OSCE book 2010

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Pharmacy Prep

OSCE Pharmacy Review

Contributors

Misbah Biabani, Ph.D

Director, Tips Reviews Centres 5460 Yonge St. Suites 209 and 210

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Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Disclaimer

Your use and review of this information constitutes acceptance of the following terms and conditions:

The information contained in the notes intended as an educational aid only. It is not intended as medical advice for individual conditions or treatment. It is not a substitute for a medical exam, nor does it replace the need for services provided by medical professionals. Talk to your doctor or pharmacist before taking any prescription or over the counter drugs (including any herbal medicines or supplements) or following any treatment or regimen. Only your doctor or pharmacist can provide you with advice on what is safe and effective for you. Pharmacy prep make no representation or warranty as to the accuracy, reliability, timeliness, usefulness or completeness of any of the information contained in the products. Additionally, Pharmacy prep do not assume any responsibility or risk for your use of the pharmacy preparation manuals or review classes.

In our teaching strategies, we utilize lecture-discussion, small group discussion,

demonstrations, audiovisuals, case studies, written projects, role play, gaming techniques, study guides, selected reading assignments, computer assisted instruction (CAI), and interactive video discs (IVD).

Our preparation classes and books does not intended as substitute for the advise of NABPLEX®. Every effort has been made to ensure that the information provided herein is not directly or indirectly obtained from PEBC®previous exams or copyright material. These

references are not intended to serve as content of exam nor should it be assumed that they are the source of previous examination questions.

Misbah Biabani, Ph.D Coordinator, Pharmacy Prep

Toronto Institute of Pharmaceutical Sciences (TIPS) Inc 5460 Yonge St. Suites 209 and 210

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OSCE Pharmacy Review

Content

SECTION A: Communication Skills and Techniques

 Chapter 1: Top 20 Rules of Communication in Exams  Chapter 2: Counselling A New Prescription

 Chapter 3: Counselling on Refill Prescription  Chapter 4: Counselling on Non Prescription Drugs  Chapter 5: Counselling techniques: Questioning  Chapter 6: Counselling techniques: Persuasion  Chapter 7: Counselling techniques: Language Skills

 Chapter 8: Counselling techniques: Language for Instructions Dosage and Administration  Chapter 9: Counselling techniques: Using written information effectively

 Chapter 10: Conducting Patient Interview: Symptom related questions  Chapter 11: Counselling techniques: Counselling on lifestyles

 Chapter 12: Counselling techniques: Discussing alternative treatments  Chapter 13: Assessing the potential for non compliance

 Chapter 14: Assessing the need for follow up

 Chapter 15: Counselling techniques: Assessing need for nutrition and supplements  Chapter 16: Communication skills: Dealing with physician

 Chapter 17: Communication skills: Dealing with other Healthcare Professionals  Chapter 18: Communication skills: Demonstrating devices

 Chapter 19: Communication Skills: Dealing Dispensing Errors  Chapter 20: Communication Skills: Managing Med Check Program  Chapter 21: Communication Skills: Discussing Payment Options  Chapter 22: Communication Skills: Dealing with difficult questions

SECTION B: Problem solving: Identifying Drug Related Problems

Problem Solving: Gastrointestinal Symptoms and DRPs  Chapter 23: Gastrointestinal Drugs

 Chapter 24: Heartburn  Chapter 25: Diarrhea  Chapter 26: Constipation  Chapter 27: Hemorrhoids

 Chapter 28: Nausea and vomiting  Chapter 29: Pinworm

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4  Chapter 47: Cardiovascular Drugs

 Chapter 48: Hypertension

 Chapter 49: Antihyperlipidemics  Chapter 50: Ischemic Heart Diseases

 Chapter 51: Anticoagulants & Warfarin Management

Problem Solving: Psychotic and Neurological Symptoms and DRPs  Chapter 52: Psychological Disorders

 Chapter 53: Neurological Disorders

Problem Solving: Endocrine Symptoms and DRPs  Chapter 54: Contraception’s

 Chapter 55: Diabetes

 Chapter 56: Thyroid disorders

Problem Solving: Respiratory Symptoms and DRPs  Chapter 57; Asthma and COPD

 Chapter 58: Cold, Cough, Congestions and Fever  Chapter 59: Allergic Rhinitis

Problem Solving: Mouth and Dental conditions  Chapter 60: Canker and cold sores

Problem Solving: Eye Symptoms and DRPs  Chapter 61 Ophthalmic drugs

 Chapter 62: Conjunctivitis

Problem Solving: Ear Symptoms and DRPs  Chapter 63: Otitis media

 Chapter 64: Otitis externa

 Chapter 65: Vertigo and Dizziness

Problem Solving: Foot Symptoms and DRPs  Chapter 66: Foot Symptom Assessment  Chapter 67: Athletes Foot

Problem Solving: Dermatological Symptoms and DRPs  Chapter 68: Diaper rash

 Chapter 69: Headlice  Chapter 70: Dermatitis  Chapter 71: Psoriasis

 Chapter 72: Dermatological Drugs  Chapter 73 Acne

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Problem Solving: Musculoskeletal DRPs  Chapter 74: Arthritis

 Chapter 75: Osteoporosis

 Chapter 76: Pain Symptoms and Analgesics

Problem Solving: Reproductive, Gynaecologic, and Genitourinary Symptoms and DRPs  Chapter 77: Dysmenorrhea

 Chapter 78: Menopause

 Chapter 79: Sexual dysfunction and DRPs  Chapter 80: Vaginitis

 Chapter 81: Benign Prostate Hyperplasia

Problem Solving: Cancer Chemotherapy DRPs  Chapter 82 Cancer Chemotherapy

Problem Solving: Antimicrobials DRPs  Chapter 83 Antimicrobials

 Chapter 84 Urinary Tract Infections

Problem Solving: Lifestyle Management  Chapter 85: weight loss

 Chapter 86: Smoking cessation

 Chapter 87: Allergies and Hypersensitive reactions  Chapter 88: Photosensitivity

 Chapter 89: Insomnia

 Chapter 90: Immunizations and vaccines  Chapter 91: Medications use in pregnancy  Chapter 92: Traveling Tips

 Chapter 93: Substance of Abuse

PART 3: Non interactive stations

Chapter 94: Non interactive stations

Chapter 95 New Approved Drugs 2007 to 2010

Part 4: NAPRA Competencies

 Chapter 96: Pharmaceutical Care

 Chapter 97: Pharmacy Regulations and Ethics

 Chapter 98: Pharmacy Practice Information Resources  Chapter 99: Communication Skills in Pharmacy  Chapter 100: Managing Drug Distribution  Chapter 101: Managing Pharmacy Operations

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Communication

Skills

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Number 1: Communication

Number 2: Communication

Number 3: Communication

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Rule # 1: Always respond to the patient/actor  Make eye contact

 Answer any question that is asked.

