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4CPS-194 Clinical impact of a pharmacist-led discharge medication review service: an analysis of prevalence and acceptance of interventions
  1. I Breitschopf1,
  2. P Bundeli1,
  3. AE Weidmann2
  1. 1Hirslanden Salem-Spital, Pharmacy Department, Bern, Switzerland
  2. 2University of Innsbruck, Faculty of Chemistry and Pharmacy, Innsbruck, Austria


Background and importance Hospital discharge is linked to an increase in the risk of drug-related problems (DRPs). If these are not recognised and solved, they could be carried over to primary care, with the risk of insufficient follow-up resulting in potential harm to the patient.

Aim and objectives To evaluate a pharmacist-led discharge medication review service by analysing identified DRPs and the acceptance rate of suggested pharmacists’ interventions (PIs) in addition to assessing the clinical significance of these findings.

Material and methods A two-phased mixed method study: (1) retrospective descriptive analyses of the number and type of identified DRPs and recommended interventions based on a validated classification system1; (2) independent expert panel rating (2 physicians, 1 clinical pharmacist, 1 registered nurse) of the potential clinical impact of a cross section of PIs using the validated rating system CLEOde.2 The overall agreement was determined by the Kendall coefficient of concordance.

Results A total of 291 identified DRPs in 205 patients were analysed: the most common included ‘drug interaction’ (34%; n = 99), ‘error in medication process’ (8.2%; n = 24) and ‘duplication’ (8.2%; n = 24). The interventions most frequently suggested were ‘optimisation of administration/route’ (19.6%; n = 57), ‘therapy stopped’ (16.2%; n = 47) and ‘dose adjustment’ (15.8%; n =46). Physicians accepted 69% (n = 74) of the pharmacists’ recommendations. 64% (n = 38) of the interventions presented to the panel were considered to have a clinical impact. Overall agreement between raters for the clinical impact of PIs was substantial (Kendall W 0.734; p<0.001).

Conclusion and relevance The expert panel’s independent assessment showed that the pharmacist-led discharge service is clinically beneficial for patients. The prevalence of analysed DRPs and the physicians’ high acceptance rate highlight the valuable role of pharmacists in improving patient safety at the time of discharge.

References and/or acknowledgements 1. Maes KA, et al. Int J Clin Pract 2017;23(6):1425–1432.

2. Stämpfli D, et al. Int J Clin Pharm 2019;41(1):56–64.

Conflict of interest No conflict of interest

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