Clinical Pharmacy

Dr. Hrishikesh N. Gupta,

Assistant Professor,
Government College of Pharmacy, Ratnagiri
Clinical Pharmacy
• “Pharmacist’s involvement in monitoring patient’s therapy and giving
advice which directly influence the decisions concerning drug therapy
and the way in which it is administered.”

• Active participation of the pharmacist in patient care with the long

term aim of giving advice on medication with an individual patient
in mind and tailoring the drug therapy for that individual

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Concept of Clinical Pharmacy

• Focuses on the direct interaction of pharmacists with patients and

healthcare providers.

• Optimize the use of medications and promote health and wellness.

• Clinical pharmacy is centered on ensuring that medications are used

effectively, safely, and appropriately for individual patients.

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
 Research and
Practice
Development

Clinical pharmacy Education Patient-

and Centered
integrates the science of Counselling Care
pharmacology with
clinical practice to Clinical
pharmacy
enhance patient care
and improve the Clinical
Collaborative
Decision-
healthcare system's Making
Practice
efficiency
Medication
Management

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Functions and Responsibilities of Clinical Pharmacist
• Medication Therapy Management (MTM) • Preventing Medication Errors
- Assessing Patient Medications - Reviewing Prescriptions
- Optimizing Drug Therapy - Promoting Safe Medication Use
- Preventing Adverse Drug Events (ADEs) • Medication Reconciliation
• Patient Counselling and Education - Reviewing Medication Histories
- Providing Medication Instructions - Ensuring Continuity of Care
- Promoting Adherence • Research and Evidence-Based Practice
- Answering Patient Questions - Conducting Research
• Collaborating with Healthcare Teams - Staying Updated with Drug Literature
- Interdisciplinary Communication - Teaching and Training
- Participating in Rounds • Public Health and Disease Prevention
- Protocol Development - Immunization Services
• Monitoring and Adjusting Drug Therapy - Health Promotion
- Pharmacokinetic Monitoring • Cost-Effective Care
- Adjusting Based on Lab Results - Pharmacoeconomics
- Managing Chronic Conditions - Formulary Management
• Specialized Areas of Practice 5
Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Drug therapy monitoring
• Medication chart review
• Clinical review
• Pharmacist intervention
• Ward round participation
• Medication history
• Pharmaceutical care

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Medication chart review
• Ensure the safe, effective, and appropriate use of medications
• Aims
- optimize drug therapy
- prevent medication errors
- identify potential issues such as drug interactions, contraindications, or
suboptimal dosing
• To be done…
- Upon Admission
- During Hospitalization
- At Discharge
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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Objectives of Medication Chart Review
• Ensure Accuracy
• Check for Drug Interactions
• Assess Appropriateness
• Monitor for Adverse Drug Reactions (ADRs)
• Check Dosing
• Assess the Need for Therapy
• Evaluate Compliance and Adherence
• Assess Timing and Administration

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Steps in Medication Chart Review
• Patient History Review
• Verify the Medication List
• Check for Duplication
• Check for Drug Interactions
• Assess Dosing
• Identify and Review Non-Pharmacological Therapies
• Monitor Laboratory Values
• Check Duration of Therapy
• Review Patient’s Symptoms and Complaints

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Benefits of Medication Chart Review
Improves
Patient Safety

Medication Enhances
Personalized Chart Treatment
Care Review Outcomes

Reduces
Healthcare
Costs

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Clinical Review
• A comprehensive assessment of a patient’s overall health status
• Goals
- evaluate a patient’s current medical condition
- review ongoing treatments
- ensure that the management plan is effective, safe, and appropriate
• Purpose
- To address patient’s clinical needs
- Analyze treatment progress
- Identify potential adjustments that may be necessary to improve health
outcomes
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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Key Components of a Clinical Review
• Patient History and Current Condition • Diagnostic Tests and Laboratory Results
- Review Medical history - Reviewing recent diagnostic tests
- Evaluate current health status - Identifying any changes in test results
• Review of Medications • Review of Therapeutic Interventions
- Medication Reconciliation - For desired clinical outcomes
- Assessing Adherence - Recommending adjustments or alternative
- Medication Efficacy and Safety treatments if necessary

• Physical Examination • Identification of Clinical Problems

- to assess the patient's current physical • Patient and Caregiver Involvement

state • Treatment Plan Review and Update
- Evaluating specific systems based on the
patient's symptoms 12
Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Types of Clinical Reviews
Routine or
Regular Clinical
Review

Post-Discharge Clinical Acute or Urgent

Clinical Review Reviews Clinical Review

Hospital Clinical
Review

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Importance of Clinical Review
• Optimizes Patient Care
• Prevents Complications
• Improves Patient Outcomes
• Enhances Communication
• Cost-Effective Care

