2 Flashcards
What are the 4 types of medicines that are identified as high risk, and so useful for MURs
NSAIDs –> Adherance to gastric protection?
Anticoagulants (including LMWHs) –> APTT
Antiplatelets –> Possible GI Bleed (No aspirin!)
Diuretics –> Non-adherence is bad
Name some things that determine whether we monitor certain patients?
The drug they’re on –> Warfarin needed more than in paracetamol
Disease state –> Drugs like paracetamol are more important when being used in somebody with liver dysfunction, than in those with a healthy liver
Acute Disease –> More intensive than chronic diseases
Certain Patient Factors –> Eg, when pregnant, immunocompromised and the elderly
Whats the DOTS classification? In terms of adverse drug reactions
Dose Relatedness –> They can occur at 3 different levels…
Supra-therapeutic = Toxic levels
Therapeutic levels = Collateral (unintentional) effects
Sub-therapeutic = Hyper-susceptibility reactions
Time –> Can occur at anytime, but often due to changes in patient factors (such as renal function)
Susceptibility –> Varies due to patient factors (eg, age/gender/pregnancy/co-morbidities/drug interactions)
What is duty of candour?
A legal duty that tells us that we have to own up to our mistakes and be held responsible for them
What are the 4 guiding principles of Medicines Optimisation?
Aim to understand the patients experience
Evidence based choice of medicine
Ensure medicines use is as safe as possible
Make medicines optimisation a part of routine practice
What’s the difference between an adverse drug reaction, and an adverse drug event?
Drug Reaction –> A reaction that is reasonably attributable to the drug
Drug Event –> An event that occurs whilst a patient is taking a drug (but the drug isn’t necessarily the cause of the event)
What type of monitoring parameter does recording INR fall under?
Haemotological
How many of the 400 MURs a year must be done on targeted groups?
70%
What are the 4 Patient Orientated Outcomes (POOs)?
Reduction in side effect and medication errors
Better access to a large range of services
More effective use of medicines
Greater involvement in my own care with support when needed
What is Medicines Optimisation?
An approach to the quality use of medicines that aims to produce the best possible outcomes for patients and maximise the value from medicines
What are the 4 largest groups of drugs that cause ADRs?
Diuretics
NSAIDs
Warfarin
Antiplatelets
How long does it normally take an IV drug to reach the steady state?
4 half lives
What are the 4 Clinical Laboratory Services?
Clinical Biochemistry
Haematology/Immunology
Histopathology
Microbiology/Virology
What are the 2 types of contraindications?
Relative –> Caution should be used, but the drugs can be used if the benefits outweigh the benefits
Absolute –> The interaction could cause a life-threatening situation. This should always be avoided
What treatments should be given for somebody undergoing an anaphalactic shock?And why?
Adrenaline –> Reduces swelling, wheezing and increases BP
Steroids –> Reduction of inflammation and swelling
Antihistamines –> Reduces swelling and inflammation
IV Fluids –> Replaces fluids that are lost through leaky capillaries
Which group of drugs has caused the most ADRs?
NSAIDs
What are the 4 target areas for an NMS?
Hypertension
Anti-platelet/Anticoagulant
Type 2 diabetes
Asthma/COPD
<p>What is clinical governance?</p>
Audits Risk management Education and Training Openness R&D Clinical effectiveness
What are the conditions for a respiratory MUR?
Must be on 2 medications, with at least one being for asthma or COPD and on the list for an NMS
Medicines optimisation will offer a step change in how issues are addressed through….
Patient Engagement
A Focus on Outcomes
Pharmaceutical Leadership
A holistic view across the medicines pathway
When should a Post Discharge MUR be done?
4 weeks after discharge ideally…..but can be 8 weeks in certain circumstances
What are the main risk factors of the drug to patients, in reference to allergies?
Nature of the Drug –> Aspirin/Penicillins/anticonvulsants/antipsychotics
Degree of Exposure –> Occurs more for intermediate courses than of moderate doses
Route of Administration –> Oral safer than IV, but topical is more sensitising
Cross-Reactivity
What are the conditions for a cardiovascular MUR?
Patients with, or at risk of, CVD and on at least 4 medications
One of these medications must be for CVD, Diabetes or thyroid
What characteristics of a drug means we need to monitor drug levels in the serum?
