Background Medication errors are common when transferring medication records between health care professionals in secondary and primary care. This can lead to suboptimal pharmacotherapy and decreased quality of health care. At our hospital pharmaceutical medication review has been successfully implemented at hospital admission on the acute ward to ensure rational pharmacotherapy.

Purpose To ensure rational pharmacotherapy and accurate medication status at hospital discharge, a clinical pharmacist supports the medical staff by conducting medication review and improves transfer of relevant discharge information to primary care.

Materials and Methods The study took place at a general medical ward at Lillebaelt Hospital, Vejle. A clinical pharmacist conducted systematic medication review according to rational pharmacotherapy for discharge patients treated with at least six medicines. In addition the clinical pharmacist conducted medication reconciliation and verified the plan for further medical treatment in the discharge information to primary care emphasising the changes in medication made during hospital stay.

Results From February to September 2012, 326 medication records (with a total of 3973 medicines) were reviewed by the pharmacist. 730 clinical interventions were suggested to the medical staff with a top-3 of; 1. Duration of medical treatment, 2. Inappropriate dosing and 3. Supplemental medicine treatment. 85% of all interventions were accepted and led to medical changes, but nevertheless, for 32% of the patients, the pharmacist still had supplementary or altered information to the discharge plan.

Conclusions Our results indicate that pharmaceutical intervention contributes to appropriate medication use and more accurate discharge information. This on-going quality initiative can ensure the use of rational pharmacotherapy and thereby increase the quality of health care.

Acknowledgement The study was financially supported by ‘Amgros og Sygehusapotekernes forsknings- og udviklingsfond’ and ‘Udviklingsrådet Hospital Lillebaelt’.

No conflict of interest.