DAY 1: Hospital Orientation & Introduction to Clinical Pharmacy
Module Overview
The first day introduces interns to Omar Hospital & Cardiac Center and the Clinical Pharmacy
Department. Interns become familiar with the hospital structure, professional responsibilities of
clinical pharmacists, ethical practice, patient confidentiality, and communication within the healthcare
team. The session also provides an overview of the clinical pharmacy services currently offered in the
hospital.
Learning Objectives
By the end of this session, interns should be able to:
• Describe the organizational structure of the hospital.
• Explain the role of clinical pharmacists in patient care.
• Differentiate between traditional and clinical pharmacy practice.
• Understand professional ethics and patient confidentiality.
• Recognize the importance of communication within the healthcare team.
Clinical Pharmacy Services
The Clinical Pharmacy Department is staffed by two clinical pharmacists who provide ward based
pharmaceutical care. Their routine responsibilities include reviewing medication orders, identifying
medication-related problems, participating in physician rounds when required, providing drug
information, performing medication reconciliation when appropriate, monitoring medication safety,
documenting clinical interventions, and educating healthcare professionals and patients whenever
needed.
Role of the Clinical Pharmacist
Clinical pharmacists work alongside physicians and nurses to promote the safe and rational use of
medicines. Their responsibilities include reviewing prescriptions, assessing medication
appropriateness, identifying drug-related problems, recommending dosage adjustments, monitoring
treatment response and adverse drug reactions, answering drug information queries, and documenting
clinical interventions.
Practical Activities
• Departmental orientation.
• Meet the clinical pharmacy team.
• Visit medical and surgical wards.
• Observe daily clinical pharmacy activities.
• Discuss the responsibilities of clinical pharmacists.
Important Definitions
Clinical Pharmacy: A branch of pharmacy that focuses on the safe, effective, and rational use of
medicines through direct involvement in patient care.
Pharmaceutical Care: The responsible provision of medication-related services to achieve desired
therapeutic outcomes and improve patient quality of life.
Medication-Related Problem (MRP): Any issue involving drug therapy that may interfere with
achieving the desired treatment outcome.
Medication Safety: Practices designed to reduce medication errors and prevent patient harm during
prescribing, dispensing, administration, and monitoring.
Patient Confidentiality: The ethical and legal responsibility to protect patient information and
disclose it only to authorized individuals.
Professional Ethics: Standards of conduct that guide pharmacists in providing safe, respectful, and
patient centered care.
DAY 2: Prescription Verification & Medication Order Review
Module Overview
Prescription verification is one of the core responsibilities of a clinical pharmacist. It involves
reviewing medication orders to ensure that prescribed therapy is appropriate for the patient's
diagnosis, clinical condition, laboratory findings, organ function, allergies, and concurrent
medications. A thorough review helps identify prescribing errors, prevent medication-related
problems, and improve medication safety.
Learning Objectives
By the end of this session, interns should be able to:
• Perform prescription verification using a structured approach.
• Identify common medication related problems.
• Evaluate the appropriateness of drug selection, dose, route, frequency, and duration.
• Document and communicate pharmaceutical interventions effectively.
Prescription Verification
A complete medication order should include patient identification, diagnosis, generic drug name,
strength, dosage form, dose, route, frequency, duration, and prescriber details. Before approving a
prescription, pharmacists should confirm the indication, assess dose appropriateness, review allergies,
evaluate potential drug interactions or therapeutic duplication, and consider relevant laboratory
findings, renal function, and hepatic function.
Common Medication-Related Problems
• Inappropriate drug selection
• Incorrect dose or dosing interval
• Drug-drug interactions
• Therapeutic duplication
• Untreated indication
• Medication without a valid indication
• Inappropriate duration of therapy
• Inadequate monitoring
Pharmaceutical Intervention
When a medication-related problem is identified, the pharmacist should review the patient's clinical
information, consult current guidelines or hospital protocols, discuss the findings with the supervising
pharmacist, when necessary, communicate recommendations to the prescriber, and document the
intervention along with its outcome.
Practical Activities
• Observe the prescription verification process.
• Review inpatient medication orders.
• Assess drug indication, dose, route, frequency, and duration.
• Check allergies, laboratory findings, and potential drug interactions.
• Identify medication related problems and discuss interventions with the supervising
pharmacist.
