Background Clinical pharmacy services provided in hospitals are more and more accepted as an important approach to prevent medicine administration errors and improve patient safety.¹ However, the way pharmaceutical interventions are documented varies from hospital to hospital, and the information is often separated from the patient’s medical record.

Purpose A project was started in 2014 at our hospital as a collaboration between clinical pharmacy and the internal medicine department. To ensure high quality and reproducible documentation and analysis of clinical pharmacy activities, a new tool called ‘pharmaceutical advice’ was directly implemented in the patient’s computerised medical record in SAP, the most widely used software for management of clinical data.

Material and methods Clinical pharmacists at our hospital have access to several documents in a patient’s computerised medical record stored in SAP. A new entry was programmed in the software so that it was now possible for clinical pharmacists to generate their own document called ‘pharmaceutical advice’ to inform physicians of drug related problems (DRPs). This document was available to doctors and nurses electronically. In addition, a hard copy was attached to the respective patient’s temperature chart. Classification of the DRPs and acceptance of the pharmaceutical interventions were reported according to the guidelines2 of the Pharmaceutical Care Network Europe (PCNE) within the same document. Statistics over a selected period of time were performed using a specific search tool.

Results The new patient document was successfully developed by our hospital multidisciplinary team in May 2015. 241 DRPs were documented during the first 4 months of implementation. The most frequently identified groups included drugs for acid related disorders (eg, proton pump inhibitors (29.5%)), followed by antihypertensive drugs (9.1%), antipsychotics/anxiolytics (6.2%) and antidepressants (5.8%). Physicians followed the pharmacist’s recommendation in 59% of cases. Conclusion Overall, the newly created ‘pharmaceutical advice’ was an effective tool to document pharmaceutical interventions within the patient’s clinical data and allowed fast statistical analyses. To our knowledge, this type of documentation is unique in our country and provides a new quality standard in pharmacist intervention.

References and/or Acknowledgements

1. Wunder C, et al. Eur J Hosp Pharm 2013;0:1-5.

2. PCNE The PCNE Classification V 6.2 2010 01, Jan 2010

References and/or AcknowledgementsNo conflict of interest.