STABILITY AND INCOMPATABILITIES is added to an aqueous solution of a drug that is

poorly soluble in alcohol

Incompatibilities Compounding strategy
- Problem which could occur as a result of interaction o Consult references
between two or more drugs or chemicals o Decrease the concentration of the drug so that
- Physical incompatibility the drug is soluble in the solvent system
- Chemical incompatibility
- Therapeutic incompatibility pH Effects
- Alteration in the degree of ionization
When interpreting compatibility reports, consider the - Problems happens when drug solutions with
following differing pH are combined or when a drug that
- Manufacturer of the drug generates another pH is added to the original drug
- Drug concentration solution
- The base solution or diluent and their manufacturer - Example: if pH of Phenobarbital Na (Salt form) has to
- Order of mixing be lowered. Some of the salt form will be converted
- Time frame to neutral free acid form = if solubility of the
- Temperature phenobarbital acid exceeds water solubility
- Test method (precipitation will occur)
- Phenobarbital Na is freely soluble in water but
PHYSICAL INCOMPATIBILITIES Phenobarbital (neutral acid) is slightly soluble to
water
- Physical or chemical interaction that leads to visible
recognizable change Handling solutions of weak electrolytes
o Incomplete Solution - Control pH at desired level
o Precipitation from solution - Administration of drug solution with incompatible
o Polymorphism pH should be separated
o Liquefaction of Solid Ingredients - For oral or topical solutions, use a cosolvent that will
o Sorption and leaching keep the free drug in a solution or prepare a
o Evaporation suspension
o Loss of water - Dilute the final solution below precipitation
concentration
Incomplete Solution
- Insolubility of components Change in temperature
- Immiscibility of components - The solubility of most drugs decreases as the
Remedies temperature of the solution decreases
- Use an appropriate solvent system —For oral or - Cisplatin, Cotrimoxazole, Metronidazole (ref) 
topical product, make suspension or emulsion, if precipitate
possible Opposite effect
- Consult prescriber for any changes in the - When Calcium gluconate and potassium phosphate
prescription are added in PN solution, calcium phosphate and
dibasic calcium phosphate will be formed in
Precipitation from solution equilibrium
- For oral or topical solution— will cause therapeutic - At warm temperature, insoluble dibasic calcium
failure or toxicity phosphate may precipitate
- For IV solutions— insoluble particles can lodge in
capillaries and block them causing severe Strategies in handling solutions sensitive to change in
consequences or even death temperature
- Solvent effects — solubility of the drug - For parenteral products — Check the product insert
o Ex. Salicylic acid soluble in alcohol but slightly and consult references
soluble in water. Codeine phosphate is very - For oral or topical solution — be aware of the
soluble in water, but not in alcohol. possible problems if product will be used or
o When water is added to an alcoholic solution of administered at a different temperature
a drug that is poorly soluble in water or if alcohol
Salting out
- a competitive process wherein the molecule of a
substance competes for the water in solution
forming precipitate
- High amount of salt in solution = solubility will
decrease and it will form precipitate
- Remedy: Use another solvent
Salting In
- Mild increase in concentration resulting increasing
the solubility of the solution
Polymorphism
- Change in crystalline form
- Different polymorphs will exhibit different physical
properties, such as melting point and dissolution
rates = affects bioavailability
- Example of drugs that exhibit polymorphism:
ampicillin, barbiturates, hydrocortisone and sulfa
drugs.
- Some drugs exist in different crystalline structures in
the solid states
- Example: Cocoa butter — With several polymorphic
forms with melting points: 18°,249, 280-319 and 34°
o Beta (melts at 34.5°C) – most stable; alpha
(melts at 23°C) and gamma (melts at 18°C) -
unstable
- When used as base for suppositories is overheated,
it may melt at room temperature or liquefy when
handled during insertion
- Should be melted slowly and carefully at
temperature not greater than 34°C
Liquefaction of Solid Ingredients
Deliquesce material (absorbs moisture then liquefy):
sodium permanganate and chlorides of magnesium,
aluminum, zinc, calcium and metacholine chloride.
Hygroscopic material (absorbs moisture) – sorbitol,
CMC, dextran
Efflorescence
Efflorescent powders (e.g., morphine acetate, ferrous
sulfate, codeine, caffeine atropine sulfate, etc.)
- Handling Strategies
- Store & dispense the powder in tight container
- Use Anhydrous substitute for hydrate
Hygroscopic and deliquescent drugs (e.g., Ephedrine
sulfate, potassium citrate, Phenobarbital Na, Sodium
iodide, etc)
- Remedy for these drugs
- Store and dispense drug in a tight container
- For solid compounded product — use inert
powdered ingredient (e.g., lactose) that will absorb
water or add insoluble powder
Sorption
- Adsorption — molecules are concentrating at the
interface
- Absorption — The molecules being absorbed are
penetrating into the capillary spaces of the absorbing
Surface
- Commonly occur in polyvinyl chloride (PVC)
containers — due to plasticizer
- Drugs that are poor water-soluble or lipophilic (e.g.
