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Walgreen Online Pharmacy-USA

WalGreen Online
Pharmacy Offering huge
Variety of USA-FDA
Approved Medications.

Health Care System

Composed of physician (including other medical and dental staffs), pharmacist ,
nurse and other paramedics
Physician ;



prescription*, dispensing, counseling, monitoring,

pharmaceutical care

Nurse ;

prescription, monitoring, medical care

administering, monitoring, nursing care

Other paramedics ; their own work

Load to physician & nurse ; high due to the system of "physicians are all in all in
hospital for the treatment of patient, with the help of nurse."

Concept of normal public/patient ; same

Perceptions of Pharmacists
How do others see us?

They just count a few tablets

They just weigh and measure things

A bunch of shop-keepers

Tell me how and when to use the



Not really health care practitioners theyre


Do you need a degree to be a pharmacist?

For practising Clinical Pharmacy

Competence of health care practitioners

-BPharm to Mpharm to PharmD*
-PharmD+ Pre-registration + registration

-Residency programs
-Continuing Professional Development

Informed general public increased expectation

Introduction; Clinical Pharmacy

Clinical pharmacy may be defined as the science and practice of rationale use of
medications, where the pharmacists are more oriented towards the patient care
rationalizing medication therapy promoting health , wellness of people.
It is the modern and extended field of pharmacy.
The discipline that embodies the application and development (by pharmacist) of
scientific principles of pharmacology, toxicology, therapeutics, and clinical
pharmacokinetics, pharmacoeconomics, pharmacogenomics and other allied
sciences for the care of patients.
(Reference: American college of clinical pharmacy)

Until the mid 1960s ; Traditional role.
The development of clinical pharmacy started in USA.
More clinically oriented curriculum were designed with the award of
PharmD degree.
These developments influenced the practice of pharmacy in U.K.,
Initially prescription and drug administration records were introduced followed
by an increasing pharmacy practice in hospital wards. Master degree programs
in clinical pharmacy were introduced for first time in 1976.
The progress of clinical pharmacy development remained at low profile in the
first decade after its birth in U.K. However, Nuffield report in1986 geared up the
momentum for progression of clinical pharmacy.

Until today, the clinical pharmacy practice in Nepal is in embryonic stage.

How does clinical pharmacy differ from pharmacy?

The discipline of pharmacy embraces the knowledge on
synthesis, chemistry and preparation of drugs

Clinical pharmacy is more oriented to the analysis of

population needs with regards to medicines, ways of
administration, patterns of use ,drugs effects on the
the overall drug therapy management.
The focus of attention moves from the drug to the single
patient or population receiving drugs.

Clinical Pharmacy Requirements

Knowledge of
drug therapy
Knowledge of
nondrug therapy

Knowledge of
the disease

Knowledge of
and diagnostic skills

Patient care

Drug Information




Level of Action of Clinical Pharmacists

Clinical pharmacy activities may influence the correct use
of medicines at three different levels:
Before the prescription
During the prescription
After the prescription is written.

1. Before the prescription

Clinical trials
Drug information
Drug-related policies

2. During the prescription

Counselling activity
Clinical pharmacists can influence the attitudes and priorities of
prescribers in their choice of correct treatments.
The clinical pharmacist monitors, detects and prevents the medication
related problems
The clinical pharmacist pays special attention to the dosage of drugs which
need therapeutic monitoring.

Community pharmacists can also make prescription decisions directly, when over
the counter drugs are counselled.

Medication-related Problems

Untreated indications.
Improper drug selection.
Subtherapeutic dosage.
Medication Failure to receive
Medication Overdosage.
Adverse drug reactions.
Drug interactions.
Medication use without indication.

3. After the prescription

Preparation of personalised formulation
Drug use evaluation
Outcome research
Pharmacoeconomic studies

Functions of Clinical Pharmacists

1. Taking the medical history of the patient

2. Patient Education
3. Patient care
4. Formulation and management of drug policies
5. Drug information

6. Teaching & training to medical and paramedical staff

7.Research and development

8.Participation in drug utilization studies
9.Patient counseling
10.Therapeutic drug monitoring
11.Drug interaction surveillance
12.Adverse drug reaction reporting
13.Safe use of drugs
14.Disease management cases

Define clinical pharmacy
Differentiate between traditional pharmacists role and
Clinical Pharmacist
Explain the qualification required for clinical pharmacists
List the clinical pharmacists responsibility
Describe the daily work activity of clinical pharmacists
Define what is Therapeutic Drug Monitoring
Discuss the different types of Therapeutic Drug