 Respond to the emotional, as well as factual, content of question

Rule #2: Listen, reflect, encourage, and offer empathy

 Introduce yourself (tell him/her who are you?/What are you doing)

 Getting the patient to talk is generally better than having the pharmacist talk  Be sure who your patient/actor is? The child, mother, or her husband

 Arrange seating for comfortable, close communication

 If at all possible, both patient/actor and pharmacist should be both be seating

Rule # 3: Notice and response to information

 Change the plans and goals as events change, new information should cause you to stop and reassess

 Don’t carry away by inertia. How you reach your goal may shift with new information, even it the goal itself stay the same

Rule # 4: Ask the prime questions

 What did your Dr. tell you this medication was for?  How did your doctor tell you to take this medication?  What did your doctor tell you to expect?

Rule # 5: Be sure you understand what the patient medical conditions /Medications/ Allergies and alternate life style (MAMA) before recommending

 Seek information before acting

 When presented with a problem, get some details before offering a solution  Begin with open-ended questions then move to close ended questions

Rule # 6: Assessment – critical thinking and analysis of the problem.  Are each of this patient’s medications appropriately prescribed?

 Is each medication the best one for this patient to be taking? Safest, most effective?  Is this the right dose given the patient specific information (severity, size, gender,

etc.)

 Is the patient having any apparent drug related side effects?  Are any possible drug interactions present?

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4  What are some other possible causes of the patient’s complaints / symptoms?

Rule # 7: Patient do not get to select inappropriate treatment

 Patient select treatments, but only from presented, appropriate choices

 If a patient asks for inappropriate medication that he/she heard advertised/ from friends/relatives, explain why it is NOT indicated and suggest an alternative Rule # 8: Never lie

 Not to patient/actor, their families, or insurance companies  Do not deceive to protect coworkers

Rule # 9: Work on developing a rapport on an ongoing basis, always seeks a good professional relationship with patient

 Ask patient/actor if this prescription/refill/concern for you?

Rule # 10: Patient is number one always placing the patient first

 The goal is to serve patient/actor, not to worry about your exam results

Rule # 11: Prepare Patient Counseling Plan before engaging in the counseling  What is the situation right now? (Special circumstances, medication itself, past

history with the patient, etc.)

 What does everyone who takes this medication need to know?  What does this patient need to know in addition to this?

Rule # 12: Identify red flags that signal “physician referral”  Blood in stool/urine or vomiting of blood

 Fever not responding to appropriate measures  Yellowing of skin or eyes

 Severe pain (described as “the worst pain i’ve ever had”)  Fever, vomiting, headache, confusion, difficulty bending neck

 Signs of infection or inflammation (fever, pus, swelling, redness, tenderness, heat)  Spontaneous bleeding or bruising

 Chest pain  Pain on urination

Rule # 13: When collaborating with the physician,

 Always position the patient and his/ her health as the basis of interaction.

 Do not make judgments on the physician’s capabilities to choose a therapy for his/her patient.

 Establishing a good channel of communication and respectful relationship with the physician is essential in building a team approach to patient care.

 Information the pharmacist passes to the doctor regarding drug interactions, contraindications or non-adherence, is highly valued by the physician. This

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Rule # 14: Listen to what patient is saying and provide any  Information missed by patient.

Rule # 15: Offer follows up and asks if the patient has any questions or concerns.  It sounds like you’ve got it. Please don’t hesitate to give me a call if you have any

problems.

 This is also a good place to remind about refills  Thank the patient

Rule # 16: Final Verification

 Assess whether verification or summary is needed

 Has patient verbalized the information you wanted them to know?  yes – summarize & reinforce their knowledge

 no – final verification (Just to make sure I haven’t left anything out, could you tell

me how you are going to use the medication?)

Rule # 17: The key is not so much what you do, how you do it?

Rule # 18: There are three things that can destroy your exam: misinformation, poor communications, and poor judgement of question.

Rule # 19: pharmacist should be able to discuss pros and cons of alternative treatment Rule # 20: Never assume patient knows every thing

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Communication Skills: Counselling

New Prescription

The sample template describes how to approach a patient who comes to fill a new prescription. This template assist you to develop a communication model, however you have to adopt your communication model upon patient have some questions in between.

COUNSELLING NEW PRESCRIPTION Opening discussion

Introduction Offer privacy

Empathy

↓

Discussion to gather information and identify problems MAMA

TOPS

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Patient’s present knowledge about medication and condition.  Potential problems

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Identify problems and Educational needs Discussion to prevent or resolve problems and educate

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Discuss real or potential problems • Agree on alternatives

• Implement plan

• Discuss outcomes and monitoring • Provide information as necessary

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Recap ● Get feedback ● Encourage questions Follow up

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Practice Station

Scenario # 1

A patient comes to fill prescription:

Patient profile: (given by patient after pharmacist candidate request) Patient Name: Amy

Age: 55 yrs

Address: Pharmacy Prep Avenue Doctor: Tips

Medical Condition: hyperlipidemia and high B.P Current Medications: Diovan HCT 80/12.5 mg po daily Rx:

Lipitor

Sig: 20 mg po daily x 3 months Mitte: 90 tablets

R: 2

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Communication Skill:

Counselling On Refill Prescription

Opening discussion Introduction Offer privacy

Empathy

↓

TOPS

↓

 Patient’s present knowledge about medication and condition.  Potential problems

↓

Compliance problems? • Evidence of side effects? • Effectiveness of treatment • Potential problems

↓

Discuss real or potential problems • Agree on alternatives

• Implement plan

• Discuss outcomes and monitoring • Provide information as necessary

↓

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Scenario # 1

A patient comes to pick up his refill 2 weeks before his due date. Patient Profile: (on the table)

Patient: Mathew

Age: 18 years

Gender: Male

Dexedrine 10mg cap 1x3 90 tablets each 30 days Refills: (3) last refill 2 weeks ago

Scenario # 2

A patient is coming for her refill with a concern. Solve her concern as you are in your pharmacy. (She is pregnant)

Rx

Epival (Divalproex Na) 250mg tablet 1x1 Mitt: 30 tablet

Refills (5)

Last refill 30 days ago Patient Profile (on the table) Patient: Rosemary Khan Age: 33 Years

Gender: Female

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4

Communication Skills: Counselling

OTC Drugs

Opening discussion Introduction Offer privacy Empathy

↓

TOPS

↓

Has Physician been consulted before? • Description and duration of symptoms • What treatment has been used previously?