Lorazepam, diazepam, nitroglycerin, nicardipine,
ISDN, etc) have greater tendency to sorb to PVC to
dissolve in its plasticizer
Handling drugs that sorb to surfaces:
- Check product inserts and other references
- Be suspicious of new drugs form an existing class
with sorption problem
- Decrease contact time
- Control temperature
Leaching
- Leaching plasticizer from plastics — for drugs that
contain surfactants or cosolvents = carcinogenic
based on study in animals
- Strategy includes: Use container substitute (glass,
polyvinyl, polyethylene, polyurethrane)
Vaporization
- AKA volatilization
- liberation of the active ingredients
Loss of Water o Control pH
- Common in liquid dosage forms o Separate drugs that are easily oxidized from
- Emulsions (phase inversions in O/W emulsions) those easily reduced
- Suspensions and solutions (increased potency)
Hydrolysis
General Remedies for Physical Incompatibilities - Most common type of incompatibility and drug
- Modify the order of mixing degradation
- Change the kind or concentration of the solvent - Triggered by presence of water, acids, bases, catalyst
- Change in the form of ingredient e.g., dextrose
- Add therapeutically inactive substance - Drugs susceptible to hydrolysis:
- Omit an inactive ingredient o Amides especially with lactam rings —
- Change the dosage form penicillins and cephalosporins
- Separate dispensing o Esters — procaine, tetracaine, aspirin,
belladonna
CHEMICAL INCOMPATIBILITY - Strategies include:
o For solid — control exposure to moisture by
- Occurs as a result of chemical interaction among the using light containers and desiccants
ingredients of a given prescription. o Control the pH
- Visible change in the reaction is not necessarily o Check appropriate references
observed but can be determined by analytical o Consider the drug’s concentration
method. o Control storage temperatures
- Oxidation
- Reduction Evolution of Gas
- Hydrolysis - Commonly caused by NaHCO3 and carbonate buffers
- Evolution of Gas = effervescence
- Complexation - Desired use in some powders and tablets e.g. Alka
- Racemization seltzer
- Epimerization - Strategy:
- Precipitation (physical and chemical - Do not combine drug products that generate acid pH
incompatabilities) with sodium bicarbonate or drug products that
contain carbonate buffers
Oxidation - For vulnerable products, store in tight container
- Occurs when one drug loses electron to the other
- Triggered by light, heavy metals, oxygen, oxidizing Complexation
agents - Forming inactive complex e.g., tetracycline with
- Drug products undergo oxidation usually changed in multivalent ions
color and they will become inactive - Strategy: Avoid combining tetracycline with drug or
- Drugs susceptible to oxidation includes: food containing multivalent ions
o Catecholamine e.g., epinephrine (oxidation
turns it to pink) Racemization
o Phenolics e.g., phenylephrine, morphine - The conversion of one enantiomer to a racemate
o Phenothiazines, chlorpromazine - Racimic mixture – combination of equal amount of
o Thiols e.g., captopril dextro and levo isomers that makes them optically
o Others: Ampthotericin B, tetracycline, inactive
furosemide, etc. - Example: Epinephrine- the I-enantiomer is
approximately 15-20x more active than d-
- Strategies enantiomer
o Protect from oxygen - Other drugs: bupivacaine, albuterol, levalbuterol,
o Protect from light omeprazole, and esomeprazole
o Add metal-chelating agent e.g., edetate - Problem exists when one enantiomer is more
disodium physiologically active than the other and
o Add an antioxidant racemization easily takes place
o Control storage temperature - Pharmacist should review literatures

Epimerization
- Formation the pair of diastereomers (not mirror
images of each other, not super imposable) that
differ only in the configuration about one carbon
atom (epimers)
- Example: Tetracycline undergoes reversible
epimerization to epitetracycline (of little
antibacterial activity) in a solution
- Rate is dependent on pH and presence of citrates and
phosphate ions
- Remedy:
o Prepare suspension of tetracyline
o Add buffer to maintain the pH
THERAPEUTIC INCOMPATIBILITY
- A problem that occurs when two or more drugs are
administered to a patient
- Also called drug interaction — one drug alters the
effect of another drug (object drug and precipitant
drug)
o Pharmacokinetic (ADME)
o Pharmacodynamics- antagonism, additive
effect
- Undesirable pharmacological interactions between
two or more ingredients that leads to:
o Additive or potentiated therapeutic effects —
may cause toxicity or death
o Antagonistic (antidote) or destruction of the
effect — sub-therapeutic or lack of effect
o Ex: decreased therapeutic activity of pen G after
giving tetracycline (bacteriostatic)
MEDICATION-RLEATED PROBLEMS
- Medications are one of the key tools in the
therapeutic management of disease. However, they
are not always used in an ideal, or appropriate,
manner.
- When medications are not used appropriately,
patients may experience adverse events or fail to
achieve their therapeutic goals. In turn, this results in
suboptimal quality of life and wasted resources for
our society.
- An undesirable event experienced by a patient that
involves or is suspected to involves drug therapy and
actually or potentially interferes with a desired
patient outcome
CLASSIFICATION OF MEDICATIONRELATED PROBLEMS
- Pharmacist providers of pharmaceutical care assume
responsibility to identify, prevent, and resolve
medication- related problems on behalf of their
patients.
