Ambulatory care

The nature of interactions between patients and outpatient providers can also contribute to adverse events. Circumstances can limit face-to-face interaction between a provider and a patient. Patients then should assume a much greater role in and responsibility for managing their own health. This elevates the importance of patient education to ensure patients understand their illnesses and treatments. Medication errors can occur due to a patient s understanding of the indication, dosing schedule, proper administration, and potential side effects of a drug. Low health literacy and poor patient education contribute to increased error risks. Patients should understand how and when to contact their caregivers outside of routine appointments. 

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Associate Professor School of Pharmacy CPNAHS Howard University Clinical Pharmacist Ambulatory Care... 

University of Iowa College of Pharmacy Clinical Pharmacy Specialist Ambulatory Care... 

Ambulatory Care Clinical Pharmacy Team Leader... 

Another related technique is the use of critical pathways. A critical pathway or clinical care plan is a detailed plan of care for a specific diagnosis, disease, or procedure [27], It describes the use and timing of all the care activities to try to optimize cost-effectiveness and improve patient outcomes. Critical pathways are much more specific than practice guidelines, which means they tend to take much more effort to produce. However, their comprehensive nature can enhance communication and coordination by different practitioners who are providing care to a particular patient. While critical pathways have been accepted within hospitals, their adoption for ambulatory care has been mixed. 

B Foxman, RB Valdez, KN Lohr, GA Goldberg, JP Newhouse, RH Brook. The effect of cost sharing on the use of antibiotics in ambulatory care results from a population based randomized controlled trial. J Chron Dis 40(5) 429-437, 1987. 

Levy DG, Stergachis A, McFarland LV, Van-Vorst K, Graham DJ, Johnson ES, Park B-J, Shatin D, Clouse JC, Elmer GW Antibiotics and Clostridium difficile diarrhea in the ambulatory care setting. Clin Ther 2000 22 91-102. 

Pharmacists have an opportunity to extend their activities in patient care as the emphasis continues to shift from inpatient care to ambulatory care. The latter situation generally encourages a team approach to health improvement, prevention, health maintenance, risk assessment, early detection, management, curative therapy, and rehabilitation [12]. Ambulatory care offers a variety of opportunities for individualizing patient care through pharmaceutical compounding. In fact, it is the area where most compounding pharmacists practice. 

From the above discussion of the activities of an ambulatory-care pharmacist, it should be evident that extemporaneous compounding can be vitally important in ambulatory patient care. 

Goode, M.A., and Gums, J.G., Therapeutic drug monitoring in ambulatory care, Annal. Pharmacotherapy, 27 502—505 (1993). 

Clinical Pharmacist Specialist, Ambulatory Care Adjunct Assistant Professor... 

Aruna AS, Akula SK, Sarpong DF. Interaction between potassium-depleting diuretics and lovastatin in hypercholes-terolemic ambulatory care patients. J Pharm Technol 1997 13 21-6. 

Hatoum HT, Akhras K. 1993. A 32-year literature review on the value and acceptance of ambulatory care provided by clinical pharmacists. Ann Pharmacother 27 1108. 

About the Author Dr. Mosavin is Chair of the Department of Pharmaceutical Sciences and Associate Professor in the Department of Pharmacotherapy and Outcomes Science at Loma Linda University s School of Pharmacy. Dr. Mosavin received a B.S. in Pharmacy from the University of Kansas, a Ph.D. in Pharmaceutical Sciences from the University of Wisconsin—Madison, and an MBA from the University of Chicago. Dr. Mosavin has experience in pharmaceutical industry, hospital pharmacy, and ambulatory care pharmacy settings. His research interests encompass economic evaluation of health care delivery systems and the role of pharmacists in these systems (especially as it relates to management of chronic diseases by pharmacists). Another key area of his research is analysis of economic gains achieved by health information technology implementation in ambulatory care pharmacy practice. 

Marco has found two other pharmacists willing to invest in purchasing an existing community pharmacy. This pharmacy has been open for only 2 years and is located in the lobby of an ambulatory-care... 

Singhal PK, Raisch DW, Gupchup GV. 1999. The impact of pharmaceutical services in community and ambulatory care settings Evidence and recommendations for future research. Ann Ilxmnsicuthcr 33 1336. 

Carol had hired a local clinical pharmacist who had expertise in ambulatory care as a consultant to assist with the pharmacists education and skills development. The clinical consultant facilitated the case discussions. The cases that were developed for this program required pharmacists to assess and modify patients dietary habits and activity levels. Also, they needed to identify and develop plans for resolving drug therapy problems. They practiced writing recommendations to physicians on the physician communication form. 

Tiggelaar JM. 1987. Protocols for the treatment of essential hypertension and type II diabetes mellitus by pharmacists in ambulatory care clinics. Drug Intell Clin Pharm 21 521. 

Most of the strategies discussed thus far can be applied to community pharmacy settings. However, this is not the only setting in which pharmacists offer value-added services. There are two specific practice settings that offer unique compensation strategies for ambulatory care pharmacists the physician office and the hospital-based outpatient clinic. 

Pharmacists and technicians play a major role in medication safety in modern pharmacy practice. After summarizing several studies performed in hospitals and long-term care facilities, Allan and Barker (1990) estimated that medication errors occur at a rate of about 1 per patient per day. In a more recent study performed in ambulatory pharmacies, they found an overall dispensing accuracy rate for prescription medications of 98.3 percent (Allan, Barker, and Carnahan, 2003). While most of these errors probably have minimal clinical relevance and do not affect patients adversely, many experts believe that medication error rates may be higher in the ambulatory care setting because errors may not always be evident to the health professionals who work there. For example, medication errors can occur when a patient purchases nonprescription medications without speaking with the pharmacist about any potential interactions with his or her prescription medications or if patients fail to verify the appropriate dose of the over-the-counter (OTC) medication. 

When pharmacists and technicians interpret prescriptions and medication orders, newly marketed drugs are a particular problem. Staff members are not as familiar with names of the drugs, and they tend to misinterpret them as older drugs. It is important that up-to-date education on all new medications is provided to the pharmacy staff, including any potential for error that may exist with these new products. In the ambulatory care setting, physicians can write both the generic and trade names legibly on the prescription, and they can add the intended purpose of the medication to further alert pharmacy staff to the correct medication name. 

Unfortunate medication use outcomes have been summarized as drug misadventuring or drug-related morbidity and mortality. This is a serious concern in health care, a concern left unresolved for many years. In addition, data and information on the incidence and economic consequences of preventable drug-related morbidity continue to mount. About 3.2% of all hospital admissions in the U.S. and Europe might be caused by preventable drug-related morbidity in ambulatory care. In 1995, the cost impact of these drug therapy problems in the U.S. health care system was estimated to be 76 billion, and a more recent update of this estimate for 2000 is 177 billion. ... 

Table 15.2 presents an example of a management plan for a pharmaceutical care practice located in an ambulatory care clinic. 

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