Clinical interventions in Australian community pharmacies

~ \. l

CLINICAL INTERVENTIONS IN AUSTRALIAN

COMMUNITY PHARMACIES

Volume 2 (Chapters Four to Eight)

Peter Tenni M Pharm

Clinical Interventions in Australian Community Pharmacies

4

PROMISE INTERVENTION STUDY

METHODOLOGY

In order to adequately address the aims of this project, a major study was designed to obtain sufficient examples of situations where

community pharmacists identified and resolved DRPs. This chapter outlines the methods used in detail.

4.1

The pilot study outlined in Chapter 3 identified a number of

improvements that could be made to various methods and techniques used. The classification system, although structurally sound, required some modification (see below). In addition the larger sample of pharmacies required the construction of an interface with a different dispensing system. Changes were also made to the information collected from pharmacies and pharmacists and also to the methods used for the determination of the value of the intervention.

The following sections outline the different facets of the classification system and how the DOCUMENT DRP classification system was modified for use in the PROMISe intervention Study.

4.1.1

In the pilot study, a number of sub-categories were used infrequently, and if these were deemed unlikely to be used in a larger study, these subcategories were revised. For example it was found that "Monitoring - Drug Levels" was not used and it was felt that problems that were of the drug level monitoring type could be included in "Monitoring

Clinical Interventions in Australian Community Pharmacies

allocated new codes, titles and definitions. One new subcategory created was "Toxicity evident".

For each of the subcategories detailed scope notes were prepared. These notes include a definition of the subcategory, details and

examples of when the subcategory should be selected and examples of when other categories are more appropriate. For each modification made during the review of the DOCUMENT system, the relevant scope notes were also updated. The scope notes form the basis of the 'help' section in both the online training and the recording interface.

The full version of DOCUMENT including the scope notes used for the PROMISe intervention study can be seen in Appendix 7. An

Clinical Interventions in Australian Community Pharmacies

Drug selection

Problems related to the choice of drug prescribed or taken Duplication (D1)

Drug interaction (D2)

Wrong drug (D3)

Wrong dosage form (D4)

Other drug selection problem (DO)

Over or underdose prescribed

Problems related to the prescribed dose or schedule of the drug Dose too high (01)

Dose too low (02)

Other Dose Problem (00)

Compliance

Problems related to the way the patient takes the medication Taking too little (C1)

Taking too much (C2) Intentional drug misuse (C3)

Difficulty using dosage form (C4)

Other Compliance Problem (CO)

Untreated indications

Problems relating to actual or potential conditions that require management Condition not adequately treated (U1)

Preventive therapy required (U2)

Other Untreated indication Problem (UO)

Monitoring

Problems related to monitoring the efficacy or adverse effects of a drug Laboratory Monitoring (M2)

Non-Laboratory monitoring (M3)

Other Monitoring Problem (MO)

Education or Information

Problems related to knowledge of the disease or its management Patient drug information request (E1)

Confusion about therapy (E2)

Demonstration of device (E3)

Disease management or advice (E4)

Other Education or Information Problem (EO)

Non-clinical

Problems related to administrative aspects of the prescription Toxicity or Adverse reaction

Problems related to the presence of signs or symptoms which are suspected to be related to an adverse effect of the drug

Toxicity caused by dose (T1)

Toxicity caused by drug interaction (T2) Toxicity evident (T3)

Other Toxicity/Adverse Effect problem (TO)

Cltnical Interventions in Australian Community Pharmacies

ACTIONS

During examination of the "Action Investigation: other" category in the PROMISe pilot study, it was found that reviewing the patients' history was a common action. A new code and definition was added for this action for inclusion into the categorisation system used in the PROMISe intervention study. The classifications used for the investigative actions in the PROMISe intervention study are shown in Table 4-2.

Investigation : Written Material Investigation: Software

Investigation: Patient History Investigation: Other

Contacted Prescriber

Discussion with Patient or Carer Corrected without Discussion

TABLE 4-2: ACTION CLASSIFICATIONS USED IN PROMISE INTERVENTION STUDY

RECOMMENDATIONS

Again, modification of the recommendation types was undertaken based on feedback and frequency of selection. Pharmacists who participated in the PROMISe pilot study commented that there was an

extensive list of recommendations to select from. To improve this

aspect of the recording, the recommendations were grouped into five main types;

• a change in therapy • a referral required • provision of information • monitoring

• no recommendation necessary

Clinical Interventions in Australian Community Pharmacies

modification allowed the pharmacist to record which medication they altered, and how. The recommendation selections available for the PROMISe intervention study are outlined in Table 4-3.

A Chanqe in Therapy

Dose change

Drug change

Drug formulation change

Drug brand change

Dose frequency/schedule change

Prescription not dispensed

Other changes to therapy

A referral required Refer to prescriber Refer to hospital

Refer for medication review Other referral required

Provision of information

Education/counselling session

Written summary of medications

Commence dose administration aid

Other written information

Monitor

Monitoring: non-laboratory Monitoring: Laboratory test No recommendation necessary

TABLE 4-3: RECOMMENDATION CLASSIFICATIONS AS USED FOR PROMISE INTERVENTION STUDY

OUTCOME

If a recommendation is made to resolve a DRP, it is appropriate to document whether the recommendation has been accepted (by the doctor or patient) or not (i.e. the outcome of the recommendation). There were no changes made to the categories for acceptance of pharmacist's resolution of the problem (outcome) used in the PROMISe pilot study.

The potential outcomes recorded regarding the recommendations were

Clinical Interventions in Australian Community Pharmacies

• the recommendations were partially accepted (that is, only some of the multiple recommendations are accepted),

• the recommendations were not accepted or

• the uptake of the recommendations was unknown at the time of recording the intervention.

Definitions and scope notes for outcomes are shown in Table 4-4.

Unknown

Definition: When the pharmacist is unaware of what happened after he made the recommendation(s).

Accepted

Definition: When all of the recommendation(s) that the pharmacist makes are accepted

Partially Acceoted

Definition: When the pharmacist makes multiple recommendations, and only some of the recommendations that were made are accepted.

Not acceoted

Definition: When all of the recommendation(s) that the pharmacist makes are rejected

TABLE 4-4: OUTCOME DEFINITIONS USED FOR PROMISE INTERVENTION STUDY

CLINICAL SIGNIFICANCE

C/Jnical Interventions in Australian Community Pharmacies

Nil (SO)

When there is no consequence to the patient.

Low (Sl)

When the consequences to the patient are related to costs or information only

Mild (S2)

When the consequences to the patient are that they have improved a minor symptom, or if the intervention had not occurred they would have developed a minor symptom. The symptom should be such that it does not require a doctor's visit to treat.