When there is a large degree of inter-patient variability
Narrow therapeutic-index
Odd/unpredictable PKs
State the ABCDE classifications of adverse drug reactions
A = Augmented B = Bizarre C = Chronic --> Continuous exposure D = Delayed --> occurs a long time after exposure E = End of use
In medicines optimisation, what does QIPP stand for?
Quality
Innervation
Productivity
Prevention
To be competent, or have capacity to consent, a patient must be able to do what 4 things?
Understand the information that has been given
Believe the information
Be able to retain and weigh up the information to make a decision
Be free from any kind of duress (against their will) to make the decision
Who can report ADRs to the MHRA? (yellow card scheme)
Anyone!
What’s the difference between Allergy and Intolerance?
Allergy –> When an immune system react to substances in the environment that are harmless to most people
A type B (Bizarre) hypersensitivityIntolerance –> When somebody has a lower threshold to the normal pharmacological action of a drug
A type A (Augmented) hypersensitivity
Which is the most frequent type of prescribing error?
Dosage errors
What was found to have the greatest impact on dispensing errors?
Workload
What is Part XVIIIA?
The black listThese items cannot be prescribed/dispensed on the NHS
What are the 3 different categories for drugs in Part VIIIA?
Cat A –> Drugs that are readily avaliable
BB is allowed for smallest pack size of over £50
Cat C –> Priced on basis of drugs that are not readily available as generics
BB is allowed
Cat M –> Readily available drugs which the department of health determines the reimbursement price
BB is allowed
What are the 4 criteria that a pharmacy must adhere to, to qualify for the quality payment scheme?
Offering MUR/NMS
NHS Choices entry for pharmacy must be up-to-date
Pharmacy staff must be able to send/receive NHS emails
EPS2 must be being used ongoing
A script for 105ml of amoxicillin oral suspension comes into your pharmacy. If you only have bottles of 100ml avaliable….what quantity do you supply?
200mlThis is because you have to fully supply the script, and the NHS BSA will pay you for the full 200ml, not just the 105ml on the Rx
When would a script be endorsed as NCSO?
When a drug (in part VIII) cannot be obtained for a reason, and so a more expensive version needs to be bought instead….like a branded version (above the price stated in the drug tariff)NCSO = No cheaper stock avaliable
Which part of the Drug Tariff states the ‘Basic Prices of Drugs’?
Part VIIIA
What is the Selected List Scheme (SLS)?
When certain drugs can be given on an FP10, when normally blacklisted, under specific circumstancesEg, Clobazam for epilepsy
What is Part IX?
AppliancesAll are out unless stated…. so specific dimensions are needed for things like dressings
What are the 2 lists included in Part XV Borderline substances?
List A –> Products and conditions for what each product can be used for (alphabetical index of products)
List B –> Conditions and what products can be used (alphabetical index of conditions)The script should have been endorsed with ACBS by the prescriber
Give a couple of examples of drugs that dont have their discount (from the manufacturer) deducted via the NHS
Immunoglobulins Insulins for injections Vaccines Cold Chain storage items Sch 1/2/3/ CDs
When would a script be endorsed with BB?
BB = Broken BulkThis would be done when the quantity on the Rx is less than the minimum amount that can be ordered from the supplier. This is usually for an unusual product that you won’t supply again.So you still get paid for the stock that is left over, that otherwise wouldnt be used. You cannot claim this for another 6 months on the same product (as it is assumed you’ve used the left over quantitiy to supply any more scripts)
When would a script be endorsed with XP or OOP?
XP/OOP = Out of pocket
This would be done in exceptional circumstances when there has been a high cost to get a product in that is not often dispensed (eg, delivery charges for specials)The cost must exceed 50p
What do you need to keep CDs in a non-regulation storage container (eg, a safe or gun locker)?
An exemption certificate
How many months worth of CDs are you allowed to take abroad without a licence?
3 months
What are the 3 drugs that can be prescribed for addiction that require the Dr to have a specific licence?
Diamorphine, Cocaine and Dipipanone (and salts)
What class of CD do you need to obtain an extra licence (from the home office) for to supply/possess?