Important Definitions
Prescription Verification: The clinical review of a medication order to confirm that it is appropriate,
safe, and suitable for the patient's clinical condition before dispensing or administration.
Medication Order: A written or electronic instruction from an authorized prescriber specifying the
medicines to be administered to a patient.
Medication Related Problem (MRP): Any event involving drug therapy that may interfere with
achieving the desired therapeutic outcome.
Pharmaceutical Intervention: An action taken by a pharmacist to resolve or prevent a medication-
related problem and improve patient care.
Therapeutic Duplication: The unnecessary use of two or more medicines from the same therapeutic
class without a valid clinical indication.
Prescription Error: Any error in prescribing that may result in inappropriate medication use or
patient harm.
DAY 3: Patient Assessment, Medication History & Medication Reconciliation
Module Overview
Patient assessment is a fundamental responsibility of the clinical pharmacist and forms the basis of
safe and effective medication management. Collecting an accurate medication history and performing
medication reconciliation help identify medication related problems, reduce prescribing errors, and
maintain continuity of therapy throughout the patient's hospital stay.
Learning Objectives
By the end of this session, interns should be able to:
• Perform a basic patient assessment.
• Obtain and document a complete medication history.
• Perform medication reconciliation (BPMH).
• Identify and resolve medication discrepancies.
Patient Assessment
Patient assessment begins with reviewing the patient's demographic information, presenting
complaint, history of present illness, past medical and surgical history, current diagnosis, allergies,
current medications, and relevant laboratory investigations. This information helps evaluate whether
the prescribed therapy is safe, appropriate, and consistent with the patient's clinical condition.
Medication History & Medication Reconciliation
A complete medication history should include prescription medicines, over-the-counter (OTC)
products, herbal medicines, dietary supplements, previous adverse drug reactions, allergies, and
medication adherence. Information should be confirmed using reliable sources such as the patient,
caregiver, previous prescriptions, medication containers, or available medical records.
Medication reconciliation is the process of comparing the patient's home medications with current
hospital prescriptions to identify and resolve unintended discrepancies such as omitted medicines,
incorrect doses, or duplicate therapy.
Common Medication Discrepancies
• Omitted medications
• Incorrect dose or frequency
• Therapeutic duplication
• Wrong dosage form
• Unnecessary medications
Patient Interview
A patient interview should be conducted in a professional and respectful manner. The pharmacist
should introduce themselves, explain the purpose of the interview, ask clear and open ended
questions, verify the information obtained, and maintain patient privacy and confidentiality
throughout the discussion.
Practical Activities
• Review patient medical records.
• Obtain medication history from an admitted patient.
• Perform medication reconciliation.
• Identify medication discrepancies.
• Discuss findings with the supervising pharmacist.
• Document one pharmaceutical intervention.
Important Definitions
Patient Assessment: The collection and evaluation of patient information to support safe and
appropriate medication therapy.
Medication History: A complete record of all medicines currently or previously used by the patient,
including prescription medicines, OTC products, herbal medicines, and dietary supplements.
Best Possible Medication History (BPMH): A comprehensive and accurate medication history
obtained by interviewing the patient or caregiver and verifying information from one or more reliable
sources.
Medication Reconciliation: A formal process of comparing a patient's home medications with
current medication orders to identify and resolve discrepancies during transitions of care.
Medication Discrepancy: Any unexplained difference between a patient's previous medications and
current medication orders that requires clarification.
Medication Adherence: The extent to which a patient takes medications according to the prescribed
regimen.
Adverse Drug Reaction (ADR): A harmful and unintended response to a medicine used at normal
therapeutic doses.
DAY 4: Interpretation of Laboratory Investigations & Clinical Monitoring
Module Overview
Interpretation of laboratory investigations is an important component of clinical pharmacy practice.
Laboratory findings help assess disease severity, monitor treatment response, detect adverse drug
reactions, and identify the need for dose adjustment. Clinical pharmacists should always interpret
laboratory results in relation to the patient's clinical condition and current medication therapy.
Learning Objectives
By the end of this session, interns should be able to:
• Interpret common laboratory investigations.
• Correlate abnormal laboratory findings with disease and medication therapy.
• Identify medicines requiring laboratory monitoring.
• Recommend appropriate monitoring and dose adjustments.
