clinical skills Flashcards
(25 cards)
medications reconciliation
The process of identifying the most accurate list of medications a patient is taking (the drug history)
Then comparing this to the list of currently prescribed medications (for example on the hospital drug chart)
Identifying discrepancies and ‘reconciling’ all identified issues
Why is medicines reconciliation important?
No central record – patients may be buying medicines over the counter, taking supplements, prescribed medicines by their GP, prescribed medicines by a specialist in a hospital – this list can only be compiled by considering all of these.
Inappropriate prescribing decisions are made if prescriber’s do not have a full, accurate list of a patient’s medication
what are the drug specific information needed in a meds rec
Name, done, frequency and duration a minimum
Drug name, strength, dose, frequency, usual times of day/week taken, route for prescribed all prescribed medications
Don’t forget: inhalers, eye drops, creams and ointments, vitamins, herbal remedies, OTCs, injections, patches, medications given at the hospital, contraceptive pills
meds rec stages
Stage 1: Taking a drug history- What information do we need about the medication?Where do we find this information?
Stage 2: Compare to the currently prescribed medications - Identify discrepancies between what a patient was taking at home and what they are now prescribed
stage 3: Compare to the currently prescribed medications- Reconcile the discrepancies identified, taking into consideration:
The reason for admission: have medications been stopped or withheld due to the current diagnosis?
Pharmacodynamic Interactions
What the drug does to the body
These occur when two drugs influence each other’s effects at the site of action, without changing how they’re absorbed, distributed, metabolised, or excreted.
🧠 Example:
Warfarin + Aspirin
→ Both increase bleeding risk by affecting clotting, even though they work in different ways
Pharmacokinetic Interactions
= What the body does to the drug
These occur when one drug alters the absorption, distribution, metabolism, or excretion of another — i.e., changes its plasma concentration.
🧪 Example:
Clarithromycin (a CYP3A4 inhibitor) + Simvastatin
→ Clarithromycin slows down metabolism → Simvastatin levels rise → increased risk of side effects.
classifications of ADRS:type A
augmented - predictable from the pharmacological and dose related- exaggerated therapeutic effect un related to therapeutic effect
classifications of ADRS:type b
Bizarre: not predictable form pharmacological- not does related - allergy, genetic, polymorphism
classifications of ADRS:type c
chronic: related to long-term continuous exposure- osteoporosis with corticosteroids
classifications of ADRS:type D
Delayed : don’t occur until a long time after exposure has occur
classifications of ADRS:type E
End of use: Happen on withdrawal
Why do we monitor?
To understand a patient’s disease, it’s severity, duration and progression
To assess if a therapeutic goal of treatment is achieved
To monitor for adverse effects of medicines
Allergies, intolerances, interactions
To monitor drug concentration in the bloodstream
Assess efficacy and toxicity
When do we monitor?
Differs dependent on care setting
Hospital – acutely unwell
Community – routine patient review, change in condition/circumstance
When starting a new treatment, changing a dose, adding in another drug
When concerned about risk of potential or actual harm
In certain special patient groups
What do we monitor?
Physiology; observations, signs and symptoms
Can be subjective or objective
Biochemistry
Haematology
Serum drug concentrations
Microbiology
DDS
domiciliary dosage system- docet box
DMS
discharge medication service
CPCS
community pharmacy consultation service
MO
medicines optimization- aim to produce the best possible outcome for patients maximize the value of medication-patinet focused improve patient outcomes- clinical and personliastion
Getting the best possible outcomes for patients from their medicines.
Person-centred approach – involves shared decision-making and understanding the patient’s experience.
Ensures medicines are clinically effective, evidence-based, and tailored to the individual.
Encourages regular review of medicines to stop, start, or change therapy when needed.
Promotes safe, effective, and sustainable medicine use.
Developed as a broader, more holistic concept by NHS England and NICE.
Medication management
focosed on outcomes rather than process and patinets Safe, effective, and efficient handling of medicines across systems.
Covers the logistics of prescribing, dispensing, storing, administering, and monitoring medicines.
Ensures medicines are handled safely and according to policy.
Often more operational/system-focused (hospital, care homes, primary care).
Less focused on individualisation, more on process and governance.
✅ Example: Ensuring proper cold-chain storage of insulin or auditing medication errors in a hospital.
why do we need MO
demographics
evidence based practice is less than ideal
scale of economic challenges
Four Guiding principles for M.O.
Principle 1
Aim to understand the patient’s experience
Principle 2
Evidence based choice of medicines
Principle 3
Ensure medicines use is as safe as possible
Principle 4
Make medicines optimisation part of routine practice
principle 1:Aim to understand the patient’s experience:
To ensure the best possible outcomes from medicines.
There is an on-going open dialogue with the patient and/or carer about the patient’s choice and experience of using meds to manage their condition
principle 2Evidence based choice of medicines:
Ensure that the most appropriate choice of clinically and cost effective meds are made that can best meet the needs of the patient
principle 3 Ensure medicines use is as safe as possible:
The safe use of meds is the responsibility of all professionals, healthcare organisations and patients, and should be discussed with patients and/or their carers.
Safety covers all aspects of medicines usage