Class 1
What class of CDs do you need to add to the CD register?
Class 1 and 2Also Savitex (Sch4 part 1) due to cannaboid nature
What is the maximum duration of a drug that can be prescribed on FP10MDA?
14 days
What is the name of the script/form that is legally needed for requisitions of Sch 2/3 drugs in the community?
FP10CDF
Which schedule drugs have limited restriction on import/export?
Sch 4(II) dont need a licence for patients to import/exportSch5 have zero restrictions
Who is the only person that is allowed to grant a licence for somebody to possess, supply, manufacture, import or export control drugs?
The secretary of state
What common requirment for a prescription is not needed for a CD requisition?
No date required!
When are the 2 exceptions that a pharmacist can possess a class 1 drug without a licence from the home office?
For destructionFor handing over to the police
Why would you add a fixed weight to studies in a meta analysis?
So thay bigger studies have a greater influence
What is an non-inferiority design?
When a RCT is done to see if a drug is ‘not inferior’ to the standard treatment
When would you add ‘random effects’ to a meta analysis?
When there is significant heterogeneityThis accounts for inter-study variability
What do opportunity costs refer to?
Benefits that could have been received but that were given up in order to take another course of action
Define health economics
The study of attempts to allocate limited health care resources among unlimited wants and needs to achieve the maximum benefit for society
Should you document an answer for a questions that has been asked?And why?
YesTo demonstrate that you have used reliable sourcesIn case of a complaint (over your own back)In case the same question is asked againSo others can see
What is a PICO question?
Patient and problem
Intervention
Comparison
Outcome
What is the Crossover type of RCT?
A person will try out both treatments to see which is most effective
Can’t use a drug that could cure a disease….as then they wouldn’t need the other drug!
In economics, what is the other word given for satisfaction?
Utility
What is diminishing marginal utility?
This is the theory that there comes a point where a products cost no longer provides enough satisfaction (utility) to the person specifically
What is an Incident Rate Ratio?
Where the incidence in the exposed group is divided by the incidence in the group that isn’t exposed to the treatment (placebo)The ratio is compared to 1
What is a confidence interval?
A range of values in which we can be confident includes the true valueSE = Standard error
What is a meta-analysis?
A statistical method for combining the results of a number of studies
What is the ‘Willing to pay approach’?
A type of cost-benefit analysis that’s used to compare the outcomes of medical interventions in monetary terms
So how much would somebody pay to extend their lives by 2 years….If their expectancy was 54……or 95……
The persons who’s 54 is more likely to pay
How do you test for heterogeneity for meta-analysis?
Cochran’s Q testFinds if there is a significant difference between each study’s odds ratio and the fixed effects odds ratio
What’s difference between Intention to Treat and Per-Protocol analysis?
Intention to Treat –> The analysis includes everybody in the trial, including those who didn’t comply properly (eg, drop out)
Per-Protocol –> Only includes those who fully complied with the drug/rules
Which type of meta analysis will give smaller studies a greater relative weight?
Random Effects Model
What are the two types of blinding that can occur in RCTs?
Double blind –> Neither the Dr or patient knows which group has what
Single Blind –> Either the patient or Dr doesn’t know what they’ve got
A good example is for surgery….as the surgeon needs to know whats going on!!
What is ICER?
Incremental Cost-Effectiveness RatioUsed when comparing 2 different treatments
What are the key points in the 3 stages of clinical trials?
Stage 1 –> Generates PK/PD data
Stage 2 –> Patients given the drug. small study of efficacy
Stage 3 –> Evaluate toxicity and efficacy
What is a QALY?
Quality-Adjusted Life YearsThe number of years lived * utility
What does a p-value under 0.05 mean?
The null hypothesis is rejected
With the null hypothesis being that any difference is caused by sampling/experimental errors…….So a low p-value means that theres a high probability that the result (in the study) is significant
What is the main reason for randomised controlled trials?
To eliminate confounding (bias) and to test for efficacy
What is cost-effectiveness?
The most cost-effective intervention is the one with the greatest effectiveness for the lowest cost
Only NHS costs are consideredBelow the line is best!! (see image)
What’s the difference between surrogate endpoints and clinical endpoints?