Clinical pharmacy specialists

Usually requires residency in a specialty area, in addition to a pharmacy practice
Job functions depend on the specialty and the institution
Usually has teaching and/or research responsibilities
Represent pharmacy for medication use meeting/committee in specialty areas

Clinical Pharmacy Practice areas

Ambulatory care
Critical care
Drug Information
Geriatrics and long term
Internal medicine and
Infectious disease
Nutrition Support

Investigational Drugs
Obstetrics and gynecology
Pulmonary disease
Nuclear pharmacy

Various ambulatory services

Anticoagulation Management
Cholesterol Management
Renal Management (CKD)
Oncology Services
Home Health Pharmacy Services
Impact Pharmacy Services (Drug Conversion Program)
Neonatal ICU
Hypertension Management
Integrated Coronary Vascular Disease (CVD)
New Member Program (assist new MD in prescribing NF
to formulary drugs)
Heart Failure Management
Asthma Management

Hospital Pharmacist Vs
Clinical Pharmacist

The service including clinical pharmacy/clinical pharmacist

-Patients get right care from all the facets (all the drug related problems can
easily be eliminated)
-Physicians n other health care professionals get more focused in their
own, work-load to them is low

-Patients feel more comfortable

"Every drug is poison, its the dose that differentiate poison or drug the
substance is."
"To kill ill by pill, not by bill"

The last person to be involved in health care team with the patient;
Pharmacist, so the system has to rely upon him/her.

The service without clinical pharmacy/clinical pharmacist

-Due to high load to physicians and other health care professionals,
the quality of patient care will be low
-Most of the drug related problems cannot be easily eliminated

-Patients may not feel comfortable

"In developing countries like Nepal; Physicians are incompetent, Nurses are careless,
Pharmacists dont know anything(??), System is corrupted, Public is foolish, Patient load is
high."...Prof Furqan Hashmi

"Medicine is for those who need them, not for those who want them."

"If your medicine is not working it may not be your medicine, it may be you"

Medicines are Dangerous

Pharmaceutical care
A practice in which a practitioner takes responsibility for a
patients drug related needs and holds him or herself accountable
for meeting these needs........ Linda Strand 1997
It describes specific services & activities through which an
individual pharmacist cooperates with patients and other health
care professionals in designing, implementing & monitoring a
therapeutic plan that will produce specific outcomes for the

Wherein the pharmacist is engaged in;

Drug monitoring,
Disease monitoring,
Drug therapy & disease management/collaborative practice
Pharmaceutical care is that component of pharmacy practice which entails the
direct interaction of pharmacist with the patient for the purpose of caring for
that patients drug related needs

Goal of Pharmaceutical Care

Goal of pharmaceutical care is to optimize the patients health-related quality
of life and achieve positive clinical outcomes, within realistic economic

Essential Components of Pharmaceutical Care

1.Pharmacist-patient relationship
Collaborative effort between pharmacist & patient

2.Pharmacists workup of drug therapy (PWDT)

Provision of pharmaceutical care is centered around this,
although the methods used for this purpose may vary.
Components are:
I.Data collection;
Collect, synthesize & interpret relevant information
Patients demographic data: age, sex, race etc.
Pertinent medical information

Medical history (current & past)

Family history
Dietary history
Medication history (prescription, OTC, allergies)
Physical findings (weight, height, B.P)
Lab results (serum drug levels, potassium levels, serum creatinine levels relevant
to drug therapy)
Patient complaints, symptoms & signs

II. Develop or identify the CORE pharmacotherapy plan

C = condition or patient need
O = outcome desired for that condition
R = regimen selected to achieve that outcome
E = evaluation parameters to assess outcome achievement

III.Identify PRIME Pharmacotherapy Problems

This includes pharmacist's intervention
The goal is to identify actual or potential problems that could
compromise the desired patient outcome
P = pharmaceutical based problems
R = risks to patient
I = interactions
M = mismatch between medication & condition or patient needs
E = efficacy

3.Documentation of pharmaceutical care

Formulate a FARM note or SOAP note to describe or document the
interventions needed or provided by pharmacist
FARM Progress Note
Description & documentation of interventions intended or provided by
F = Findings,
pt-specific informationgives basis for recognition of pharmacotherapy
problems or indication for pharmacist intervention.
A = Assessment,
The pharmacists evaluation of the findings, including a statement of:
Any additional information needed to best assess the problem to make
The severity, priority or urgency of the problem
The short term & long term goals of the intervention proposed

