Pharmaceutical Care

Pharmaceutical care: definition, classification of drugs related problem.

Compiled by Alok Bains

Pharmaceutical Care:

Classification of drugs related problems (DRPs)

Drug-related problem or medication-related problem is a concern with pharmaceutical care. “A Drug-Related Problem is an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes”. Drug-related problems (DRPs) is further divided into several classes. There are several classes of drug-related problems. No one is a perfect and universally accepted classification of DRP. It is very difficult to develop a classification accepted universally. Each DRP classification defines DRPs in its own way.

1. ABC of DRPs: This classification focuses on drugs' side effects and adverse drug effects. It divides DRPs into three categories.

   • Type A: adverse effects related to drug actions,

   • Type B: adverse effects related to patient reaction.

   • Type C: statistical, adverse effects.

2. Pharmaceutical Care Network Europe (PCNE) system: PCNE classification states DRP is an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes. It develops a standardised DRP classification system. It develops codes for problems, causes and interventions. These are structured hierarchically. This classification is in use in UK and Sweden. It classifies DRPs into the following classes:

   • Adverse drug reactions,

   • Drug choice problem,

   • Dosing problem,

   • Drug use/administration problem,

   • Interactions,

3. SHB-SEP classification: This DRP classification was developed in the Netherlands. It covers both patient and pharmacy-related aspects. It classifies DRPs into the following classes:

   • Insufficient understanding,

   • Questions about drug use, dosage,

   • Worries about complications/adverse reactions,

   • Self-care advice,

   • Advice on medical aids,

   • General/disease/complaint/disorder Information request 

   • Pharmacy team initiative administration,

   • Prescription Alterations,

   • Consultation evaluation by invitation,

   • Evaluation without patient consultation.

4. American Society of Hospital Pharmacists (ASHP) classification: ASHP proposed this classification. It named DRP a “medication therapy problem”. It defines “A medicated therapy problem as an event or circumstance involving medication therapy that actually or potentially interferes with an optimum outcome for a specific patient”. It classifies DRP into the following classes.

   •  Medication with no indication,

   • Condition for which no drug is prescribed,

   • Medication is prescribed inappropriately for a particular condition.

   • Inappropriate dose, dosage form, schedule, route of administration, or method of administration,

   • Therapeutic duplication,

   • Prescribing of medication to which the patient is allergic.

   • Actual and potential adverse drug events.

   • Actual and potential drug-drug, drug-disease, drug-nutrient, and drug–laboratory test interactions that are clinically significant.

   • Interference with medical therapy by social or recreational drug use.

   • Failure to receive the full benefit of prescribed therapy xi. Problems are arising from the financial impact of therapy.

   • Lack of understanding of the medication.

   • Failure of the patient to adhere to the regimen.

5. Problem–intervention documentation (PI-Doc): It was developed in Germany, especially for use in community pharmacies. It classifies DRPs into the following classes:

   • Unsuitable drug choice,

   • Unsuitable use by the patient,

   • Unsuitable dosage,

   • Drug-drug interactions,

   • Adverse reactions.

6. Cipolle/Morley/Strand classification: They define DRPs as drug therapy problems. This classification is mainly used to evaluate community pharmacies. These are employed when the patient experienced drug-related problems. It defines DRP as Any undesirable event experienced by the patient that involves or is suspected to involve drug therapy and that actually or potentially interferes with a desired patient outcome. It classifies DRP into the following classes:

   • Need for additional therapy,

   • Unnecessary therapy,

   • Wrong drug,

   • The dosage is too low,

   • Adverse drug reaction,

   • The dose is too high,

   • Adherence problem,

7. Granada consensus: It mainly focuses on negative clinical outcomes and patient behaviour. It does not include potential health problems of the patient. It defines DRP: Negative clinical outcome due to pharmacotherapy that produces an undesirable effect without achieving therapy objective. It classifies DRP into the following classes:

   • Indication,

     • The patient does not use the medicines needed,

     • The patient uses medicines that he does not need.