Clinical –> Reflects the survival or symptomatic status of a patient (eg, has the treatment fully worked?)
Surrogate –> Certain biomarkers, like BP/tumour size, are decreased (or start changing for the good). This isn’t always correlated with clinical endpoints, but can often show that the drug is on its way to achieving the clinical endpoint
What assumption should be made when undergoing cost-minimisation analysis?
That the effectivness of the treatments are equal
What are the 4 stages of answering a medicines information enquiry?
Understand the questions
Carry out your research
Prepare your answer
Feedback your answer
What are the weaknesses of FMEA?
Different teams won’t always have the same analysis
Very time consuming
Little guidance on interventions
Name 5 different Proactive Risk Managment Techniques
Data Collection
Task Description
Task Simulation –> Eg, SIM Man
Human Error Identification and Analysis –> FMEA
Human Error Quantification –> Probability of an error
What are the 6 stages in ‘Faliure Modes and Effects Analysis’ (FEMA)?
1 –> Graphically describe the process
2 –> Identify failure modes
3 –> Assign each failure modes to the causation model (eg, lapses/slips/violations/mistakes)
4 –> Design Interventions for failure modes (eg, what to do to prevent slips/lapses etc)
5 –> Identify outcome measures for interventions (eg, near miss sheet)
6 –> Implement and monitor interventions
What type of ‘Unsafe Acts’ can occur?
Unintended Action –> Slip/lapse/mistake
Intended Action –> Mistake/violation
What is FMEA?
Failure Modes and Effects Analysis
A systematic method, carried out by teams, to identify and prevent process errors and product problems before they occur
What is Root Causes Analysis?And what are the 6 stages?
A structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate them
1 –> Gathering information about the incident
2 –> Mapping the information
3 –> Identifying problems
4 –> Analysing contributory factors (eg, why? questions)
5 –> Determining the root causes
6 –> Developing recommendations and implementing solutions
What’s the difference between Proactive and Reactive risk management?
Proactive –> Before the mistake has occurred (eg, FMEA)
Reactive –> After the mistake has occurred (eg, root cause analysis)
Describe Reasons’ Swiss Cheese Model
Every organisation will have a set of ‘barriers’ to prevent mistakes, however if a specific set of things all happen at once then mistakes (organisational losses) can still happen (eg, fit through the holes in the cheese)
Resident Pathogens (latent conditions) –> Decisions made by management that can cause mistakes more common
Unsafe Acts/Failures –> Things done by people carrying out the task
What are the 2 types of ‘Resident Pathogens’ within a system?And what are the 5 different factors?
Error provoking conditions & Long lasting weaknesses
Work Environment –> Eg, high workload/stress
Team –> Eg, poor communication
Individual/Staff –> Eg, lack of knowledge
Task –> Eg, test results not being available
Patients –> Eg, a distressed patient/language problems
What do the following stand for?MRCP MRCS FRCGP DRCOG BMA
MRCP –> Member of the Royal Collage of Physicians
MRCS –> Member of the Royal Collage of Surgeons
FRCGP –> Fellow of the Royal Collage of General Practitioners
DRCOG –> Diploma of the Royal Collage of Gynaecologists
BMA –> British Medical Association
What POMs can a optometrist supply?
Eye drops with the API of chloramphenicol under 0.5%
Eye ointments with under 1% of Chloramphenicol, Cyclopentolate hydrochloride, Fusidic acid or Tropicamide
What is the purpose of Health Education England (HEE)?
To help improve the quality of care by ensuring our workforce has the right numbers, skills, values and behaviours to meet the needs of patients
What is a VMP?
Veterinary Medicinal Product Any substance (or combination of products) that have properties that can treat or prevent disease in animals
List the veterinary cascade
An Authorised Veterinary Medicine for the condition in the species
The same condition in another species or a different condition in the same species
A product licensed for use in humans or a veterinary medicine from the EU (with an special import certificate)
Extemporaneous preparation
What are the nine domains of the RPS Pharmacy Leadership Framework?
