• Trine Rune Høgh Nielsen, Stig Ejdrup Andersen, Mette Rasmussen, and Per Hartvig Honoré.
• Region Zealand Hospital Pharmacy, Næstved Hospital, Ringstedgade 65, 4700, Næstved, Denmark, trn@regionsjaelland.dk.
• Int J Clin Pharm. 2013 Dec 1; 35 (6): 1137-51.

BackgroundThe 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.ObjectiveTo 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.SettingAcute wards at three Danish hospitals.MethodsThe 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 MeasureAcceptance rate of the clinical pharmacists' interventions through the described method and inter-rater agreement using the PCNE classification for drug-related problems.ResultsDuring 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.ConclusionThe 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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