2. Introduction:
Clinical Pharmacy is a health science discipline in which
pharmacists provide patient care that optimizes
medication therapy and promotes health, wellness, and
disease prevention.
It is services provided by pharmacists in an attempt to
promote rational drug therapy that is safe, appropriate, &
cost-effective
Clinical pharmacy is well developed in Western
countries, but in Nepal it is in a primitive state.
There are many reason for slow growth of clinical
pharmacy in Nepal:
1. industry-oriented undergraduate pharmacy education,
2. the lack of established hospital pharmacy
3. undefined role and responsibilities by hospital and
3. Role of clinical pharmacists
1. Taking the medication history of the patient
It includes taking of the past and current medication
history of the patient both for the prescription and non-
prescription drugs.
Determining drugs allergies and hypersensitivities, noting
the side effects, toxicity, incorrect drug administration etc
2. Patient Education
Patients need to be educated on the mode of
administration, use and storage of drugs, their possible
actions and side effects.
The importance of compliance and possible interactions
with other prescription and non-prescription drugs help
the patients to know what food or drinks to avoid while
taking the medicines and what type of measures should
4. 3.Patient care
They must monitor the drug therapy of the patient
making use of the pharmacokinetic data and should
check the medication order and review the prescriptions
for the patient's best care.
4. Formulation and management of drug policies
Formulation of drug related policies is considered the
duty of the clinical pharmacists.
formulation and management of drug related policies like
antibiotic police, cancer chemotherapy protocol, addition
or deletion of drugs for hospital formulary all providing
better therapeutic outcome
5. Drug information
It is good position to provide drug information being the
expert in related field and in close relation with the health
5. 6. Education of medical and paramedical staff
Having a vast knowledge regarding the drugs and related
area, pharmacist is considered a capable person in
educating the medical and paramedical staffs on the
rationale drug therapy.
7. Research and development
Clinical pharmacists can carrying out research on drug
development, formulations and bioavailability studies.
They can be involved in both clinical and pharmaceutical
research.
8. Participation in drug utilization studies
They are good position to participate in drug utilization
studies. They can highlight the deficiencies in the existing
system and formulate strategies for the overall
management in the quality of health care of the patients.
6. 9. Patient counseling
It is the initial and important way for pharmacist to interact
and show their efficiency in patient focused area of clinical
practice.
10. Therapeutic drug monitoring (TDM)
It is the process of monitoring the pharmacokinetic
parameters of drug after its use which helps in maintaining
the therapeutic level of drugs in the body.
They are involved in TDM process regarding the collection
of plasme level of drug and its analysis maintaining safe
drug concentration in vivo for rationalizing the therapy.
11. Drug interaction surveillance
It is the another main duty of the clinical pharmacists by
which they can reduce be harms associated with the use of
more than one drugs which interact with each other altering
7. 12. Adverse drug reactions (ADRS) reporting
To detect and monitor ADRs and to report to the
respective place is the function of clinical pharmacists to
eliminate drug related problems of the patients.
13. Safe use of drugs
It includes rationale prescribing, rationale dispensing and
the rationale use of drugs which is accomplished by
proper pharmacy practice by clinical pharmacist.
14. Disease management cases
They utilizing their in-depth knowledge, are involved in
management of disease cases (especially chronic
diseases) for the betterment of the healthy system.
15. Clinical trial
The central role is in research process can influence
directly the success of clinical trial for the development of
drug
8. 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 is pharmaceutical
care." Linda Strand 1997.
It can describes as specific services and activities through
which an individual pharmacist cooperates with patients
and other health care professionals in designing,
implementing and monitoring a therapeutic plan that will
produce specific outcomes for the patient.
The mission of the pharmacist is to provide
pharmaceutical care. Wherein the pharmacist is
engaged in;
Drug monitoring,
Disease monitoring,
Drug therapy and disease management/collaborative
practice.
9. Care:
In pharmaceutical care, one pharmacist is in a direct
professional relationship with one patient. In this
relationship, the pharmacist provides care directly to the
patient and for the benefit of the patient.
Quality of life
Pharmacists are highly-educated and trained health
professionals
Pharmacists help ensure the best patient outcomes
Responsibility
Pharmacist has responsibility to reduce preventable drug-
related morbidity and mortality is explored
Changing the focus of practice from products and
biological systems to ensuring the best drug therapy and
patient safety is another responsibility
10. Outcomes
It is the goal of pharmaceutical care to improve an
individual patient's quality of life through achievement of
predefined medication related therapeutic outcomes.
The outcomes sought are:
Cure of the patient's diseases,
Elimination or reduction of a patient's symptomatology,
Arresting or slowing of a disease process,
Prevention of a disease or symptomatology.
11. Principle elements
The principle elements of pharmaceutical care as follows:
It is medication related,
The care is directly provided to the patient,
It is provided to produce definite outcomes,
These outcomes are intended to improve the patent's
quality of life,
The provider accepts personal responsibility for the
outcomes.
12. Medication related problems
A medication-related problem is an event or circumstance
involving medication therapy that actually or potentially
interferes with an optimum outcome for a specific patients
Following are some categories of medication related
problems:
Untreated indications:
The patient has a medical problem that requires drug
therapy but is not receiving a drug for the indication.
Improper drug selection:
The patient has a drug indication but is taking the wrong
drug, or is taking a drug that is not the most appropriate
for the special needs of the patient.
