PHRM 251 Lecture Notes - Lecture 1: Tacrolimus, Warfarin, Carbamazepine
Document Summary
Pharmacist reviews patient"s medication profile daily to identify potential and actual dtps. Health care record review review of patient"s chart, labs, Comprehensive care pharmanet, other records to identify potential and actual dtps. Interview patients to clarify, and resolve dtps identified through other methods. Pharmacist identifies selected patients to receive more comprehensive care. E. g. those with multiple dtps, complex drug therapy, very elderly patients. Automated reports or tools to help identify dtps. A computer generated list of medications that should be assessed by a pharmacist. Drugs that require therapeutic monitoring (e. g. phenytoin, carbamazepine, vancomycin, aminoglycosides, tacrolimus) Iv medications that may be able to be stepped down to po alternatives (ppis, abx) May include non-formulary medications as medication not available . Computer generated reports that combine drug, lab and other data to make it easier to spot drug therapy problems. Cross-reference patients with gfr < 50 ml/min and any medications they are receiving that require dose adjustment in renal impairment.