Moderate (S3)

When if the intervention did not occur, it was likely that the patient would have had to go to the doctor because of the consequences. Also covers the situation where you need to refer the patient to the doctor because of the seriousness of the situation.

Hiqh (S4)

When if the intervention did not occur, it was likely that the patient would have had to go to a hospital because of the consequences. Also covers the situation where you need to refer the patient to a hospital because of the seriousness of the situation.

TABLE 4-5: SIGNIFICANCE DEFINITIONS USED IN PROMISE INTERVENTION STUDY

IDENTIFICATION OF THE PROBLEM (PROACTIVENESS)

The results from the PROMISe pilot study indicated that a large

proportion of the interventions documented resulted from direct patient requests for information. In this situation, pharmacists would always provide (to a greater or lesser extent) the information

requested. Thus the pharmacist would not have initiated the intervention. This led to the development of a classification of

interventions by whether the intervention was proactive or reactive. Reactive interventions were those that were either not initiated by the pharmacist, or required addressing before the prescription was able to be dispensed (many of the intervention classified as Non-clinical in the pilot study would fall into this category). Proactive interventions were initiated by the pharmacist and were not necessary to be undertaken in order to dispense the medication.

Cltnical Interventions in Australian Community Pharmacies

from the PROMISe pilot study indicated that 33.5% (85) of the interventions were proactive in nature and 66.5% (169) of the

interventions were reactive in nature. Proactive interventions were found to be of higher significance and were likely to be more

"discretionary" in the pilot study.

Given the predicted numbers of interventions for the PROMISe

intervention study, it would not be possible to individually re-code each intervention. Therefore, pharmacists who participated in the PROMISE intervention study were asked to indicate who initially identified the

problem as a guide to the proactiveness of the intervention. Training on this aspect of the classification of the intervention was included in

the on-line DOCUMENT training.

4.1.2

A number of technical changes were made to the "behind the scenes" aspects of the WiniFRED dispense system to accommodate the

PROMISe project requirements. This included the development of a communications interface using a modified version of the messaging components developed for a previous project where secure

transmission was required.

PRELIMINARY STEPS

The basic commencement screen is shown in Figure 4-1. This

consisted of some demographic and patient specific information above a series of tabs regarding the intervention. Where the intervention was

associated with a prescription, information concerning the prescription was imported automatically from the dispensing system (see Figure 4-2). Information that was imported into the intervention module

automatically consists of:

• the patient's name

• the prescriber's name and prescriber number

• the drug involved

Clinical Interventions in Australian Community Pharmacies

• the number of different medications that the patient has had in

the previous six months (medication count)

Other information needed to be manually entered for each

intervention. The recording pharmacist entered :

• the gender of the patient (unless previously stored in the dispensing software)

• the age group of the patient

• who initiated the problem (proactiveness)

• pharmacist identifier (usually done for each prescription) When the clinical activity was not related to a prescription, all of the information was entered manually. For situations where the patient

was not listed in the pharmacy database, an unlisted patient could be

created. This allowed for the documentation of "off the street"

interventions relating to customers who had not received prescriptions

from that particular pharmacy. The adopted "tab" structure allowed this demographic information to be in view while different aspects of

the intervention documentation were completed. The titles on these

Clinical Interventions in Australian Community Pharmacies

UnbtedPotient Gendel:

ol !Female [.]

S\bstit!.tion ModCC>Jrll:

D

013

PiescOOer No:

I

I

o

r=-

----.

D

Intervention sutrcate o

J {. Significance Intervention cateaorv

D Drug Selection

0 Over or Underdose Prescribed C Compliance

U Untreated Indications

.::.J D1 Duplication D2 Drug interaction 03 Wrong Drug 04 Wrong dosage form M Monitoring 00 Other drug selection problem E Education or Information

N Non-clinical

T Toxicity or Adverse Reaction

Cate o clari!ication notes

New Intervention

SoOlch by SURNAME FIRST NAME ADDRESS"' NlMl\ber or <S>oino or <P>rovious. Abo; <F>OINy S001ch. <A>ddron S001ch. Sur<N>ome Sootch. E<Sciipt No> lo Eat 0t E<X>~ Fred

FIGURE 4-1: INTRODUCTION SCREEN FOR THE WINIFRED INTERVENTION INTERFACE

O Othec'Msg's Olocal ... s

Good.'. ?"~G~'"'-

--,-,---,-,--~-~ • 21-66 yura old (adult)

METFORMIN (CHEM·MART) TAB 860M [J 931611J0008.j11

or

1-11

Medeo.rt

m

1. Categortn Z.Adloos

I

1=='' - --1 D Drug Selection

0 Over or Undudo1e Prescribed

~----t JC Compliance

U Untreated lnchcat1ons

IL~ - 1 - -•• -1 ~ IAF '#lthO

10A L10A Dono M

l

~T

Monitoring

Educ1.tion or Information Non~llnlcal

T oxlcjty or Adverse Reution

New Intervention

Intervention sut>-cate

U1 Condition not adequatety treated U2 Preventive thuapy required

UO Othtr Untreated indication Problem

c~~rffkatlon.~n~o~"'~·

---Erier Orecllonl ·'I .t start lo lunOlt S'4* Sigs. <0.W> toJt.ri; Em. 'SS'l0t 5¥ne Slgs, Move wilh <Pgl/p> to SIM er <PoDown> lo Erdol OredJOns.

]

FIGURE 4-2: POPULATED INTRODUCTION SCREEN FOR THE WINIFRED INTERVENTION INTERFACE

Clinical Interventions in Australian Community Pharmacies

RECORDING OF CATEGORY AND SUBCATEGORY

The first step in the recording of an intervention in this system was

selection of the main category of the clinical activity. By selecting the main category on the left-hand side the appropriate subcategories appear on the right-hand side of the entry screen. Help screens were available for each of the different selections.

Once the initial category and subcategory has been selected, a draft of the intervention can be saved and completed at a later time. A list of all interventions that are in draft mode can be accessed by selecting

activities; draft interventions (see Figure 4-3).

PER

Patient Name Drug De:icription

<- Sbaw all lk•f't . .i.Dterv.nt..ioa8 ->

J

• Unknown O Partially acc•pt•d O Accepted O Not 1.ccept•d

New Intervention

FIGURE 4-3: SAVING AND RE-ACCESSING A DRAFT INTERVENTION

At any time during the recording process, help could be accessed using

Clinical Interventions in Australian Community Pharmacies

. .

"

°"""

...

IMRJOHN c

~10 _ _

...

_:...:.

... _,_: . ·c .. : ..

1. Categories z, Actions Of.c:bonl Intervention cate o

r"T"'•k"'o' " - --1 D Drug Selection

...

