Abstract
For the majority of Belgian hospitals, a pharmacist-led full medication review process is not standard care and, therefore, challenging to introduce. With this study, we aimed to evaluate the successes and barriers of the implementation of a pharmacist-led full medication review process in the geriatric ward at a local Belgian hospital. To this end, we carried out an interventional study, performing a full medication review on older patients (≥70 years) with polypharmacy (≥5 drugs) who had an unplanned admission to the geriatric ward. The process consisted of 3 steps: (1) medication reconciliation upon admission; (2) medication review using an explicit reviewing tool (STOPP/START criteria or GheOP3S tool), followed by a discussion between the pharmacist and the geriatrician; and (3) medication reconciliation upon discharge. Ethical approval was obtained from the Ethical Commission of the Ghent University Hospital. Outcomes included objective data on the interventions (e.g., number of drug discrepancies; number of potentially inappropriate prescriptions (PIP)); as well as subjective experiences (e.g., satisfaction with service; opinion on inter-professional communication). There was a special focus on communication aspects within the introduction of this process. In total, 52 patients were included in the study, taking a median of 10 drugs (IQR 8–12). Upon admission, 122 drug discrepancies were detected. During medication review, 254 PIPs were detected and discussed, leading to an improvement in the appropriateness of medication use. The satisfaction of community pharmacists concerning additional communication and the satisfaction of the patients after counselling at discharge were positive. However, several barriers were encountered, such as the time-consuming process to gather necessary information from different sources, the non-continuity of the service due to the lack of trained personnel or the lack of safe, electronic platforms to share information. The communicative and non-communicative successes and hurdles encountered during this project need to be addressed in order to improve the full medication review process and to strengthen the role of the clinical pharmacist.
Highlights
Transitions of care are defined as the movement of a patient from one healthcare provider or setting to another [1]
The communicative and non-communicative successes and hurdles encountered during this project need to be addressed in order to improve the full medication review process and to strengthen the role of the clinical pharmacist
The introduction of clinical pharmacy should be considered in every hospital as this has a significant impact on patient safety and patient care
Summary
Transitions of care are defined as the movement of a patient from one healthcare provider or setting to another [1]. Pharmacy 2018, 6, 21 communication between the different care providers [1,2]. A lack of communication between caregivers during these transfers of care has been shown to be linked to poor patient outcome [3] as well as to medication errors [4]. The process of medication reconciliation guarantees that the medicines the patient should be prescribed match those that are prescribed. By performing reconciliation at each transfer of care, a comprehensive medication list is continuously available and adapted to the current clinical situation [4,5,6,7,8,9]. The comprehensive medication list is important to reduce the risk of medication errors and serves as the starting point for medication review [5]
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