Pharmacy Practice

1 Induction
Journey of the Patient
Dr Angela MacAdam
Pharmacy Practice
2 Induction
Stages of the journey
Diagnosing
Prescribing
Dispensing
Monitoring
Consulting
Pharmacy Practice
3 Induction
Diagnosing
The minute you walked in the door . .

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4 Induction

A twelve year old boy and his mum ...
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5 Induction

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6 Induction
How can I help?
Complaining of . . . .
Listen to the patient's story
90% of the process of diagnosis comes from
the history


Pharmacy Practice
7 Induction
Pharmacists Approach
Mnemonics
WWHAM
ASMETHOD
ENCORE
SIT DOWN SIR

Read Introduction to Community Pharmacy by
Paul Rutter

Pharmacy Practice
8 Induction
Past Medical History

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9 Induction
Family History
Sometimes family
history gives us
a clue . . .
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10 Induction
Social History
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11 Induction
Drug History
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12 Induction
Lets have a look at you . .
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13 Induction

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14 Induction
Pitting in psoriasis
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15 Induction
Oral Candidiasis
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16 Induction
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17 Induction
Vital signs
Pulse
Temperature
Blood Pressure
Blood sugar
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18 Induction
Investigations . . .
Blood/urine tests
haematology
biochemistry
Immunology
Infection screen
Cytology/Histology
X Rays
Scans, ultra sound, MRI etc






Pharmacy Practice
19 Induction
Differential diagnosis
History
Observation
Examination
Investigations

The process of weighing the probability of one
disease versus that of other diseases possibly
accounting for a patient's illness.

Pharmacy Practice
20 Induction
Most common medical intervention in
patient care
Drugs costs account for a significant
amount of NHS expenditure
Approx 8.2 billion / year (doubled over last 10 years)
DH 2008


Prescribing
Pharmacy Practice
21 Induction
Maximise effectiveness
Achieve therapeutic aim in suitable timescale
Minimise risks
Managing side effects vs. benefits
Minimise costs
Respect and include patient choice
Lifestyle
Evidence Based Medicine
Good prescribing practice
Pharmacy Practice
22 Induction
Medical practitioners / Doctors
Dentists
Non-medical prescribers:
Supplementary
Independent

Who can prescribe medicines?

Pharmacy Practice
23 Induction
Pharmacists, nurses and other HCP e.g.
podiatrists, physiotherapists
Do not diagnose
Repeat Rx and monitor under supervision of
independent prescriber
Work under a detailed Clinical Management
Plan for a named patient who shares in the
decision making

Supplementary prescribers
Pharmacy Practice
24 Induction
Pharmacist, Optometrist and Nurse
Take full responsibility for the patient
Not acting under direction of another
prescriber
Can prescribe any medicine, almost, for any
condition within their competence
Independent prescribers
Pharmacy Practice
25 Induction
Must be qualified prescriber!
1. Collect information see diagnosing
2. Analyse information and make a
prescribing decision
3. Make appropriate records
4. Monitor
Prescribing process
Pharmacy Practice
26 Induction
Interpret and analyse patients signs, symptoms
and any results (part of diagnosis)
Consider treatment options (may not include
medication)
Concurrent disease and medications
Involve the patient
Side effects vs. Benefits
Lifestyle
Ask questions

2. Prescribing decision

Pharmacy Practice
27 Induction
Once class of drug decided upon
Choose specific drug and formulation
Dose
Duration
Short course (antibiotics)
Longer (when next monitoring required)
Do they pay for their Rx?
Likely to overdose / ADR?
BNF
Local / national guidelines

2.cont. Choosing the drug
Pharmacy Practice
28 Induction
Document in medical notes
Drug, duration and dose
Review and monitoring plan
Follow up GP / IP /Hospital?
Document drug allergies, inc type of reaction and
date
Report all ADRs

Electronic prescribing will automatically save
record of Rx

3 & 4. Recording and monitoring
Pharmacy Practice
29 Induction



Cheapest?
What is new on the market?
Design and colour of tablets?

How do prescribers choose
what drug to prescribe?
Pharmacy Practice
30 Induction
Closing the gap between research and everyday
practice to ensure clinical decisions are based on the
best available scientific evidence

Compare evidence for different treatment
options
Clinical trials
New drug and outcomes
Drug A vs. drug B
Guidelines
NICE

Evidence based medicine
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31 Induction

Chapter 10: Understanding and interpreting prescriptions in
Foundations of Pharmacy Practice by Whalley, Fletcher, Weston, Howard
and Rawlinson

Dispensing
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32 Induction
What is a prescription?
Legal message from prescriber to dispenser to
provide a patient with a medicinal product.
Legal requirements
Unique patient identification, prescriber
identification, details of drug, signed and dated
Legal classifications
P and GSL dont legally need a prescription BUT
you wouldnt get paid on NHS without one.
POM legally required
4:08:04 PM
Pharmacy Practice
33 Induction
What types of prescription are there?
NHS
Doctor
Dentist
Other prescribers
Private
Doctor
Dentist
Vet
Hospital