Common Laboratory Investigations
Clinical pharmacists should understand the clinical significance of Complete Blood Count (CBC),
Renal Function Tests (RFTs), Liver Function Tests (LFTs), serum electrolytes, blood glucose,
coagulation profile, cardiac biomarkers, and culture & sensitivity reports. These investigations assist
in evaluating organ function, infection, electrolyte imbalance, glycaemic control, bleeding risk, and
the effectiveness of antimicrobial therapy.
Clinical Monitoring
Clinical monitoring involves regular assessment of laboratory parameters and the patient's clinical
status to evaluate medication safety and therapeutic response. Pharmacists should recognize abnormal
laboratory values, determine their clinical relevance, and identify medicines that require additional
monitoring or dose modification.
Common Monitoring Parameters
• Vancomycin: Renal function, serum drug concentration
• Colistin: Renal function, urine output
• Digoxin: Potassium, renal function, heart rate
• Furosemide: Electrolytes, fluid balance, blood pressure
• Insulin: Blood glucose, signs of hypoglycaemia
• Warfarin: INR, bleeding
• Heparin: aPTT (when indicated), platelet count
Practical Activities
• Review laboratory reports of admitted patients.
• Identify abnormal laboratory values.
• Correlate findings with current medications.
• Assess the need for monitoring or dose adjustment.
• Discuss observations with the supervising pharmacist.
Important Definitions
Complete Blood Count (CBC): A laboratory test that evaluates red blood cells, white blood cells,
haemoglobin, haematocrit, and platelets to help assess infection, anaemia, and other haematological
disorders.
Renal Function Tests (RFTs): A group of tests, including serum creatinine and blood urea nitrogen
(BUN), used to assess kidney function and guide medication dosing.
Liver Function Tests (LFTs): Laboratory tests that assess hepatic function and help detect liver
injury or monitor hepatotoxic medications.
Culture & Sensitivity (C/S): A microbiological test used to identify the causative organism and
determine its susceptibility to antimicrobial agents.
International Normalized Ratio (INR): A standardized measure of blood coagulation used to
monitor patients receiving warfarin therapy.
Activated Partial Thromboplastin Time (aPTT): A coagulation test commonly used to monitor
unfractionated heparin therapy.
Clinical Monitoring: The ongoing assessment of a patient's clinical condition, laboratory results, and
medication response to ensure safe and effective treatment.
DAY 5: Antimicrobial Stewardship Program (ASP) & Rational Antibiotic Use
Module Overview
Antimicrobial Stewardship (AMS) promotes the responsible use of antibiotics to improve patient
outcomes, reduce antimicrobial resistance, and minimize unnecessary antibiotic exposure. Clinical
pharmacists contribute by reviewing antimicrobial prescriptions, interpreting microbiology reports,
assessing dose appropriateness, and supporting the rational use of antibiotics.
Learning Objectives
By the end of this session, interns should be able to:
• Explain the principles of antimicrobial stewardship.
• Assess the appropriateness of antimicrobial therapy.
• Interpret culture and sensitivity reports.
• Identify opportunities for de-escalation and IV to oral conversion.
Antimicrobial Stewardship
The aim of AMS is to ensure that patients receive the right antibiotic, at the correct dose, by the
appropriate route, and for the required duration. Selection of antimicrobial therapy should consider the
site of infection, likely pathogens, patient factors, culture results, local resistance patterns, and
hospital treatment guidelines.
Antimicrobial therapy may be:
• Empirical: Initiated before identification of the causative organism.
• Targeted (Definitive): Based on culture and sensitivity results.
• Prophylactic: Used to prevent infection.
• Pre-emptive: Started in high-risk patients based on early evidence of infection.
Principles of Antibiotic Review
Antibiotic prescriptions can be evaluated using the Five Ds:
• Right Diagnosis
• Right Drug
• Right Dose
• Right Duration
• Right De escalation
Culture and sensitivity reports should be reviewed to identify the causative organism, susceptibility
pattern, and the need to narrow or modify therapy.
IV to Oral Conversion
Conversion from intravenous to oral therapy should be considered when the patient is clinically
stable, afebrile, able to tolerate oral medications, and has a functioning gastrointestinal tract.
Common medicines suitable for IV to oral conversion include:
• Levofloxacin
• Ciprofloxacin
• Metronidazole
• Linezolid
• Fluconazole
• Azithromycin
Role of the Clinical Pharmacist
Clinical pharmacists support rational antibiotic use by reviewing prescriptions, assessing dose
appropriateness, identifying opportunities for de escalation, evaluating renal dose adjustments,
interpreting microbiology reports, and providing drug information when required.