M E N

Over or UnderdoH Prescribed

Compliance Monitoring

Education or Information Non-clinical

21~ years old (adult)

1-.clby _ , _ , ...

DI

D

J., Recommendations & Outcomes J Intervention sub-tale o

PrewntJw Therapy lhqulr911 (U2)

When to Use: ,._. ;

B IAf wtth 0 10A L10A Do no

Toxicity or Adv1r11 Reaction

T When the patient requires add~1onal therapy to prevent a likely adverse event as a result of the '--====:-:====--~patient's therapy, coexisting d1seaus or nsk factors

Examples of when to use:

• Patient commences on morphine slow release and you suggeS1 lhe addl11on of a stool softener

• You suggest 1he addnion of an11pla1ele1 therapy man elderly, obese, mate patient wrth type 1wo diabetes and hypertension

When Not to Use:

1-- - - ; : :=f If the patient already has treatment for a particular problem, but 1t 1s not etrectrve enough, then use

t:! "Unlreated Indication -Cond111on not Adequately Tre<ited (U1)"

Now Intervention

Enlef Orectiont-·r • tl:$1 toiunOft Supei Sigi. <Ori+J> to Jui:. E

FIGURE 4-4: HELP SCREEN FOR THE WINIFRED INTERVENTION INTERFACE

RECORDING OF ACTION(S}

~

'

OA L10A Do not

Cltnical Interventions in Australian Community Pharmacies

oou.r-11sg·1

OLoca&llSg"s

21-N yurs old (•dult)

0 ~

METFORMIN (CHEM-MART) TAB 8GOM 019316100008411

1. C.tego11.. z.. Actions

...

A1 lnve1d9ate, written material

KJ. Investigation: Softwv•

~ lnvestlgatJon: Patient History M Contacted prescriber

M Corrected without dl1cu11lon A7 Other action

New Intervention

Precrbef No: lr.Dlted Phamaast l,...s:

I -11 [[] PHARMACIST @ CRAIG COOPER

I

M Ol1cu11lon with patient or carer

1

~

""""-"""'

I

Erter 01ecbons • '' « atM to b.Mn Off Super Siga, <0.W> to Jlri-. E

·~

:

FIGURE 4-5: RECORDING OF ACTIONS ON THE WINIFRED INTERVENTION INTERFACE

RECORDING OF RECOMMENDATION(S) AND OUTCOME

rug related

last lime the s intentional.

cerved or grvmg tact the doclor"

Recommendations made to resolve the drug-related problem were

entered into the system in a similar manner to the actions using a left

-to-right selection arrow in the centre of the screen (see Figure 4-6).

Although multiple recommendations could be recorded against each

intervention, it was not possible to make the same recommendation

more than once. The system was designed to allow for multiple unique

recommendation selections.

Where the recommendation related to a direct change in therapy,

information concerning the before and after situation was collected to

allow for clarification of what changes were recommended. To collect

this information, an 'edit' key was created. So, for example, if a

change in drug was recommended, the drug could be entered with an

C/Jnical Interventions in Australian Community Pharmacies

The outcome of the recommendation was included on this same screen

and the entry related to a composite outcome for all of the

recommendations made.

PatienlNGmSOf No

MR JOHN CIT 146.20

Oiections

Tako

"'

Drug Formulation Change

RA ONg !!rand Chango

~ DoH Frequency/Schedule Ch1119• R6 Prucrlption not Dispensed R7 Other Ch1.n9•1 to Therapy

OCM-. .... s

0 Local MIG'•

Pretaber No: lnb.led Pharmacist lnibols:

I -11 [ [PHARMACIST @E]CRAJGCOOPER

3. Recommendedons & Outcomes J t S .. allunce

• jlJ' R2 Drug Chango

~

[f!)]

B IAF withor

10AL10A Donat A.!!'!_rnl ~ _ _ _ ____.,:,

""""""

Now lntorvontion

O PartJally accepted

O Not accepted

ErU Orec:Dorw ·'fat start kl llM"IOll St4>el Sig1. <on.J> toJtft E

rug related

lastl1methe s 1nten11onal

J

tact the doctor"

Clinical Interventions in Australian Community Pharmacies

"""""""""

OLocalMq's

Patient Name°' Repeat No

MR JOHN CIT

T•k•

~~·rp

I

10A L10A Do no1

I

Pharmaastlnitielc: @:£]CRAIG COOPER

1. Cat.gorl• 0=~---~ J t. Slgnllunce

A~• In 111 • .._ I i.=. . -...