↓

Identify problems and Educational needs

Discussion to prevent or resolve problems and educate ↓

Non Prescription Drugs

Medication Recommended Medication Not recommended  Name  Purpose  Directions  Side effects  Precautions  Future treatment

 Self care recommendation  Reassurance

 Advice patient to see physician  Suggest non-drug treatment  Give self care recommendation  Reassurance

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Practice Stations

_______________________________________________________________ Scenario # 1

A young man approaches you requesting smokeless tobacco. He heard from his friend that smokeless tobacco reduces cancer and lung diseases.

On the table:  Nicotine gum,  Nicotine patches  Nicotine inhaler  Nicotine gargle

 Herbal products for smoking cessation.

Patient profile: (given by patient after pharmacist candidate request) Age: 45 yo

Allergies: none

Current medications: None Current medical conditions: none

Scenario # 2

A woman come with a concern, and she wants an OTC product. She has white flakes on the shoulders of her black sweater after she brushes her hair. Her hair is clean, and the scalp is itchy.

Available on the table:

 Ketoconazole2% shampoo,  Selsun shampoo,

 Zinc Pyrithione (Head and shoulders),  Salicylic

 Sulphur bar and lotion  Coal tar shampoo

Patient profile: (given by patient after pharmacist candidate request) Age: 22 yo

Allergies: None

Current medications: None Medical conditions: none

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Counselling Techniques:

Questioning (Probing)

The following questions may assist you to counsel efficiently and effectively to succeed solving problems.

Do’s

Asking the right questions?

 What did doctor tell you about your medication?  How the doctor told you to take this medication?

 The doctor just wrote to take as directed. How did he/she tell you take them?

 Medications can occasionally cause some unwanted side effects. What did the doctor tell you about possible side effects?

 Is there anything further that you would like to do discuss or ask.

Don’ts

 “ You do know how to take medication, don’t you? (leading questions)  “Did the doctor tell you about side effects” (close ended question)

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Counselling Techniques:

Persuasion

During information giving phase of the counselling, it may be necessary for the

pharmacist to provide information such a way that change the patient beliefs, attitude or behavior towards the medication use. This can be accomplished by persuading the patient that following his/her advice regarding medication is in the patient’s best interest.

The pharmacist’s ability to persuade depends on his or her style of communication, effective methods of presenting information, organizing information, and confidence and credibility of information.

Do’s

 Use friendly tone, caring, use two sided communication, gently encourage the patient comply, and the same time making the patient aware of the risks of non-compliance.  Be neat and tidy

 If you note on the prescription telling him that the patient prescription was one month late in being renewed, or earlier than refill time and prepare to discuss compliance.  I am concerned about your medication use, as it is very important to take medication

regularly in order for it to work better.

 You still need to take medications to continue feeling well

 It is particularly important with this medication that you don’t stop suddenly. Although it is problem free, it could cause drug withdrawal symptoms. Don’ts

 Preaching and threatening

 Getting upset and loud when the patient does not accept pharmacist advice.

 Boldly staring that this medication should be taken as directed, several reasons are given for the advice.

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Counselling techniques: Mastering

Language skills

It is important to have smooth flow of communication and organized approach before you start your counselling. Here are the few points master your language skills

Empathy statements  It must be hard …  It must be difficult…  It seems your……….

 It sounds like pain is real ordeal for your…  I am glad you told me that

Paraphrasing

 Paraphrasing allows the pharmacist to verify that he/she understood the patient. Paraphrasing is simply restating what he or she believes the patient has said and verifying the facts.

 Paraphrasing also helps to reflect that your paying attention to patient concern or question.

 Repeating the patient’s exact words is another techniques that encourage patient to talk more about a particular topic.

Do’s

 Repeat the patient exact words..  Are you saying that……

 Is your concern is…..

Don’t

Repeating frequently patient’s exact words, it would be annoying Summarizing

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 Before making a recommendation to problem, a pharmacist can summarize all that has been said in previous discussion.

 After a pharmacist summary statements, the patient can correct the pharmacist if the summary is incorrect or provide additional information necessary.

Do’s:

You have told me that you have had diarrhea before starting medications..

Transition

A transition is a specific, planned attempt to change to topic , in order to provide structure and continue during interview.

This is especially useful when pharmacist needs to change to different topic like counselling on how to use medications to patient self care recommendations.

This is also very useful especially when patient interrupt with comments on another topic. Do’s

What if patient interrupts with other topic while your communications? After briefly discussing the patient’s comments, the pharmacist can return to

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Communication Skills:

Giving Instructions

Do’s

Use future forms,” softens your language: for example:

Be + going + infinitive

“You’re going to take one pill in the morning and one at bedtime.”

Be + going + to be + V-ing

“You’re going to be taking this tablet once a day at bedtime.”

Will + be + V-ing

“You’ll be taking one tablet at breakfast one at lunch, and one at dinner.” Don’t’ (avoid using commands)

“Take one pill in the morning” (sounds command)

“Take this tablet with a full glass of water (sounds command) Use Passive Forms for Embarrassing Topics

Do’s

 Be + past participle

 “The suppository is going to be inserted into the rectum.”  Will + be + part participle

 “The suppository will be inserted into the rectum.”  Don’t (Avoid using you or your)

 “You are going to insert this suppository into your vagina,” you can use a passive construction to remove the emphasis from the “doer.”

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 Also, avoid using personal pronouns such as your when talking about potentially embarrassing topics with a patient. Instead, say “the vagina,” or the “the penis.” Use Sequencers

Do’s

 Try to use se short statements. Use simple (lay) language, as to talk to 6th

or 7th graders

 When giving instructions to patients, it’s very important to use sequencers such as

“First,” “Next,” “Then,” etc. so the patient can easily follow the instructions. You

can also use phrases such as,

 “After washing your hands, you are going to remove the cap and place it on a tissue.”

