Background In February 2017, a clinical pharmacy service (CPS) team based on the ward was implemented at the internal medicine service in a first-level Portuguese hospital with several objectives: to identify, solve and prevent the occurrence of therapeutic problems, to guarantee the rational use of medicines, to reduce hospital stay and improve treatment adherence to ensure medicines optimisation along with a multidisciplinary team.
Purpose To identify the actions and results obtained after the implementation of a CPS at the internal medicine service in a first-level hospital in Portugal.
Material and methods Retrospective and descriptive study carried out for 8 months (February to September 2017). Patients’ data were compiled and analysed in Microsoft Excel. Patients’ age, sex and provenance (home/hospice) were recorded. All the CPS interventions, the degree of acceptance by the medical team and main drugs involved were also recorded.
Results CPS vetted remotely on the electronic prescription system 14 955 prescriptions with 902 alerts sent to the prescribers. One hundred and ninety-six active interventions (discussed on the ward) were performed in 163 patients, of whom 79 were males (48.47%). The mean age was 76.61 years. The majority of them (123) (75.46%) lived at home at the moment of hospital admission. A total of 121 interventions (61.73%) were accepted. The top drugs involved were paracetamol with 48 interventions (24.49%), enoxaparin with 29 (14.8%) and vancomycin with 20 (10.2%). The switch from endovenous to the oral route, inappropriate dose according to patient renal function and medicines’ reconciliation were the most frequent type with 61, 29 and 20 interventions (31.12%, 14.8% and 10.2%, respectively).
Conclusion The CPS identified and intervened in a large number of inadequate/incomplete prescriptions in the internal medicine service. As a challenge it is expected that an extension to other clinical services will benefit from the activity of the clinical pharmacy team.
References and/or Acknowledgements Thanks to all the great multidisciplinary internal medicine and pharmacy services teams
No conflict of interest
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