R1 Dong• Chana• Dieciions ~

~~~~-R3 DNg Formulation C

I

·.1

R5 Dou Fr•quencylSc

R6 Pr•scriptlon not Dis ' - - - ' " " " '

R7 Other Ch•ngH to T A rofernl re41ulrod _

a"'°'"' O Unknown o Acc1pt1d

New Intervention

0 P&ttlally &ccopt.d o Not accepted

EM Oiecbons ·'I ot st«llo h.mOff S~ Sigs, <OlkJ> toJtd E

rug related

last time the

s intentional.

FIGURE 4- 7: RECORDING RECOMMENDATIONS IN THE WINIFRED INTERVENTION INTERFACE: DETAILS OF DRUG CHANGE

RECORDING OF CLINICAL SIGNIFICANCE AND TIME TAKEN

The clinical significance screen, (see Figure 4-8) allowed for a selection

to be made to indicate the appropriate level of clinical significance for

the activity. For interventions that were rated as moderate or high,

additional information concerning the patient's other medical

conditions was requested. This additional information was collected in

order to enable reconstruction of the clinical situation which, in turn,

would enable adequate examination of the activity by an external

clinical panel. A reminder of the importance of this additional

information was automatically presented when either moderate or high

clinical significance was selected (see red reminder message in Figure

4-9).

The time taken to perform the intervention was also recorded on this

screen. Individual buttons for particular brackets of time were made

U>I 0

B W

1GA L10A

Cltnical Interventions in Australian Community Pharmacies

·-""'

J l.. Recommendado• & Ovtcom . .

51 Low

S2 Mild

S3 ModerJ.t•

~lg_h _ _ _ _ _ _ _ _ _ _ _ _ __,

Likely WorHnlng of Disease or Symptoms

2m1nl •mini ~ em1nl

1om1nl 15mlnf 20minl JOm!nJ

r•an

f'helmocititlri:iab: @£)CRAIG COOPER

f..Sl, . . _co

m the last 11me !he gewasmtentional

~ int1n11ntlon _e 1ng _{I contact t}rtce~d _ho_{e d}r g_oM_cin_og _r"

.._~~~~~~~~-,.l!l"lll!l'Tl!m~"'"""'!'tm!'?rnlll~~~~~~~-'

Enis Orecilonl ·'I at at.wt to unOn Si.oer Sigs. <on.J> toJlril E

FIGURE 4-8: RECORDING OF SIGNIFICANCE IN THE WINIFRED INTERVENTIONS INTERFACE (MILD SIGNIFICANCE)

51 Low 52 Mild

~ High

ol

z.. Actions ;i. Recommendatlon1 & Outcomn

Medeort

m

@I)CRAJG COOPER

{. St1nfflcanca

Diabetes, hyperchole1trolHmia

Likely Doctors Con1ult1.tion Avoided or Requir•d l

This '9 • potenti•lly Important lntervendon.

Plnse e..ure relennt information 1a provided

In the appropriate textboxes above.

ing a drug 1elated

m 1he lut lime the 91 was mtenllonal.

Now lntorvontion _e ing received or _{I conlaci the doctor•} Q1'11nQ

.._~~~~~~~~--:""1l!"'J'mmm,,,,,,.,,lm"T!llnmftlllmlW.-~~~~~--'

Erler Otedl::nl · '/ .tt u t lo 11.mOff 514* Sips. <CtrW> toJlri. E

Clinical Interventions in Australian Community Pharmacies

LOCAL INTERVENTION RECORD: PATIENT HISTORY AND SUMMARY

Once an intervention had been recorded, an entry concerning the intervention appeared in the patient history file (see Figure 4-10). The full details of the intervention could be accessed by double-clicking on this entry. In addition, a summary of the intervention could be

generated (see Figure 4-11).

O Olher Msa's

I

~IM_R_J_O_H_N_C__lT_IZ_E_N _ _ _ _ _ ~l1 BROWN STREET, HOBART 7000 $46.20

Disp Drug Name 14(07 LIPITOR TAB 40mg

2005

14/07 AVAPRO TAB 150rng 30 2005

Qty Directions

30 Take 011!: tablet at night

30 Take ONE tablet daily

I Finel: Over or Underdo~e Pre~cribed - Do~e too low

Press <Enter> to Continue or

Use Cursor Keys to Select an Item then Press <F4> to Edt or <F11 > lo Ae·D~pense Item

FIGURE 4-10: INTERVENTION NOTE IN PATIENT HISTORY

MCare 2543-75299-11 (Specioll

Doc Rpt Op By l.:.

SHI 5 1 23.10 CC 1058

'O.S

Cltnical Interventions in Australian Community Pharmacies

Intervention Summary

Patient and Script

lnteivention ID: O

Rx Number:

Palient: Mr John Citizen

Age Group:

Prescriber: Ian Smith 56461

Drug: Me~ormin (chem-mart) Tab B50mg

CateglllJ(. Untreateclndications

Sub Colegory. Preven~ve therapy required Calegoty Notes:

Actions

Selected Actions:

Discussion with patient or carer

Action Notes:

Recommendatjons

Selected Reconvnendations: Drug Change

Recommendation Notes:

1/1 ...!..!_] ..!J Ready

Generated on: 28 July 2005

Dale: 28 July 2005 Rx Form Type: Original

Gender: Male

Med Count:

FIGURE 4-11: PRINTABLE INDIVIDUAL INTERVENTION SUMMARY

LOCAL INTERVENTION RECORD: REPORTS

A number of reports could be produced for the recording pharmacist (see Figure 4-12). These include a detailed report, a summary report and a statistical report of interventions. The detailed report is shown

Cltnical Interventions in Australian Community Pharmacies

Patient Name or Repeat No

I

:i_cript Drug U.sage

eatient

~octor

t'tursing Home

>I

Intervention Reports •

8.Qed Script Reports

(No Aged Scripts)

l[iew Last Report

~ast Report to ASCII

o other Msg's o Local Msg's

Detailed Report of Interventions Summary Report of Interventions Statistical Report of Interventions

FIGURE 4-12: REPORTS FOR INTERVENTIONS AVAILABLE AT EACH PHARMACY

Detailed Report of Interventions

Generated on: 08 JUiy 2005

• 0.9

Filter Conditions

Date: From 01/01/2005 To: 08/07/2005

lnteiwntion ID: 16 Date: 05105/2005 04:12:42 PM Rx Number: O Rx Form Type: Original

Drug:

Prescriber: Category.

Sub Category.

Selected Actions: Blank

Over or Underdose Prescribed Dose too high

Investigation: Patient History Discussion with patient or carer Discussion with patient or carer

Recommendations: Refer to Prescriber Drug Brand Change

Other Changes to Therapy Outcome: Accepted

Time taken: 2

MedCount: O

Significance: Moderate -Likely Doctors Consultafion Avoided or Required

Other Condition Notes:

test

1 /6 GlS ..£) Ready

FIGURE 4-13: PHARMACY-BASED DETAILED REPORT OF INTERVENTIONS

PHARMACIST AND PHARMACY DEMOGRAPHICS ASSESSMENTS

Prior to commencing the pilot study, it was clear that certain aspects of

a pharmacist and/or the pharmacy would influence the frequency and

nature of the interventions performed. The small sample size of the

Cltnical Interventions in Australian Community Pharmacies

However, the surveys used identified the type of information required

in order to adequately examine issues such as workload, "business

style", clinical skills and so on.

The details of the surveys and information collected from each

pharmacist and pharmacy are shown in Sections 4.3.1 and 4.4

respectively.

CLINICAL SIGNIFICANCE AND VALUE ASSESSMENTS

The pilot study assessment of the value of the interventions was a trial

of a system that could be used remotely. This system was further

refined, and the technical refinement made it possible to create a

web-based intervention assessment process. This enabled the use of expert

assessors from throughout Australia, without the expense and

inconvenience of a face-to-face meeting. Details of the modified

system can be found in Section 4.5

4.2

The main aims of this project were to:

• determine the frequency with which Australian community

pharmacists resolve or prevent DRPs,

• evaluate the nature and severity of the problems and the drugs

involved in the problems, and

• estimate the potential value of these clinical interventions in

health and economic terms.

In order to be able to address the aims above, the PROMISe

intervention study used an observational controlled design, where

details of interventions that occurred were collected, and an

assessment of the potential severity of the outcomes of the

