DRUG THERAPY MONITORING

INTRODUCTION
The most fundamental responsibility of a clinical
pharmacist is to ensure that each patient
receives effective, safe and cost-effective.
Drug therapy monitoring is to optimize drug
therapy and patient outcomes by implementing
a strategy involving the following components.
Collection and interpretation of patient specific
information
Identification of drug related problems
Individualising medication regimens
Assessment of therapeutic goals
Monitoring of treatment outcomes
Medication chart endorsement

Medication chart review

It is the responsibility of pharmacist to ensure the
appropriateness of medication orders. The review of
such orders serves as starting point for other
clinical pharmacy activities including patient
medication counselling, therapeutic drug monitoring
and assessment and managements of ADR.
AIM
The aim of medication chart review is to optimize the
patients drug therapy. This includes ensuring that
the patient receives the most appropriate drug,
dose, dosage form, the timing of dosage and the
duration of therapy and that the drug related
problems are minimized.

PROCEDURE

The patients medical record should be

reviewed in conjugation with medication
administration record and medication history
obtained, recent consultations, pathology
results and investigation, treatment plans and
daily progress should be taken into account
when determining the appropriateness of
current medication orders.

Components of medication chart review

Checking that the medication order is written in

accordance with the legal and local requirements.
Ensuring that the medication order is
comprehensible and unambiguous
Detecting orders for medication to which patient
may be hypersensitive.
Ensuring that the medication order is appropriate
with respect to the patients previous medication.
Check for specific consideration like pregnancy,
age, renal function, liver function etc.
Checking for medication duplications, interaction
or incompatibilities

Ensuring that the administration times are appropriate

E g: with respect to food, other drugs and procedure.
Ensuring appropriate therapeutic monitoring is
implemented.
Reviewing medication for cost effectiveness
Endorsing the medication orders comprehensively with
information such as dilution/flow rates for IV infusion,
generic drug names and trade names, allergies &
ADRs.
Consultations regarding suggested and necessary
changes must be undertaken with the relevant health
care professional and the patient. Consultation and
interventions in patient care must be documented in
patients history and pharmacy records where
appropriate

Clinical review

Clinical review is an integral component of drug therapy

monitoring and should be performed routinely. Clinical
review is the assessment of the patient for the purpose of
evaluating the nature of the response to therapy. This may
include the review of patients signs symptoms and results
of investigations.

GOALS

The primary goals of clinical review are

1. Determine the priorities of treatment with respect to the
therapeutic outcomes desired by the patient and to corelate these with the strategies employed by the
healthcare team.
2. Monitor the patients therapy
3. Review the outcomes of treatment.

Procedure
The collection of patient specific data should be
undertaken routinely. The data collected should be
clinically relevant and documented in the patient
profile when required. To evaluate a patients
therapy, the pharmacist may review the results of
biochemical, haematological microbiological
radiological and other investigations.
Information regarding patients signs and symptoms
and progress may be obtained from
An accurate medication history interview
Review of patients clinical progress notes
Discussion with other healthcare team
Discussion with the patient

The information obtained must be interpreted

and evaluated with reference to:
The clinical features and pathophysiology of
the condition being treated
The indication for its investigation, its
sensitivity and specificity
The time frame of drug-related effects
The patients medication history
The planned outcomes of treatment

Pharmacist intervention
Pharmacist intervention is defined as any
action that directly results in change in
patients management or therapy.
Intervention by pharmacist to assist prescribing
can take several forms:
1. Active(use of guidelines particularly backed
up by personal visit)
2. Passive(eg: drug information services)
3. Reactive (Monitoring prescription and
seeking amendments to those that are
unclear, inadequate and inappropriate)

For the purpose of analysis, intervention can

be classified into types
Eg: using the categories Hawkey et al. This
system categorizes the intervention into
classes including the addressing
Errors of dosage
Choice of drug
Duration of treatment
Prescribing precautions, adverse effects and
interactions
Errors in administration

Interventions can be classified according to

clinical or economic significance
Interventions can also be classified according
to the categories of drug related problems

Recording of the following details of all

pharmacist intervention is recommended in
Drugs involved
Brief description of intervention
Brief details of response to interventions
Patient name and unit record number
Date, ward, pharmacist.

Other activities include

Supply of drug information
Counselling and education
Cost saving initiatives
Recommendation for patient monitoring &
TDM
Reporting ADR
Review of laboratory results
Patient medication history
Participation in ward rounds
Medication chart review