Background Taking a complete medical history of patients before hospital admission includes an accurate assessment of the current drug history which provides the basis for appropriate pharmacotherapy during the stay in hospital and at discharge as we know from the literature, this is best performed by a clinical pharmacist.

Purpose To evaluate specific aspects of medicines reconciliation by pharmacists performed as part of the clinical routine.

Material and methods Throughout a 4 week pilot phase, 178 patients were seen by a pharmacist for medicines reconciliation. During an interview, the current medicines were assessed including brand name, administration form and strength, dosing scheme and temporarily discontinued treatment. Moreover, information about patients’ allergies, intolerances and concomitant diseases was collected. After verifying the medicines (check for omissions, duplications, dosing errors or drug interactions), the appropriate medicines were switched to the hospital drug formulary. If drug-related problems were found the attending physician was informed by the clinical pharmacist and possible solutions were discussed. As a follow-up, patients’ medical records were reviewed and physicians’, nurses’ and pharmacists’ feedback on the project was evaluated.

Results Clinical pharmacists performed medicines reconciliation as part of the clinical routine. In the pilot phase, 133 patients were regularly taking medicines and 36 brought a medicines list, however, this list was out-of-date or differed from patients’ statements in many cases. The average total time required per patient was 18 (2–80) min. Frequent discrepancies or medicines errors were associated with fixed combinations, statins, ASA and bridging of anticoagulants. Feedback was generally positive although process optimisation possibilities were identified.

Conclusion Our project has shown the successful integration of a clinical pharmacist in the clinical routine of preadmission. Pharmaceutical interventions were largely accepted by the physicians, (potential) medicines errors and critical drugs could be revealed, and new SOPs will be created. We intend to continue the project.

References and/or acknowledgements No conflict of interest.