In the inpatient setting, our pharmacists add value to the care and safety of our patients by:
Medication Reconciliation and Medication Therapy Management
Medication reconciliation and medication therapy management is a service that aims to optimise clinical outcomes by managing drug therapies for patients with chronic diseases. Our pharmacists have demonstrated high rates of patient interventions and documentation of medications, medication interactions, drug-related admissions, and previous drug failures.
Our pharmacists perform the following tasks:
- Obtain and maintain accurate and complete medication information for patients, and use the information within and across the continuum of care, to ensure that medication is used safely and effectively.
- To review medications and identify any drug-related problems.
- To communicate with doctors and caregivers about medication plans, in order to improve patients' understanding of their diseases/medications, reducing drug-adverse events, meeting patient-defined clinical goals, and improving medication adherence.
Therapeutic Drug Monitoring (TDM)
Maximising the effectiveness whilst minimising the toxicity of medications, such as antimicrobial agents, is an essential step in the treatment of infections. One such method to improve antimicrobial dosing in individual patients is through application of therapeutic drug monitoring (TDM).
The roles of our pharmacists are to:
- Perform critical evaluation of patient-specific parameters, and the pharmacokinetics and pharmacodynamics of the specific antibiotics.
- Ensure timely monitoring of toxicity and efficacy of antibiotic treatment.
Our pharmacists help in managing anticoagulation therapy, when it comes to inpatient care. Therapy management by pharmacists had shown to increase the percentage of therapeutic anticoagulation therapy and reduce hospitalizations for thromboembolic or bleeding events.
Our pharmacists do the following:
- Timely evaluation of patient-specific pharmacokinetic response
- Working in collaboration with doctors and nurses, to ensure appropriate monitoring and administration of oral and intravenous anticoagulants.
Diabetes Mellitus and Blood Sugar Monitoring
Today, one in three Singaporeans has a lifetime risk of developing diabetes, and the number of patients with the condition is estimated to reach one million by 2050. On sick days, serious illness can cause a rise in blood sugar levels due to the effects of stress hormones such as corticosteroid and adrenaline being produced by the body. Uncontrolled blood sugar levels during inpatient will complicate medical management and increase risk of undesirable complications, such as excessively high levels of blood sugar. Inpatient pharmacists help to optimise blood sugar control in the wards, and prevent complications from arising.
Role of pharmacists:
- Review patients' sugar profile and correlate with oral intake, use of anti-diabetic medications and any side effects. Identify undesirable sugar level trend and optimise management in ward and also upon discharge.
- Provide in-depth diabetes counselling to patients. These include disease management, hypoglycaemia management, diabetes medication and insulin injection technique.