Background There is strong evidence supporting that pharmacist involvement strengthens quality of the medication process. There is also evidence indicating that many emergency admissions among the older are medicine related. Hillerød Hospital is chosen to perform an implementation study of front-line-clinical pharmacy in an Emergency Department. Hillerød Hospital is a mid-size teaching hospital in the capitol region of Denmark. Purpose The purpose of the study is to investigate how front-line clinical pharmacy can be implemented in a Danish Emergency Department. Materials and methods The implementation study is designed as an action-research project using ‘Model for Improvement’ as the driver methodology. The task is to implement pharmacist driven medication reconciliation and medication review at admission of patients over 50 years of age receiving more than five prescribed drugs. The pharmacists produce an updated medication status before physicians see the patient. The pharmacists document problem-oriented findings and recommendations in the patient record and inform clinicians directly in urgent cases. The evaluation of implementation will be based on; audits of 10 patient records every fortnight to monitor the implementation of pharmacists' recommendations, sequential analysis of recommendations (sample; recommendations made in 14 days recorded every 3 months), qualitative analysis of pharmacist records and finally merging of all PlanDoStudyAct supporting the implementation process. Results The pharmacists have adjusted known models for medication reconciliation and medication review to the acute care setting. Up to 90% of pharmacists' recommendations are included in clinicians' management plan for their patients. On average the pharmacists find 1.3 drug related problems per medication review. The implementation process is continuously supported by PlanDoStudyAct's and input from the ongoing qualitative analysis. Conclusions A close collaboration between pharmacy managers and clinicians has formed a successful basis for coordinating and evaluating the task.

Background ‘Pharmacists in the Emergency Department’ is a two-year implementation project carried out in collaboration between the pharmacy of Capital Region and the Emergency Department (ED) at Hillerød hospital. The task of the pharmacist is to draw up a current and valid medicines history and to make a medicines review before the physician sees the patient at the ED. During the first year of the project the interventions developed gradually while the professional skills and clinical experience of the pharmacists built up. Purpose To describe the evolution of the interventions recommended when Drug Related Problems (DRPs) are identified, as described in the pharmacist’s notes. Materials and Methods 5 samples of pharmacist’s notes were recorded. The samples represent the interventions made in the 2 first weeks of each quarter of 2011 and the first quarter of 2012. This showed the development in interventions made by pharmacists. The interventions were coded based on 8 categories of DRP introduced by Hepler and Strand. In total 383 pharmacist’s notes were analysed. ResultsIn all 549 DRPs were identified. 70–80% of the pharmacist’s notes contained one or more DRP. On average 1.4 DRPs were identified per note. During the first 15 months of the project the DRPs recorded evolved as follows: The number of comments tended to increase in the categories “inappropriate choice of drug”, “overdose”, “adverse drug events” and “medicine without reasonable indication”. The number of comments identified in the category “interactions” decreased. The categories “untreated indication”, “subtherapeutic dosing” and “inappropriate use by the patient” were stable throughout the study period. Conclusions When introducing a new pharmaceutical service one must expect a gradual evolution of the interventions as the pharmacist gradually develops hands-on-competencies and clinical experience on the particular ward. After 12 months, the findings in the pharmacist notes were stable. This must be taken into account when introducing new pharmaceutical services in the clinic. No conflict of interest.

Background Safety and quality of patient medication upon hospitalisation has been in focus at Amager Hospital, Denmark during 2009 and 2010. Pharmacists working at the hospital were engaged to perform systematic medication reconciliation and medication review upon hospitalisation. Purpose Increase the focus of the medication process at Amager Hospital and hereby ensure the quality of the medical treatment of patients. Pharmacists help reduce discrepancies in medical records and ensure quality of medical treatment by obtaining and reviewing information about the medication from medical records, Electronic Patient Medication list (EPM), the general practitioner, inhome care provider and the patient. Materials and methods Most patients are admitted to the hospital via the emergency room. The ward experiences a great patient flow, therefore pharmaceutical resources were allocated here. Hence, pharmaceutical interventions were more likely to benefit the majority of hospital patients. Pharmaceutical interventions were communicated in the medical record and included discrepancies between the medical records upon hospitalisation, rational pharmacotherapy and optimising the use of EPM. Furthermore, pharmacists were delegated limited prescribing rights, hence implementing specific interventions independently. Results The pharmacists reviewed medical records from 616 patients during 2009 and 2010. Comparing medical records and EPM the pharmacists found 557 discrepancies, equivalent to 0.9 discrepancies per patient. By medication reconciliation 929 pharmaceutical interventions were recommended, equivalent to 1,5 interventions per patient. The interventions lead to 624 (67%) changes in the medical records, implemented by the pharmacists or the physicians. Conclusions Safety and quality of the hospital medication was increased by pharmaceutical expertise and interventions, by revealing discrepancies within patient medication upon hospitalisation.