- These problems have been defined broadly as
undesirable events that are of psychological,
physiological, social, or economic origin and may be
the function of a patient:
1. Needing pharmacotherapy but not receiving it 2
2. Taking or receiving the wrong medication
3. Taking or receiving too little of the correct
medication
4. Taking or receiving too much of the correct
medication
5. Experiencing an adverse reaction to a medication 6
6. Experiencing a drug-drug or drug-food interaction 7
7. Not taking or receiving a medication that has been
prescribed
8. Taking or receiving a drug for which there is no valid
indication.
- In this context, pharmacists collaborate with
patients, patient caregivers, physicians, nurses, and
other healthcare providers to initiate, monitor,
modify, and discontinue pharmacotherapy to avoid
or resolve these medication-related problems.
- To that end, pharmacist providers of pharmaceutical
care engage in a series of sequential steps to ensure
that individual patients receive cost-effective
pharmacotherapy that results in optimal therapeutic
outcomes.
WAYS TO MINIMIZE MEDICATION RELATED PROBLEMS
These steps include having the pharmacist
1. Establish a committed relationship with individual
patients
2. Collect, synthesize and interpret relevant patient
information
3. Define and prioritize the potential and actual
medication-related problems of the patient
4. Establish a desired pharmacotherapeutic outcome
for each medication- related problem
5. Determine feasible pharmacotherapeutic
alternatives to achieve each desired outcome
6. Select the best pharmacotherapeutic solution based
upon individual patient circumstances
7. Design a monitoring plan to determine if the desired
pharmacotherapeutic outcome has been achieved
8. Implement the individualized pharmacotherapeutic
and monitoring plans and evaluate and document
the results of pharmacotherapeutic and monitoring
plans.
COLLECTION, SYNTHESIS, AND INTERPRETATION OF
RELEVANT PATIENT INFORMATION
- The pharmacist’s primary responsibility in the
delivery of pharmaceutical care is to identify,
prevent, and resolve medication problems.
- A key factor in the fulfillment of this obligation is the
availability of essential patient data. This ensures
that all potentially useful information is considered
for each patient.
Useful demographic information includes the
patient’s name, age, gender, and race.
- Age, gender, and race are often important factors in
the selection of medications and dose
determinations.
- For example, medication doses are often lower in
elderly patients because of diminished renal or
hepatic function.
- Gender is important in the case of a female of
childbearing age if medications that are being
considered for treatment are potentially harmful to
unborn children.
- Race is an important factor in the treatment of
hypertension in African-American patients because a
number of antihypertensive medications are
ineffective in this population.
Patient Information for the Provision of
Pharmaceutical Care
- The pharmacist also must determine an appropriate
source of each type of information.
- Common sources include the patient, the patient’s
caregiver or family, the pharmacy patient profile,
medical records, laboratories, physicians, nurses,
and other healthcare providers. Appropriate sources
vary from situation to situation.
- In each case, the pharmacist must consider a
source’s ability to provide accurate, reliable
information and the ease with which the source may
be accessed
DEFINITION AND PRIORITIZATION OF THE PATIENT’S
POTENTIAL AND ACTUAL MEDICATION- RELATED
PROBLEMS
- The definition and prioritization of patients’
medication-related problems requires a systematic
approach to prevent problems from being
overlooked.
- This also helps to avoid omissions in the patient’s
medication-related problem list and in the
subsequent formulation of therapeutic goals.
Pharmacists examine individual patient
databases for actual and potential problems in the
following 10 categories.
1. History of adverse effects
2. Potentially unwarranted/unintended changes in
therapeutic regimen
3. Potential quantitative misuse (noncompliance,
misuse, overuse)
4. Duplication of medications
5. Additive effects from similar medication use
6. Inappropriate dosage, route of administration,
dosing schedule, or dosage form
7. Potential current adverse effect
8. Drug-drug interactions
9. Drug-disease interaction
10. Irrational therapeutic regimen
If this problem was defined simply as a drug
interaction, the pharmacist would not know whether the
solution is to
1. Discontinue a drug and recommend a new one
2. Increase the dose
3. Decrease the dose
4. Add a new drug
5. Discontinue all therapy
6. Implement some other appropriate action (eg,
stagger medication doses)
ESTABLISHMENT OF A DESIRED
PHARMACOTHERAPEUTIC OUTCOME FOR EACH
MEDICATION-RELATED PROBLEM
- Pharmacotherapeutic outcomes are predefined
medication-related goals for the resolution of
problems identified in the previous step of the
pharmaceutical-care process.
- Similar to problem statements, these outcomes
should be clearly articulated to help the pharmacist
identify feasible problem solutions and to evaluate
results of the alternative that is ultimately chosen
Typically, these statements are simply the mirror
image of the problem and fall into one of the three
following categories:
- The patient is receiving appropriate
pharmacotherapy for each definitively diagnosed
disease.
- The patient is receiving the appropriate dose of each
medication at appropriate time intervals.
- The patient is free from adverse drug reactions, side
effects, and drug interactions.