Inspiring shared purpose Leading with care Evaluating information Connecting our service Sharing the vision Engaging the team Holding to account Developing capability Influencing for results
What do the following stand for?POM-VPOM-VPSNFA-VPSAVM-GSL
POM-V –> Veterinarian
Clinical assessment needed before supply can occur
POM-VPS –> Vet, Pharmacist and Suitably Qualified Person
NFA-VPS –> for Non-Food producing Animals
Don’t always need a prescription
AVM-GSL –> Authorised Veterinary Medicine
What did The Francis Report look into?
Widespread failings across mid-staffs
Found a culture of secrecy and defensiveness
Emphasised that patient focus was key
What drugs may a midwife possess for use?
Diamorphine, morphine, pethidine and pentazocine
Only supplied against a signed order by a doctor
What did The 5 Year Forward View talk about?
A new shared vision of care for the NHS based around models of care
What the NHS needs to do to close the widening gaps in the health of the population
What kind of advertising can be done for vetinary products?
None to the public!!POM-V/VPS can be as long as they are aimed at professionals
What did The Berwick Report relate to?
Improving patient safety in the NHS
What can dentists prescribe?
Only under the formulary on FP10D
On private scripts they can prescribe anything, but down to the discretion of the pharmacist
How long should veterinary documents be kept for?
5 years
What class of control drugs can’t doctors/dentists prescribe in the EEA/Switzerland for dispensing in the UK?
Sch 1/2/3
What can Nurse/Pharmacist independent prescribers, prescribe?
Any medicines, for any condition, as long as within their competence
Including any Sch2-5 drugNOT diamorphine, cocaine or dipipanone for the treatment of addiction
What kind of POMs can optomitrists obtain for use in their practice…..but NOT sell/supply
Amethocaine hydrochloride
Lignocaine hydrochloride
Oxybuprocaine hydrochloride
Proxymetacaine hydrochloride
So basically things with a suffix of -caine
Can Independent Optomitrist Prescribers prescribe a CD?Can they request emergency supplies?
No
Yes….but obviously not for anything
What is the Health and Care Proffessions Council?
The council responsible for 16 different professions, such as physios/paramedics/radiographers
Define Adherence, Concordance and Compliance
Adherence –> The extent to which the patient takes their medication as prescribed
Initiation –> Implementation –> Persistance –> Discontinuation
Concordance –> Process of shared decision making about treatment
Compliance –> Old fashioned term that implies that the patient should just do what the Dr tells them!
How could the social learning theory be used to explain why people start smoking?
Modelling/observing others smoking
Reinforcement –> Eg, social opportunitiesVicarious
Reinforcement –> Eg, people thinking that they look cool by smoking (seeing others being rewarded for smoking)
What’s the difference between Sensation and Perception?
Sensation –> The process by which stimuli affect sensory organs
Perception –> How we make meaning of sensation
What are the 4 key components of self-management?
Support for patients health behaviours
Reducing distress and increasing coping
Helping patients to manage their healthcare team
Education about their condition and how to find more information
What are some of the positive aspects of a diagnosis?
Access to treatment/social support
Relief after periods of uncertainty
Practical benefits –> eg, benefits/mitigating circumstances/sick leave
What can chronic stress do to the body?
General Alarm Stage –> Reduction in fat tissue, liver/lymph size, fall in body temp
Resistance stage (48 hours+)–> Homeostasis returns, with the adrenal glands enlarging…causing a reduction in pituitary secreted hormones
Exhaustion –> When stress is repeated
What is Kubler-Ross’s 5 stage model of grief?
Denial –> shock
Anger –> why me?
Bargaining –> if I do this maybe i’ll get more time?Depression
Acceptance –> my time has come
What are SMART goals?
Specific Measurable Achievable Results focused Time bound
What is cognitive dissonance?
When peoples behaviour is inconsistant with their beliefs and attitudes
What are some of the barriers to using contraception (eg, condoms)?
Religious/cultural values –> eg, catholics
Unrealistic optimism on contracting an STI
Beliefs that it reduces sexual pleasure
What’s the difference between Distal (distant) influences and Proximal influences?
Distal –> Demographic influences, which cant be changed easily
Proximal –> Somebodies attitudes and/or beliefs that can cause certain behaviours…..these can be changed more easily
What are the 2 types of change talk?
DARN CATS
Preparatory –> Desire, Ability, Reasons and Need
Mobilising –> Commitment, Activation and Taking Steps
What are the 4 factors that contribute to unrealistic optimism?
