Doctors should mentor Pharmacists and utilize their expertise to ensure safe medications


 Healthcare is a team work in which Physician is the Team Leader

Doctors should mentor Pharmacists and utilize
their expertise to ensure safe medications

Pharmacists are key stake holders in medication
management system-Mr. Latif Sheikh

About 8% ADRs lead to death of the patients and
6% result in permanent disability

KARACHI: Pharmacists are the key stake holders in medication management system. Members of the medical profession particularly the senior physicians should mentor them and utilize their expertise in ensuring safe medications which will reduce the chances of medication errors to a great extent and thus ensure patient safety. This was stated by Mr. A. Latif Sheikh an eminent pharmacist and Director of Pharmacy Services at Aga Khan University Hospital Karachi. He was speaking on “Transforming the Pharmacy into a strategic Asset” at a meeting organized by PharmAssist an entity established by PharmEvo Pharmaceuticals at Karachi on November 4, 2015. The meeting was very well attended by Chief Operating Officers of various hospitals in the city besides a few pharmacists.

In an hour long presentation Mr. Latif Sheikh dealt at length on the existing health services, pharmacy services in the country, available manpower in the health sector and how the hospitals can convert the pharmacy in to a strategic asset. Pharmacy in Pakistan, Mr. Latif Sheikh said was still in a growing phase.  Healthcare is a team work in which physician is the team leader.  Unfortunately almost 99% of the pharmacists in Pakistan were those who could not get admission to medical colleges and it was not their profession by choice, hence most of them suffer from inferiority complex. Speaking about the medication management system, he said, medicines were being used without any supervision at all. When the accrediting team come to the pharmacy these days in the developed world, they do not ask you how many pharmacists you have but they ask you how you are selecting the medicines, how you are using and monitoring medication? They are more concerned about the quality and safety of the drugs being used in that facility.

Mr. A. Latif Sheikh

Pharmacists have a complimentary and supportive role in medication management. Our objective is to sensitize the physicians and hospital leadership about criticality of pharmacy services. The life expectancy in Pakistan at present, he said, was about 66.2 years, (65.2 Years for Male and 67.2 Years for Female). Our infant mortality rate was 69.9 per thousand. Our total spending on healthcare is 4.4% of GDP. Almost 81.5% of the expenditures incurred by people on healthcare are out of their own pocket and government spending on health was just 1.4%.

Giving details of road to medication order Mr. Latif Sheikh mentioned review of medication order, provision of medicine information, distribution and storage, transfer of verified information and decision to prescribe medicines,issues of medicines, administration of medicine and monitoring for response. At the chemistsshops we have drug retailers instead of pharmacists. The one with low or no technical know how in the family of a hospital owner is posted at the pharmacy to dispense drugs. They have lack of knowledge and also lack reliable information. Then we have counter selling of drugs. We see medical stores nearby the hospitals with whom the healthcare facilities have some arrangements and dispensing of drugs takes place. A study done by a postgraduate in Aga Khan University some years ago revealed that only 5% of the pharmacies were air-conditioned, 96% had no alternative arrangements for electricity despite frequent power failure and load shedding. Almost 60% of these medical stores also sold vaccines. Almost 64% of them were selling Septran an antimicrobial agent over the counter in those days. Sometimes foods and drugs are stored in the same Refrigerator without any regard to temperature stability of various products but since in most cases there is no change in the shape of drugs, it goes on un-checked.

Referring to a study of IOM in United States some years ago Mr. Latif Sheikh mentioned that despite controls and monitoring, 98,000 deaths took place in United States due to medication errors. This was due to adverse events and due to drug administration which cost the United States between 17-29 Billion Dollars annually. The causes of medication error include lack of knowledge, lack of reliable availability of information, regimen complexity, prescriptions and hand writing. He then showed same size 2 ml vials with same colour which have different medicines which increases the chances of medication errors tremendously. At present most of the pharmacies have no check and balance in their pharmacy system. If we do not change our systems, blunders which was witnessed at the Doctor’s Hospital Lahore leading to the death of a young girl will continue to happen. The problem in that particular case was first the drug was administered too fast and when adverse reaction occurred, they had no antidote available. We have acute shortage of nurses in Pakistan and lack of mentoring results in medication errors. Then there are the issues with drug compliance. Adverse Drug events take place because the patients are not given proper information how to use the medications. About 39% errors in medication are due to prescribing, 11% due to dispensing, 12% due to transcribing and drug administration accounts for 38% of medication errors. Medication errors comprise a significant portion of overall errors in hospital setting. Almost 8% ADRs lead to death of the patients, 6% result in permanent disability. He laid emphasis that medication error is always a system failure, system problems and not people problems.

