ward rounds

[Asterix]

when a pharmacist checks a drug chart on ward rounds, do they check the drug details for that particular days administration or is it weekly? For example, I could check the drug chart on a tuesday and then Mr X could check it on a Wednesday. What exactly needs to be checked apart from interaction and correct dosing.

[crit care]

you don't just check whats been given on that particular day, you look at all the drugs which are prescribed on the chart..check they are appropriate doses, dosing intervals, route, and that it is appropriate to the patient, and appropriate to be taken alongside the other medication the patient is written up for, check its appropriate dosing for their organ functions (if applicable)

[Nik]

Also have they prescribed it properly, eg tapering doses of steroids, to ensure that nurses give appropriate doses and don't suddenly stop, antibiotics frequently cause problems as some docs like to use them for a very long time and often things like nystatin and chloramphenicol get overlooked and docs forget that they may still be on the chart (and also watching for allergies). Docs may also unintentionally miss things off the chart which patients should be taking, whether its stuff identified from a drug history, or if it's something which should be prescribed eg statin post CVA. Most pharmacists will also endorse things like TDM for appropriate drugs by writing the results of plasma levels on the chart for each day or whatever and highlighting on what days and times blood should be taken for serum monitoring. Another thing which most jr docs like to do is prescribe co-codamol and paracetamol together or sometimes even write paracetamol twice .

[Asterix]

but how can you keep adrift of changes like reducing steroids, you may be on the ward come monday and then different ward tuesday?

[Asterix]

also, say if a patient was prescribed a drug on monday and I look at it, its fine etc. Then nik comes onto the same ward looks at the same chart on tuesday, what exactly is he looking at it, the weekly supply or the daily?

[Nik]

With things like reducing steroids, there'd usually be a clear plan on the chart, i.e days crossed off and reducing strengths written on, so that the nurses clearly know what dose to give and when.
You don't just look at the chart on its own every day, patient's treatment plans might change. One day they may be started on trimethoprim, the next day the docs may cross it off and put co-amoxiclacv on instead. Or patients' renal function may suddenly deteriorate, so dose adjustment may be needed - hence notes and things like blood results should be looked at. Essentially, you'd review the chart every day to make sure the medicines being prescribed are still appropriate. Looking at charts weekly is not good enough - so much can change for a patient, drugs started/stopped, dose increased/decreased, deterioration in clinical condition or presentation of something new.

[Asterix]

thats fine nic, but say i did the ward the day after you, am i just checking whats on the chart or referring back to any previous changes?

[Nik]

If you were there the next day, you should be checking the chart again and reviewing any possible changes that may have been made if the docs had seen the patient before you. It is very easy to get complacent if a patient has seen by a pharmacist before you see them, as you'd assume that everything was OK.
Only yesterday a patient came to the ward I was working on who was on IV clarithromycin 250mg bd and simvastatin. This is such a common interaction and easily manageable, but the pharmacist who had been reviewing the patient previously on one of the admissions wards hadn't made the appropriate intervention (withholding the doses of simvastatin while the patient was on clarithromycin), so I then did so and endorsed appropriately. The pharmacist had also endorsed the IV clarithromycin "review to oral as soon as possible". IV clarithromycin is equivalent to oral, so there is virtually no reason, except for cases like vomiting, in which you would give it IV. So I spoke to the reg who was like " Oh yes he can take that orally" (Well why the bloody hell didn't you change it then, I thought). Just an example of a typical patient.

[Asterix]

when do you look at a patients medical records on wards. I am confused at the minute as the pharmacist is checking drug charts and checking 1 or 2 records

[Nik]

Depends on the types of patients you're looking at. If they're relatively stable and are only awaiting discharge plans to be put in place, then there's hardly going to be anything worth looking at from a clinical point of view in the notes. However, you should look at the notes more often for newly admitted pts or those really sick or on loads of drugs. To be honest you need to use a fair bit of common sense - if the patient looks ill and you're looking at charts where drugs are frequently being changed or added or whatever then you look at the notes.