intervention was made by experts.

Within the study design, it was important to collect information on

various aspects of pharmacists and pharmacies that may relate to

intervention frequency and type. In addition, testing of whether the

Clinical Interventions in Australian Community Pharmacies

prompting interventions, observing and encouraging the pharmacist or

simply remunerating the pharmacist for the activity was an important

aspect of the study.

The initial intended design included a crossover of remuneration over

two, two week periods, with randomised allocation of the intervention

prompt and the presence of observer pharmacists between these arms

(see Figure 4-14).

Pharmacies Enrolled

Phase 1 (2 weeks)

Observation , . . . _ ..t Present

Intervention

Obs.erv•tlon Prompt Pharm•clst _{No Intervention}

Prompt

Intervention

No observ•tion Prompt Pharmacist

No Intervention Prompt

Intervention

Observ•tlon Prompt Pharmacist

No Intervention Prompt

Intervention No observation Prompt

Ph.,maclst

No Intervention Prompt (") .., 0 "' "' 0 < t'I) ..,

Phase 2 (2 weeks)

Unpaid ln PhH•2

Paid In Phase2

FIGURE 4-14: INTENDED PROMISE INTERVENTION STUDY DESIGN

1n-terventlon Prompt No Intervention

Prompt

Intervention Prompt No Intervention

Prompt

However, as there were some initial installation difficulties with the

communications software, some pharmacies were delayed in

commencing their data collection. The intervention prompt that was

installed also caused a small overlap problem. When the intervention

prompt was de-commissioned, this occurred with the routine monthly

software update. The update was available to pharmacies from the 24th

of the month, and could be installed by individual pharmacies at any

Clinical Interventions in Australian Community Pharmacies

"turned off" their intervention prompts up to a week earlier than

others. In addition, the number of interventions documented was lower

than expected and extension of the study and the observation process

was required in order to collect information concerning a sufficient

number of interventions.

The final schema, randomisation outcome and duration of observation

and intervention prompt for the participating pharmacies are shown in

Figure 4-15.

52

Phormocies fnrollod

Phase 1 (2 weeks)

Observation

9

5 Intervention

Prom t 6 No Intervention

Prom t

9 Intervention

Prom t 9 No I ntervendon

Prom t

(3weeks)

Phase 2 (2 weeks)

9

Phase 3 (4 weeks)

5 2 - · Poldin

-J

FIGURE 4-15: RANDOMISATION SCHEMA FOR PROMISE INTERVENTION STUDY

Despite the difficulties and overlaps, there was still sufficient

information obtained to indicate the effects of observation,

remuneration and the intervention prompt. The effects of these could

be assessed independently and together using univariate and

multivariate analyses. The combined effect of all three techniques

(adjusted for non-recording of interventions) was used to determine an

Clinical Interventions tn Australian Community Pharmacies

Figure 4-16 represents the steps involved in conducting the project in

the Melbourne pharmacies.

ti n Sy tem

5.Rand

7. D t olle tion nd Ele tr ni Re ording of lnte ention (in luded egul ite vi it vith feedb k of suits)

FIGURE 4-16: OVERALL PROCESS OF ENROLMENT AND TRAINING OF PHARMACIES IN PROMISE INTERVENTION STUDY

4.2.1

PHARMACIES AND PHARMACISTS

Pharmacies registered as users of the WiniFRED dispensing soltware in

metropolitan Melbourne were contacted and provided with information

on the PROMISe project. Expressions of interest were sought from the

260 registered users, with the opportunity to reply via email or fax.

Information concerning the project was also generally distributed

through AusPharmList and the Australian Pharmacist.

A flyer was developed to increase awareness of the project and

distributed in the Australian Pharmacist, the Victorian Guild Newsletter,

Clinical Interventions in Australian Community Pharmacies

Once the pharmacies had expressed interest in the project, preliminary

information was obtained, relating to:

• computer hardware,

• so~ware configuration and

• the number of staff likely to be involved.

This information provided detail for the logistical planning of the

project and ensured the sample provided a good representation of

community pharmacies. Appendix 8 contains information distributed

to the potential pharmacies. Only pharmacies who had installed the

Windows operating systems Windows 2000 or Windows XP were

accepted for enrolment.

Once each pharmacy had received information on the project, had

agreed to participate and met the so~ware requirements, they were

enrolled into the project. This involved signing an agreement with the University to participate in the project. The agreement covered aspects

C/1nical Interventions in Australian Community Pharmacies

What Is an Intervention? It is common for pharmacisl5 to carry out clinical interventions each day. For example

Mr Brandl presents presc~~on for Monodur 60mg one tablet twice a day

He has been previouslf taking 6()ng daily He CorT¥Jlains that his angina has been worse recenlly. The pharmacist cantacls the GP IJJ discuss nitrete IJJler-anca. The pharmacist recommends daily dosing •Mth Monodur 12()ng.

The PROMISe project wll explore the po-tential savings, in parocular health and econorric outcomes ot community phar-macisl5' clincal intervennons. Recording Interventions

Those community phanmac1sts who cur-rently record 1ntervenoons tend to do so in many different terms. including into a book or the notes section within their dispensing soltware. By establishing a standardised and centralised recording system 11 will be possible in the luture to compile repMs on community pharma-cists' clinical acti>ity. 'Mth this as sup-pornve eV1dence the acnV1ty ol commu-nity pharmacists can be more clearly defined to the Government and other stakeholders.

Back!JOUld to PROMSe A system for the electronc recordng, collabon and management ol medcation incidents in community pharmacy has been deveklped within the Unit for Medcaoon Outcomes Re-search and Educ anon at the School ot Phar-macy, Universny ot Tasmana. The system was pibttested in phanmacies in Tasmania to evaluate its funcoonality and to provide some prelirrinary infonmation. In this next phase we am to collect intervention data from phanmaaes 1n Melbourne and analyse these interventions tor cirncal and ecomonc benefit.

When the project 1s completed, Austraia will be the only country in the world with a mecha-nism for collecnng naoon-wide infonmanon re-lated to problems 1denofied 1n community pharmacies

Community phanmaasl5 otten idenofy issues relanng to medcation safety. The PROMISe project will proV1de a method for standardsed recOfdng ot these situanons and may lead to remuneration tor the documentation process.

For more infonmation Contact: PeterTenrn

Project Manager (03) 62261005 [email protected]

Funding for the prOJ•ct W'IS made available thrw~theAUlittalianDepUUhentofHealth

andA8'ing as part. of the Thud Commuruty Phannacy Aguemeri, which is managed by

The Pharmacy Owld of AuNaha

For more information vis~

www.promlse.Id.au

U

TAS

School of 'hannacy

U

MORE

~

>

School of Pharmacy University of Tasmania Private Bag 83 Hobart Tas 7001

ContactPetcrTenni (OJ) 6226 1005 [email protected] au

The PROMISe project, a message