Sub-therapeutic dosage:
The patient has a medical problem that is being treated
13. Failure to receive medication:
The patient has a medical problem that is the result of
not receiving a medication due to economic,
psychological, sociological or pharmaceutical reasons
Over dosage:
The patient has a medical problem that is being treated
with too much of the correct medication.
Adverse drug reactions:
The patient has a medical problem that is the result of
an adverse drug reaction or adverse effect.
Drug interactions:
The patient has a medical problem that is the result of a
drug-drug, drug-disease, or drug-lab test interaction.
14. Drug use without indication:
The patient is taking medication for not medically valid
indication.
Treatment failures:
The patient has a medical problem that is being treated
with a medication that is generally considered
appropriate for the indication, but the desired therapeutic
outcome is not achieved.
15. Medication errors
It is a mistake in prescribing, dispensing and
administration of drugs.
Types
Prescribing errors:
It happens when a prescriber recommends a wrong drug,
dosage form, dose and/or amount of medicament.
Omission errors:
It happens when a patient or caregiver forgets to
administer dose till the next consecutive dose.
Wrong time errors:
It happens when the time of administration varies than
scheduled.
Unauthorized drug errors:
It happens when the patient is taking other forms of
16. Improper dose errors:
It happens when the case of over or under dosing is
followed.
Wrong dosage form errors:
It is the practice of taking dosage forms, other than
prescribed one. For example; tablets in place of syrups
Wrong drug preparation errors:
In case of combination therapy and extemporaneous
preparations, taking the drug with wrong compositional
proportion
Wrong administration technique errors:
Chewing of enteric coated tablets, swallowing of
sublingual tablets,
Compliance errors:
Not following the way as the drug is prescribed and
17. Essential components of pharmaceutical care
1. Pharmacist-patient relationship
Collaborative effort between pharmacist and patient is
needed for the provision of better pharmaceutical care.
Pharmacist should understand the patient's feelings and so
is the case with patients too, if they both are not in proper
coordination, then aim of care cannot be achieved.
2. Pharmacist's workup of drug therapy (PWDT)
Provision of pharmaceutical care is centered on this,
although the methods used for this purpose may vary.
The components are:
i. Data collection
It is to collect, synthesize and interpret relevant information.
Patient's demographic data; age, sex, race, etc.
Medical history
18. Dietary history
Medication history
Physical findings
Lab results
Patient complaints, symptoms and signs
ii. Develop or identify the CORE pharmacotherapy plan
C = Condition or patient need.
0 =Outcome desired for the condition.
R = Regimen selected (prescribed).
E = Evaluation parameters.
iii. Identify the PRIME pharmacotherapy problems
The goal is to identify actual or potential problems that
could compromise the desired patient outcomes
19. P = Pharmaceutical based problems.
R = Risk to patient.
I = Interactions.
M = Mismatch between medications and conditions or
patient needs.
E = Efficacy issues.
iv. Formulate a FARM/SOAP progress note to describe
& document the interventions intended or provided
by the pharmacist
F = Findings.
A = Assessment (the pharmacist's evaluation)
R = Resolution (including prevention).
M = Monitoring and follow-up (the parameters)
Or, SOAP is generally
20. S = Subjective finding
o = Objective finding
A = Assessment
P = Plan
21. Clinical skills and pharmacist's roles in pharmaceutical
care
i. Patient assessment
a. Physical assessment
b. Barriers to adherence
c. Psychological issues
ii. Patient education and counseling
a. Interview skills
b. Communication skills
c. Ability to motivate, inspire.
d. Develop and implement patient education plan based on
an initial education assessment.
e. Identification and resolution of compliance barriers
22. iii. Patient specific pharmacist care plan
a. Recognition, prevention, and management of drug
interactions
b. Pharmacology and therapeutics (innovative and
conventional)
c. Interpretation of laboratory tests
d. Knowledge of community resources, professional
referrals
e. Communication and report with community medical
providers
iv. Drug treatment protocols
a. Develop and maintain (update) protocols
b. Follow protocols as pharmacist clinician
c. Monitor aggregate adherence to treatment protocols
(e.g. drug evaluations, especially for managed care or
23. v. Dosage adjustment
a. Identify patients at risk for exaggerated or sub-
therapeutic response.
b. Apply pharmacokinetic principles to determine patient
specific dosing.
c. Order and interpret relevant tests at correct time intervals
to assess dosage adjustment. E.g. plasma drug conc.,
blood glucose levels
vi. Selection of therapeutic alternatives
a. Use drug information resources effectively.
b. Review and critique drug literature.
c. Construct comparative analysis to support decisions.
vii. Preventive services
a. Immunizations
b. Screenings
24. viii. Managerial skills
a. Plan, direct and implement pharmaceutical activities
within various environments, such as community
pharmacy, ambulatory care settings, practice inpatient
hospital practice and others.
b. Allocate resources.
25. Barriers to pharmaceutical care
Given below are the barriers to pharmaceutical care:
1. Pharmacist's attitudes
a. Lack of comprehension
b. Misconceptions
c. Fear of change
d. Lack of motivation
2. Lack of advanced practice skills
a. Therapeutics
b. Clinical problem solving
C. Communication skills
d. Documentation
e. Drug information
26. 3. Resource related
constraints
a. Time
b. Finance
c. Space
d. Personnel
e. Management
4. System related
constraints
a. Reimbursement
b. Patient demand
c. Acceptance by nurses
and physicians
d. Lack of data
5. Intra-professional
obstacles
a. Professional
relationships
b. Boards of pharmacy
c. Colleges of pharmacy
6. Academic obstacles
a. Lack of role models
b. Curricula