- The reason for this brainstorming step is to ensure
that all possible solutions have been considered
before any one is chosen.
- It is also a useful backup tool when the first
alternative selected is ineffective for a particular
patient.
Generally, pharmacotherapeutic goals may be
achieved by:
- correction of a system problem
- adjustment of current pharmacotherapy
- development of an entirely new
pharmacotherapeutic plan.
The pharmacist should begin the development of
a list of feasible solutions by considering alternative
solutions within each of these categories.
SELECTION OF THE BEST PHARMACOTHERAPEUTIC
SOLUTION BASED UPON INDIVIDUAL PATIENT
CIRCUMSTANCES
- During this step, the pharmacist must determine
which therapeutic alternative is best for the patient.

Once the pharmacist has articulated the desired In this context the pharmacist’s
pharmacotherapeutic outcome for each medication- recommendation for the solution of each medication-
related problem, he or she must define appropriate related problem should include:
indicators for each goal. Indicators are measurable - chosen medication
variables that can be used to monitor the effectiveness - dosage form
of the pharmacotherapeutic solutions to medication- - dose frequency and duration
related problems - any special instructions (eg, uncommon
administration procedures) for the patient.
To be optimally useful in this regard, indicators must be - At this point it is especially important to involve the
designed to include: patient in the selection of appropriate therapy. This
A patient factor helps to ensure that the patient is able and willing to
- can be measured to determine the impact of therapy comply with all associated therapeutic and
and include reports of symptoms, laboratory values, monitoring instructions.
and the results of quality-of-life assessments.
A progress factor DESIGN OF A MONITORING PLAN TO DETERMINE IF THE
- describe the degree of improvement in patient DESIRED PHARMACOTHERAPEUTIC OUTCOME HAS
variables that can reasonably be expected to result BEEN ACHIEVED
from the pharmacotherapy.
A time factor - Prior to implementing any therapeutic
- the time frame in which the pharmacotherapy recommendation, the pharmacist must develop a
should have achieved the desired degree of plan to monitor the patient’s progress toward each
improvement. goal established in a previous step.
- This plan should include appropriate
DETERMINATION OF FEASIBLE pharmacotherapeutic monitoring parameters,
PHARMACOTHERAPEUTIC ALTERNATIVES TO ACHIEVE realistic endpoints for each parameter, and the
EACH DESIRED OUTCOME frequency with which each parameter will be
- Following articulation of a goal for each assessed.
medicationrelated problem, the pharmacist must
generate a list of all feasible problem solutions.
 The number and nature of each plan component
depends on the:
1. Properties of the recommended medications
2. Patient’s background characteristics
3. Availability of practical, cost-effective monitoring
methods.
- Pharmacotherapeutic monitoring parameters are
either quantitative or qualitative assessments of
patient progress toward specific therapeutic goals.
- Quantitative assessments are objective measures of
a particular variable and include
o blood pressure, pulse, temperature, serum drug
levels, and blood glucose determinations.
- Qualitative assessments are subjective
determinations of change in a particular variable
o patient self-reported changes in symptoms such
as nausea, pain, and sedation
IMPLEMENTATION OF INDIVIDUALIZED
PHARMACOTHERAPEUTIC AND MONITORING PLANS
This involves:
1. securing physician approval for any changes in the
originally prescribed therapy
2. Counseling the patient about the proper use of the
recommended therapy
3. Collecting monitoring data to evaluate the efficacy of
the pharmacotherapeutic plan.
FOLLOW-UP EVALUATION AND DOCUMENTATION OF
THE RESULTS OF PHARMACOTHERAPEUTIC AND
MONITORING PLANS
- At predetermined intervals, the pharmacist must
review collected monitoring data to determine if
satisfactory progress is being made toward the
desired medication-related goals.
- The pharmacist must ascertain if any new problems
have developed since the last review.
- If the desired outcomes have not been met or if new
problems have occurred, the pharmacist, physician,
and patient may need to make changes in the
original pharmacotherapeutic and monitoring plans.
- Final step: the pharmacist document all
interventions and outcomes in the patient’s record.
- This information then becomes baseline information
upon which subsequent adjustments and/or new
therapeutic decisions are made.
- This information also may be required if the
pharmacist attempts to obtain reimbursement for
pharmaceuticalcare services from a third party.
REPORTING OF SUSPECTED ADVERSE DRUG REACTION
- Under Republic Act No. 9711, the Food and Drug
Administration (FDA) is mandated to strengthen the
postmarketing surveillance (PMS) system in
monitoring health products.
- PMS refers to activities in safety, efficacy, and quality
monitoring of health products, including drug
products. This shall also include among others
adverse events reporting, product safety update
reporting, collection and testing of health products
in the market.
- To operationalize this mandate, under the same law,
all drug establishments, including consumers and
non-consumer user (e.g. healthcare professionals)
are enjoined to take part in PMS, by reporting to FDA
any incident that reasonably indicates that a health
product has caused or contributed to the death,
serious illness, or serious injury to a consumer, a
patient, or any person.