   • Effectiveness,

     • The patient uses an erroneously chosen.

   • Drug,

     • The patient uses a dose, interval, or duration inferior to the one needed.

   • Safety

     • The patient uses a dose, interval, or duration greater than the one needed,

     • The patient uses an agent that causes an adverse reaction,

8. Hanlon approach: This classification is based on the medication appropriateness index (MAI). The inappropriate medication causes DRPs. Inappropriateness in drug therapy. It classifies DRP into the following classes:

   • Indication,

   • Effectiveness,

   • Dosage,

   • Correct direction,

   • Practical directions,

   • Drug-drug interaction,

   • Drug-disease interaction,

   • Duplication,

   • Duration,

   • Expense,

9. Hepler–Strand classification: An event or circumstance involving a patient’s drug treatment that actually or potentially interferes with the achievement of an optimal outcome. It defines DRPs as “An event or circumstance involving a patient’s drug treatment that actually or potentially interferes with the achievement of an optimal outcome”. It classifies DRP into the following classes:

   • Untreated indications.

   • Improper drug selection.

   • Sub-therapeutic dosage.

   • Failure to receive drugs.

   • Over-dosage.

   • Adverse reaction,

   • Drug interactions,

   • Drug use without indication.

10. Krska et al. System: This classification is based on drug use evaluation. It uses the term pharmaceutical issues. It classifies DRP into the following classes:

    • Potential/suspected adverse reactions,

    • Monitoring issues,

    • Potential ineffective therapy,

    • Education required,

    • Inappropriate dosage regimen Untreated indication,

    • No indication,

    • Repeat prescription no longer required,

    • Inappropriate duration of therapy,

    • The discrepancy between doses prescribed and used,

    • Potential drug-disease interaction.

11. Mackie classification: It named DRPs as clinical DRPs. Clinical DRPs exist when a patient experience or is likely to experience a disease or symptom. This disease or symptom may have an actual or suspected relationship with drug therapy. It classifies DRP into following classes It classifies DRP into following classes:

    • Appropriateness,

    • Unnecessary therapy,

    • No indication apparent,

    • Untreated indication,

    • Safety,

    • Adverse reaction,

    • Clinically significant drug interaction,

    • Contraindication,

    • Effectiveness,

    • Ineffective therapy,

    • Inappropriate choice of therapy,

    • Inappropriate formulation/delivery,

    • Inappropriate dose/dosing schedule,

    • Admitted non-adherence,

    • Monitoring required,

    • Miscellaneous.

12. National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP): The NCC-MERP defines DRP as a preventable event that may cause or lead to inappropriate medication use or patient harm, whereas the medication is in the control of the healthcare professional, patient, or consumer. It separates the problem from the cause. Its classification is mainly based on the administration of parenteral drugs in non-ambulatory patients. It classifies DRP into the following classes:

    • The medication is in the control of the health care professional, patient, or consumer.

    • Dose omission,

    • Improper dose,

    • Wrong strength/concentration,

    • Wrong drug,

    • Wrong dosage form,

    • Wrong technique (includes the inappropriate crushing of tablets) viii. Wrong route of administration

    • Wrong rate (probably relating to administration),

    • Wrong duration,

    • Wrong time,

    • Wrong patient.

    • Monitoring error (includes contraindicated drugs)

    • A Dispensing drug that has expired.

13. Westerlund system: It states DRP is a circumstance related to the patient’s use of a drug that actually or potentially prevents the patient from gaining the intended benefit of the drug. It classifies DRPs into the following classes

    • Uncertainty about the aim of the drug,

    • Drug duplication,

    • Drug-drug interaction,

    • Contraindication,

    • Therapy failure,

    • Adverse effect,

    • Underuse of drugs,

    • Overuse of the drug,

    • Other dosage problems,

    • Difficulty swallowing tablets/capsules,

    • Difficulty opening drug containers,

    • Another problem with administration/handling.