Practical Activities
• Review antimicrobial prescriptions.
• Assess indication, dose, spectrum, and duration.
• Review culture and sensitivity reports.
• Identify opportunities for de-escalation.
• Assess renal dose adjustments.
• Discuss recommendations with the supervising pharmacist.
Important Definitions
Antimicrobial Stewardship (AMS): A coordinated approach to promote the responsible use of
antimicrobials and reduce antimicrobial resistance.
Empirical Therapy: Antimicrobial treatment started before the causative organism is identified.
Definitive Therapy: Antimicrobial therapy guided by culture and sensitivity results.
De escalation: Modification of broad-spectrum therapy to a narrower-spectrum antibiotic based on
clinical response or microbiological findings.
Culture and Sensitivity (C/S): A laboratory test used to identify microorganisms and determine their
susceptibility to antimicrobial agents.
Antibiogram: A summary report showing antimicrobial susceptibility patterns of microorganisms
within a hospital or healthcare setting.
IV to Oral Conversion: Changing therapy from intravenous to oral administration when clinically
appropriate.
Antimicrobial Resistance (AMR): The ability of microorganisms to survive or grow despite
exposure to antimicrobial agents.
DAY 6: Pharmacokinetics, Therapeutic Drug Monitoring & Dose Adjustment
Module Overview
Understanding pharmacokinetics is essential for selecting safe and effective drug doses. Patient-
specific factors such as age, body weight, renal function, hepatic function, and disease severity can
influence drug disposition and therapeutic response. Clinical pharmacists use these principles to
recommend appropriate dose adjustments and monitor medicines that require Therapeutic Drug
Monitoring (TDM).
Learning Objectives
By the end of this session, interns should be able to:
• Explain the basic principles of pharmacokinetics.
• Identify medicines requiring therapeutic drug monitoring.
• Assess the need for renal or hepatic dose adjustment.
• Recommend appropriate monitoring and dosage modifications.
Pharmacokinetics & Therapeutic Drug Monitoring
Pharmacokinetics describes how the body handles a medicine through Absorption, Distribution,
Metabolism, and Excretion (ADME). Alterations in these processes due to renal impairment,
hepatic dysfunction, age, obesity, or critical illness may require dosage modification.
Therapeutic Drug Monitoring (TDM) is performed for medicines with a narrow therapeutic index to
achieve effective drug concentrations while minimizing the risk of toxicity. Drug levels should always
be interpreted together with the patient's clinical condition and laboratory findings.
Common Medicines Requiring TDM
• Vancomycin: Serum concentration, renal function
• Aminoglycosides: Peak/trough concentrations, renal function
• Digoxin: Serum concentration, potassium, renal function
• Phenytoin: Serum concentration, albumin
• Valproic Acid: Serum concentration, liver function
Dose Adjustment
Dose adjustment is commonly required in patients with impaired renal or hepatic function. Renal
dosing should be guided by creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR),
while hepatic dose modification depends on the extent of liver dysfunction and the pharmacokinetic
properties of the medicine. Current clinical guidelines and patient-specific factors should always be
considered before recommending dosage changes.
Practical Activities
• Calculate creatinine clearance (CrCl) for admitted patients.
• Identify medicines requiring renal or hepatic dose adjustment.
• Review available therapeutic drug monitoring results.
• Discuss dosage recommendations with the supervising pharmacist.
Important Definitions
Pharmacokinetics (PK): The study of how a medicine is absorbed, distributed, metabolized, and
eliminated from the body.
Therapeutic Drug Monitoring (TDM): Measurement of drug concentrations in blood to optimize
therapy and reduce the risk of toxicity.
Narrow Therapeutic Index (NTI): A characteristic of medicines in which small changes in drug
concentration may lead to treatment failure or toxicity.
Creatinine Clearance (CrCl): An estimate of kidney function commonly used to adjust medication
doses in patients with renal impairment.
Estimated Glomerular Filtration Rate (eGFR): A calculated measure of kidney function used to
assess the severity of renal impairment.
Loading Dose: An initial higher dose given to achieve the desired therapeutic concentration rapidly.
Maintenance Dose: The dose administered at regular intervals to maintain the desired therapeutic
drug concentration.