Clinical Pharmacist

Pharmacist

The pharmacist provides appropriate selection of drug therapy based upon the pharmaceutical principles of pharmacokinetics and pharmacodynamics; monitoring for efficacy, side effects and clinical outcome; and advises prescribers as appropriate. Provides patient-specific therapeutic drug monitoring and communicates relevant findings and/or recommendations to other health care providers in charge of the patient both orally and in writing. Monitoring will include prospective review and intervention in: therapeutic appropriateness of a patient's drug regimen, therapeutic duplication in the patient's drug regimen, appropriateness of the route and method of administration, degree of patient compliance with the prescribed drug regimen, drug-drug, drug-food, drug-laboratory, or drug disease interactions, clinical and pharmacokinetic laboratory data to evaluate the efficacy of drug therapy and to anticipate side effects, toxicity, or adverse effects, physical signs and clinical symptoms relevant to the patient's drug therapy. Performs continuous evaluation of prescribed medications to assure optimal drug therapy. Provides medication counseling to patients and caregivers (when applicable). Completes medication histories including patient interviews. Serves as a drug information resource by providing up-to-date drug information to prescribers, other health care professionals, patients and caregivers. Participates in patient care rounds, review charts, evaluates pertinent laboratory data, drug-drug and drug-nutrient interactions, monitors for adverse drug effects, and screens for allergies. Performs medication reconciliation at all transitions of care, including updating the medication profile to reflect an accurate, active list of VA and non-VA medications. This may include adding non-VA medications or discontinuing duplicate medications or those the patient is not taking. Assesses drug safety and efficacy, including evaluation of physical symptoms. Reports adverse drug events (ADE), near misses, and medication errors in alignment with VA ADERS reporting program and e-PER reporting program. Participates in the medical center medication utilization evaluation (MUE) program. Recommends formulary alternatives and completes non-formulary consults as assigned. Participates in medical emergencies (if BLS or ACLS certified) and emergency preparedness activities. Provides pharmacokinetic consultation, including dosing vancomycin and aminoglycosides, in accordance with local policy. Implements P&T Committee policies including therapeutic interchanges and automatic substitutions to include appropriate patient and provider education. Manages recalls and medication shortage situations by substituting alternate dosage strengths and instructions of the same medication to equal the prescribed dose and schedule. Enters supply orders appropriate for patient care per facility policy. Manages various actions, as appropriate, for medication orders to include: flagging prescriptions, managing view alerts, using the "hold medication" function, and generating unsigned discontinued orders using Service Reject. Extends refills until next scheduled appointment under the provider's name per facility policy. Serves as a role model and preceptor to pharmacy students and residents. Other duties as assigned.

US Department of Veterans Affairs