Don’t

 Avoid using long complications sentences  Avoid using textbook type of statements

Use Signifiers of Importance

Use language that tells your patient that the instruction is important, such as:  It’s important to wash your hands first.

 It’s important that you take this tablet with a full glass of water.  You must avoid alcohol while taking this medication.

My reference shows that patient must avoid taking alcohol with medication: Avoid using “must” in lifestyle recommendation

Confirm the Patient’s Understanding

Confirm that the patient has understood your instructions by using the following language:

 Just to make sure I’ve explained myself completely, would you mind telling me how you’re going to use this medication?

 Do you have any questions about how to use this medication?

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Do’s

 Maintain professional attitude, and eye contact.  Speak clearly

 Use logical sequence

 Use sequencer in phrases such as “ first, next, then, after etc.  Use future forms instead of commands

 Give enough information, rather over information (do not over kill)  Use appropriate body language while presentation

 Use simple language (avoid text book type of professional language)  Use signifiers, such as it is important, or must avoid etc.

Lay language

Describing how a class of drugs works and o explain Mechanism of actions:

Antihistamines – These medications help to reduce your allergy by reducing certain substances in your blood.

Nitrates – These medications help prevent you from having chest pains and shortness of breath by delivering more oxygen supply to your heart and lungs.

Beta-Blockers – These medications slow down your heartbeat and slow down your blood pressure by blocking certain chemicals to avoid any heart complications. Bisphosphonates – These medications help strengthen your bones by adding calcium to them, thus helping to prevent fractures.

Anti-Anxiety Agents – These medications help reduce your anxiety (calm down) and make you feel more relaxed by reducing certain messengers in your brain.

Diuretics – These are water pills that help to remove fluids from your body and lower blood pressure and prevent a heart attack.

Anticoagulant – These medications help to make your blood thinner and prevent clot formation, thereby preventing you from having a stroke or heart attack.

Statins – These medications help elevate levels of good cholesterol and reduce bad cholesterol by inhibiting certain enzymes in your blood, thus helping prevent you from having a stroke.

Birth Control Pills – These medications help prevent pregnancy by inhibiting ovulation.

Anti-Depressants – These medications help to control your mood and make you feel well by inhibiting certain messengers in your brain.

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Cough Suppressants – These medications help to reduce your cough by blocking the cough centres in your brain.

NSAIDs – These medications help to reduce pain by clocking certain substances in the body. They also work as pain killers.

Sulfonylureas (for Type 2 Diabetes) – These medications help to reduce your blood sugar by stimulating the production of insulin in your body.

Carbonic Anhydrase Inhibitors (for Glaucoma) – These medications help to reduce the pressure in your eye by draining the accumulated fluid, thus improving your eyesight and reduce pain.

Bronchodilators – These medications help open your body airways and make your breathing easier.

Proton Pump Inhibitors – These medications help treat your stomach ulcers by reducing the acidity in your abdomen.

Anti-Psychotics – These medications help improve your emotions and behavior by controlling certain substances in your brain.

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9

Counselling techniques:

Using written patient information

effectively

Along with verbal counselling, pharmacist needs to select the right information sheet for each patient, and know how to present that information.

Commonly used written information:

 Computer generated patient information sheet  Package inserts

 Photocopies of articles  Scientific journal articles  Health Canada food guide

 Drug recall from health Canada and manufacturers

Do’s

 It is very important to review highlights of written information, relevant to patient questions. Make sure the information provided is accurate and well presented.  Pharmacist may need to modify the written information by highlighting certain areas

that is most relevant patient.

 Written information can be useful in addition to verbal counselling to provide detail information

 Written information also helps patient family and caregiver to understand the therapy  In all cases, pharmacist should review information with patient and offer it to discuss it further after patient have had reading and understanding information it in detail at home.

Don’t

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Conducting Patient Interview:

Symptom related questions

Pharmacist is a primary healthcare provider, and has responsibility to identify symptoms that need medical attention.

Do’s

 Memorize all disease and drugs overdose and withdrawal symptoms

 Identify symptoms that need medical attention and determine urgency of referral  Identify symptoms to make recommendations on drug therapy to treat identified

symptoms

 Be alert for undiagnosed conditions, pharmacist have some time an excellent opportunity to help identify a serious condition.

 Appropriate questioning during a symptom related patient interview might help to determine urgency of further medical assessment and intervention.

Don’t

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[Type text] Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

Scenario # 1

Mr XP a regular patient at my best pharmacy, patient approaches you for

recommendation. Sounding a little discomfort in stomach and have hard time with bowel movements.

On the table:

 Anusol Plus suppositories  Anusol Plus ointment  Tuck’s wipes

 Senokot  Metamucil

 Soflax (Sodium Docusate)

Patient information (gives this information after asking questions)  Age: 45 year old

 Allergies: Not known  Current Medications: None  Medical conditions: None

Life style:  Non-smoker

 Alcohol: moderate 3 to 4 drinks/wk

 Works as courier delivery, and always on wheels and eats on the run

Scenario # 2

A 55 year old man comes into the pharmacy and complains of chest pains. He asks if you could recommend something for heartburn.

Counsel the patient.

Patient information (gives this information after asking questions)  Allergies: Not known

 Current Medications: atorvastatin 20 mg daily, enalapril 10 mg  Medical conditions: high cholesterol and high blood pressure

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11

Counselling techniques:

Counselling on Healthy lifestyles

The pharmacist the most important concern is counselling on appropriate use of

prescription and non-prescription drugs. The pharmacist should also consider the overall health of their patients.

Health and lifestyle issues that pharmacist may emphasize include:  Smoking

 Alcohol  Exercise  Safe sex

 Unwanted pregnancy  Illegal drug use  Wife and child abuse

How to approach problem Do’s

 Offer help, rather than preach

 Communicated non judgemental way

 Help patient to set achievable, individualized goals

 Delivering lifestyle information should be done by tact and empathy since lifestyle is personal issue and as well as difficult thing to change

 Be empathetic in challenges to lifestyle changes that faced by patient

 Make your patient aware of facts concerning the risk of any unhealthy behavior

Don’t

 Don’t be taskmaster

 Don’t counsel in an authoritative and aggressive manner  Don’t be judgemental

(30)

(31)

12

Counselling techniques: Discussing

alternative treatment

It is important for a pharmacist to become knowledgeable about herbal remedies, homeopathic medicines, naturopathic treatments, and acupuncture.

