Introduction Clinical supervision is defined by Barber and Norman as having four main functions: educational, supportive, managerial and development of self-awareness.1
It is common practice within initial pharmacy education for clinical supervision to take place at undergraduate, pre-registration and foundation level pharmacist stages. But what about the specialist trainees? It is probably a fair observation that the amount of clinical supervision provided for pharmacists undergoing their advanced level practice drops vividly.
One study suggests that clinical supervision improves patient outcomes,2 however this and many other studies are related to nursing clinical supervision, there is little published evidence to support this claim with regards to pharmacy clinical supervision.
We present a case where effective clinical supervision of a specialist trainee had a direct impact on patient safety and outcome in a paediatric intensive care unit. The case involves a child with a presentation of sepsis related to group A Streptococcus toxic shock syndrome (TSS) and associated acute kidney injury (AKI) that may have been precipitated or worsened iatrogenically.
Method An experienced band 7 pharmacist attends the daily ward round and refers complex patients to the nominated senior specialist pharmacist. An educational pharmacist ward round takes place twice a week where the band 7 pharmacist will present each patient, proposed pharmaceutical management plan and the patient's care is discussed in an open, non-judgemental forum.
After each discussion an agreed action plan is implemented, further educational needs identified and goals agreed to meet them. A strong component of this ward round is a reflective element with the senior pharmacist encouraging specialist trainees to reflect verbally. Significant event reflections will be documented.
Results The specialist trainee identified that this patient required senior review, and referred the patient up appropriately.
Following independent assessment by the senior specialist, two highly nephrotoxic medicines (gentamicin and furosemide) were discontinued which prevented any further kidney injury and inevitably helped recovery from the already established AKI. The patient only received haemodiafiltration for 48 hrs which could have been prolonged with further nephrotoxicity.
The potential harms of these medicines had not been identified by the specialist trainee pharmacist on the medical ward round. These interventions and discussions resulted in a number of reflections including:
▸ Management of AKI
▸ Use of nephrotoxic medicines in sepsis, TSS and AKI
▸ Assertiveness in multi-disciplinary ward rounds
▸ Communication with senior medical staff
Conclusions There is a place in practice for clinical supervision to continue beyond foundation practice that may be overlooked once specialist training begins. We have demonstrated that patient outcomes benefit from the input of senior specialist pharmacists providing structured supervision to specialist trainees. One of these methods has been described within this case review. Formal studies comparing methods and the impact on patient outcomes and safety are required.
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