Cp

Question 1

comprises a set of functions that promote the safe, effective and economic use of medicines for individual patients.

Answer 1

Clinical pharmacy

Question 2

has allowed pharmacists to shift from a product-oriented role towards direct engagement with patients and the problems they encounter with medicines.

Answer 2

• The emergence of clinical pharmacy

Question 3

• is generally an essential component of pharmaceutical care.

Answer 3

The practice of clinical pharmacy

Question 4

is a co-operative, patient-centred system for achieving specific and positive patient outcomes from the responsible provision of medicines.

Answer 4

• Pharmaceutical care

Question 5

• The three key elements of the care process are

Answer 5

patient assessment, determining the care plan and evaluating the outcome.

Question 6

• The ability to consult with_______is a key process in the delivery of pharmaceutical care and requires regular review and development regardless
of experience.
•

Answer 6

patients

Question 7

has been incorporated into a professional development framework that can be used to enhance skills and knowledge.

Answer 7

clinical pharmacy process

Question 8

, unlike the discipline of pharmacy, is a comparatively recent and variably implemented form of prac- tice. It encourages pharmacists and support staff to shift their focus from a solely product-oriented role towards more direct engagement with patients and the problems they encoun- ter with medicines.

Answer 8

Clinical pharmacy

Question 9

as a form of practice has been attributed to the poor medicines control systems that existed in hospitals during the early 1960s (Cousins and Luscombe, 1995).

Answer 9

The emergence of clinical pharmacy

Question 10

In the_______, the approach was to adopt unit dose dispens- ing and pursue decentralisation of pharmacy services. In the_______the unification of the prescription and the administra- tion record meant this document needed to remain on the hospital ward and required the pharmacist to visit the ward to order medicines

Answer 10

USA
UK

Question 11

Clinical pharmacy thereby emerged from the presence of pharmacists in these patient areas and their inter- est in promoting safer medicines use. This was initially termed _______but participation in medical ward rounds in the late 1970s signalled the transition to clinical pharmacy.

Answer 11

ward pharmacy

Question 12

Medication safety may have been the spur but clinical phar-macy in the ______grew because of its ability to promote cost- effective medicines used in hospitals. This role was recognised by the UK government, which, in ________endorsed the imple- mentation of clinical pharmacy services to secure value for money from medicines.

Answer 12

1980s
1988

Question 13

were necessary to aggregate large amounts of data in a reliable manner and many of these drew upon the eight steps (Table 1.1) of the drug use process (DUP) indicators (Hutchinson et al., 1986).

Answer 13

Coding systems

Question 14

Drug use process indicators

Answer 14

Need for a drug
Select drug
Select regimen
Provide drug
Drug administration
Monitor drug therapy
Counsel patient
Evaluate effectiveness

Question 15

Ensure there is an appropriate indication for each drug and that all medical problems are addressed therapeutically

Answer 15

need for a drug

Question 16

Select and recommend the most appropriate drug based upon the ability to reach therapeutic goals, with consideration of patient variables, formulary status and cost of therapy

Answer 16

Select drug

Question 17

Select the most appropriate drug regimen for accomplishing the desired therapeutic goals at the least cost without diminishing effectiveness or causing toxicity

Answer 17

Select drug regimen

Question 18

Facilitate the dispensing and supply process so that drugs are accurately prepared, dispensed in ready-to- administer form and delivered to the patient on a timely basis

Answer 18

Provide drug

Question 19

Ensure that appropriate devices and techniques are used for drug administration

Answer 19

Drug administration

Question 20

for effectiveness or adverse effects in order to determine whether to maintain, modify or discontinue

Answer 20

Monitor drug therapy

Question 21

Counsel and educate the patient or caregiver about the patient’s therapy to ensure proper use of medicines

Answer 21

COUNSEL PATIENTS

Question 22

Evaluate the effectiveness of the patient’s drug therapy by reviewing all the previous steps of the drug use process and taking appropriate steps to ensure that the therapeutic goals are achieved

Answer 22

Evaluate effectiveness

Question 23

comprises a set of functions that promote the safe, effective and economic use of medicines for individual patients.

