Clinical Pharmacy and Pharmaceutical Care
Clinical Pharmacy and Pharmaceutical Care tests patient assessment, medication reconciliation, monitoring, adverse drug reaction (ADR) management and medication safety. The focus is what the pharmacist does with the patient’s data.
Core rules
- Pharmaceutical care is a structured cycle: assess the patient, identify drug-related problems, set a plan, monitor outcomes and document.
- Medication reconciliation compares the pre-admission list with current orders and resolves omissions, duplications and dose errors.
- ADRs are assessed for causality and severity; use temporal relationship, known reaction pattern, dechallenge/rechallenge and alternatives. Naranjo scoring can support, not replace, clinical judgement.
- High-alert medicines such as anticoagulants, insulin, opioids and concentrated electrolytes need independent checks and clear monitoring plans.
Worked example
A patient on warfarin has an INR of 6.5 without bleeding. The pharmacist should hold warfarin, assess bleeding risk and interacting drugs, monitor INR, and avoid routinely giving large vitamin K doses unless bleeding or very high risk is present. The plan must document the reason, the monitoring interval and when to restart.
Traps
- Treating an abnormal laboratory value without assessing the patient.
- Missing an interacting antibiotic or analgesic in a warfarin review.
- Documenting an ADR without considering alternative causes.
- Failing to set a monitoring parameter and follow-up time.