How to approach a problem Do’s

Pharmacist should be able to discuss pros and cons of alternative treatment

 Provide information about available products and recommend reputable practitioners of reputable alternative treatment, if required

 Discourage unproven or products that have insufficient information about clinical studies.

 Prevent harm by becoming knowledgeable about serious drug interactions of alternative treatment with medications

 Prevent harm

Don’t

 Do not recommend alternative product that may result into serious risk to patient.

What is often asked?

Pharmacist are often asked about alternative treatment, and requested supply various products?

Herbal Remedies Ginseng

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[Type text]

 American Ginseng (Panax quinquefolium) has shown to lower post-prandial glucose & improves glucose metabolism

 Prevention & treatment of cardiovascular disease (induce nitric oxide, block Ca channel in the heart, prevent platelet adhesion)

 Obesity and hyperlipidemia  Cold & Flu treatment Ginseng & Digoxin

 Ginsenosides (Asian & American ginseng) & Eleutherosides (siberian ginseng) partly resemble the structure of digoxin

 Patients taking ginseng may have falsely ñ or ò digoxin levels due to laboratory interference

 Case report: patient asymptomatic for digoxin toxicity exhibited supratherapeutic digoxin levels (5.2 nmol/L) [Therapeutic range 2.2 nmol/L]

Ginseng & Warfarin

 In vitro Ginsenosides inhibit platelet aggregation & prolong the activated partial thromboplastin time (aPTT)

 Two case reports show a ò in warfarin effect (drop in INR) in pts taking ginseng & warfarin

 Patients should avoid ginseng due to possible reduction in INR.

St. John’s Wort (SJW)

 Has been used in a variety of psychiatric disorder, including depression

 MOA: alters serotonin (inhibits its reuptake), dopamine & norepinephrine activity.  Typical antidepressant dose: 300 gm TID

 Inducers of CYP 3A4 & intestinal P-glycoprotein

St. John’s Wort (SJW) & Immunosuppressants

 Cyclosporine & SJW reduced plasma levels of cyclosporine & even graft rejection  Tacrolimus & SJW reduced plasma levels of tacrolimus

 Cyclosporine & Tacrolimus both are eliminated by CYP 3A4 & are substrates of P-glycoprotein

 Mycophenolate (CellCept®) & SJW, no effect

St. John’s Wort (SJW) & Oral Contraceptives

 Both Ethynyl estradiol & progestin in OC are metabolized by CYP3A4  Studies show a low probability of significant interaction between SJW & OC  However, St. John’s Wort (SJW) & Oral Contraceptives ] breakthrough bleeding &

theoretical risk of contraceptive failure, & also reported cases of pregnancy

 Warn patients about possibility of breakthrough bleeding and reduced effectiveness of OC

(33)

 Pharmacodynamic Interaction (SJW & SSSRIs, Effexor, etc.) ] Serotonin Syndrome  Serotonin Syndrome symptoms:

 Altered mental status (agitation, delirium)

 Autonomic hyperactivity (tachycardia, hypertension, chills, sweating, hyperthermia)



Neuromuscular (tremor, myoclonus (involuntary twitching of a muscle)

St. John’s Wort (SJW) & Antidepressants

 Pharmacokinetic interaction with amitriptyline

 Amitriptyline is metabolized by CYP2D6, CYP3A4, CYP2C19 & is a substrate of P-glycoprotein

 Efficacy of amitriptyline may be ò when taken with SJW

 Digoxin & SJW ] reduced digoxin levels ] loss of disease control

 (P-glycoprotein is involved in intestinal absorption, distribution & renal elimination of digoxin)

 Antiretrovirals & SJW reduced systemic exposure to PIs & NNRTIs viral load ñ & drug resistance ñ(PIs & NNRTIs: both metabolized by CYP3A4



PIs: substrates of P-glycoprotein) Garlic & its uses



Anti-infective properties  Immune-enhancing properties

 Prevention & treatment of cardiovascular disease  Allicin (active compound in garlic) induce CYP3A4

 Garlic my also inhibit CYP2C9, CYP2C19 & CYP3A4, as well as P-glycoprotein

Garlic & Warfarin

 Antiplatelet activity of Garlic may enhance the anticoagulant activity of warfarin  Case reports (Garlic & Warfarin):

 bleeding

 increase in INR (in two cases, the INR increased approximately twofold)

Ginkgo Biloba

 Has been used to treat Alzheimer’s disease & dementia  Ginko Biloba & reported interactions

 Ginko may increase risk of bleeding with ASA, ibuprofen, and warfarin

Echinacea

 Stimulates immune system

(34)

[Type text]

 Contraindicated in systemic & autoimmune diseases such as rheumatoid arthritis, lupus, inflammatory GI disease, tuberculosis, multiple sclerosis, leukemia, diabetes, connective tissue disorders

 Use by AIDS & HIV patients is contraindicated

 Should not be given to children younger than 2 years old

Other important herbal products that recommended to read are : Saw Palmetto Indicated for BPH, Cranberry-Indicated for UTI and Velarian - To treat insomnia. Kava - To treat insomnia.

(35)

Practice Stations

Scenario # 1

A young man comes to your Pharmacy asking for your assistance. He has got a concern regarding his condition and wants to purchase something that he feels would help him. On the table:

 Echinecea Tablets

 Pseudoephedrine 30mg tablets  Saline nasal drops



Dextromethorphan cough syrup Scenario # 2

A 25 year old women is inquiring about the use of Echinacea  Profile: Materna and Multivitamins

 On the table:

 Echinacea lozenges

Scenario # 3

A lady is inquiring about the use of St. John’s Wort.

 Currently using: Carbamazepine 200mg po TID and Folic acid 5 mg po od  On the table

(36)

[Type text]

Scenario # 4

A female in her 50’s

Patient Profile: (given on table) Age: 51 yo Current medications  Eltroxin 100 mcg daily  Crestor 10 mg daily  HCTZ 25 mg daily  Atenolol 50 mg dailyWarfarin 2 mg ud  Warfarin 1 mg ud Medical History:  Dyslipidemia  Hypothyroidism  Hypertension  DVT 3 month ago

COLD-fX® is a highly purified extract derived from North American ginseng (Panax

(37)

13

Assessing the potential for non

compliance

In pharmaceutical care it is an important to make sure, to the best of pharmacist ability, that the patient received the necessary necessary medication at the required time in order to get desired effect.

