Clinical Pharmacy Practice Flashcards

What is medication reconciliation and when should it be performed?

Answer: Comparing a patient's current medications with newly prescribed orders at each care transition to identify and resolve discrepancies

Medication reconciliation compares all medications the patient is taking (home, OTC, herbal) with new orders at every care transition: admission, transfer between units, and discharge. It identifies discrepancies (omissions, duplications, interactions) to prevent medication errors.

What is the pharmacist's role in antimicrobial stewardship in Saudi hospitals?

Answer: Reviewing antibiotic prescriptions for appropriateness, dose optimization, de-escalation, IV-to-oral conversion, and monitoring duration

Clinical pharmacists are key antimicrobial stewardship team members: reviewing appropriateness (culture-directed therapy), optimizing doses (renal adjustment, PK/PD targets), recommending de-escalation from broad to narrow spectrum, facilitating IV-to-oral switch, and monitoring treatment duration.

What is a Drug Use Evaluation (DUE) program?

Answer: A systematic review of prescribing, dispensing, and use of medications to ensure optimal patient outcomes

DUE programs systematically evaluate medication use against predetermined criteria covering indication, dose, route, duration, interactions, and outcomes. Saudi hospital pharmacy departments conduct DUEs to improve prescribing practices, reduce costs, and enhance patient safety.

What patient counseling information should a pharmacist provide when dispensing a new prescription?

Answer: Drug name and purpose, dosage instructions, potential side effects, drug-food interactions, storage requirements, and what to do if a dose is missed

Comprehensive counseling covers: medication name and indication, dose/frequency/duration, administration technique, common and serious side effects (when to seek help), drug-food-herbal interactions, storage conditions, missed dose instructions, and when to return for refills.

What is therapeutic drug monitoring (TDM) and which drugs commonly require it?

Answer: Measuring drug blood levels to optimize dosing for drugs with narrow therapeutic indices: vancomycin, aminoglycosides, digoxin, lithium, phenytoin

TDM measures serum drug concentrations to ensure therapeutic (effective but not toxic) levels. Drugs requiring TDM have narrow therapeutic indices: vancomycin (trough 15-20 for serious infections), gentamicin (peak/trough), digoxin (0.5-2 ng/mL), lithium (0.6-1.2 mEq/L), phenytoin (10-20 mcg/mL).

What is the pharmacist's role in total parenteral nutrition (TPN) management?

Answer: Calculating macronutrient and micronutrient requirements, checking compatibility, monitoring electrolytes, and adjusting formulations

Clinical pharmacists manage TPN by: calculating caloric/protein/lipid requirements, determining electrolyte and trace element additions, ensuring component compatibility (calcium-phosphate precipitation check), monitoring labs (electrolytes, glucose, liver function, triglycerides), and adjusting formulations based on patient response.