Thus, in the interest of protecting public health
and safety, the FDA reiterates to all consumers and
healthcare professionals to report any suspected adverse
reactions on the use of medicines, and any suspected
adverse events on the use of vaccines, using the
prescribed adverse drug reaction (ADR) form
(https://ww2.fda.gov.ph/industrycorner/downloadables
/625-suspected-adverse-reaction). Reports may be
submitted via:
- mail at adr@fda.gov.ph
- fax: +63 2 809-5596
- phone: + 63 2 809-5596
- online reporting using the ADR tab at
http://ww.fda.gov.ph/adr-rport- new
- courier at FDA Central office at Civic Drive, Filinvest
City, Alabang 1781 Muntinlupa City, Philippines
- or though the nearest DOH-FDA Regional Office
PATIENT COUNSELING
- It is the provision of verbal or written information
about drugs and other health related information by
a pharmacist to a patient or an agent of the patient
during pharmacist-patient interaction
- The pharmacist acts as both sender and receiver of
the message
- Transmission of messages needs to be clear and
accurate.
Factors which necessitates Patient Counseling
- Increase in drug use-related problems
- Increase in the number of drugs
- Increase in the number of drug regimens
- Inappropriate prescribing
- Increase in self-medication practice
- Increase in the use of alternative medicines
DESIRED OUTCOMES OF PATIENT COUNSELING
- Results of a properly conducted counseling
interaction:
o Patient will recognize why a prescribed
medication is helpful for maintaining or
promoting well being
o Patient will develop the ability to make more
appropriate medication-related decisions
concerning compliance or adherence
o Patient will become a more informed, efficient,
active participant in disease treatment and self-
care management
o Patient will show motivation toward taking
medications to improve his or her health status
PATIENT BENEFITS FROM PATIENT COUNSELING
- Improved therapeutic outcomes and decreased
adverse effects
- Improve patient adherence to the treatment plan
- Decrease medication errors and misuse
- Enhanced self-management by involving the patient
in designing the therapeutic plan
PHARMACISTS BENEFITS FROM PATIENT COUNSELING
- Enhanced professional status in the view of the
patients and other health care providers
- Establishment of an essential component of patient
care that cannot be replaced by technicians or
automation
- Enhanced Job satisfaction through improving patient
outcomes
- A value-added service to offer patients
- Revenue generation through payment for counseling
services – limited at present but growing
- Fulfillment of legal responsibility to counsel patients
PREPARING FOR THE COUNSELING SESSION
- Pharmacists should spend few moments mentally
preparing for the interchange that is about to occur
- Determine the physical state of the patient
- Have as much information as possible about the
patient
o In the hospital setting – review the medical
chart and get information from health care
providers
o In the community setting – review the
prescription and patient’s medication record;
for a first pharmacy visit, ask the patient to fill
out medication history form if there is no time
to complete a medication history interview at
the time the prescription is dispensed
Main Concerns in Patient Counseling: HOW AND WHAT
PROCESS
1. Introduce yourself and identify the patient
2. Ask patient to talk with you about the medication.
Explain the purpose and the importance of the
counseling session
3. Update the patient’s medication profile
4. Assess what the patient already knows about the
newly prescribed drug and the reason it was
prescribed.
5. Assess whether the patient knows how to take the
medication
6. Assess the patient’s understanding of what to expect
from medication including the expected outcomes of
the therapy as well as its potential adverse effects
7. Ask the patient if he or she has any concerns or
questions that have not been addressed in the
previous discussion
8. Check patient understanding of the information
discussed in the counseling session
9. Close the session
CONTENT OR SCOPE OF PATIENT COUNSELING
- Any counseling episode may contain one or more of
the following information as deemed appropriate:
o Trade name or generic name of drug
o Use, action, and onset of action
o Route, dosage form, and storage
o Direction for use
o Action in case of missed dose
o Precautions
o Side effects and adverse effects
o Techniques for self-monitoring
o Potential drug interactions
o Contraindications
o Relationship with laboratory and other
procedures
o Disposal of drug and devices
o Any other health information unique to an
individual patient, disease or medication
ASSESSING THE SUCCESS OF THE PROCESS
- During the counseling process:
o Check if the information is being understood by
the patient
o Watching the patient’s body language and
maintaining eye contact can give useful clues to
whether the message is being understood and
whether it is likely to be complied with
AIDS IN COUNSELING
- Patient information leaflets – should be used where
appropriate, important points should be highlighted
- Placebo devices
- Warning cards
COUNSELING CHILDREN AND ADOLESCENTS
- Talk to parents and children about how to protect
young children from accidental poisoning and what
to do if it occurs
- When children are old enough to understand, speak
directly with them about their medicines. Tell
children what you expect them to do and why.
- Encourage children to ask you questions about their
illness and treatment
COUNSELING THE ELDERLY PATIENT
- Elderly Patient may have functional barriers
- Vision and hearing are often impaired
- Patient may have difficulty removing child- proof
tops, self-injecting insulin, or applying creams and
ointments.
- Many elderlies have low literacy skills
- Cognitive impairments become more common with
increasing age
- AS patients age, chronic condition and the number of
medication prescribed increase,
- Additional time may be required to address the
needs of the patient
- Written information and compliance reminder aids
are particularly helpful with large number if
prescription products.