Do’s

It is essential consider the individual patients personal and environmental characteristics, these include:

 The patient attitude to medication use

 Their knowledge of their condition and medication treatment

 Their previous experience with medication use, including family and friends.  Their lifestyle and time schedule

Although you short time with patient, however look for factor that can contribute to non-compliance, such as:

 Number and types of medication currently patient using

 Drugs that require that have special instructions, such as taking empty stomach, with full glass water, should not combine with other drugs, and do not chew etc.

How to figure out non-compliance in patients;

 A careful and direct discussion with patient at the time of medication provision

Motivate patient by explaining of taking medication regularly gives desired effect Strategies To Enhance Adherence To Medication Regimens

 Integrate new behaviours in patient lifestyle.  Provide or suggest compliance or reminder aids.

(38)

 Monitor use on an ongoing basis.  Refer patients when necessary.

(39)

14

Assessing the need for follow up

counselling

In pharmaceutical care practice it is important for pharmacist to ensure that appropriate outcome achieved from medication use

Do’s

Pharmacist need to schedule follow up counselling with patient, when they are conducting initial prescription counselling. It is challenging to assess the risk level of each situation

The nature of follow up arrangement will depend on: Pharmacist assessment of the risk of drug related problems such as side effects and non-compliance.

 High risk drug situations follow up:

 Pharmacist should discuss with the patient an appropriate time for follow up schedule either by phone or in person.

 Low risk situation follow up:

 Follow up schedule may involve a suggestion that the patient call if he or she has any questions. If certain drug side effects occur or if after a given period of time the desired effect has not been achieved

(40)

15

Counselling techniques: Assessing

patient need for supplements

It is important for a pharmacist to become knowledgeable about calcium supplements, iron supplements, and multivitamins.

How to approach a problem Do’s

 It is important to assess necessity of supplements

 Pharmacist should ensure that the client uses the product appropriately and identify and resolve any drug related problems

 It is important to know dosages and how to take them

 Pharmacist is often asked about calcium, iron supplement and multivitamins, supplement drops for children

Iron supplements

Know available iron salts

 Ferrous Gluconate 300 mg tablet – 35 mg of elemental Iron  Ferrous Sulfate 300 mg tablet – 60 mg of elemental Iron  Ferrous Fumarate 300 mg tablet – 100 mg of elemental Iron

 Triferexx - Polysaccharide-Iron Complex – 150 mg of elemental Iron

 Proferrin is a heme iron polypeptide. It is the same form of iron found in red meat 11 mg of elemental iron.

Iron supplements in Pregnancy

 Ask more questions about pregnancy?  Recently, have you seen your Dr?

(41)

 But for better assessment please see your Dr.

Iron Supplement counselling tips

 Take between meals to increase absorption  May take with food if GI upset occurs  Do not take with dairy products  May cause dark colored stool

 During the first 3 months of pregnancy a proper diet provides enough iron. However, during the last 6 months an iron supplement recommended in order to meet the increased needs of the developing baby.

 Antacids May make the iron supplement, less effective do not take at the same time. It is best to space dose 2hours

Calcium supplements Know Calcium formulations

 Chewable Tablets (Caltrate, Tums)  Soft chews (Caltrate)

 Liquid Calcium

 Effervescent Calcium (Calcium Sandoz)

Know available calcium salts

 Calcium Carbonate – the most concentrated (40% elemental calcium), least expensive, has slowest absorption (pH dependent)

 (Caltrate, O-Calcium “Natural Source”, Tums, Calcia)

 Calcium Citrate – more soluble; OK for patients with hypochlorhydrea (on PPI, H2

antagonists); does not cause gas, bloating or constipation; can be taken with or without meals

 Citracal, Calcium Citrate Tablets Each tablet provides 200 mg of elemental calcium as Ca citrate,

 Citracal, Caplets + D One caplet provides 315 mg of elemental calcium as calcium citrate, 200 IU of Vitamin D

 Citracal Plus with Magnesium

Counselling tips

 Bisphosphonates, tetracycline, ciprofloxacin, iron supplements – absorption of these drugs is negatively affected by calcium

 Food with high levels of sodium & caffeine accelerate Ca loss through urination (Recommend: one glass of milk for every cup of coffee consumed)

(42)

Practice Stations

Scenario # 1

A lady comes to you in the Pharmacy and wants advice on a certain products for her 4-month-old infant. Assist her and solve her concern as you would in the Pharmacy. On the Table:

 Multivitamin Drops for infants  Vitamin D Drops

 Iron supplemental drops  Enfalac formula with iron

Scenario # 2

Patient comes to fill the Rx Rx

Actonel 75mg

Take 2 tablets every month M: 1 mo supply

(43)

16

Communication skills:

Dealing with Physician

Pharmacist responses to physician questions are handled a little different than those to patients. Most of these questions are not difficult to answer, but it is important require building a good relationship with the physician

How to approach a problem: Do’s

 When collaborating with the physician, always position the patient and his/ her health as the basis of interaction.

 Be forthright & assertive and state the nature of your call right up front. If the patient asked you to make this call, make the physician aware of this.

 Establishing a good channel of communication with the physician is essential in building a team approach to patient care.

 Establish a respectful relationship where all the parties are aware of how each professional can contribute to optimize the overall care of the patient.

Don’t

 Do not make judgments on the physician’s capabilities to choose a therapy for his/her patient.

 Pharmacist are often asked about regarding  Alternate antibiotics therapy options,  Drug interactions,

 Contraindications or non-adherence, is highly valued by the physician.

(44)

16-2

Practice Stations

Scenario # 1

You are supposed to have a dialogue with the Doctor, who will be inside the room waiting for you. Go through the patient’s therapy. You may ask the Doctor anything you feel is relevant to the case. Recommend any changes that you believe are necessary for the benefit of the patient and document your response.

