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Clinical pharmacy and clinical trials (including case series)
Pharmaceutical interventions in hospital practice- care of the polypharmacy-patient upon hospitalisation
  1. L. Jarvig,
  2. K.W. Fjære,
  3. L.G. Gammelgaard
  1. 1The Capital Region of Denmark Hospital Pharmacy, Clinical Pharmaceutical Services, Copenhagen, Denmark


Background Safety and quality of patient medication upon hospitalisation has been in focus at Amager Hospital, Denmark during 2009 and 2010. Pharmacists working at the hospital were engaged to perform systematic medication reconciliation and medication review upon hospitalisation.

Purpose Increase the focus of the medication process at Amager Hospital and hereby ensure the quality of the medical treatment of patients. Pharmacists help reduce discrepancies in medical records and ensure quality of medical treatment by obtaining and reviewing information about the medication from medical records, Electronic Patient Medication list (EPM), the general practitioner, inhome care provider and the patient.

Materials and methods Most patients are admitted to the hospital via the emergency room. The ward experiences a great patient flow, therefore pharmaceutical resources were allocated here. Hence, pharmaceutical interventions were more likely to benefit the majority of hospital patients.

Pharmaceutical interventions were communicated in the medical record and included discrepancies between the medical records upon hospitalisation, rational pharmacotherapy and optimising the use of EPM. Furthermore, pharmacists were delegated limited prescribing rights, hence implementing specific interventions independently.

Results The pharmacists reviewed medical records from 616 patients during 2009 and 2010. Comparing medical records and EPM the pharmacists found 557 discrepancies, equivalent to 0.9 discrepancies per patient. By medication reconciliation 929 pharmaceutical interventions were recommended, equivalent to 1,5 interventions per patient. The interventions lead to 624 (67%) changes in the medical records, implemented by the pharmacists or the physicians.

Conclusions Safety and quality of the hospital medication was increased by pharmaceutical expertise and interventions, by revealing discrepancies within patient medication upon hospitalisation.

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