Mr. Latif Sheikh urged the hospital administrators to look at the pharmacy as an asset. The term used these days is Pharmaceutical Care which covers total oversight of therapy the patient is getting. Now pharmacists look at disease management. They have been allowed and are involved in prescribing certain drugs in some countries but I do not support that in Pakistan. Pharmacy, he further stated, was a revenue generator for the hospitals. Pharmacy practice is a direct patient care activity. We now have even emerging pharmacy specialists. Hospitals should capitalizeon these new growth opportunities. Rationale use of drugs will reduce hospital medication costs. Infection control personnel has reduced the use of antibiotics. Remember now we have patients who have enhanced expectations and they are also more knowledgeable. We have many patients who are suffering from endocrine and cardiac diseases. These are chronic diseases and the patients need counselling. Post discharge medication was also important. We need to have durable medical equipment, take care of over the counter medications. Patients have total support team through pharmacists in the hospitals. There are various studies which have showed that utilizing the expertize of pharmacists in medication management has reduced mortality by  1.9%, medical expenditures were decreased by  48%, cost of drugs decreased and overall cost of care also decreased. However, the pharmacists mind set, Mr. Latif Sheikh remarked needs to change. They should not point out mistakes in prescriptions by the physicians, instead suggest them how to improve the prescription or change dosage or take care of drug-drug interactions. It is also a fact that almost 40-50% of Adverse Drug Events are reported by the pharmacists. He also talked about relative risk reduction and absolute risk reduction.   Mr. Latif Sheikh further stated that since hospitals have to remain in business, the hospital administrators must look how they can cut costs and enhance their revenues. This can be done by developing the Pharmacy as a strategic asset.

Continuing Mr. Latif Sheikh said that wrong dosage was mentioned as one of the cause of medication errors in 6% of cases while in another study this figure was 9%. Now clinical pharmacists are working in certain clinical areas. We have guidelines for use of antimicrobial drugs. He then talked about antimicrobial susceptibility, correct choice of drug, dosage and treatment duration which were all very important. In case the patient is taking too many drugs, one has to be careful about the drug-drug interactions. We have to be careful of drug dosing, side effects. My personal experience Mr. Latif Sheikh said was that whenever I have pointed out these things, the physicians have accepted my advice in 99% of cases. He advised his pharmacist’s colleagues to request the physicians rather than telling them which makes all the difference. In many cases even switching the medication from parenteral to oral in the ICU results in substantial cost saving. Physicians and pharmacists working in close collaboration can prevent ADR due to prescribing errors. Rational use of antibiotics results in better patient care. It is important that pharmacists should move from behind the counter. Now working pharmacists are also entering the Academia and hopefully the situation of pharmacy services in Pakistan will change for the better in the days to come, Mr. Latif Sheikh concluded.

Replying to various questions Mr. Latif Sheikh said that pharmacy education no doubt needs to be improved, standardized and teaching faculties also need to be strengthened. Responding to yet another question he agreed that wecan standardize some prescriptions for primary healthcare. It is important that we know the disease burden in the area. Who is prescribing drugs is also important. We can standardize drug therapy with the help of pharmacists. Many countries in the word are using Essential Drugs List prepared by WHO and hopefully Pakistan will also implement it. As regards the expiry of drugs, usually it is meant last day of the month but it does not mean that on the next day the drug has become ineffective but he hastened to add that he was not advocating the use of drugs after the expiry date. But we must remember that there are several breaches in the cold chain. There are problems with the supply chain and then we have identical ampoules. In pharmacotherapy youdo have a choice, you can have some rationalization. Misuse of X-ray and laboratory services can be avoided. It is a long term programme to develop a multidisciplinary team to ensure medication safety. Pharmacists need to develop a rapport and become a part of the patient care team and get themselves accepted.  The senior physicians can mentor and mound the pharmacists, he added.

Earlier Mr. Jamshed Ahmad Chief Operating Officer PharmEvo in his welcome address said that pharmacists re the key member in the healthcare team but they are missing in Pakistan. We are looking at the possibilities as to how it can be established and how it can be customized. He thanked Mr. Latif Sheikh for sparing some of his precious time to advise and guide the hospital administrators on how to organize the pharmacy services utilizing the expertize of the pharmacists. Mr. Latif Sheikh has established the state of the art pharmacy services at AKU where over ninety qualified pharmacists are working.  Through PharmAssist we are looking after the interests of the patient. He hoped that such scientific sessions organized by PharmEvo will help to treat the patients in best possible manner. Why pharmacists could not get proper recognition in our healthcare set up, there are several reasons for that and one of them is the lack of professional development of thepharmacists themselves. Later Mr. Haroon Qasim Chief Executive of PharmEvo thanked the speaker, the participants and also presented a memento to Mr. Latif Sheikh.