Short term goals: elimination of symptoms , Lowering of BP ,Management of acute

asthma without requiring hospitalization
Long term goals:Prevent recurrence of disease,Control B.P.,Prevent progression of
R = Resolution, including prevention
Observing & reassessing
Counseling or educating the patients & care givers
Informing the prescriber
Making recommendation to prescriber
Withholding medication or advising against use
M = Monitoring to assess the efficacy, safety & outcome of the intervention
This should include
The parameters to be followed (e.g. pain, depressed mood, serum levels)
The intent of monitoring e.g. efficacy, toxicity, adverse events
How the parameters will be monitored e.g. interview patients, serum drug
level, physical examination

Frequency of monitoringweekly or monthly

Duration of monitoring e.g. until resolved, while on antibiotics,then monthly for
one year
Anticipated or desired finding e.g. no pain, healing of lesion
Decision point to alter therapy when or if outcome is not achieved e.g. pain still
present after 3 days, mild hypoglycemia more than 2 times a week.
SOAP Note ;
This is used primarily by physicians,
S=subjective findings
O=objective findings

Clinical skills & pharmacists role in Pharmaceutical

Patient assessment
Physical assessment
Barriers to adherence
Psychosocial issues

Education & counseling

Interview skills
Communication skills (e.g. empathy, listening, speaking or
writing at patient's level of understanding)
Ability to motivate & inspire
Develop & implement patient education plan based on an initial
education assessment
Identification & resolution of compliance barriers

Patient Specific Pharmacist Care Plan

Recognition, prevention & management of drug interactions
Pharmacology & therapeutics
Interpretation of lab tests
Knowledge of community resources, professional referrals
Communication & support with community medical providers
Drug Treatment Protocol
Develop & maintain (update) protocols
Follow protocols as pharmacist-clinician
Monitor,aggregate adherence to the treatment protocols e.g. drug
utilization evaluation, especially for managed care or health
system facility

Dosage adjustment
Identify patients at high risk for exaggerated or
subtherapeutic response
Apply pharmacokinetic principles to determine patient
specific dosing
Prescriptive authority
In designated practice site and positions

Effective drug

What does the

patient view as an
improved quality of

quality of life

Will the patient take

the therapy?

Safe drug

Aims of

Economic drug

A case

44 year old lady with fever and green sputum and cough no known
previous medical history Diagnosed with URTI, 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?
History of 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?

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 ?

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
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

Elderly lady was 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).
Prescription for MTX 10mg/daily written and dispensed.
30th April patient dies.

Deaths from medicines in the UK

1999 - 2000 (ICD9 & 10 data)

A spoonful of sugar - Audit Commission (2001)

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 causes errors
Patients suffer adverse events much more often than previously
Errors often NOT immediately observed
The same error, even a minor one, can have quite different
consequences in different circumstances.

The System:
Only as safe as its designed to be!

I assumed the brown glass

ampoule was frusemide

The Accident Causation Model

(Adopted from Reason & Dean)



- Slips&lapses
- Mistakes



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

Lack of user education - actions to take.

Drug therapy assessment

Six types of problems which may result in treatment
: e
1.Inappropriate selection of medication
2.Inappropriate formulation of medication

3.Inappropriate administration of drug therapy

4.Inappropriate medication-taking behaviour


5.Inappropriate monitoring of drug therapy

6.Inappropriate response to drug therapy

Clinical Pharmacy Role in Reducing Risks

Admission medication history
Prescribing protocols
Allergy check
Prospective review
Administration instructions
Clinical pharmacy
Drug distribution system

For Error

What if we are not there!

Admission medication history

Prescribing protocols

Allergy check
Prospective review
Administration instructions
Clinical pharmacy
Drug distribution

For Error

Patient Assessment Questions

Does the patient need this drug ?
Is this drug the most effective and safe ?
Is this dosage the most effective and safe ?
If side effects are unavoidable does the patient need
additional drug therapy for these side effects?
Will drug administration impair safety or efficacy ?
Are there any drug interactions ?
Will the patient comply with prescribed regimen ?

To be a drug expert,society needs practitioners who ..

Todays pharmacists

Ideal Pharmacist Candidate?

Teamwork spirit
Good communication skills
Problem solver

The End

Any Questions?