title: Evaluation of pharmacist clinical interventions in a Dutch hospital setting.
abstract: OBJECTIVE
  Assessing the relevance of a clinically active pharmacist method compared to the traditional working method.
  
  
  METHODS
  The study was carried out in a general internal/gastro-enterology unit during two 8-weeks periods in 2004. It was an observational, non-randomized prospective study. Outcome measures were compared before and during the intervention. The intervention was the active presence of a junior hospital pharmacist on the unit. The pharmacist focused on the pharmacotherapy of the individual patient. Patients were included when they used 5 or more medicines on day 1 or 2 of their stay at the ward and/or used at least 1 high-risk drug. Clinical pharmacist interventions were counted and classified. A hospital pharmacist and an internal medicine specialist assessed the clinical relevance of all clinical pharmacist interventions retrospectively. The degree of acceptance of the interventions by physicians was measured. Finally, time associated with the clinical activities was measured.
  
  
  METHODS
  Number of interventions (related to number of medication orders), clinical relevance and degree of acceptance.
  
  
  RESULTS
  In the pre-intervention period 79 patients were included versus 84 in the during-intervention period. About 82 interventions in the pre-intervention period were made compared to 173 during the during-intervention period. There was little agreement between the professional raters (weighted kappa(A-E)=0.30 and weighted kappa(1-5)=0.20). Nevertheless both ratings showed a substantial increase of clinically relevant interventions. The number of interventions accepted by the physician increased from 16 in the pre-intervention period to 75 in the during-intervention period. Working with this method took over 4 h a day.
  
  
  CONCLUSIONS
  Clinical pharmacy services provided by a junior hospital pharmacist on an internal medicine ward contribute to rationalization of drug therapy and are therefore likely to increase medication safety.
authors.affiliation: Hospital Pharmacy, Isala Klinieken, Zwolle, The Netherlands. b.bosma@ahz.nl
authors.forename: Liesbeth
authors.initials: L
authors.lastname: Bosma
authors.forename: Frank G A
authors.initials: FG
authors.lastname: Jansman
authors.forename: Anton M
authors.initials: AM
authors.lastname: Franken
authors.forename: Johannes W
authors.initials: JW
authors.lastname: Harting
authors.forename: Patricia M L A
authors.initials: PM
authors.lastname: Van den Bemt
mesh_terms: D000368:Aged; D005260:Female; D006757:Hospital Units; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D009426:Netherlands; D010348:Patient Care Team; D010595:Pharmacists; D010607:Pharmacy Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D024382:Professional Role; D011446:Prospective Studies