Answer 23

Clinical pharmacy

Question 24

requires the application of specific knowledge of pharmacology, pharmacokinetics, pharmaceutics and therapeutics to patient care select drug select and recommend the most appropriate drug based upon the ability to reach therapeutic goals, with consideration of patient variables, formulary status and cost of therapy select regimen select the most appropriate drug regimen for accomplishing the desired
therapeutic goals at the least cost without diminishing effectiveness or causing toxicity

Answer 24

Clinical pharmacy process

Question 25

is a co-operative, patient-centred system for achieving specific and positive patient outcomes from the responsible provision of medicines. The practice of clinical pharmacy is an essential component in the delivery of pharmaceutical care

Answer 25

Pharmaceutical care

Question 26

encompasses the way in which medicines are selected, procured, delivered, prescribed, administered and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes of patient care

Answer 26

medicines management

Question 27

is dependent on the practice of clinical pharmacy but the key feature of care is that the practitioner takes responsibility for a patient's drug- related needs and is held accountable for that commitment.

Answer 27

delivery of pharmaceutical care

Question 28

has enabled pharmaceutical care to permeate community pharmacy, particularly in Europe, in a way that clinical pharmacy and its bedside connotations did not.

Answer 28

avoidance of factionalism

Question 29

Box 1.1 Categories of medication-related problems

Answer 29

Untreated indication Treatment without indication Too little drug Too much drug improper drug selection non-compliance Drug interaction adverse drug reaction

Question 30

are associated with significant morbidity and mortality. Preventable medication-related hospital admissions in the USA have a prevalence of 4.3%, indicating that gains in public health from improved medi- cines management would be sizeable (Winterstein et al., 2002).

Answer 30

MRPs

Question 31

, defined as pre- ventable events that may cause or lead to inappropriate medi- cines use or harm, in NHS hospitals has been estimated to lie between £200 and £400 million per year. To this should be added the costs arising from litigation (DH, 2004).

Answer 31

The direct cost of medication errors

Question 32

Recognition that many patients either fail to benefit or experience unwanted effects from their medicines has elicited two types of response from the pharmacy profession.

Answer 32

The first response has been to put in place, and make use of, a range of post- graduate initiatives and programmes to meet the develop- mental needs of pharmacists working in clinical settings. The second has been the re-engineering of pharmaceutical services to introduce schemes for medicines management at an organisational level.

Question 33

has served to improve the knowledge of clinical pharmacists but fully achieving the goals of pharmaceutical care has proved more challeng- ing.

Answer 33

Structured postgraduate education

Question 34

is predicated on a patient-centred approach to identifying, preventing or resolving medicine- related problems.

Answer 34

Pharmaceutical care

Question 35

has shown that self-management is promoted when patients more fully participate in the goal- setting and planning aspects of their care (

Answer 35

Research in chronic diseases

Question 36

In community pharmacy, one approach to help patients used their medicines more effectively is

Answer 36

medicines use review (MUR).

Question 37

Two goals of MUR are to

Answer 37

improve the adherence of patients to prescribed medicines to reduce medicines wastage.

Question 38

Key elements of the care process

Answer 38

Assessment Care plan Evaluation

Question 39

The main goal is to establish a full medication history and highlight actual and potential drug-related problems

Answer 39

assessment

Question 40

This should clearly state the goals to optimise care and the responsibilities of both the pharmacist and the patient in attaining the stated goals

Answer 40

Care plan

Question 41

This reviews progress against the stated patient outcomes

Answer 41

evaluation

Question 42

The ability of a pharmacist to_______effectively is fundamental to pharmaceutical care and this includes establishing a platform for achieving adherence/ concordance.

Answer 42

consult

Question 43

provide the pharmacist with a rigid structure to use when questioning patients about their symptoms but, although useful, serve to make the symptom or disease the focus of the consultation rather than the patient.

