Hi

For 1st question" Are clinical pharmacy service included before first drug administering to the patients", plz check out the following attacged artile.

regards

http://www.uwhealth.org/quality-reports/the-pharmacists-role-on-the-patient-care-team/12224

For 3rd question"Are interventions written by clinical pharmacists to prescribers?"

you can see this link , might be useful.

Regards

https://www.ualberta.ca/~csps/JPPS8(2)/L.Emmerton/pharmacists.htm

In the "good old days," MDs prescribed, pharmacists dispensed, and RNs administered, AND ALL COMMUNICATED --as an MD, I liked having pharmacists and RNs pick up possible mistakes: managed care and HIPAA have made communication so difficult that this once time honored manner of assuring that patients received what had been ordered and/or that MDs were informed that their orders were 'suboptimal' is, unfortunately, compromised.  Technology (eprescribing, etc) can be a good thing, but we must figure out ways to make up for what's been lost by becoming more "efficient" and in the process losing human contact between patients/doctor/pharmacist/nurse.

Lewis A. Opler, MD, PhD

Our prescriptions are validated by a pharmacist team through assisted prescription software. This validation is to confirm or correct the original prescription. There is feedback to the prescriber about the appropriateness of the indication by telephone.

High-risk medication is marked on the screen of the prescriber, pharmacist and nurse with instructions for use and additional controls.

At all times, you can see who and when prescribed, when and who validates and who administers the medication.

A climate of patient safety it is necessary to create. Everyone involved must know the safety of the drug strategy.

Dear Dr. Lewis Alan Opler thanks for your comment. I agree with you that in "good old days," MDs prescribed, pharmacists dispensed, and RNs administered and everything was done. However, in the time of great expansion of medications, patients' rights and quality assessment and low adherence and high costs led to coolaborative care, which has many support in EBM and metaanalyses. Consequently the position of MD has changed in many countries from 'all make decision' to the team leader, who cannot ignore other healthcare professionals. In this point of view clinical pharmacists are great value of additional health care service which can help others to ensure better clinical outcomes. In this cooperation this is not a kind of 'fight', but is running to the better outcomes via different ways. The position of clinical pharmacist has changed dramatically during the last two decade from dispenser to provider in direct patient's care. This led to serious need for comunication between MD and Pharm.D., which is always not very easy and sometimes is easier to work alone, although for the patients this is not very good. As psychiatric clinical pharmacist specialist I can be involved in the medication history review, drug chosing, conducting and measuring the outcomes. This is a new dimension of clinical pharmacists' work, which is oriented towards the patients. That towards oriented clinical pharmacy provides better clinical outcomes than work alone have been proven in many trials. In many countries (also European) there are many non-supporters of clinical pharmacy next to the patients' beds, because tradition is different.

For example as I work mostly with psychiatric patients i can be involved in the treatment. Accroding to the Dr. Lewis Alan Opler's questions (very interesting about psychopharmacology) we can conclude that clinical pharmacist can help in ensuring optimal treatment outcomes.

Regards,

Matej Stuhec, Pharm.D., Ph.D.

Clinical pharmacists are vital! Attempts to marginalize them must be fought by themselves but also by advocates/nurses/patients/physicians!

Thanks Dr. Lewis Alan Opler for very positive and supportive opinion about clinical pharmacy. I am very glad and this opinion written by so famous psychiatrist I accept with a great honor. We should establish cooperation next to the patients' beds and our collaboratice care is type of care, which ensure the best clinical outcomes. In many countries there are still supporters of non-patient-oriented clinical pharmacy, which separate clinical pharmacy from the patients. This is very bad, because pharmaceutical care is avoided. In most countries clinical pharmacy is still very young and therefore every step is very important.

Regards!

In general in UK hospitals, pharmacists review all prescriptions and discuss any issues directly with the prescriber, documenting in medical notes where necessary.  In some areas the pharmacist is embedded into the environment (such as in critical care http://www.ics.ac.uk/ics-homepage/latest-news/guidelines-for-the-provision-of-intensive-care-services/ ), though this is not yet a universal thing even in critical care. We have looked at interventions in critical care (PROTECTED study) and it is important to remember that interventions both intercept prescribing errors AND improve medicines optimisation/use.  In that environment many of the medicines optimisations were made on the ward round.

The form of feedback to prescribers is likely dependant on the impact of the intervention, minor stuff needs minor action/feedback, more major stuff likely needs formal documentation and maybe even leads to system redesign.

Also in UK, pharmacists and nurses can be prescribers too - in that context team based working is an advantage as the clear lines that once existed between the roles of Dr, Nurse, Pharmacist are blurring significantly. Responsibility always lies with the prescriber regardless of professional background.