4:08:04 PM
Pharmacy Practice
34 Induction
How to find your way around a
prescription
Name and
address of
patient
Age (legal
requirement if
under 12)
Endorsement box
(to tell the pricing
authority what you
have supplied to get
the right payment)
Name of
drug, dosage
form,
strength, how
to use and
quantity
Prescribers signature
Relevant date. Either
the date the
prescription was
written or the date
after which the
prescriber wants the
drug supplied
Prescribers name and
address and NHS number
Number of days supply
4:08:04 PM
Pharmacy Practice
36 Induction
Latin Abbreviations
O = one e.g. od = one daily
b = two e.g. bd = twice a day
t = three e.g. tds or tid = three times a day
q = four e.g. qds or qid = four times a day
Nb qqh = every four hours
Mane = morning, e.g. 1 mane = one in the
morning
Nocte = night, e.g 1 nocte = one at night.

4:08:04 PM
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37 Induction
Abbrev. Contd.

ac = (ante-cibum) = before food
pc = (post cibum) = after food
stat = immediately
im = intra muscular
iv = intravenous
4:08:04 PM
Pharmacy Practice
38 Induction
NHS
Patient seen by a prescriber under the NHS
(doesnt pay)
Prescriber writes a script on an NHS script form
Pharmacy dispenses it (if patient is not exempt
they pay one charge for each item)
Scripts sent to NHS Business Services Agency
(NHSBSA) at end of each month
NHSBSA calculate payment for drug plus
dispensing charge minus fees taken at the till


What is the journey of a prescription
4:08:04 PM
Pharmacy Practice
39 Induction
What is the journey of a prescription
Private
Prescriber seen as a private arrangement (pays)
Writes a prescription
Dispensed at pharmacy
Patient charged cost of drug, plus 50%(usually)
Prescription filed at pharmacy for two years
Record of prescription in prescription record book
4:08:04 PM
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40 Induction
MAIN POINTS OF DISPENSING
Necessary Checks
Legal
patient details
legal requirements
Clinical
product details and dosage and directions for
use
for drug interactions

4:08:04 PM
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41 Induction
MAIN POINTS OF DISPENSING
Necessary Actions
Produce appropriate label
Dispense correct product
Ensure correct patient given medication
Patient counselling
Disposal of Prescription
4:08:04 PM
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42 Induction



Labelling and picking

Right drug/right patient dispensing part 2
Chapter 12 : Labelling medicines in Foundations of
Pharmacy Practice by Whalley, Fletcher, Weston, Howard and
Rawlinson

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43 Induction
Why label medicinal products?
Identify
Inform
Warn
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44 Induction
What types of product
Direct from manufacturer sold straight to
public
Those you dispense
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45 Induction
Direct from manufacturer
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46 Induction
Tell you what it is Tell you how to use it
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47 Induction
Batch numbers and Expiry
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48 Induction
Warnings
Highly flammable
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49 Induction
Labelling Requirements for dispensed
Products
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50 Induction
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51 Induction
Dispensing Correct Product
Beware similar
Names
Packs
Strengths

Beware
Very busy times
Very quiet times
Other factors leading to greater chance of
error
Low Lighting
Little space
Insufficient staff
Distractions
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52 Induction
What can go wrong?
Elizabeth Lee
http://www.dailymail.co.uk/news/article-1081069/Grandmother-cancer-died-Tesco-pharmacist-gave-
lethal-dose-wrong-drugs.html

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53 Induction

Monitoring
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54 Induction
Today
Safe use of medicines lecture - human error causing harm

Drugs causing harm
Yellow card scheme
Reporting
Adverse drug reactions
Role of the pharmacist
Therapeutic drug monitoring
Pharmacy Practice
55 Induction
Medicines and Healthcare products Regulatory Agency
Executive agency of the Department of Health
No product is risk-free
Responsible for assessing safety, quality and
efficacy (i.e. protect public/patients)
Issue licences for sale/supply of human
medicines/products in UK.

Pharmacy Practice
56 Induction
Drugs are discovered, undergo clinical trials
and are then licensed
Only most common ADRs are detected at
time of marketing
Post marketing surveillance
Reporting
Investigation
Monitoring




The Yellow card scheme
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57 Induction
The Yellow card scheme
Who can report to MHRA
NHS / Private healthcare professionals
Doctor, dentist, pharmacist, nurse, coroner
Patients and carers
By post / online
HCP - Voluntary reporting (problem!)
Drug companies have legal obligation to
report ADRs to MHRA

Pharmacy Practice
58 Induction
Newly licensed medicines
Shown in BNF
Monitored intensely by MHRA
New active substances
New route or delivery system
New indications
New combination of active substances
All suspected reactions involving a drug must
be reported (even if not serious)
Reported even if unsure that medicine caused the
reaction or the reaction is well recognised
Black triangle data is reviewed after 2 years

