ampoule was frusemide”(ICU RN afterinjecting 10mg adrenaline)

38. Latent Conditions Error producing conditions Active Failures - Slips&lapses - Mistakes Accident Defences The Accident Causation Model(Adopted from Reason & Dean)

40. The Medicines Management Cycle • What happens between a doctor seeing a patient and them receiving or taking their medicine ? • 2 minutes discuss with neighbor

41. Transfer information Order entry Review order Patient Supply medicine Administer Supply information Distribute The Medicines Management Cycle DOCTORS Decision to prescribe Monitor response Nurses Pharmacy From Bates et al 1995

42. Sources of Error • Prescribing error - selecting the wrong or inappropriate drug/dose/formulation/duration etc • Communicating those instructions • Supply error - timely; wrong drug, dose, route; expired medicines, labelling. • Administration error - timing; wrong route; wrong rate/technique. • Lack of user education - actions to take.

43. Where do things go wrong with medicines?

44. Comparability to Australian National Health Priority Areas In 2000-01, hospital admissions • Angina: 88,500 • Myocardial infarction: 37,500 • Asthma: 49,000 • Diabetes: 46,000 • Adverse Drug Events: 140,000

45. Reducing the risk of adverse events • Always • include a detailed drug history in the consultation • Only • use drug treatment when there is a clear indication • Stop • drugs that are no longer necessary • Check • dose and response, especially in the young, elderly and those with renal, hepatic or cardiac disease

46. Pharmaceutical Care “ A practice in which a practitioner takes responsibility for a patient’s drug related needs and holds him or herself accountable for meeting these needs.” Linda Strand 1997

47. Safe drug therapy Effective drug therapy Aims of Pharmaceutical Care Economic drug therapy Improve quality of life

48. Aims of Pharmaceutical Care • Identify actual and potential drug related problems, • Resolve actual drug related problems, • Prevent potential drug related problems.

49. Drug therapy assessment Six types of problems which may result in treatment failure : Inappropriate selection of medication Inappropriate formulation of medication Inappropriate administration of drug therapy Inappropriate medication-taking behaviour Inappropriate monitoring of drug therapy Inappropriate response to drug therapy

50. Pharmaceutical care planning • Process of work • collect relevant patient information • assess information • identify problems • state desired outcomes • prioritise problems • develop an action plan for each problem • was desired outcome achieved?