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5PSQ-128 Clinical interventions in the area of inpatient prescriptions performed by a hospital pharmacy resident
  1. R Serrano Gimenez,
  2. I Castañeda Macias,
  3. M Florido Francisco,
  4. I García Giménez
  1. Juan Ramon Jimenez University Hospital, Hospital Pharmacy, Huelva, Spain


Background and importance Pharmaceutical validation of inpatient treatments is a fundamental activity in the clinical practice of the hospital pharmacist. Thanks to this, many prescription errors are detected, promoting patient safety.

Aim and objectives To describe the interventions performed by a hospital pharmacy resident in the area of pharmaceutical validation, supervised by consultant pharmacists, and to evaluate their degree of acceptance.

Material and methods Prospective interventional study conducted during September 2021. Adult inpatients, whose hospital treatment was reviewed, were included. Demographic (sex and age), clinical (clinical judgement (CJ) and inpatient clinical service) and pharmacotherapeutic (number of chronic medicines and polymedication (≥6 drugs)) variables were collected. Interventions were reported to the clinician via electronic prescribing software. They were classified as: Activity (reconciliation on admission/information to the clinician), Adequacy (detection of prescribing error/therapy reconciliation error), Change (therapeutic exchange), Initiation (usual treatment not prescribed/need for additional treatment), Modification Dosage Form (DF) or Posology, Suspension (duplicity/unnecessary medication/allergy). Patient lists and data were collected through medical records and electronic prescribing software, and processed using Excel 2020.

Results Interventions were performed in 56 patients. 63.2% male; median age 73 years (IQR 61–80). The most frequent CJ were: heart failure (10.7%), COVID-19 (7.1%), liver dysfunction (7.1%). Services with most interventions: Internal Medicine (25.8%), General/Vascular Surgery (19.4%), Digestive (11.3%). Median number of chronic medicines: 8 (IQR 5–12). Polymedication in 71.4%. 62 interventions were performed (12.9% were ‘not evaluable’, reasons: discharge/death). Of the evaluable interventions, 77.8% were accepted. The percentages were: duplicity (30.9%), modification DF/posology (23.8%), usual treatment not prescribed (7.1%), therapeutic exchange (7.1%), discontinue medication due to allergy (7.1%), therapy reconciliation error (4.8%), reconciliation on admission (4.8%), information (4.8%), additional treatment (4.8%), prescribing error (2.4%), unnecessary medication (2.4%). Of the accepted interventions, 11.9% were related to high-risk medicines according to the Institute for the Safe Use of Medicines1–2 (nonsteroidal anti-inflammatory drugs (NSAIDs), beta-blockers, heparin, immunosuppressants). Of the not-accepted interventions, 50.0% corresponded to errors in home treatment reconciliation.

Conclusion and relevance The data obtained demonstrate that clinical interventions performed by the hospital pharmacy resident have a high degree of acceptance, increasing the quality and safety of healthcare and avoiding medication errors.

References and/or acknowledgements 1. High-risk medicines in hospitals. ISMP, 2012.

2. High-risk medicines in chronically ill patients. ISMP, 2014.

Conflict of interest No conflict of interest

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