include high risk medicines, pharmaceutical
complexity, referrals from other health professionals
and patients’ individual clinical factors were the
most important factors that were considered.
Electronic resources such as dashboards and
electronic prescribing systems were shown to not
have as much influence when prioritising workload
for medicines reconciliation. Workload pressures
were also shown to have less influence on how
activities were prioritised. Similar results were seen
when it came to pharmacy staff prioritising clinical
activities (see Table 3 for responses on factors that
influence pharmacy staff prioritising). Response
about discharge priority however did show that
pharmacy teams were influenced by non-clinical
factors such as pressure to discharge patients
quickly and maintain flow of patients through the
hospital. This was in addition to the factors around
the patient’s clinical condition and complexity.
The most common barrier to effective clinical
prioritisation was a lack of time and information.
Pharmacy staff felt that due to a lack of readily
available information effective prioritisation
was a time consuming process. Communication
was highlighted as a key facilitator to enable
effective prioritisation practice. It was felt that
pharmacy staff needed to work flexibly to prioritise
patients dependent upon the individual patient
factors and overall workload. Common ideas that
were highlighted to improve clinical pharmacy
prioritisation included developing an evidence-based
prioritisation tool that would consistently flag up
high-risk patients. To support this, pharmacy staff
felt that effective IT solutions would help, as well
as a robust definition to define a clinical pharmacy
priority. Other improvements included better
training for pharmacy and non-pharmacy staff
about clinical pharmacy priorities and standardised
methods of prioritisation. In particular respondents
felt the need to empower junior staff to feel
confident to make decisions. There were 80 (39%)
of respondents who felt that they were happy with
how they prioritise.
Common themes identified through thematic
analysis were that prioritisation was an essential
skill that all pharmacy professionals required. It
is described as a ‘skill that needs to be learnt’ and
that ‘professional judgement needs to be applied’.
Respondents views were prioritisation changes
dependent upon the context of the patient, ward
environment and pharmacy team circumstances.
Prioritisation is a skill that is viewed as ‘continually
developing’ throughout an individual’s career. The
process of prioritisation ‘involves the analysis and
interpretation of situations’. Individuals described
‘using multiple methods to prioritise’ and changing
their prioritisation practice dependent upon
workload or complexity of patients.
One respondent stated that ‘insulin is a highrisk
medicine but the risk associated depends
upon the context. A patient prescribed insulin on
a diabetes ward is likely to have a different level
of risk profile than if they were prescribed insulin
on a ward without speciality diabetes input’.
Individuals described needing to understand the
context of the clinical service they were working
within. Key competencies that were described were
communication with the wider healthcare team
and confidence to make decisions. Training was a
main theme that was identified by respondents.
They described ‘junior staff members being taught
prioritisation skills’ involving understanding
and interpreting the complexity of patients’
pharmaceutical care.
FIGURE 1
Principles and relationships of prioritisation
Experience and knowledge
• Appropriate knowledge and
skills
• Ability to clinically overview
• Appropriate use of resources
Empowerment/confidence
• Clinical ability
• Know when to refer
• Decision making ability
Communication
• Systems to allow efficient handover
• Concise transfer of information
Discussion
Prioritisation is a developing part of clinical
pharmacy practice in secondary care. It can be
thought of as complex multifactoral process that
requires interpretation and understanding of the
system. The core act of prioritisation for pharmacy
staff is to perform a risk assessment considering
the importance and urgency of a patients’ clinical
condition. The risk level will be determined by
the clinical situation and the individual patients’
circumstances. To undertake this risk assessment,
information is key and pharmacy staff use a wide
range of resources to prioritise. They need to
communicate with other healthcare professionals
as well as gather information about a patient’s
specific circumstances. Prioritisation needs to be
a rapid process that assimilates and analyses the
pertinent patient specific issues to assign a degree
of pharmaceutical risk to a patient. Electronic
prioritisation tools have been developed to aid
pharmacy staff to collate the complex information
involved with prioritising a patient. The experience,
knowledge and skill of pharmacy staff is however
essential to be able to put context into the situation
when prioritising. Pharmacy staff need to use their
experience and knowledge to interpret the risk
and complexity of the individual and consider this
within the wider context of the current clinical
picture. Patients’ pharmaceutical risks and clinical
needs evolve as they journey through hospital.
Systems need to enable pharmacy staff to focus
on activities when a patient is most at risk or has
greatest pharmaceutical need. It is important to
highlight that pharmacy staff appear to place
Context of current services
• Effective targeting of resources
• Adaptability of services to meet
demands
• Decision making ability
Risk assessment
• Assess urgency
• Differentiate urgent vs important
• Assessment made based on clinical situation
Complexity
• Assess all medicines prescribed in the clinical
context
• Presenting condition and past medical history
• Patient centred focus
hospitalpharmacyeurope.com | 2019 | Issue 91 | 21