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4CPS-214 Implementation of a clinical pharmacist in an internal medicine service of a tertiary referral hospital
  1. A Perez Morales1,
  2. A Nieto Sanchez2,
  3. M Mendez Bailon2,
  4. A Santiago Pérez1,
  5. ML Recio Blazquez1,
  6. I Larrosa Espejo1,
  7. E Roson Sanchez1,
  8. G Hernando Llorente1,
  9. P Pacheco Ramos1,
  10. MI Borrego Hernando1
  1. 1Hospital Clinico San Carlos, Pharmacy, Madrid, Spain
  2. 2Hospital Clinico San Carlos, Internal Medicine, Madrid, Spain


Background The presence of a clinical pharmacist in the medical services has been shown in numerous previous publications as a great additional factor in the quality and safety of pharmacological treatment. In many hospitals there is still no clinical pharmacist, and the implementation process is the critical stage to be overcome so that this professional activity could be consolidated within the multidisciplinary hospital team.

Purpose It was proposed to evaluate the degree of activity achieved by a clinical pharmacist newly implemented in an internal medicine service during the first 2 months from the beginning of its activity.

Material and methods The clinical pharmacist carried out the medication reconciliation (MR) of the patients with polypharmacy who were admitted to the internal medicine service. He also reviewed the patients’ treatments daily and carried out the patients’ MR at discharge. All of the interventions were recorded for an initial period of 2 months, and then analysed.

Results The treatments of 119 patients were analysed. Each patient had an average of 10+6 medications at admission. A total of 145 pharmaceutical interventions were performed, corresponding to 19 different categories. The most common interventions were the absence of patients’ chronic treatment (26.9%), the need for additional treatment during admission (24.1%), the presence of unnecessary medications (17.9%), the need to reintroduce a medication at discharge (5.5%), insufficient doses (4.1%), allergies (4.1%), the need for nutritional evaluation (3.4%), excessive doses (2.8%), intravenous-to-oral switch therapy (2%) and contraindicated medications (1.4%). The major therapeutic groups for which interventions were performed were vitamin and mineral supplements (23.4%), proton pump inhibitors (7.6%), antiplatelet agents (5.5%), beta-blockers (5.5%), haematopoietic growth factors (5.5%), alpha-blockers (4.1%), anticholinergics (3.4%), antidepressants (3.4%), anticonvulsants (2.8%), androgen antagonists (2%) and antiarrhythmics agents (2%).

Conclusion With the presence of a clinical pharmacist, an average of 1.2 interventions were performed for each patient reviewed. Through these interventions, it was possible to optimise the pharmacological treatment, providing the necessary medicines for each patient, adjusting the doses to their requirements and preventing medication-related problems.

References and/or Acknowledgements We thank the anonymous clinical pharmacists, who develop this profession every day.

No conflict of interest

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