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Clinical pharmacist service in the acute ward

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Background The majority of hospitalised patients have drug-related problems. Clinical pharmacist services including medication history, medication reconciliation and medication review may reduce the number of drug-related problems. Acute and emergency hospital services have changed considerably during the past decade in Denmark, and the new fast-paced workflows pose new challenges for the provision of clinical pharmacist service. Objective To describe and evaluate a method for a clinical pharmacist service that is relevant and fit the workflow of the medical care in the acute ward. Setting Acute wards at three Danish hospitals. Methods The clinical pharmacist intervention comprised medication history, medication reconciliation, medication review, medical record entries and entry of prescription templates into the electronic medication module. Drug-related problems were categorised using The PCNE Classification V6.2. Inter-rater agreement analysis was used to validate the tool. Acceptance rates were measured as the physicians’ approval of prescription templates and according to outcome in the PCNE classification. Main outcome measure Acceptance rate of the clinical pharmacists’ interventions through the described method and inter-rater agreement using the PCNE classification for drug-related problems. Results During 17 months, 188 patients were included in this study (average age 72 years and 55 % women). The clinical pharmacists found drug-related problems in 85 % of the patients. In the 1,724 prescriptions, 538 drug-related problems were identified. The overall acceptance rate by the physicians for the proposed interventions was 76 % (95 % CI 74–78 %). There was a substantial inter-rater agreement when using the PCNE classification system. Conclusion The methods for a clinical pharmacist service in the acute ward in this study have been demonstrated to be relevant and timely. The method received a high acceptance rate, regardless of no need for oral communication, and a substantial inter-rater agreement when classifying the drug-related problems.

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We would like to thank the three wards in Region Zealand who participated in this study. A special thanks to Mie Dyrholm and Karen Søgaard for performing the clinical pharmacist service in the study period. Thank you to the management for support and to the colleagues who have been involved in the study period at Region Zealand Hospital Pharmacy.


This study was funded by Sygehusapotekernes og Amgros’ Forsknings- og Udviklingspulje, Region Sjællands Sundhedsvidenskabelige Forskningsfond, Region Sjælland Sygehusapoteket and Helsefonden.

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Correspondence to Trine Rune Høgh Nielsen.


Appendix 1: Procedure for the clinical pharmacist service in the acute ward

Workflow acute ward

Clinical pharmacist task


Patient is admitted to the acute ward


Inclusion criteria:

Age ≥18

Drugs ≥4 (incl. OTCs and supplements)

Able to give consent in Danish

Not in palliative or terminal care

Patient is evaluated by triage nurse

Assess patient

Proceed if patient can wait more than 15 min. for a physician

Patient is allocated a bed, changes clothes and is interviewed by nurse

Compile preliminary medication list

Check relevant sources for information on medications, if present:

Previous medical records

Referral papers

Home care or nursing home notes, or personal medication lists

Patient has EKG taken and blood drawn

Patient interview

Medication history: (see details below)

Explain purpose of the interview

Obtain POD if present

Comprise medication history using the POD and/or preliminary medication list as interview guide

Ask if the patient has drug-related questions for the clinical pharmacist.

Patient waits for physician (time dependent on triage)

Patient is interviewed by physician

Medication review

Medication reconciliation:

Compare obtained medication list to the prescriptions in EMM

Obtain further information from pharmacy dispensing records or GP if needed

Patient is examined by physician


Medication review: (see details below)

Verify if dosage, duration, indications, contraindications are within recommendations (SPC or treatment guidelines)

Check for interactions (SPC or online interaction tool)

Check for more cost-effective drug (hospitals formulary)



Enter clinical pharmacist’s note in medical record with headings:

Secondary medication history

Summary of patient interview (compliance, ADR, DRP found)

Proposed drug interventions

Interactions and/or allergies

Physician dictates entry to medical record

Prescription templates

Enter allergy status templates and prescription templates for the patients medication including proposed interventions into the EMM

Physician writes admission orders and approves or dismisses prescription templates


Patient is transferred to specialised ward

  1. OTC over-the-counter drugs, POD patient’s own drugs, EMM electronic medication module, GP general practitioner, SPC summary of product characteristics, ADR adverse drug reaction, DRP drug related problem

Medication history

  • Compile medication history using the PODs and/or preliminary medication list as interview guide

  • Ask specifically for OTCs such as; pain-, allergy- or alimentary preparations.

  • Ask specifically for herbal- and dietary supplements

  • Ask specifically for non-oral medications, such as; inhalation-, ophthalmic-, dermatologic-, nasal-, sublingual-, or rectal preparations

  • Ask for the patient’s perceived effect of the medication

  • Ask about compliance and adverse drug reactions

  • Ask about known allergies or alerts, such as; antibiotics, opiates, NSAIDs, iodide, food dyes

  • Also ask relatives or caregivers if they are present, especially if patient has aphasia, dyspnoea or otherwise cannot participate well in the interview

Medication review

  • Check that medication prescribed is indicated and not contra-indicated (SPC)

  • Check for untreated indications or missing prophylaxis medications (treatment guidelines)

  • Check that the medication is effective for patient (interview)

  • Check that dosing and dosing intervals are within recommendations (SPC)

  • Check for cost-effectiveness (formulary and guidelines)

  • Check for clinical relevant drug–drug interactions with good documentation (SPC or online interaction tool)

  • Check for side effects, compliance or concordance problems (interview)

  • Check that relevant monitoring is planned (e.g. blood work, blood pressure, blood glucose)

  • Check for prescription errors especially in high alert medications such as; antibiotics, antidepressants, antipsychotics, antithrombotics and coagulation inhibitors, benzodiazepines, cytostatics, diuretics, insulin, NSAIDs, strong opioids (EMM)

(Reference tools in brackets)

Appendix 2

See Table 6.

Table 6 Adapted and translated version of the PCNE classification for drug-related problems

Appendix 3

See Table 7.

Table 7 Distribution of the drug-related problems on PCNE Classification codes

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Nielsen, T.R.H., Andersen, S.E., Rasmussen, M. et al. Clinical pharmacist service in the acute ward. Int J Clin Pharm 35, 1137–1151 (2013).

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