Lack of personal experience of the problem
Belief that the behaviour is controllable
Belief that the problem has not yet occurred, and so it never will!
Belief that the problem is infrequent
What are monitors and blunters?
Monitors –> Direct more attention to themselves, so feel more sympathy
Blunters –> Direct less attention to their body, avoids and minimises threats etc
What’s the difference between a Health Risk Behaviour and Health Enhancing Behaviour?
Health Risk Behaviour –> Any activity undertaken by people with a frequency or intensity that increases risk of disease or injury
Health Enhancing Behaviour –> Activity that may help prevent disease, detect disease and disability at an early stage, promote and enhance health or protect from risk of injury
What is Exploring Decisional Balance?
The motivational interviewing technique used when somebody is ambivalent, so they can see both the pros and cons of the behaviour
What are some of the ways of identifiying non-adherance?
Checking the PMR for when medication was last collected
Patients can take questionnaires
Technologies that allow electronic records of when medication is taken
In reflective listening, what does OARS stand for?
Open ended questions
Affirmations
Reflections
Summarising
What are some of the techniques used to address non-adherance?
Dossette box/compliance aids
Electronics –> Remind you when to take (eg, texts)
Visual Aids (see picture)
What is the Biopsychological Model? (in reference to pain)
A combination of Biological, Psychological and Social Factors that lead to seeking of treatment
In the case of pain, the pain feeling is gated by other sensory inputs and psychological factors
What are the 4 processes used in motivational interviewing?
Engaging –> Focussing –> Evoking –> Planning
Explain the model of unitentional and intentional nonadherance?
Unintentional –> Practical barriers that prevent patients from being compliant
Intentional –> A conscious decision not to take the treatment
Middle Bit –> When there is a conscious decision not to make treatment a priority…so they let certain barriers be the priority
What are the 2 different types of accountability?
Personal –> Internal and personal (eg, our conscience/duty to ourselves)
Professional –> Members of a profession claim particular knowledge and expertise that had to be proven to get on the register (so you are accountable for those qualities)
What’s the difference between an ad hominem argument, and a tu quoque argument?
Ad hominem –> An attack against the particular person that is intended to discredit what they say
Tu quoque –> A method used to reflect or deflect from the argument that the person is trying to make (you too argument)
What is Beneficence/Non-maleficience?
Acting in ways that benefit a patient –> their cares and interests”Do good if you possibly can, but above all do no harm”
What is the 4 stage approach? (in terms of decision making)
Gather relevant facts
Prioritise and ascribe values
Generate Options
Choose an option
What are the 3 stages of Kohlbergs stages of moral reasoning?
Pre-conventional –> Based on self interest (eg, obeys rules to avoid punishment)
Conventional –> Being a ‘good boy’ and conforms to social norms to gain appraisal and prevent being disliked
Post-conventional –> Conforms to democratic law and concepts of individual rights
What are the 3 types of ethics?
Deontological Ethics –> Duty based, so you stick to the law and don’t think of the consequences.
Duty is more important than the outcome
Consequentialist Ethics –> Main consideration is favouring the action that will lead to the best consequence or result
“The needs of the many outweigh the needs of the few”
Virtue Ethics –> Always do what is best for the patient
What are the 3 different types of Morality?
Duty Based –> As pharmacists you are expected to morally act in the 9 ways that the GPhC lays out
Goal Based –> Internal motivations to use one’s knowledge and skills to better the lives of as many people as possible
Virtue Based –> Ones own personal values (eg, Honour/Integrity/Confidentiality/Empathy/Compassion)
What is the Georgetown Mantra? (Key moral concepts of healthcare)
Beneficence –> Act in ways to benefit the patient
Non-Maleficence
Respect for Autonomy –> The right for the patient to make their own decisions/pursure their own actions
Justice –> In healthcare this means the distribution of resources correctly
What are the 3 main types of terms used in professional accountability?
Responsibility –> Your job is to do a specific task (nothing more)
Accountability –> Your job is to achieve a specific outcome, and you can be blamed for failure of this
Liability –> Can be called to account in law and possibly punishment if the failure lead to harm