- Provide small pieces of specific information coupled
with a reminder aid and verbal reinforcement of the
information.
- Consider their own feelings about aging. One
recommendation to increase empathy for elderly
patient is to consider what the patient and the world
were like when he/she was younger and to
remember that patient was not always old
COMMUNICATING WITH PERSONS WITH DISABILITIES
- Speak and interact directly with the person
- Identify yourself and other persons in the group to
the person who is virtually impaired.
- Stoop or squat to communicate with a person in a
wheelchair; position yourself in front and at an eye
level
- Avoid leaning or sitting on a person’s wheelchair; use
care for handling assistive aids
- Make the person who has hearing impairment aware
of your presence
- Be patient and listen carefully when interacting with
a person who has difficulty speaking, use questions
that require brief responses.
PATIENT COUNSELING SETTING
- Community pharmacy
- Hospital
COMMUNITY PHARMACY
- Lack of expectation by costumers for counseling and
advice should not be a barrier
- Counseling on medication is not optional but an
integral part of the dispensing of a prescription
- Pharmacists must ensure that they are visible and
accessible in community pharmacies to provide it.
Disadvantages of community Setting
- No formal screening takes place.
- The process is random
HOSPITAL SETTING
- Opportunities for patient counseling in hospital:
- On admission
- On discharge
- At outpatient clinics
- Rehabilitation groups
Advantages of Hospital Setting
- Access to a considerable amount of information
about the patient.
o Details of disease states, current therapy, home
circumstances
- Counseling in hospital can be approached in a more
formalized way
Concerns in Hospital Setting
- Financial pressure in hospitals affect manpower
levels – staffing level may be reduced/
- Limited access to a pharmacist
- Patients in hospital often have their medication
changed and they should be fully aware of any
alterations.
- Patients may be discharged from hospital without
the knowledge if the pharmacists – little guidance on
the use of medicines
- Due to limited resources, patients are screened to
prioritize who is counseled
PLANNING FOR DISCHARGE MEDICATION COUNSELING
R – reason for admission
- Is it due to a drug-related problem or
noncompliance?
- How many and what kind of disease does the patient
have?
- What medications are currently prescribed?
- Asses the patient’s physical, emotional, and mental
states in light of patient history
E – Evaluate current medication for drug related
problems including noncompliance.
- Prioritize questioning, beginning with the most
important medication that relate to the primary
problem.
- Prioritize questioning, also focusing on those drugs
with multiple daily dosing regimen and those with
special administration technique such as inhaler
A – Asses the patient’s knowledge base and skills to self-
medicate, asses compliance
- promoting strategies.
P – Plan to avoid drug-related problems after discharge.
Discharge Counseling Session
- Includes review of the following for each prescribed
medication:
- Indication
- Dosage
- Administration
- Self-monitoring
- Follow-up laboratory tests (if necessary)
- Follow-up appointment (if necessary)
COMMUNICATION IN PATIENT CARE
COMMUNICATION
- Communication between and among persons is a
primary function of life w For a pharmacists and
other care givers, communication with patients,
family members, other practitioners, and coworkers
is necessity.
COMMUNICATION IN THE CONTEXT OF PATIENT CARE
 Patient – centered care depends on the pharmacist’s
ability:
- To develop trusting relationships with patients
- To engage in an open exchange of information
- To involve patients in the decision making process
regarding treatment
- To reach therapeutic goals that are endorsed by
patients as well as by health care providers
THE IMPORTANCE OF COMMUNICATION IN PATIENT
CARE
- It establishes the ongoing relationship between the
provider and the patient
- It provides the exchange of information
RESPONSIBILITIES OF PHARMACISTS IN PATIENT CARE
 Obtain information about the patient and provide
information to patient for the purpose of identifying,
resolving, and preventing potential medication
related problems.
 Maintain patient profiles that contains the following:
 Patient demographic information
 Comprehensive list of medications
 Patient’s allergies, ADR, disease states
 Pharmacist comments relevant to an individual
patient’s drug therapy – prospective DUR
- Offer to engage in discussion of a patient’s therapy
whenever a medication is dispensed
 Counsel patients on their medication (both new
and refill)
COMPONENTS OF THE INTERPERSONAL
COMMUNICATION MODEL
- The SENDER
- Transmits message to another person
- Formulates or encodes the message before
transmitting it.
- The MESSAGE
- The element that is transmitted from one person to
another.