Patient Profile: (on the table) Patient Name: John carlos

Age: 45 years

Address: Prep Ave Allergies: Septra

Medications: Ferrous Sulphate (started 6 months ago) Comments: Ulcerative Colitis

Dr: Tips

New Rx: Sulfaslazine 1.5gms TID x 1 / 12 On the Table: CPS and TC

Scenario # 2

Patient Profile: (on the table)

Patient Name: Mrs Joshua Comments: Breast Cancer

Age: 52 years Parkinson’s disease

Address: XYZ Medications: Pergolide 1mg TID

Dr: Gaucher (Started 3yrs ago)

Sinemet CR 200/50 QID

(Started 10 yrs ago)

Tamoxifen 20mg BIB (Started 2 wks ago) New Rx: Metochlorpromide 10mg po PRN (30 Tablets)

(45)

Scenario # 3

Patient Name: Miss Jane Comments: Otitis Media

Age: 28 months Medications: Amoxicillin Suspension

Address: Prep Ave (Stopped today)

Dr: Tips Allergies: None known

New Rx: Cefuroxime Suspension 250mg, 1tsf BID x 5 / 7

Scenario # 4

You are a Hospital Pharmacist and you are supposed to have a dialogue with the Doctor, who will be inside the room waiting for you. Go through the patient’s therapy. You may ask the Doctor anything you feel is relevant to the case. Recommend any changes that you believe are necessary for the benefit of the patient and document your response.

Patient Name: Ms Casie Comments: Community Acquired

Age: 29 years Pneumonia

Address: Prep Ave Medications: Materna Multivitamins

Dr: Tips (Started 4 months ago)

New Rx: IV Levofloxacin 500mg Q24HRS x 10 / 7

Scenario # 5

(46)

16-4 Patient Name: Mrs Jacky Comments: Osteo-Arthritis

Age: 55 years Medications: Tylenol 1000mg QID

Address: Prep ave (Started 2 months ago)

Dr: Tips Codeine SR 60mg QID x 2/52

(Started 2 days ago)

New Rx: Carbamezapine 100mg TID x 5/7 then, 200mg TID x 1/12 (For Trigeminal Neuralgia)

Scenario # 6

Patient Name: Billy Comments: Asthma & phenylketonuria Age: 9 years Medications: Salbutamol Inhaler PRN Address: Prep Ave Fluticasone Inhaler 1puff BID

Dr: Tips (Started 2 years ago)

New Rx: Zafirlukast 20mg tablets BID x 1 / 12, then to review.

Scenario # 7

Patient Name: Catherine Comments: hypothyroidism and Hypertension

Age: 82 years

Address: Prep Ave Medications: Levothyroxin tablets

Dr: Tips Chewable Aspirin 81mg QD

Metoprolol SR 100mg QD

(47)

17

Communication Skills: Collaborating

with healthcare professional

Pharmacist and Pharmacy Technician Relation

If the pharmacist observes the pharmacy technician making mistakes, the pharmacist has to deal with the errant technician in a proper way.

Politely ask the technician to excuse himself from his work and talk to him/her in a private area.

Talk in a calm and firm manner and discuss about his/her error.

Appreciate his/her hard work, her/ his contribution to the pharmacy (like doing his/her job properly), etc., but discuss the problem clearly. For e.g. if the technician has counseled a patient for an OTC formulation, he/she has to be told that there are 2 reasons why a technician cannot counsel:

It is not legal for a pharmacy technician to counsel on any OTC medication. Only the pharmacist is allowed to counsel patients.

One may risk the health of patients probably due to an allergy triggered by the OTC

formulation or if the patients have medical conditions in which the product is contraindicated. Pharmacist has the knowledge needed to explain the potential dangers of natural health products to customers and he can advise them about herb-drug or herb-disease interactions. Pharmacist always uses his professional judgment to make a decision.

Alternative therapies are not always safe and without side effects contrary to general opinion. There is a lack of scientific data on their effectiveness ad safety profile and their interactions with Rx drugs. That is why it is important to refer patients to the pharmacist if they have any queries about natural / alternative products as the pharmacist can determine if the benefits of using alternative product is worth the risk/side effects.

(48)

3-2 Take his/her signature over the copy.

Always use positive words (USE POSITIVE CRITICISM) and expect the technician to learn from the mistake and not repeat it.

Encourage the technician to keep up with his/her good work.

A situation where the technician has taken a new Rx over the phone from a doctor.

Firstly, technicians are not allowed to take new Rx from a doctor over the phone, the call must be transferred to the pharmacist as the pharmacist can discuss any drug related problems or any other question related to the therapy, with the doctor. Even if the pharmacist is busy, the

technician should take the doctor’s phone number and let the pharmacist call the doctor and take the new prescription personally.

Take this opportunity to go over the duties of the technician. Call the doctor and verify the prescription.

(49)

Practice Stations

Scenario # 1

The pharmacy technician comes to you, the pharmacist, in your office with a Prescription for a patient who is already on Hydrochlorthiazide Tablets 25mg and asks for your opinion. Have a dialogue with him and guide him accordingly.

Rx: Enalapril 20mg QD. On the desk:

Photocopies of regulation and CPS

Scenario # 2

You are a Hospital Pharmacist and you overheard one of the junior Pharmacists having a conversation with a Doctor over the phone and advising him that Vancomycin IV can be replaced with oral vancomycin. Have a dialogue with the Pharmacist and advice him accordingly.

Scenario # 3

You just dispensed Paroxetine 20 mg tablets to a male patient. While paying for his medication you overheard the patient asking the cashier at the Dispensary that he read in the leaflet of the medication, it causes sexual dysfunction in males. The cashier’s response to the patient was that many men take it and not so many complain of it. Talk to the cashier and take the right action to solve the situation.

Scenario # 4

You are the Pharmacy Manager and you overhear one of the staff Pharmacists in the Pharmacy recommending a mother of an 18 month-old Lopramide capsules for her child. If you believe that it is a problem, talk to him accordingly and assist in solving it.

(50)

3-4 Scenario # 5

A patient comes in to collect a prescription for Amoxicillin. Prescribed by a dentist to be taken just before dental treatment. The patient profile shows that the patient is allergic to penicillin. Discuss an alternative with the dentist.

(51)

18

Communication Skills:

Devices Demonstrations

Aerochamber

 Remove cap.

 Shake inhaler and insert in back of aerochamber

 Place mouthpiece in mouth (or mask over mouth and nose)

 Encourage person to breathe in and out slowly and gently. (If you hear a whistling sound the person is breathing in too quickly*)

 Once breathing pattern is well established, depress canister with free hand and leave canister in same position as person continues to breathe in and out slowly (tidal breathing) five more times

 Remove the aerochamber from person’s mouth

 For a second dose wait a few seconds and repeat steps 2-6 The child

Aerochamber The child aerochamber device with mask and infant aerochamber device with mask do not whistle

Metered dose inhalers

Metered dose

inhaler  Remove cap and shake inhaler  Breathe out gently

 Put mouthpiece in mouth and at start of inspiration, which should be slow and deep, press canister down and continue to inhale deeply  Hold breath for 10 seconds, or as long as possible then breathe out

slowly

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62

Diskus

Diskus  Hold the outer casing of the Diskus in one hand whilst pushing the thumb grip away until a click is heard (OPEN)

 Hold diskus with mouthpiece towards you, slide lever away until it clicks. This makes the dose available for inhalation and moves the dose counter on

 Breathe out gently away from the device, put mouthpiece in mouth and breathe in.