Answer 43

WWHAM, AS METTHOD and ENCORE

Question 44

Box 1.2 Mnemonics used in the pharmacy consultation process WWHAM

Answer 44

Who is it for? What are the symptoms? How long has it been going on? Action taken? Medicines taken?

Question 45

AS METTHOD

Answer 45

Age of the patient? Self or for someone else? Medicines being taken? Exactly what do you mean (by the symptom)? Time and duration of the symptom Taken any action (medicine or seen the doctor)? History of any disease? Other symptoms? Doing anything to alleviate or worsen the symptom?

Question 46

ENCORE

Answer 46

Evaluate the symptom, its onset, recurrence and duration. No medication is always an option. Care when dealing with specific patient groups, notably the elderly, the young, nursing mothers, pregnant women, those receiving specific medication such as methotrexate and anticoagulants, and those with particular disease, for example, renal impairment. Observe the patient for signs of systemic disturbance and ask about presence of fever, loss of weight and any accompanying physiological disturbance. Refer when in doubt. Explain any course of action recommended.

Question 47

Active listening Appropriate use of open and closed questions. Respect patient Avoid jargon Demonstrate empathy Deal sensitively with potentially embarrassing or sensitive issues

Answer 47

Box 1.3 Consultation behaviours

Question 48

Pharmaceutical consultation process

Answer 48

Introduction Data collection and problem identification Actions and solutions Closure

Question 49

Building a therapeutic relationship

Answer 49

Introduction

Question 50

Identifying the patient's medication-related needs

Answer 50

Data collection and problem identification

Question 51

Establishing an acceptable management plan with the patient

Answer 51

Actions and solutions

Question 52

Negotiating safety netting strategies with the patient

Answer 52

Closure

Question 53

Invites patient to discuss medication or health-related issue Discusses structure and purpose of consultation Negotiates shared agenda

Answer 53

Introduction

Question 54

Takes a full medication history Establishes patient's understanding of their illness Establishes patient's understanding of the prescribed treatment Identifies and prioritises patient's pharmaceutical problems

Answer 54

Data collection and problem identification

Question 55

Involves patient in designing management plan Tailors information to address patient's perception of illness and treatment Checks patient's understanding Refers appropriately

Answer 55

Actions and solutions

Question 56

Do i know more now about the patient? Was i curious? Did i really listen? Did i find out what really mattered to them? Did i explore their beliefs and expectations? Did i identify the patient's main medication-related problems? Did i use their thoughts when i started explaining? Did i share the treatment options with them? Did i help my patient to reach a decision? Did i check that they understood what i said? Did we agree? Was i friendly?

Answer 56

Key postconsultation questions

Question 57

The_________ role, therefore, is often one of providing information to the independent prescriber on the expected benefits and risks of drug therapy by evaluating both the evidence base and individ- ual patient factors.

Answer 57

pharmacist's

Question 58

also draw on these concepts as they become more involved in prescribing and adjusting therapy for patients under their care.

Answer 58

Pharmacists

Question 59

Factor of relvant patient details

Answer 59

Age Gender Ethnic or religious background Social history Presenting complaint Previous medical history Working diagnosis Laboratory or physical findings

Question 60

The very young and the very old are most at risk of medication-related problems. A patient's age may indicate their likely ability to metabolise and excrete medicines and have implications for step 2 of the drug use process

Answer 60

Age

Question 61

This may alter the choice of the therapy for certain indications. It may also prompt consideration of the potential for pregnancy or breast feeding

Answer 61

Gender

Question 62

Racially determined predispositions to intolerance or ineffectiveness should be considered with certain classes of medicines, for example, ACE inhibitors in Afro-Caribbean people. Formulations may be problematic for other groups, for example, those based on blood products for Jehovah's Witnesses or porcine-derived products for Jewish patients

Answer 62

Ethnic or religious background

Question 63

This may impact on ability to manage medicines and influence pharmaceutical care needs, for example, living alone or in a care home or availability of nursing, social or informal carers

Answer 63

Social history

Question 64

Symptoms the patient describes and the signs identified by the doctor on examination. Pharmacists should consider whether these might be attributable to the adverse effects of prescribed or purchased medicines