- Can be thoughts, ideas, emotion, information, or
other factors that can be transmitted verbally or non-
verbally
- The RECEIVER
- Receives and decodes the message and assigns a
particular meaning to it. w
- The FEEDBACK
- The process of initial receiver’s communicating back
to the original sender his/her understanding of the
sender’s message
- Can be verbal, non-verbal, or both
- BARRIERS – Refer to interferences that affect the
accuracy of the communication exchange
PHARMACIST’S ROLE IN COMMUNICATION
- As a sender - assure that the message is transmitted
in the clearest form, in terminology understood by
 the other person, and in an environment conducive
to clear transmission
- As a receiver – Listen to what is transmitted by the
sender and provide feedback to describe how you
understand the message
PERCEPTION
- One of the most important element in the
communication process
- Perceptual barriers should be recognized and
minimized
- Use feedback skills to enhance the ability to grasp the
true meaning of the message
BARRIERS IN COMMUNICATION
Environmental Barriers
- Environmental factors that may inhibit one-to-one
communication of pharmacist to patient
- Examples: Height of the prescription counters
separating the pharmacists and patient; crowded,
noisy prescription counters; lack of privacy; presence
of clerk or technician who stands between patient
and pharmacists
Personal Barriers
- Personal (pharmacists) characteristics or perception
that can lead to distraction communication
- Examples: Lack of confidence or low self- esteem;
internal conversation or internal monologue;
tendency to transfer problems to other person
(patient to pharmacists); Cross cultural factors; fear
of being in the situation that is sensitive or difficult;
pharmacists belief that talking to patient is not a high
priority activity
Patient Barriers
- Patient characteristic or perception
- Example: patient perception that pharmacist is not
knowledgeable; patient’s experience with the
pharmacist; belief that the health care system is
impersonal; perception of their medical condition
Administrative Barriers
- Policies that discourage pharmacistpatient
relationship
- Examples: Pharmacist are not paid directly for
educating the patient; pharmacy setting; limited
number of staff; mechanics of dispensing
prescription
Time Barriers
- Timing of the interaction; inappropriate time may
lead to communication failure
- Examples: patient is in a hurry; lack of time the
pharmacists to talk to the patient
Removal of these barriers involves a two-step process:
- Recognized that the barriers exist
- Take appropriate actions to overcome them
FACTORS WHICH COULD AFFECT COMMUNICATION
- Pharmacist-related factors/ patient related factors
- Verbal Expressions
- Non-verbal expressions
- Sensory and emotional factors
- Environmental factors
VERBAL COMMUNICATION
- Terms and concepts should be presented in language
the listener understands – Lay language
- Examples:
o “bend” instead of “flex”
o “turn or twist” instead of “rotate”
o “straighten” instead of “extend”
o “pain reliever” instead of “analgesic”
NON-VERBAL COMMUNICATION
- Done through facial expressions, posture, gestures,
body movements, or changes in body responses.
- Some are planned; others are spontaneous,
uncontrollable or involuntary.
NON-VERBAL CUES IN COMMUNICATION
 Body position – tensed, relaxed, leaning toward or
away.
 Eyes – teary, open, closed, blinking
 Eye Contact – Steady, avoiding, shifty
 Body movement – nodding, tapping, hand gesture.
 Body posture – stooped shoulder, rigid, relaxed
 Mouth – smiling, tight, lip biting
 Facial expression – distracting, frowning
 Skin – general, pale, perspiration
 General appearance – clean neat, sloppy
 Voice – fast, slow, whisper, high tone
NON-VERBAL CUES OF WARMTH AND COLDNESS
TIPS ON GOOD COMMUNICATION
- Provide clear instructions
- Use a balance of closed and open questions
- Use vocabulary suitable for the patients w Use non-
biased questions
- Give patient time to respond w Interrupt or redirect
if necessary
- Listen to the patient
- Discuss one topic at a time
- Move from general to specific
- Pursue unclear questions
- Identify and recognize the patient’s feelings
- Attend to patient cues
- Give feedback to the patient
- Invite patient to ask questions
- Use translational statements to summarize
- Close interview
PROFESSIONAL COMMUNICATION
COMMUNICATING WITH HEALTH CARE PROFESSIONALS
- Communication is a vital skill, necessary for success
in personal and professional settings. Pharmacists
often serve as the guardians of appropriate drug
therapy. Therefore, communicating effectively is key
to reinforcing the value of the pharmacist within the
health care system.
- Pharmacy career options have expanded into
multiple, different settings including hospital,
community, managed care, academia, and industry.
- In all of these settings, communication is critical.
Whether verbally responding to a physician’s
question during patient care rounds, providing an
educational program to nursing staff, or publishing
results of a research project in a biomedical journal,
communication skills are paramount to effective
pharmacy practice.
VERBAL COMMUNICATIONS
- Regardless of the practice setting, verbal
communication is the most common type of
communication that pharmacists utilize.
- Pharmacists should be encouraged to remember
that any type of question or interaction, regardless
of how informal it may seem, is an important
method of professional communication.
- The most common verbal communications that
pharmacists engage in involve responding to drug
therapy questions and receiving verbal drug orders
RECEIVING DRUG THERAPY QUESTIONS
- Requestors of information are sometimes unclear
when asking questions pertaining to specific-patient
needs. This most likely occurs because they are not
aware of the specific information that pharmacists
need to provide a comprehensive response.
- Pharmacists should recognize this potential
challenge and use appropriate listening and
questioning skills to collect pertinent background
information to determine the exact context of the
question.
- When receiving drug-related information requests
from health care professionals, it is particularly
useful to ask the information requestor if his or her
question is about a specific patient.
- If a physician asks a pharmacist a question regarding
the dose of a medication, inaccurate and potentially
harmful information may be provided if patient-
specific factors such as age, weight, and renal or
hepatic function, are not considered.
- Use open-ended questions.
