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Clinical
Pharmacy
Standard Operating Procedures
Labasa Hospital Pharmacy Department

Authors and Contributors:

Amele Lalibuli (Acting Principal Pharmacist, Clinical Pharmacist)

Alex Bongers (Australian Youth Ambassadors for Development)
CONTENTS

Preface ................................................................................................................ 3

Purpose ............................................................................................................... 3

Scope .................................................................................................................. 3

Prerequisites......................................................................................................... 3

Responsibilities ..................................................................................................... 3

Procedures ........................................................................................................... 4

Pre-admission Medication History ......................................................................... 4

Medication Reconciliation ..................................................................................... 5

Clinical Review ................................................................................................... 5

Discharge Medication Counseling .......................................................................... 6

Patient Referral .................................................................................................. 7

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PREFACE

Clinical pharmacy services aim to promote rational medicine therapy that is safe,
appropriate and cost-effective.

Put simply, the main function of the clinical pharmacist is to comprehensively monitor
drug therapy with the aim to optimize medicine therapy.

The role of medicines in patient care is provided for the direct benefit of the patient, and
the clinical pharmacist is responsible for the level of quality of this care.

Furthermore, the clinical pharmacist can provide medicine information to a patient to

improve the understanding and therefore use of their medicine.

PURPOSE

There are clinical pharmacy services provided by the pharmacy department at Labasa
Hospital. These standard operating procedures have been designed by the Pharmacy
Department at Labasa Hospital to assist pharmacy staff to conduct clinical pharmacy
services correctly and consistently.

SCOPE

For use by all pharmacists and intern pharmacists involved in clinical pharmacy services
within the Labasa Hospital.

PREREQUISITES

The clinical pharmacist should have access to all the latest Fiji Standard Treatment
Guidelines. They should also have access to extra up-to-date medicines information to
base their clinical pharmacy services on. This may include written or electronic
resources. Access to a computer and secure internet connection may is necessary to
access this information.

RESPONSIBILITIES

The principal pharmacist should review and approve changes to this procedure. The
clinical pharmacist is responsible for ensuring staff read and follow these Standard
Operating Procedures. He/she is responsible for making updates and revisions to this
document and submitting it to the principal pharmacist for approval.

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PROCEDURES

The clinical pharmacist provides a comprehensive clinical pharmacy service to the

medical wards at Labasa Hospital. The medical wards at Labasa Hospital include Men’s
Medical Ward, Female Medical Ward, Isolation Ward, Coronary Care Unit and medical
patients in Intensive Care Unit.

The clinical pharmacist should dedicate their time according to the following timetable.

Monday to Friday
8am-11am Ward Round
11am-1pm Discharge counseling
1pm-2pm Lunch
2pm-4pm Clinical review & completion of Pre-admission Medication History

PRE-ADMISSION MEDICATION HISTORY

To facilitate continuity of care a pre-admission medication history should be completed.

Note: All writing on the medication chart by a pharmacist should be in purple pen to
avoid confusion with doctors writing.

Firstly, the pharmacist should confirm if the patient has any allergies and complete
details under allergies on the front page of the medication chart.

The clinical pharmacist should complete a pre-admission medication history for all
medical inpatients by the end of each weekday.

The inpatient medication history should be completed under ‘Pre-admission Medication

History’ on the front page of the medication chart.

The inpatient medication history should include all medicines the patient takes, this may
include:

 Oral medications
 Inhalers
 Injections
 Patches
 Creams or ointments
 Eye preparations
 As required or ‘prn’ medication
 Complementary and alternative medications

The clinical pharmacist should provide the correct details of drug name, dose, route and
frequency. The clinical pharmacist should go to all reasonable lengths to ensure that the
Pre-admission Medication History is 100% correct, this may involve confirming
medications using Patis, questioning the patient or the patients’ family, communication
with the patient’s pharmacy or getting the patients’ family to bring their medication into
hospital.

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If the clinical pharmacist identifies any issues with compliance or other issues that are
relevant to inpatient medication management these details should also be noted on the
medication chart.