 Remove Diskus from mouth and hold breath for about 10 seconds  To close, slide thumb grip back towards you as far as it will go

until it clicks

 For a second dose repeat sections 1to 5

Turbohaler

Turbohaler  Unscrew and lift off white cover. Hold turbohaler upright and twist grip forwards and backwards as far as it will go. You should hear a click  Breathe out gently, put mouthpiece between lips and breathe in as deeply

as possible. Even when a full dose is taken there may be no taste

 Remove the turbohaler from mouth and hold breath for about 10 seconds. Replace the white cover

Patient Counseling Information on Nasal Decongestants: Drops

 Blow your nose.

 Squeeze rubber bulb on dropper & withdraw medication from bottle

 Recline on a bed & hang head over the side (preferred) OR tilt head back while standing or sitting.

 Place drops into each nostril & gently tilt the head from side to side to distribute the drug.  Keep head tilted for a few minutes after instilling the drops.

 Rinse the dropper with hot water. Spray (atomizer)

 Remove cap from spray container.

 For best results, don’t shake the squeeze bottle.

 Administer one spray with head in upright position. Sniff deeply while squeezing the bottle.  Wait 3-5 minutes & blow nose.

 Administer another spray if necessary.

 Rinse the spray tip with hot water taking care not to allow water to enter the bottle.  Replace cap.

(53)

Inhalers

 Warm inhaler in your hand to increase volatility of the medication.  Remove the protective cap.

 Inhale medicated vapor in one nostril while closing off the other nostril, repeat in other nostril. Wipe the inhaler clean after each use.

 Replace cap immediately.

 Note: Inhaler loses its potency after 2 to 3 months even though the aroma may linger. Metered Dose Pump (Spray)

 Remove the protective cap.

 Prime the metered pump by depressing several times (for first use), pointing away from the face.

 Hold the bottle with the thumb at the base & nozzle between first & second fingers.  Insert pump gently into the nose with the head upright.

 Depress pump completely & sniff deeply.

 Wait 3-5 minutes & then blow nose. Administer another spray if necessary.

 Rinse the spray tip with hot water taking care not to allow water to enter the bottle.  Replace cap.

Transdermal patches

 Evra patch (Hormonal Contraceptive) – The patch should be applied to a clean, dry intact healthy skin on the buttock, abdomen, upper outer arm or upper torso, in a place where it won’t be rubbed by tight clothing. Not on a breast. Half of the clear protective liner is peeled away. The patient should avoid touching the sticky surface of the patch. The patch is positioned on the skin and the other half of the liner is removed. The patient should pres down firmly on the patch with the palm of her hand for 10 seconds, making sure that the edges stick well. The patch is worn for 7 days. On the “Patch Change Day”; Day 8, the used patch is removed and a new one is applied immediately.

 Estalis and Estalis Sequi Patch (HRT) – Immediately after removal of a patch from the pouch, and removal ½ of the protective liner, the adhesive side of the Estalis or Vivelle patch should be placed on a clear, dry area of intact skin and peel off the remaining one-half of the protective liner. The site selected should also be one at which little wrinkling of the skin occurs during movement of the body (buttocks and lower abdomen). The waist should be avoided, since tight clothing may dislodge the patch. Patches should not be applied to the same skin site for at least 1 week. Not on breast.

(54)

64  Nitro – Dur patch – Apply it on arm or chest. Application site should be rotated. A

suitable area may be shaved if necessary. Don’t put it on the distal part of extremities. Hands should be washed thoroughly after application.

(55)

Practice Station

Scenario # 1

A patient comes to pick up his prescription Patient profile (given on the table)

Patient: John Hirtz Patient Profile

Age: 40 years Pulmicort turbohaler 200μg 1x2 Allergies: Unknown Serevent Diskus 50μg 1x2 Gender: Male Ventolin inh 1-2 puff prn

Rx

Advair Diskus 250μg 1x2

60 blisters

Scenario # 2

A patient comes to pick up a prescription Rx

Ventolin MDI i-ii puffs q 4 to 6 hours prn Flovent 250 MDI 2 puffs BID

Patient profile: (given by patient after pharmacist candidate request)  Allergies: none

 Current medications: benadryl for cough  Medical conditions: just diagnosed with asthma

(56)

19-1

19

Communication Skills:

Handling Dispensing Error

It is important to handle situation appropriately to minimize the harm to patient health and the pharmacist and patient relationship. Communication is the key of handling dispensing error. If an error does occur, the cause of error must be assessed and correct action should be taken to prevent future error.

Client Presentations  May not be error?

 Error but medication not used?

 Error and medication used but no risk?  Error and medication used and risk?

 Error and medication used and risk to patient?

Pharmacy Accident Flow Chart

Immediately take control pharmacist on duty – advise pharmacist/owner

Isolate

- take customer to private area-do not discuss in front of other customers - if personal visit or telephone call, pharmacist must give patient individual attention

Get the facts

-inquire and show concern for the patient’s well being -determine if any medication was ingested or used

- do not deny

(57)

- determine if indeed error has been made; if so apologize “I am sorry, it appears an error has been made”

If not used If used

- immediately replace the incorrect - immediately return medication for item with the proper one – personally professional evaluation

deliver/taxi as needed

- assure patient that this is an isolated - immediately replace the incorrect incident, you will review Rx filling and item with proper one- personally Rx checking process deliver/ taxi.

- be genuine, spend as much time with patient as required to alleviate all concerns Counsel New medication

Follow up

Evaluate - notify Dr., state facts only

- use reference text before talking to

patient or Dr.

 tell patient no risk and assure no danger

 notify Dr. and explain giving professional analysis  if necessary, have Dr reinforce with patient

 show empathy, concern  notify Dr

 notify Dr. in all cases

 based on Dr recommendations  direct patient to hospital for tests  Call regional pharmacy operations

 complete Rx incidence report  Follow- up