So patients are protected from harm by removing hierarchical structures that can impede discussion (ie stopping the 'because I said so' type culture), encouraging team working, providing feedback that is proportionate to problems identified in a supportive way (with consistent poor performance escalated), and the development of a good reporting culture in terms of incident reporting to identify trends / commonly occurring issues allowing remedial action.

Mark

Thanks Mark!

Very nice answer has been given. I fully agree with you that this cooperation is the best for the patients (in terms of efficacy, safety and costs). A collaborative model is the most powerful model in health system. In this model a role of clinical pharmacist is very important and should be next to the patients' beds. This is very important and essential for better clinical and economic outcomes. In many cases i saw that pharmacists have been given out of the patients or even wards. This is the worst mistake done by hospitals' managers. Patients should be treated in the best possible way, and refuse a collaborative model means refuse the best model. In the year 2015 we should divide patient care on different healthcare professionals and clinical pharmacist should check and be included in to the patients' pharmacotherapy. Appropriate discussion should be establis among the team members and mistakes should be reported and solved. This is one of the key issue of our healt systems how to report, solve and teach from the mistakes. The team members should not have the bad feelings and kind of very strong hierarchy should be removed as soon is possible. Still in year 2015 i see in the European hospitals many answers 'I know, because i am here 30 years, you do not know; sorry i have better clinical experience and forget your trials; I am right although you have supportive trials etc ...'. Evidence-based case-by-case based system should be establis within each hospitals. And in this team each team member should respect EBM data and accept different opinion if this opens a new window for better clinical outcomes. Why the physician does not respect the opinion of clinical pharmacist if it has supportive opinion by EBM (and vice versa)? Why the medical errors are not solved so often? Because appropriate communication has not been established within each hospital and people are threatened often when their mistake has been reported by clinical pharmacist/nurse/physician. As a patient I think we should know how safe is our hospital and this is very important issue. To avoid these analyses means avoid EBM and the best option for the patients.

Regards,

Matej Stuhec, Pharm.D., Ph.D.

"Cost containment" in the USA is hurting MDs like me....but the money making managed care companies are marginalizing and laying off pharmacist.

I'm other words, as bad as the attack on MDs is, it is even more RE: pharmacists.

THIS IS WRONG!

1. We need more MDs AND PHARMACISTS 

2.We need to create conditions where MDs and PHARMACISTS can communicate freely

AND

3. We need less "managed care" corporations with top management profiteering from DENYIN SERVICES 

Thanks Dr. Lewis Alan Opler for very positive and supportive opinion again. I highly agree with you!

1. We need more MDs AND PHARMACISTS. Absolutely! Together we are stronger and we should not exclude each other from the patients' beds. We should establish condition for both speciality. This is not very easy in some countries, because many MDs still think they do not need clinical pharmacists next to the patients' beds. But it usually happens in countries where no risk assessment has been done (e.g. medical errors, serious mistakes and comparison between collaborative and only MDs care). MDs should support clinical pharmacy service if we want to move up. As surveyor in many European hospitals i see sometimes big refuse of clinical pharmacy. This is not good.

2. We need to create conditions where MDs and PHARMACISTS can communicate freely. I again highly agree with dr. Opler. This is even more important topic as knowledge sometimes and both professionals are not well teached in a communication often. In my clinical practice I have also bad experince and communication has not been established, although it would be necessary for better outcomes. I often ask myself why... This is one of the most important issues how we will communicate, when and why. For example we can discuss before patients during clinical rounds (this is very effective, however some of us have bad feelings (no this is not a mistake, i know this etc...)., another possible place is via electronic system (patients' e-documentation), or via telephone etc...). However, the best way is to discuss after rounds in separate place based on case-by-case basis supportive by evidence-based-medicine. This is the best way, to recognize mistake or suggestion or smth and after discuss. All interventions done by clinical pharmacist should be written.

Dear Dr.Stuhec

Once more I carefully read everything you write on the role of clinical pharmacy in hospitals. Absolutely supported by your attitude, very well documented!

See you Great connoisseur of his work I can access things very analytical, meticulously and you finally pulled logical conclusion that the required clinical pharmacist ubolnicama for several reasons:

- To reduce the possibility of prescribing the wrong

-that are selected medicines with the least adverse reactions by patients

-to the transcription of several drugs of the same or similar action by those who are less expensive

- rationalization transcription therapy as the basis of pharmacoeconomics

etc.

Only those medikus and clinical pharmacist  guarantee safe copying of therapy and a reduced possibility polipragmacy malpractice of drugs

Regards

Jasenko

And of course my answer would be complete and correct, should be inserted clinical pharmacologist and I then this is a team that is a complete and multidisciplinary and compatible for transcription therapy!

Unfortunately it has only occasional countries in the world where I was staying, living and working is obvious rarity!

Why is this so, I have my own opinion about that another time!

greeting