Pharmacy Practice
59 Induction
Established drugs and vaccines
Health care professionals must report all serious
suspected reactions
Fatal,
Life threatening,
Disabling or
Result in prolonged hospital stay, even if reaction well
recognised
E.g.- Anaphylaxis
Blood disorders
Jaundice and any drug interactions
Pharmacy Practice
60 Induction
Adverse drug reactions
An adverse reaction to a drug is defined as any
noxious or unintended reaction to a drug that
is administered in standard

doses by the
proper route for the purpose of prophylaxis,
diagnosis,

or treatment (BMJ 1998;316:1511-1514)

http://www.bmj.com/cgi/content/full/316/7143/1511?eaf

an unwanted side effect

Pharmacy Practice
61 Induction
Type A & B reactions
Type A
Augmented
pharmacologic effects
Dose dependent and
predictable
e.g. Insulin and
hypoglycaemia
- Warfarin and bleeding

Type B
Bizarre effects (or
idiosyncratic)
Dose independent and
unpredictable
e.g. tinnitus with use of
Aspirin
Amoxicillin and rash


Pharmacy Practice
62 Induction
Therapeutic drug monitoring (TDM)
Dosage of (some) drugs can be monitored by
measuring their plasma concentration


Drug

Therapeutic plasma
concentration range
Digoxin
1-2 mcg /L
Phenytoin
10-20 mg /L
Theophylline
10-20 mg/L
Gentamicin
(Pre)Trough <2mg /L
(Post) Peak 5-10mg /L
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63 Induction
Therapeutic window

Pharmacy Practice
64 Induction
Monitoring
Drugs with a narrow therapeutic window (TDM)
Digoxin etc
Dangerous drugs
WBC during chemotherapy
Interactions
Warfarin and amiodarone ( INR)
Efficacy
Blood pressure medication / BP

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65 Induction
Consulting for Pharmacists
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66 Induction
What types of communication are
there in a pharmacy?

Responding to Symptoms
Counselling after dispensing a prescription
Taking a drug history in the hospital

Pharmacy Practice
67 Induction
Traditionally, counselling is

Just telling the patient something about their
medicine

Examples:
Take it after food
Finish the course
May make you drowsy


Pharmacy Practice
68 Induction
Counselling or Consulting?
Unstructured

Telling what to do
Any problems?
Provide as much
information as possible
One formula for all
Structured
Gather data first
Assess patients
pharmaceutical needs
Close the knowledge
gap
Target individual
Pharmacy Practice
69 Induction
THE TITANIC OF CONSULTING (Davies, 1997)
HOW
& WHEN
PROVIDE
INFORMATION
OR REFER
ESTABLISH THE PATIENTS NEEDS
DATA COLLECTION
Drug history, Compliance assessment,
Patients knowledge, Understanding of illness,
Views about medicines, Perception of benefits
and risks,
Lifestyle, Past experiences
Pharmacy Practice
70 Induction
Calgary-Cambridge Model
Medical model from 1996 for consultation
Five Stages
Initiating the session
Gathering the information
Physical examination
Explanation and planning
Closing the session
Pharmacy Practice
71 Induction
Initiating the session
Greet the patient by name
Introduce yourself (full name & role)
Explain the purpose of the interview
Ask consent
Start to develop rapport

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72 Induction
Gathering the information

Information from prescription?
Drug indication?
Dose does patient take it?
Information from PMR?
Drug history reliability?

Pharmacy Practice
73 Induction
Information from the Patient?
A large amount of information comes directly
from the patient
What Information Do We Need From the
Patient?
Pharmacy Practice
74 Induction
Social/Family history
Patient-Centred Approach
Compliance assessment
Symptom patterns
Reasons for poor
compliance
Full drug history
OTC
Complementary
Allergy
Any test results
Prescribed
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75 Induction
Physical examination

See under diagnosis


Pharmacy Practice
76 Induction
Explanation and planning

Identify potential and real pharmaceutical
problems
Produce practical solutions
Prioritise
Discuss with patient so concordant
Provide information
Refer where necessary
Monitor outcomes
Document care plan

Pharmacy Practice
77 Induction
Closing the session

Summarise the discussion
Check patients understanding
Ask patient if there are any other questions
Thank patient for their time
Pharmacy Practice
78 Induction
Consultation Checklist
1. Do I know more now about the patient?
2. Was I curious?
3. Did I really listen?
4. Did I find out what really mattered to them?
5. Did I explore their beliefs and expectations?
6. Did I identify the patients main problems?
7. Did I use their thoughts when I started explaining?
8. Did I share the treatment options with them?
9. Did I help my patient to reach a decision?
10. Did I check that they understood what I said?
11. Did we agree?
12. Was I friendly?