The theme of the 2022 Canadian Patient Safety Week was “Press play on safety conversations.” These safety conversations are intended to be part of building a culture focused on patient safety, especially for patients who are older adults. In 2016, 1 in 143 Canadian seniors was hospitalized due to harmful effects of their medication. Adverse drug events also account for one in nine emergency room visits.
In the pharmacy environment, one critical tool to reduce potential harm to patients and contribute to more effective patient care is a comprehensive patient assessment.
1 in 143 Canadian
seniors was hospitalized
due to harmful effects
of their medication
Adverse drug events
account for one in nine
emergency room visits
Patient Assessments: An Opportunity for Conversation
For every new and refill prescription that is dispensed, pharmacists must assess whether the prescription is therapeutically appropriate. Important factors to consider are whether the medication is safe (based on the specific patient) and whether it will be effective (based on the evidence for the indication).
This means that pharmacists must assess the safety of the medication by considering specific information about the patient such as allergies, contraindications, dose, and drug interactions. In addition, pharmacists must confirm the indication and assess whether it is the most appropriate option based on evidence (i.e., clinical guidelines). During this process, all relevant information from the patient should be considered, which may include other medications or health products, and changes to the patient’s health status.
While the pharmacist, or other pharmacy professional, may be able to gather some of this information from the patient profile, it is important to engage in a conversation with the patient to confirm that there have not been any changes since the last update to the patient profile. For example, a quick basic check-in on a refill prescription may include asking how the medication has been working for them, and if there have been any changes in their health status or medication use.
During practice assessments of community pharmacists, the College has found that 55.7% of pharmacists have a competency gap with the performance indicator “Gathers relevant information through dialogue with the patient and/or their advocate.” This means that while the pharmacist is approaching the standard for this activity, they are not fully meeting it. Pharmacies generally fill significantly more refills than new prescriptions and the patient assessment expectations around refills are the largest gap.
of community pharmacists have a competency gap related to gathering relevant information through dialogue with the patient
Resources to Help Guide Patient Assessments
There are a number of resources available that can help support the process of a patient assessment. An example of a systematic approach to identify problems related to the patient’s drug therapy is Alberta College of Pharmacy’s Chat, Check, Chart method. Use the “Check” method of four questions to identify potential drug therapy problems and evaluate the appropriateness of therapy for a patient: is it indicated, effective, safe and is the patient willing to use/adhere to the therapy. The College’s Practice Assessment for Community Pharmacists Criteria includes resources while the Patient Assessment Practice Tool has links to relevant articles and resources.
One of the tools that can be used in assessing medications is the 3 prime questions (3PQs):
For new medications:
- What did your prescriber tell you your medication is for?
- How did your prescriber tell you to take the medication?
- What did your prescriber tell you to expect?
For refill medications:
- This medication has many uses – what do you use it for?
- How long have you been taking this medication?
- How is this medication working? What side effects have you had?
Open-ended questions like the ones above can help overcome assumptions related to the indication of a medication (for example, assuming that a prescription for metformin means the patient has diabetes when there are other off label uses or possibly an error). It is important to determine the indication and not base the assessment on the medication class as the dose and duration could be very different depending on why the medication is being used. A best practice is to document the indication for each medication in the patient profile.
Open-Ended and Interactive Approach
Having a conversation with the patient is the most effective way pharmacy teams can ensure they have the information they need.
When providing information about the medication, a best practice is first to assess the patient’s knowledge of the medication. This is an effective and efficient communication strategy that streamlines what information the pharmacist needs to share with the patient and allows the pharmacist to correct any misinformation or misunderstanding that the patient may have. The use of open-ended questions during assessments with patients and/or their caregivers is also a useful technique as it encourages dialogue and avoids the yes/no answers that might not get at important information to support safe and quality care.
In determining the questions to guide the conversation, pharmacists can consider the following:
- What information do you need from this patient based on your knowledge of them/their medications/conditions? For example, a senior with multiple ongoing medications may need a different approach than a young adult with a new prescription for short-term use.
- What tools can you use to help guide this conversation? For example, a structured approach like Chat, Check, Chart or 3PQs may help you ensure you get all the information you need.
- Are there any special considerations to support this conversation? For example, accessibility needs (e.g., hearing impairment), ensuring a caregiver is present, using a private area.
- How can you support ongoing safety for this patient? For example, developing a follow up plan to ensure that they are achieving optimal outcomes and are not experiencing any adverse effects. This may include self-monitoring parameters such as recommendations and targets for blood glucose/blood pressure.
Imparting information in a conversational tone, making eye contact and asking patients questions helps to foster effective dialogue between both the patient and the pharmacy professional. When gathering information, it may be helpful to focus on one question at a time, instead of compounding multiple questions (e.g., ask about allergies first and then ask about medical conditions separately). Closing a consultation by inviting questions or asking the patient to repeat the information they found important can help the patient’s retention of critical information related to their medication or care.
- https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Medication-Without-Harm-2018-09-14.aspx ↑
- https://cihr-irsc.gc.ca/e/52248.html ↑
- https://www.mdpi.com/2226-4787/8/3/111/htm ↑