For Clinicians​

Medicines Reconciliation. (Note this involves a clinical review for appropriateness and is not just a technical task)

• Reconcile medicines following hospital discharge.

• Resolve any discrepancies, discussing changes with patients to clarify any misunderstandings, updating the records, provide medicines education and ensure an appropriate follow up plan is in place for monitoring including blood tests, adverse effects , clinical review, and dose titration.

• Requires collaboration with General Practitioners, Community Pharmacists, and secondary care colleagues. May include inviting in for a consultation (or a home visit depending on the service provision)

• Reconcile medicines following outpatient clinic visits- as above, includes updating the patient records, confirming the patients have understood the instructions, checking the outpatient clinic are aware of the patients’ current medications.

• Reconcile medicines on transfer between care providers - as above, including new patients.

• Ensure the patient management system medication records are updated, and any changes made are fully documented with reasons for stop, start or change of dose documented as well as usual documentation in the patients notes.

• Update patients medicine allergies and adverse drug reactions to ensure safety with prescribing.

 

Clinical audits

▪ Undertake in-depth clinical audits to identify patients in whom pharmacotherapy can be improved including:

• High risk medicine or combinations of medicines e.g. warfarin, Direct Acting Oral Anticoagulants (DOACs) dual antiplatelets, non-steroidal anti-inflammatory drugs (NSAIDs) Triple Whammy, disease modifying anti-rheumatic drugs (DMARDs), anti-epileptic drugs.

• At risk populations e.g. frail and elderly, Māori and Pacific Island people

• Targeted medical conditions e.g. diabetes, gout, COPD

• Targeted indicators e.g. blood pressure, HbA1c, uric acid, creatinine clearance

• Feedback this information in a useful, practical manner with further review of individuals as agreed so that recommendations are individualised and not merely guideline driven- this may result in clinic appointments with the clinical pharmacist or GP

• Increase quality and safety of prescribing through mechanisms such as audit and Plan-Do-Study-Act (PDSA) cycles which contributes to continuous quality improvement.

 

Medicines Education and Information For Clinicians

• Medicines information resource – readily accessible in clinic for day-to-day medicine related queries

• Respond to requests for complex medicine information queries. This may include quantification of risk / benefit for an individual.

• Providing up-dates on changes/ trends in medicines therapy – providing independent critical appraisal of the literature. This is especially useful in rapidly changing therapies.

• Developing medicine information bulletins, that could be shared locally and/ or nationally.

• Improve prescribing practice through educational support for prescribers within the practice.

• Lead where changes in evidence require changes in prescribing across patient population e.g., where a drug is withdrawn, or indications or evidence changes.

• Participation in peer group discussions or continuing professional development sessions.

• Present on topical medicine related issues, significant events and issues that cross primary and secondary care

• Present at conferences nationally and internationally, promoting the role of general practice based-Clinical Pharmacists

 

Quality use of medicines/ Quality improvement

▪ Work with primary care professionals and patients to implement evidence-based guidelines within local or NZ context

▪ Participant in inter-disciplinary teams

▪ Report on the result of audits and discuss actions arising from them

▪ Contribution to quality improvement of the practice

▪ Development and review of practice medicines related policies and standing orders

▪ Centre of Adverse Reaction Monitoring (CARM) reporting