Background: Interprofessional collaboration between physicians and clinical pharmacists has become very useful with the growing complexity of patient care during hospital stay. This synergy can be mediated by various types of interactions aimed at optimizing the quality of care through medication safety and ensuring the appropriateness of prescriptions.
Objective: To describe the current pharmaceutical services provided by clinical pharmacists in the internal medicine department of a regional hospital (120 beds).
Method: A qualitative description of the current activities involving physicians and clinical pharmacists in January 2024 was made from the activity records of the hospital pharmacy.
Results: Clinical pharmacists provide the following activities: Medical rounds and medication review: Clinical pharmacists participate in medical rounds twice a week. Patients’ treatments are critically reviewed and suggestions for drug therapy management are transmitted to the physician. Medication review is additionally performed twice a month and discussed between the pharmacist and each training physician.
Pharmaceutical hotline: a clinical pharmacist can be reached during working hours for any questions relating to drugs (dosage, interactions, side effects, administration, alternatives). Medication reconciliation at discharge: all patients taking ≥7 drugs are identified on the day before discharge through the clinical information system. A clinical pharmacist carries out therapeutic reconciliation when appropriate. Modifications of treatments or dosage are highlighted in the discharge documents. Education on drug-related topics: short formal teachings are given to physicians every two weeks. Various topics issued from clinical visits or questions from the hotline are presented. Clinical decision support system: Pharmaclass® detects patients at risk of iatrogenic events related to the use of a drug. The algorithm considers drugs prescribed, vital parameters, laboratory values and patient characteristics. Clinical pharmacists receive alerts and decide depending on the clinical context if the physician needs to be informed. After a 3-month pilot phase in 2023, the activity will be effective mid-2024.
Conclusion: Several activities are now implemented in our hospital involving close collaboration between physicians and clinical pharmacists. The aim is to promote a rational use of drugs and contribute to quality of care during hospital stay and at discharge.