from The Phannacy GuUd of Australia. One of the key roles cu"enlly being investigated

for pharmacists is the recording of

clinical interventions.

Pharmacists carry oul clinical interventions every d8j but lhe polential savings in terms of heaRh and economic DU/comes are nol clearly kn<JMl.

The Pharmacy Guild of Australia has corrmssioned this project to quantify and demonstrale the bene!is of communily pharmacies carrying oul these interventions and documenting this acl1viy Using the resuRs from this project # may be possible lo negoliale with the Government for remuneration to corrmunity pharma:ists to do clinical interventions and document them. ·we cannot stress enough how impol1ant this project is with the cuffent threats lo supply based remuneration. We hope you take this oppol1unily lo be involved in a project of high signiflcance to the profession and use this experience for your own benefit:

John Bronger Bill Scott National President Victorian President

The Pharmacy Guild of Australia

FIGURE 4-17: PROMISE PROMOTIONAL BROCHURE

Pharmacy Recording of

Medication Incidents and

Services

The PROMISe project

UMORE~)

.l!I. l ' l \ \ l l ' l \ t ~ ~ ( 11 JI ~ I \ I ' \

PCAINU SYSTEMS

The 2005 lrlal

Participating pharmacies will be

provided with ongoing technical and software support. Regula' visls to each pharmacy will ensure any potential problems are resolved quickly and easily

Full training wll be pro.,;ded to phanmaasts pal1iapating in the project. Generous pay. ment for the Orne taken for this trarnng 1s included.

The trial will run for three weeks in Apnl 2005.

At least ha~ ot the traring can be conn-pleted onhne at www.promseJd.au and each parnapant will have a chance win $2500

Training for the PROMISe Intervention Study involved education in

Clinical Interventions in Australian Community Pharmacies

PROMISe user interface. The training for the DOCUMENT classification

system was undertaken online, and demographic information

concerning the participant's background, opinions of pharmacy and

clinical skills was also collected during this process (see Section

4.2.2.1).

4.2.2

2:

CLASSIFICATION

Training in the DOCUMENT system was completed online. The training

was designed to familiarise the pharmacists with the selection of

appropriate categories during the process of documenting

interventions. The training module was available on the PROMISe

website (www.promise.id.au). This website was also used for ongoing

feedback and information for PROMISe trial pharmacists (see Figure

Clinical Interventions in Australian Community Pharmacies

PROMIS

e

Pharmacy Recording of Medication Incidents and:Ser.vices electronic documentation system

Home

About

What's new

Class1ficat1on

Training

Trial pamc1pants

Contact

Classification of interventions using DOCUMENT

The PROMISe Project Phase One involved the development of an

appropriate dassification system, DOCUMENT.Thi• system currently links in 1Nith community dispensing software, thereby enabling the accurate and

complete recording of pharmacist's interventions. These indude detection

of drug related problems and other dinical services. For further

information on the DOCUMENT dassification system developed for the PROMISe project, ~to view POF version (185 KB).

Email this page to friend

Click the button below to view a Flash presentation

View

Don't Have Flash? Download Flasr. Player.

Internet-based case scenarios of typical pharmacist interventions have been used to validate the DOCUHENT dassifitation scheme. To date over 400 pharmacists have enrolled to learn more about

the dassification system. Completion of all of the case scenario's is encouraged as this displays the

complete functionality of the system. The scenarios and DOCUMENT classification system has been refined for PROHISe phase 2. Returning users simply login to complete the new set of scenarios.

DOCUHENT dassification scheme allows interventions to be classified by:

• Type of medicaticn-related issue;

• Actions taken by the pharmacist to resolve the issue

• Recommendations (what the pharmacist did) for each intervention and

• dinical significancej

In the following cases you •Nill be asked to classify the intervention. This will include assigning the

appropriate Type and Subtype . (referenoe to the help notes is useful for new users of the system) Also documentation of the Action.s and Recommendations made by tile pharmacist are to be recorded. You will also be asked to assign a Significance categorisation for each intervention. These

classifications will be explained further as you start using the inyteractive OOCUHENT classification

tool.

Please note the following cases have been set up to familiarise the user with the DOCUMENT

d?1ssification system. The actions and recommendations made by the pharmacist may not reflect what

you would personally carry out in practice. Record only those actions undertaken by the pharmacist.

Ongoing feedback has been incorporated into these online scenarios.

Continue

FIGURE 4-18: DOCUMENT ON-LINE TRAINING WEBSITE

The online training included three types of activities

• Completion of two clinical problem solving skill tests.

• Completion of a demographics questionnaire.

• Allocation of DOCUMENT categories to 20 case-based scenarios

in which the problem and the steps taken to resolve the problem

were described.

The process of registration is depicted in Figure 4-19. Once registered,

the participant could complete the training. This registration also

allowed the participant to complete the training in different stages if

Clinical Interventions in Australian Community Pharmacies

PROMIS

e

,;~

Pharmacy Recording of Medication Incidents and.

Semices

-- .. .ir;, .;:".

Training

Home _{The training requires you to complete the following.}

l. Two diniatl problem solving tools (15 minutes each) What's new 2. A questionnaire about you and your bac ground (5 minutes)

Class1flcat1on 3. Vdinic-alidatal ion oscenf a arios ( the DOCUMl hour). ENT dassification scheme using 20 Training

Tnal part1opants

You can commence the training at any time, but it must be completed

by Friday 13th May, 2005. You do not have to t<>mplete all of the trainino at one time, each time you retum to the website you will be able to start from where you left off in a previous ses.sion. Contact

To proceed, Register (new users) or Login (retummg users) by chdong

Registration

To register, choose a username and password:

semame

I

Password !._•_•_ .. _•_• ____ _. Regis er

login

login

Usemame ,.I p ... ct._e ... n_n_io ... s.__ ___ __,

Password .. I•_•_•_•_•_• _____ _. Login

Email this page to fiend

k.cturn,n9 us.er=;

Email tTis oage to a fnEnd

·-

·

computer with others, please

ch•ck the corre-ct

us.ername and

pa•sword is in the boxes on the

left before you

dick Login. • You need to

FIGURE 4-19: REGISTRATION AND LOGIN PROCESS FOR ONLINE TRAINING

4.2.2.1

Testing of clinical skills involved two interactive scenarios which

allowed the identification and assessment of a number of clinical

Clinical Interventions in Australian Community Pharmacies

Each step involved multiple choice questions or lines of investigation,

which then provided additional information depending on the path

chosen (see Figure 4-20). Individual participants in the clinical problem