 Open-ended questions cannot be answered by
oneword, short answers; but require responses
with detailed descriptions, and enhance
information exchange about the context of the
question.
 For pharmacists to gain a clear understanding of
the actual question, a mixture of different types
of questioning strategies should be used.
- In addition to asking appropriate questions, it is
important to have strong listening skills. Pharmacists
should avoid all possible distractions when gathering
background information.
- Ask for clarifications when necessary to ensure a
complete understanding of the situation
- Repeat the question or request to verify the inquiry.
- Questions to Consider When Collecting Pertinent
Background Information
o What is the requestor’s name, profession, and
affiliation?
o Does the question pertain to a specific patient?
 o Do I have a clear understanding of the question
or problem?
o Do I know if the correct question is being asked?
o Do I know why the question is being asked?
o Do I understand the requestor’s expectations?
o Do I know pertinent patient history and
background information?
o Do I know what unique circumstances generated
the question?
o Do I have insight about how the information I
provide will actually be used?
- Displaying confidence is obviously very important
during the delivery of the response. If the pharmacist
does not appear confident in his or her response, the
requester may certainly have reservations about the
information provided.
- Additionally, the vocabulary and terminology that is
used should be appropriate for the given audience.
- For example, when communicating with a physician,
professional terminology should be used and all
medical terms should be pronounced correctly.
- However, when communicating with a patient,
terminology that a layperson can easily understand
should be used.
- Finally, follow-up questions should be expected and
addressed in advance to save valuable time.
USING THE TELEPHONE FOR COMMUNICATION
- All pharmacists should be familiar with professional
phone etiquette. Face-to face interactions are
preferred, as they are more personal; however, in
many situations telephone interactions are
necessary.
- Regardless of the professional setting, the telephone
should always be answered by providing a greeting
that identifies the pharmacist’s name and affiliation
(eg, “Pharmacy Department, this is John, a
pharmacist, speaking”).
- It is also helpful for pharmacists to have a pen and
paper readily available before answering the
telephone to document any notes that are necessary
during the conversation.
- Many pharmacists find it helpful to write down the
exact date and time that a call is received.
- The hold option should always be used when asking
someone to wait on the telephone line. This
maintains a professional setting and avoids the
potential for the caller to overhear background
conversations while waiting for the pharmacist to
return to the telephone line.
- Repeating information to clarify any discrepancies is
also especially important to avoid any confusion.
FOLLOW-UP AND DOCUMENTATION
- Follow-up is extremely important to maintaining
professional practice. This allows pharmacists to
verify if their recommendations were taken and to
investigate patient outcomes while demonstrating
dedication to patient care.
- Documentation also reinforces the usefulness of
pharmacists to other health care professionals and
contributes to pharmacist workload assessment.
RECEIVING VERBAL DRUG ORDERS
- Verbal drug orders may not be the ideal means of
communicating drug therapy orders, but this
method is sometimes employed for urgent
institutional orders or as a means of convenience in
community settings.
- Verbal drug orders emphasize the importance of
excellent communication skills to allow accurate and
rapid decision-making processes.
- The Institute for Safe Medication Practices (ISMP)
recommends that all verbal orders and telephone
prescriptions be repeated back to the prescriber to
reduce the likelihood of medication errors.
WRITTEN COMMUNICATIONS
- DOCUMENTATION OF PATIENT CARE IN THE
PERMANENT MEDICAL RECORD
- Recommendations made by pharmacists on behalf of
their patients should be documented in a permanent
manner, such that information is accessible to all
health care professionals caring for the patient.
- These recommendations may include the patient’s
medication history, allergies, consultations to other
health care professionals regarding drug therapy
management, verbal orders, order clarification,
drug-related problems, drug therapy monitoring
findings, and patient education.
- It is stressed that documentation by pharmacists
should incorporate a standard format and be written
in a legible, clear, and complete manner.
- SOAP method of documentation has been most
utilized and accepted by health care professionals
including pharmacists. This is a written patient care
communications into subsections related to:
o Subjective
o Objective
o Assessment
o Plan
S – Subjective: Patient’s complaints or symptoms; data
provided by family members should be characterized as
such.
O – Objective: Patient data including age, sex, race,
height, weight, vital signs, results of laboratory and
diagnostic tests, and physical exam findings.
A – Assessment: The pharmacist’s evaluation of
therapeutic alternatives or resolution of drug-therapy
problems which may define the necessity for all drugs in
the patient’s regimen, evaluate the potential for drug
interactions, document the appropriateness of the drug
regimen and/or evaluate the patient’s previous response
to pharmacotherapy.
P – Plan: The plan should include specific drug therapy
recommendations (drug, dose, route, frequency,
duration), monitoring parameters and the necessity for
further studies or tests.

- The authors have expanded this methodology to

include two additional components, Education and
Outcomes.
- These were incorporated into the authors’
formalized documentation program because of the
belief that most patients require some type of
educational support to optimize therapy and
because pharmacists often provide
recommendations without identifying the desired
specific endpoint in terms of outcomes.
- Addition of the latter component serves as a
mechanism for followup to determine whether or
not therapeutic goals have been met