The pharmacist should initial under allergies and pre-admission medication history to
acknowledge that they have completed each of these tasks.

MEDICATION RECONCILIATION

Medication reconciliation also facilitates continuity of care for the patient. This may be
achieved through identifying medications that have not been charted unintentionally or
medicines which are stopped abruptly which should not be.

Once the pre-admission medication history is completed, medication reconciliation

should be completed by the clinical pharmacist. Medication reconciliation involves
comparing the medication the patient was taking before admission to the medicines that
are being administered in hospital. The clinical pharmacist should identify any issues and
make recommendations to doctors, where appropriate.

CLINICAL REVIEW

Clinical review by the pharmacist is undertaken to ensure the ongoing quality use of
medicines.

Note: All writing on the medication chart by a pharmacist should be in purple pen to
avoid confusion with doctors writing.

The clinical pharmacist should complete clinical review of all medical inpatients at ward
rounds with other health care professionals and also individually in the time allocated
(see clinical above).

Clinical review is completed to ensure the Quality Use of Medicines (QUM). During clinical
review the clinical pharmacist should consider the following.

 Is each medication indicated based on the patients’ medical history?

 Is the patient allergic to this medicine?
 Are any of the medications contraindicated for this patient based on the patients’
medical history or clinical picture?
 Is the dose of each medication correct?
 Is the frequency of each medication correct?
 Is the route of each medication correct?
 Is each medication charted at the appropriate time in relation to meals?
 Are there any medications indicated that are currently not charted?
 Are the doses of all medications correct when considering the individual patients
renal function?
 Are the doses of all medications correct when considering the individual patients
hepatic function?

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  Are there any clinically significant medication-medication interactions?

If the clinical pharmacist is satisfied with the current medication management of the
patient they should initial under and to the left of the medication to which they have
reviewed and also under the date they reviewed the patient along the bottom of the
medication chart. The clinical pharmacist should also initial under the as required or ‘prn’
medication on the back page of the medication chart.

DISCHARGE MEDICATION COUNSELING

The clinical pharmacist can provide discharge counseling to patients to improve patient
knowledge on their medication, their condition, and how these relate to each other.

The clinical pharmacist should prioritize which patients that discharge counseling should
be provided to. The discharge counseling service is provided to priority medical patients,
with the hope to extend this service to all medical inpatients in the future. The clinical
pharmacist will be able to identify which patients are likely to benefit based on
suggestions of other health professionals and during pharmacist-patient interactions
during the patient’s admission.

Factors to consider when deciding who to provide this service to include:

 Amount of medications the patient was taking before admission

 Amount of medication changes during admission
 Previous issues with medication compliance
 Lack of medication knowledge
 Patient prescribed a medicine that requires dosage adjustment
 Previous issues with use of medication administration device e.g. inappropriate
use of inhaler

When providing discharge medication counseling the pharmacist should focus the
information they provide based on the issues identified during admission and which
required discharge medication counseling.

The pharmacist may provide the following during medication counseling:

 Information (either written or verbal) on new or old medications, where required

 Information (either written or verbal) on how their medication relates to their
condition
 Education on how to use a medication administration device e.g. inhaler

The condition focused medication information pamphlets, produced by the Labasa

Hospital Pharmacy Department, are a useful resource in discharge medication
counseling.

The Labasa Hospital Discharge Medicine List can also be used to facilitate this process.

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PATIENT REFERRAL

Ward-based clinical pharmacy services are only provided to the medical wards. To
extend this service to other inpatients of the hospital, it is recommended that other
medical staff initiate referrals for patients they believe would benefit from a clinical
pharmacy review.

A patient referral can be received by any means which suits the clinical pharmacist. It is
suggested that referral is initiated by phone rather than email to allow a prompt
response from the clinical pharmacist to the patient.

When accepting a referral the clinical pharmacist should gather the information they
require from the referring medical staff. Following this the clinical pharmacist should
follow the steps listed above to complete a clinical pharmacy review.

It is important that the clinical pharmacist and principal pharmacist promote this service
so other medical staff are aware of this option.

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