Clinical pharmacy and pharmaceutical care in hospitalized patients: reconciliation, drug therapy review, ward rounds
This domain tests the operational core of ward pharmacy: can you build a reliable medication history, spot the discrepancies that matter, and convert a drug therapy review into a recommendation a prescriber accepts?
Medication reconciliation
Take the best possible medication history (BPMH) from at least two independent sources - structured patient interview, community pharmacy dispensing record, GP letter, blister packs, eMediplan. Classify every difference as an intentional change (documented reason) or an unintentional discrepancy (to be corrected). Reconcile at all three transitions: admission, internal transfer, discharge. The discharge document is a new prescription, not a copy of the admission list.
Structured drug therapy review
Work through a fixed sequence so nothing is skipped: indication present? effective at the chosen dose? safe given renal/hepatic function, interactions, duplication, age? adherence and handling feasible? any untreated indication (vaccination, VTE prophylaxis, statin, laxative under opioids, calcium/vitamin D)? Prioritise by risk: polypharmacy, renal impairment, anticoagulation, opioids, antibiotics, high-alert drugs, paediatrics.
Ward rounds
Prepare the night before: current labs, renal function trend, microbiology, drug levels, outstanding issues. Speak in recommendations, not questions - "I suggest reducing to 500 mg twice daily, creatinine clearance is 28 mL/min" - and record interventions (accepted/not accepted, reason) so that impact can be measured.
Worked example
An 84-year-old admitted after a fall takes 11 drugs. Creatinine 130 µmol/L, weight 52 kg → Cockcroft-Gault ≈ 24 mL/min. Findings: metformin 1000 mg twice daily (stop, eGFR too low), apixaban 5 mg twice daily with age ≥80 and weight ≤60 kg (dose reduction to 2.5 mg twice daily indicated), zolpidem at bedtime (falls risk, taper), no laxative despite oxycodone (add), no vitamin D (add). Two unintentional omissions found: statin and bisphosphonate dropped by the emergency department.
Traps
- Producing a tidy list instead of a reconciliation: the mark is for discrepancies found and resolved.
- Forgetting OTC products, herbals and eye drops.
- Missing the "untreated indication" arm of the review.
- Estimating renal function with CKD-EPI when the drug label specifies Cockcroft-Gault.
- Not documenting the intervention - unrecorded clinical pharmacy work cannot be defended or billed.