solving skills case studies received an overall score, which was based

on:

• the number of problems that they identified,

• the appropriateness of the recommendations they made, and

• the number of investigative steps that they used to detect the

problems.

It was possible as a result of the design of the system to track the

number of pages that the pharmacist visited in order to identify the

underlying drug-related problems.

Thus, the total score was collated from an investigation score, a

problem identification score, and an appropriateness of

recommendation score. It was felt that pharmacists with different

levels of clinical skills would have different ratios of scores within these

three components.

A complete summary of the choices and details of the clinical skills

assessment scenario is shown in Appendix 9.

CPSA -1

You ~r• logged In ~s pct8nn103

A 54 year old man presents you with a new prescription for Avandia (Rosiglitazone)

4mg twK;e daily. He has taken the rosightazone at a dose of one daily for the last

month, and tells you that he has just been to the doctor, who said to increase to

twice daily. He also has a new prescription for frusemid<l 2°"'11 daily which he needs dispensed.

Wlolch ONE of the following would you do first?

F"ind out from the patient his previous treatment for diabetes, more information regarding other IT19dicai conditions and symptoms, and recent BSLs.

Dispense the prescnpbOn as written with appropnate counseflfng

regarding monitoring of BSLs on diabetes.

Contact the prescriber, primarity to tmd out the reason for the addition of the frusemtde.

contact the prescriber, pnmarity to find out c...,.ent ijver function tests.

Cltnical Interventions in Australian Community Pharmacies

4.2.2.2

The online pharmacist demographic questionnaire is shown in full in

Appendix 10, and addressed three main areas:

• Section 1: the pharmacist's background in terms of training and

experience (Figure 4-21)

• Section 2: the pharmacist's current practice profile (Figure 4-22)

• Section 3: the pharmacist's opinions regarding the profession of

Cltnical Interventions in Australian Community Pharmacies

You - logged 1n as pdanni05

ction 1- G tion nd b ck round

The folio ing 1nformatio is important to enable us o determine ho your background inflenoes the

ay e intervention soenaroos are classi 1ed.

Informed consent

Sy e<>mple no the forms 1n the folio. ing pages you COl'lsent to the collection and use of the data

collected on this website on the understanding 1t ill be de-iden "fied, processed and analysed in groups

and held acoording to University of Tasmania requirements. This project has been approved by the Human Research E hies Committee (Tasmania) Ne or .

• Please complete the details on the following pages as bes you can.

• Leave blan any questions you are unable to complete.

General infonnation

Gender

I

3

Aoef<20

3

Year of graduation

C=:J

OR

r ot ye oraduated 1.4 Where did you complete your pre-reomrat1on tl"ammg?

I

If other please specify

1.5 Are you accredited to conduct mcd1cat1on l"ev1ews? r Yes r 0

3

1.6 Since you graduated, have you gamed any fonnal chmcal quahf1cat1ons? r Yes r No

If Yes please specify

1.7 Indicate the approximate number of full-t•me years that you have worked m the following prachce ,.,,,Hing" (sevel"al may etpply).

Humbel" of years

< 2 2 - s >S Nil

Communrty Pharmacy

r

r

r

Hospital Pharmacy r

r

r

Medicabon rev1e s on nurs1 g homes

r

r

r

Univen•tY or other tertiary eduait1on 1nstiution r r

r

Other

r

r

r

FIGURE 4-21: PHARMACIST DEMOGRAPHICS (SECTION 1: BACKGROUND, TRAINING

Clinical Interventions in Australian Community Pharmacies

Validation> Your details You are logged in as pdenniO·S

Section 2- About your main area of work (Community Pharmacists)

The following questions related to the practice setting where you spend the majority of your time practicing as a pharmacist.

2.2 What is your current role in community pharmacy?

r

r

r

r

2.3 How long have you worked in your current position?

C : Jvears

2.4 When you work in this area, what proportion of the time do you do so?

(' Full-time

(' Part-time r Other

2.5 When you are at work, how many other pharmacists also are present the same time?

(' None, I am the sole pharmacist

r

r

2.6 How many hours do you work in community pharmacy during an average week?

r

r

r

Clinical Interventions in Australian Community Pharmacies

You _ logg..:I ., u pdlannlOS

ection 3 - P rson I views of ph rm

cv

6.1 I am comfortdble with the technology changes tdkmg place in pharmacy

(' ('

gree

('

I

lydl

6.2 I .. ee the tradrtmnill .. ource.s of ph.umacy remunerahon a,. the only source of funds.

for the future

<' r

trongly gr

6.3 for me pharmacy as JUSt ii JOb

('

I

('

~ ro gr U ure

Str n ly di gr Un re

6.4 I believe that phdrmacasts. currently h<1ve too much to do and there 1s no capdcrty for

change

r

r

Stronq1y gr

('

I

r

r

~tron ly ~i gr Un ure

FIGURE 4-23: PHARMACIST DEMOGRAPHIC QUESTIONNAIRE (SECTION 3: OPINIONS OF PHARMACY PROFESSION)

The opinion-based statements requested in section 3 of the questionnaire targeted aspects of the pharmacist's professional integrity, job satisfaction and readiness for change.

Scores for each of these three characteristics were determined from

the responses to questions in these areas. Thus, each pharmacist

completing the survey could be assigned an indicative score for professional integrity, job satisfaction and readiness for change, in addition to providing the demographic information.

4.2.2.3

Clinical Interventions in Australian Community Pharmaetes

DOCUMENT system. Some particularly difficult to categorise scenarios

were included with explanations for why particular selections should be

made. This allowed the participant to have greater exposure to the

different selection options (and their explanations).

Once the user selected training for the DOCUMENT classification

system, a welcome screen for their first assessment appeared. There

was an option on this screen to view an online demonstration of how to

categorise an intervention using the DOCUMENT system (see Figure

4-24 ).

Home

About

What's new

Training

Tnal part1c1pants

Contact

Go to scenario ...

There are 20 scenarios to classify using th.. DOCUMENT

system. Click on the button below to start. Note that

you do not nave to complete all 20 scenarios at one time. You may retum to this page at any time to continue dassrfying the sceanrios~ To view an example cf how to classify a scenario, dick~ (allow a few seconds for the

file to download).

The scenarios you have completed to date will have a tick next to them -you may view the feedback for completed

scenarios at any time by dicking Go ... in the feedbac column.

Go to Next Scenano

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

FIGURE 4-24: ONLINE DOCUMENT TRAINING WELCOME SCREEN

Login n

..•

Clinical Interventions in Australian Community Pharmacies

II Ttw • DOCUWEHT

·

-Go to sce11 •

~-.:.-There are 21 syJtem. Ok

you do not I'

You .,,_y ret

dafflfying tf c:feMlfv • K

fife to downl

.

...

-·

-Example of how to classify

The scen~rio

A 54 year okt woman was corrmenced on zolptdam to heEp her 5'eep about Z weeks ago. She comes ., to YOU" phannaq after using the meclic:ation fOf" 2 weeks to ask 1f her tablets coutd be making her forgetful and vague. You tel her that you wil have to check, and go and k>ok it up in the Australian

