Background Hospital pharmacists are expected to play a key role as members of a multidisciplinary therapeutic team, to ascertain the best therapeutic results with respect to limited resources available in all healthcare systems.

Purpose To investigate the extent that medication review takes place in everyday clinical practice, the number and type of proposed interventions, as well as identification of barriers to be overcome, so that seamless care, regarding pharmacotherapy, is assured.

Material and methods Medication review at the prescription and ward level, by hospital pharmacists, was investigated in 2 (general and terminal patient clinics) hospitals located in the same health region, for a period of 3 months. Benchmarking of all implemented procedures was evaluated by weekly questionnaires.

Results In both hospitals, a computerised physician order entry system was available, characterised more by its administrative and less by its clinical value. In both cases, all prescriptions were reviewed by pharmacists, while the average number of medicines/patient was 8. However, the fact that pharmacists do not participate in direct patient care (ward rounds) in combination with limited access to the complete patient record renders medication review time consuming and fragmented. In the general hospital, the absence of any type of feedback, regarding the actual administration at ward level, hinders the intergraded evaluation of pharmacotherapy outcomes. In the case of the end stage patients’ hospital, where an extended length of stay is observed along with a higher ratio of pharmacists per hospital beds (1/50 vs 1/200 for the general hospital), a more complete monitoring of medication use is feasible, as interventions take place before transformation of medical instructions into prescriptions. In both cases, the majority (almost 60%) of the hospital pharmacists’ interventions concern the dosage form, length of drug administration, incompatibilities and interactions, polypharmacy management and substitution with low cost generic formulations.

Conclusion Although medication review should be a high priority, the extent that this happens depends on the initiative/expertise of the hospital pharmacists and the type of institution. Lack of and deficiencies in relevant legislation, infrastructure and collaboration culture are identified as key barriers. Nevertheless, hospital pharmacists are engaged in medicines optimisation, against all odds.

No conflict of interest