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Pharmacist Intervention
• Any action or recommendation made by a clinical pharmacist aimed
at improving patient care, optimizing medication use, and ensuring
patient safety
• Need for intervention
- Incorrect or Incomplete Prescriptions
- Renal or Hepatic Impairment
- Hospital Admissions or Discharges
- Complex Chronic Disease Management
- Chemotherapy or Specialty Drug Management

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Pharmacist Interventions
• Medication Reconciliation during • Monitoring and Follow-Up
transition of care • Patient Education and Counselling
• Dose Adjustments • Preventing and Resolving
• Identifying and Resolving Drug Polypharmacy Issues
Interactions • Antimicrobial Stewardship
• Managing Adverse Drug Reactions • Optimizing Chronic Disease
(ADRs) Management
• Therapeutic Substitution • Preventing and Managing Drug
• Medication Adherence Support Shortages
• De-prescribing
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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Benefits of pharmacist intervention
• Improves Patient Safety
• Enhances Therapeutic Outcomes
• Reduces Hospitalizations
• Promotes Cost-Effective Care
• Improves Patient Satisfaction

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Ward round participation
• The active involvement of clinical pharmacists in multidisciplinary
ward rounds alongside physicians, nurses, and other healthcare
professionals.
• Pharmacists contribute their expertise on medication therapy
management that-
- help identify and resolve drug-related problems
- provide recommendations to optimize patient care
- leads to better treatment outcomes
- increase patient safety
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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Need of Pharmacist in ward round
• Polypharmacy
• Renal or Hepatic Impairment
• Chronic Disease Management
• Critical Care Patients
• Antibiotic Management

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
 Role of Pharmacist in Ward round
• Medication Therapy Optimization: • Monitor Lab Results and Clinical Data:
- Provide Medication Recommendations - Assess Lab Data
- Adjust Doses - Monitor Therapeutic Drug Levels
• Identifying and Preventing Drug-Related • Provide Education and Counselling:
Problems: - Educate Healthcare Team
- Detect Drug Interactions - Patient Counselling
- Prevent Adverse Drug Reactions (ADRs) • Antimicrobial Stewardship:
- Monitor for Side Effects - Optimize Antibiotic Use
• Medication Reconciliation: - Prevent Antibiotic Resistance
- Review Medication History • Discharge Planning:
- Verify Prescriptions - Prepare Discharge Medications
• Provide Evidence-Based Recommendations: - Transition of Care
- Review Treatment Guidelines
- Tailor Therapy to Patient-Specific Needs 20
Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Advantages of Pharmacist participation in ward round
• Improved Patient Safety
• Enhanced Treatment Outcomes
• Reduction in Healthcare Costs
• Collaborative Care
• Optimized Resource Use
• Promotes Education and Knowledge Sharing

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Pharmaceutical Care
• Pharmaceutical care is a patient-centered, outcomes-oriented
practice in which the pharmacist takes responsibility for a patient's
medication-related needs to improve their quality of life and health
outcomes.
• Involves the direct interaction of the pharmacist with both the patient
and other healthcare providers to
- ensure optimal medication use
- to prevent, detect, and resolve medication-related problems

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Objectives of Pharmaceutical care
• Improve Patient Outcomes
• Prevent and Resolve Drug-Related Problems
• Enhance Patient Quality of Life
• Ensure Cost-Effective Care

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Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
Steps involved in Pharmaceutical care
1. Assess the Patient:
o Review the patient’s medical history, medication list, laboratory results, and
current health status to identify any potential medication-related problems.
2. Develop a Care Plan:
o Create a personalized care plan that outlines goals for medication therapy,
taking into consideration the patient’s conditions, preferences, and lifestyle.
3. Implement the Plan:
o Work with healthcare providers to implement the care plan, which may
involve initiating, adjusting, or discontinuing medications.
4. Monitor and Follow Up:
o Regularly evaluate the patient’s response to therapy, adjusting the plan as
necessary to achieve optimal health outcomes.
o Address any new or ongoing medication-related issues as they arise. 24
Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri
 Components of Pharmaceutical care
• Medication Therapy Management (MTM): • Patient Education and Empowerment:
- Assessment - Counselling
- Plan - Empowerment
- Implementation - Lifestyle Guidance
- Follow-Up • Preventive Care:
• Identifying and Resolving Drug-Related - Health Screenings
Problems (DRPs): - Vaccinations
- Unnecessary Medications • Collaboration with Healthcare Providers:
- Wrong Drug - Multidisciplinary Approach
- Inappropriate Dose - Medication Reconciliation
- Adverse Drug Reactions (ADRs) • Documentation:
- Non-Adherence - Record Keeping
- Monitoring Outcomes 25
Pharmacy Practice - Dr. H. N. Gupta, GCOP, Ratnagiri