Medcnes Handbook. A.5 it's a new(ish) drug.. its not mentioned ., the book

you firs:t look in, so you consUt the eMims and find that zofptdem has been

associated with arnn1i&ia. According to the entry in eMims, the amnessa IS

more likely If the patient wakes Wlthin 4 hour'S of when the drug is taken. You go back to talk to the patient about whet:her her forgetfulness occurs:

during the day or night. She tels you that the forgetfuAness t5 mostty

during the mornings and describes several situations where she has

forgotten ,,_. - shopping, mosplaced CM keys and lost an umbrea..

You susp«t that the zolpid<!m may be hav.ng some sort of 'hanQov'

effect after she takes it the rjght before and you ask het" what tine she

rakes the zolpidem. 5"" teUs you sh<! takes ot last t!Wlg at night, just before she goes to bed at around llpm. You go back to the eMims to lind

the onset of action of the wlptdem which os o.s to 3 hours. You deode to recOf1'11TKHlC:t that she tnes takng the z.olptdem earlier n the evenng, at aroc..nd gpm and see 1f the "Hangover"' IS kiss of a problem. You also teJJ twr

that if this doesn't imp<ove the situation, sh<o shoUd go bad< to her docto< and Wlform hm of what IS happening.

Assessment and Classification

Type of Intervention

15

16

17

••

19

••

• Jn ths case, the type of problem is an adverse reacbon

due to the drug, so it would be one of the T (Toxicity or Adverse reaction) categories.

·

-

FIGURE 4-25: EXAMPLE OF CLASSIFICATION IN DOCUMENT ONLINE TRAINING

Once the user selected a particular scenario, they were presented with

a scenario summary and instructions for completing the first step of

the categorisation process (see Figure 4-26). The scenario summary

remained active whilst assigning categories, actions and

recommendations.

For PROMISe trial participants, an audio visual presentation was also

made available to facilitate the training process; this was accessible

Clinical Interventions in Australian Community Pharmacies

'f" ;JH

PROMIS

e

.\;·

Pharmacy Recording of Medication Incidents and ~er.~ices electronic documentation system

Home

About What's new

Class1f1cat1on

Training

Tnal part1c1pants Contact

.

_

..

Scenc:1rio 1

A 76 year old woman presents with a new prescription for mirblzapine. She is currently receiving sertraline lOOmg daity. She was undear about the doctor's instructions ,.-egarding the sertntline, and

WllS going to continue taking both antidepressents. You contltd: the prescriber to confirm their

intentions, and advise the patient of the outcome. You discuss: with the dod:or that thi.s patient may

be suitat:Me for an HMR.

• To begin, read the scenario above and identify the drug related problem (ORP).

• The DOCUMENT classification of DR.Ps are li.st~ below. First select a broad category by dicking

on one c.f the links. This wilt expand the subcategories. Then select ONE subcategory which best

describes: the ORP you have identified.

• V/hen you have made your selection go to the bottom of the page and dick Next.

• Ncte: To see all the sub-categories, dick on each link to expand the enb,.e table.. • Click~ he,.e to view an example scenario and now to classify it.

0 Drug seJection

... Help Select One ...

Jll. Duplication Orug 1ntentcbon

w,.ong drug

Wrong do$t!tQB form other dl"Ug selection problem*

*specify fn notes sectiort at the end of th;s scenario O over or underdose orescribed

C Compliance

U Untreated indications M Monitoring required E Education or information N Non-clinical

('

("

r r

("

FIGURE 4-26: ASSIGNING TYPE OF DRP IN DOCUMENT ONLINE TRAINING

The previously mentioned scope notes and detailed definitions of each

subcategory were available by selecting the help section. Once

selection of the category and subcategory was completed actions could

be selected.

Pharmacists were asked to document the actions that were undertaken

by the pharmacist in the scenario presented (see Figure 4-27).

However, as the results of the training were examined, it became clear

that many pharmacists recorded the actions that they considered

appropriate i.e. 'what they would have done', rather than those

Clinical Interventions in Australian Community Pharmacies

Home

What's new

Classification

Trammg

Tnal participants

Contact

2. Select actions to investigate the problem

Login nllme: pctenn10S

Scendrio 1

A 76 year old woman presents with a new prescription for mirtaz.apine. She is currently receiving

sertraline lOOmg daity. She was unclear about the doctor~s instructions regarding the sertraline, and

was going to continue taking both antidepressants. You contact the prescriber to confirm their intentions, and advise the patient of the outcome. You discuss with the doctor that this patient may

be suitable for an HMR.

What did the pharmacist do to sort out the problem?

• Check the boxes below · more than one may be checked if multiple actions done.

• Click Next at the bottom of this page when you have made your selections.

Select one or more .J a;. Investigation: written material r

l'!z. Investigation: software r

~ lnvesbgotlon: patient history r

Investigation: other

- specify Jn notes section tJt e.nd of r

scenario

~ Contacted prescriber r ~ Discussion with patient or carer ~ Al Corrected without discussion r

FIGURE 4-27: ASSIGNING ACTION TO INVESTIGATE DRP IN DOCUMENT ONLINE

TRAINING

Selecting appropriate recommendation(s) for the scenario was the next

step in the classification process. As with action selection, where

multiple recommendations were made by the pharmacist in the

C/1nical Interventions tn Australian Community Pharmacies

3. Select recommendations to resolve the problem

ogi name: pctenniOS

Scenario 1

A 76 year old woman presents wit a ne• pr-escnptlo for mi azapine. She is currently receiving sertraline 100mg daily. She was unclear about the doctor's instructions regarding the sertraline, and was going to continue ta · g bcth antidepressants. You contact the prescriber to confirm their intentions, and advise the patient of the outcome. You discuss with the doctor that this patient may

be suitable for a HMR.

What did the pharmacist recommend as a solution to the problem?

• Chee the boxes below - more than one may be checked if multiple recommendations are

necessary.

• dick Next at the bottom of this page when you have made your-selection.

Select one or more•

A Change in Therapy

R.._ Dose change

r

R2 Drug change

r

R3 Drug formulatio change

r

R.._ rug brand change

r

RS Dose frequency/schedule change

r

R6 Prescription net dispensed

r

...J.. other changes to therapy

r

A referral required

R8 Refer to prescriber

r

R9 efer to ospital

r

__Q efer for medication review

r

g_ Other referral required

r

Provision of information

.!Ll Education/Counselling session

r

r

Rl4 Commence dose administration aid

r

B...2 Other written information

r

B...§ Monitoring: non-laboratory

r

R.7 Monitoring: Laboratory test

r

RO No recommendation necessary

r

FIGURE 4-28: ASSIGNING RECOMMENDATIONS TO RESOLVE DRP IN DOCUMENT ONLINE TRAINING

The significance of the situation was then assessed as nil, low, mild,

moderate or high, with the relevant definitions available (see Figure