Drug-related problems: their structure and function.

In order to better focus the role of the pharmacist on patient need and patient outcome, a means of categorizing drug-related problems (DRPs) is presented. A DRP exists when a patient experiences or is likely to experience either a disease or symptom having an actual or suspected relationship with drug therapy. Eight different categories of DRPs are described and examples of each category are offered. This categorization serves a number of functions, such as: (1) to illustrate how adverse drug reactions form but one category of extant DRPs, (2) to make tangible the pharmacist's role for the future, (3) to serve as a focus for developing a systematic process whereby the pharmacist contributes significantly to the overall positive outcome of patients, (4) to bring to pharmacy practice a vocabulary consistent with that of other healthcare professionals, and (5) to aid in the development of standards of practice for pharmacists.

Integrated patient-specific model of pharmacy practice.

The deficiencies of traditional models for the provision of clinical pharmacy services are discussed, and a patient-specific model that integrates drug distribution and clinical pharmacy functions is proposed. Traditional models have either designated specific individuals as providers of clinical pharmacy services or have combined distributive and supportive services with clinical services. In both cases, clinical services have been of secondary importance. Such models have resulted in inconsistent clinical services for which the patient is not necessarily the primary focus and have made it difficult for pharmacists to understand their mission. The lack of a well-defined primary clinical role for pharmacists has confused health-care providers and created problems for managers attempting to evaluate pharmacists and justify clinical services. The integrated patient-specific model is based on the ethical imperative that the patient must be central to any health-care endeavor. Under this model, clinical pharmacy services are of central importance and distributive services are integrated as a secondary but still very important aspect of comprehensive institutional pharmacy services. Critical elements of the integrated model include a patient-centered philosophy of practice, a definition of clinical pharmacy work, and a managerial framework. The integrated patient-specific model of pharmacy practice puts pharmacists in a professional relationship with patients and explicitly defines clinical services and priorities.

Documenting the clinical pharmacist's activities: back to basics.

The profession of pharmacy has applied the term "documentation" to count activities that more closely approximate descriptive protocols or administrative reports. This extended nonclinical use of the term documentation has resulted in the profession losing sight of a necessary step in the development, justification, and successful implementation of clinical pharmacy services. An instrument that helps to standardize the documentation of a clinical pharmacist's database, patient-care activities, and therapeutic plans is presented. This process, the pharmacist's workup of drug therapy (PWDT), consists of the following six interrelated steps: (1) establish a comprehensive patient-specific database; (2) identify patient-specific, drug-related problems; (3) describe desired therapeutic outcomes; (4) list all therapeutic alternatives that might produce the desired outcomes; (5) select the drug recommendation(s) that most likely will result in the desired outcomes; and (6) establish a plan for therapeutic drug monitoring that documents that desired effects occur and undesired effects are minimized. A formative method of documenting the clinical pharmacist's activities such as the PWDT must be functional on a daily basis in order to generate meaningful summative management reports.

Functional and structural prerequisites for clinical pharmacy services.

Pharmacy directors and pharmacists in charge of clinical services at 46 medium-sized hospitals were surveyed to identify possible explanations for previously documented inconsistency in the implementation of clinical pharmaceutical services. There were three study objectives: to determine the extent to which basic structural and functional management prerequisites have been implemented at these institutions; to determine whether a relationship exists between the kind and number of clinical services offered and implementation of these prerequisites; and to identify discrepancies between responses of the pharmacy director and the pharmacist in charge of clinical services at the same hospital to the same questions. One hundred hospitals providing clinical pharmaceutical services were randomly selected from a master list of 190 hospitals that had been grouped into nine geographic areas. Of 17 functional and structural prerequisites studied, 4 to 13 of them had been implemented at the hospitals surveyed. Only 24% of the hospitals had implemented the basic functional prerequisites of unit dose drug distribution and decentralized pharmaceutical services. Of nine clinical pharmaceutical services, one to eight were being delivered. A weak correlation between the number of prerequisites implemented and the number of clinical services provided was found. Significant disagreement was found between the directors and their pharmacists about which prerequisites and clinical services were being implemented. This pilot study suggests that pharmacy directors and clinical pharmacists need to assess how effectively basic management prerequisites are being put into practice in the delivery of clinical pharmaceutical services.