Answer 64

Presenting complaint

Question 65

This should enable the pharmacist to identify the classes of medicines that would be anticipated on the prescription based on current evidence

Answer 65

Working diagnosis

Question 66

Understanding the patient's other medical conditions and their history helps ensure that management of the current problem does not compromise a prior condition and guides the selection of appropriate therapy by identifying potential contraindications

Answer 66

Previous medical history

Question 67

The focus should be on findings that may affect therapy, such as renal function liver function full blood count blood pressure cardiac rhythm Results may convey a need for dosage adjustment or presence of an adverse reaction

Answer 67

Laboratory or physical findings

Question 68

is the part of a pharmaceutical consul- tation that identifies and documents allergies or other serious adverse medication events, as well as information about how medicines are taken currently and have been taken in the past. It is the starting point for medicines reconciliation and medi- cation review. Obtaining accurate and complete medication histories has been shown to have a positive effect on patient care and phar- macists have demonstrated that they can compile such histo- ries with a high degree of precision and reliability as part of medicines reconciliation.

Answer 68

A medication history

Question 69

is the part of a pharmaceutical consul- tation that identifies and documents allergies or other serious adverse medication events, as well as information about how medicines are taken currently and have been taken in the past. It is the starting point for medicines reconciliation and medi- cation review. Obtaining accurate and complete medication histories has been shown to have a positive effect on patient care and phar- macists have demonstrated that they can compile such histo- ries with a high degree of precision and reliability as part of medicines reconciliation.

Answer 69

A medication history

Question 70

may occur when a medicine has the potential to make a pre-existing condition worse. Older people are particularly vulnerable due to the co-existence of several chronic diseases and exposure to polypharmacy. Prevention of drug-disease interactions requires an understanding of the pharmacodynamic properties of medicines and an apprecia- tion of their contraindications.

Answer 70

drug-disease interaction

Question 71

may affect the action of other medicines in a number of ways. Those with similar mechanisms of action may show an enhanced effect if used together whilst those with opposing actions may reduce each other's effectiveness.

Answer 71

Medicines

Question 72

of one medicine can be affected by a second that acts as an inducer or inhibitor of the cytochrome P450 enzyme system.

Answer 72

Metabolism

Question 73

has extensive capacity for drug metabolism, even when damaged. Nevertheless, the degree of hepatic impair- ment should be assessed from liver function tests and related to potential changes in drug metabolism. This is particularly important for medicines that require activation by the liver (pro-drugs) or those whose main route of elimination is trans- formation into water-soluble metabolites.

Answer 73

liver

Question 74

Giving medicines via the____route is the preferred method of administration. Parenteral routes carry significantly more risks, including infection associated with vascular access. This route, however, may be necessary when no oral formulation exists or when the oral access is either impossible or inappro- priate because of the patient's condition.

Answer 74

oral

Question 75

Pharmaceutical considerations in the administration of medicines

Answer 75

Dose Route Dosage form Documentation Devices

Question 76

Is the dose appropriate, including adjustments for particular routes or formulations? Examples: differences in dose between intravenous and oral metronidazole, intramuscular and oral chlorpromazine, and digoxin tablets compared with the elixir

Answer 76

Dose

Question 77

Is the prescribed route available (is the patient nil by mouth?) and appropriate for the patient? Examples: unnecessary prescription of an intravenous medicine when the patient can swallow, or the use of a solid dosage form when the patient has dysphagia

Answer 77

Route

Question 78

Is the medicine available in a suitable form for administration via the prescribed route?

Answer 78

Dosage form

Question 79

Documentation Is documentation complete? Do nurses or

Answer 79

Documentation

Question 80

carers require specific information to administer the medicine safely? Examples: appropriateness of crushing tablets for administration via nasogastric tubes, dilution requirements for medicines given parenterally, rates of administration and compatibilities in parenteral solutions (including syringe drivers) Are devices required, such as spacers for inhalers?

Answer 80

Devices