Sample procedures

The sample included all adults over 18 years old admitted to the medical wards during the study period: Internal Medicine, Gastroenterology, Geriatrics, Neurology, Pneumology. Cardiology, Oncology and Haematology were excluded due to the presence of transplanted patients and special characteristics in relation to pharmacotherapy.

The study consisted of the assessment of activities and interventions made and registered in regular clinical pharmacy practice. Briefly, three pharmacists performed regular pharmaceutical care activities following their standard workflow (Fig. 1). Firstly, they assessed specific aspects regarding pharmacotherapy at the time of admission and subsequent changes in prescription, including a wide range of activities (i.e. medication reconciliation, allergy check, indication, posology) (Appendix 1). Secondly, certain patients were selected for daily follow-up based on pre-specified criteria (i.e. pharmacokinetics monitoring, risk of adverse effects, potential interaction, renal impairment) or any other clinical criteria (Appendix 1). Additionally, pharmacists received queries raised by physicians, nurses, caregivers or patients. All these activities resulted in specific pharmaceutical interventions.

Pharmaceutical care workflow diagram.

All patients assessed throughout the aforementioned steps were registered in the pharmacy work database, as part of their standard practice, including selected variables. Pharmaceutical interventions were also registered for those patients with detected DRP.