Admission to a specialist HAU was associated with a significant reduction in PIMS. Very few patients discharged with a PIM had a documented follow-up plan. PIM prevalence was lower than published rates found internationally. Similar studies in settings of varying types across the UK are needed.

In recent years a number of countries have extended prescribing rights to pharmacists in a variety of formats. The latter includes independent prescribing, which is a developing area of practice for pharmacists in secondary care. Potential opportunities presented by wide scale implementation of pharmacist prescribing in secondary care include improved prescribing safety, more efficient pharmacist medication reviews, increased scope of practice with greater pharmacist integration into acute patient care pathways and enhanced professional or job satisfaction. However, notable challenges remain and these need to be acknowledged and addressed if a pharmacist prescribing is to develop sufficiently within developing healthcare systems. These barriers can be broadly categorised as lack of support (financial and time resources), medical staff acceptance and the pharmacy profession itself (adoption, implementation strategy, research resources, second pharmacist clinical check). Larger multicentre studies that investigate the contribution of hospital-based pharmacist prescribers to medicines optimisation and patient-related outcomes are still needed. Furthermore, a strategic approach from the pharmacy profession and leadership is required to ensure that pharmacist prescribers are fully integrated into future healthcare service and workforce strategies.

Background Several clinical pharmacy activities are common to UK hospitals. It is not clear whether these are provided at similar levels, and whether they take similar amounts of time to carry out. Objective To quantify and compare clinical pharmacist ward activities between different UK hospitals. Setting Seven acute hospitals in the Greater London area (UK). Methods A list of common ward activities was developed. On five consecutive days, pharmacists visiting hospital wards documented total time spent and how many of each activity they undertook. Results were analysed by hospital. The range and number of activities per 100 occupied bed days, and per 24 beds were compared. Main outcome measure Time spent on wards and numbers of each activity undertaken. Results Pharmacists logged a total of 2291 h carrying out 40,000 activities. 4250 changes to prescriptions were made or recommended. 5901 individual medication orders were annotated for clarity or safety. For every 24 beds visited, mean time spent was 230 min-seeing 6.2 new patients, carrying out 3.9 calculations and 1.3 patient consultations, checking and authorising 1.8 discharge prescriptions, and providing staff with information twice. Other activities varied significantly, not all could be explained by differences in hospital specialties or Information Technology systems. Conclusion This is the first detailed comparison of clinical pharmacy ward activities between different hospitals. There are some typical levels of activities carried out. Wide variations in other activities could not always be explained. Despite a large number of contacts, pharmacists reported very few consultation sessions with patients.

Objectives: The role of clinical pharmacists in hospitals has evolved and continues to expand.In the UK, outside a few national policy drivers, there are no agreed priorities, measures or defined outcomes for hospital clinical pharmacy (CP). This paper aims to 1) highlight the need to identify and prioritise specific clinical pharmacy roles, responsibilities and practices that will bring the greatest benefit to patients and health-systems and 2) describe systemic weaknesses in current research methodologies for evaluating clinical pharmacy services and propose a different approach Method: Published reviews of CP services are discussed using the economic, clinical and humanistic outcomes (ECHO) framework. Recurring themes regarding study methodologies, measurements and outcomes are used to highlight current weaknesses in studies evaluating CP.Results: Published studies aiming to demonstrate the economic, clinical or humanistic outcomes of clinical pharmacy often suffer from poor research design and inconsistencies in interventions, measurements and outcomes. This has caused difficulties in drawing meaningful conclusions regarding clinical pharmacy's definitive contribution to patient outcomes.Conclusion: There is a need for more research work in NHS hospitals, employing a different paradigm to address some of the weaknesses of existing research on clinical pharmacy practice. We propose a mixed-methods approach, including qualitative research designs, and with emphasis on cost-consequence analyses for economic evaluations. This approach will provide more meaningful data to inform policy and demonstrate the contribution of hospital clinical pharmacy activities to patient care and the NHS. 4 Key MessagesWhat is already known on this subject• Clinical Pharmacy is a diverse, complex discipline and clinical pharmacy activities are not easily defined or described • It is important to robustly show the benefits of clinical pharmacy, in order to justify resource use and to prioritise and measure activities • Studies purporting to demonstrate the outcomes of clinical pharmacy activities are often criticized due to methodological flaws, poor intervention descriptions and weak conclusionsWhat this study adds• The current positivist mindset is weakening the case for clinical pharmacy. There is a need for a new research approach for studying and evaluating clinical pharmacy interventions • Mixed-methods studies, incorporating quantitative and qualitative methodologies are more appropriate for evaluating the outcomes of clinical pharmacy • Cost-consequence analyses are more suitable for evaluating the economic outcomes of clinical pharmacy 5

Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists’ medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routinely write discharge medication orders as part of the clinical pharmacy service. Convenient days, based on researcher availability, between October 2013 and January 2014 were selected. Pre-registration pharmacists reviewed all discharge medication orders written by pharmacists on these days and identified discrepancies between the medication history, inpatient chart, patient records and discharge summary. A senior clinical pharmacist confirmed the presence of an error. Each error was assigned a potential clinical significance rating (based on the NCCMERP scale) by a physician and an independent senior clinical pharmacist, working separately. Main outcome measure Incidence of errors in pharmacist-written discharge medication orders. Results 509 prescriptions, written by 51 pharmacists, containing 4258 discharge medication orders were assessed (8.4 orders per prescription). Ten prescriptions (2%), contained a total of ten erroneous orders (order error rate—0.2%). The pharmacist considered that one error had the potential to cause temporary harm (0.02% of all orders). The physician did not rate any of the errors with the potential to cause harm. Conclusion The incidence of errors in pharmacists’ discharge medication orders was low. The quality, safety and policy implications of pharmacists routinely writing discharge medication orders should be further explored.

ObjectiveTo describe the cost–benefits of pharmacy-led medicines reconciliation (MR) on admission by applying a theoretical model (University of Sheffield School of Health and Related Research—SCHARR model) to real-world data.MethodsThis was a retrospective, single-centre study. Setting 1000-bedded teaching hospital in London, UK. Clinical pharmacy contributions related to unintended medication discrepancies (averted preventable adverse drug events, pADEs), documented by pharmacy staff on prearranged days during 2012, were assessed for clinical significance by a panel of senior clinical pharmacists using the SCHARR model. Costs avoided were allocated according to the SCHARR model. Pharmacy staff carrying out admission MR were timed. Net cost avoidance was calculated by subtracting cost of time taken to carry out MR from the costs avoided by averting pADEs. Sensitivity analyses were carried out.Results118 pADEs averted as a result of MR were recorded over the 6 reporting days. 116 were rated for clinical significance. Gross costs avoided were £36 135–£75 249 (€44 446–€92 556). The admission MR process was timed for 48 patients. The mean time to complete MR for one patient was 14 min (range 1–40 min). The cost of carrying out one MR, based on the cost of employing a first-level post-foundation clinical pharmacist was £7.56 (€9.30). The net benefit of one MR was £34–£80 (€42–€98). The benefit:cost ratio was 5.53:1–11.51:1.ConclusionsPharmacy-led MR on admission has significant economic, as well as clinical benefits. Further work is required for full economic evaluations of MR.

The aim of this study was to explore the nature of clinical enquiries received by UK vaccination centres during the early stages in the roll-out of the COVID-19 vaccination programme. Four centres were situated in acute hospitals and one centre was in a designated public site. Data were collected for eight consecutive weeks between January and February 2021. The hospital centres administered a total of 28 995 doses of the Pfizer BioNTech vaccine, receiving 806 enquiries (1 enquiry per 36 vaccinations, 2.7%). The public centre administered 29 167 doses of AstraZeneca vaccine, receiving 439 enquiries (1 enquiry per 66 vaccinations, 1.5%). Combined enquiry rate was 2.1%. The most common enquiries were related to allergies (44%), compatibility with other medicine (22%) and immunosuppression (16%). These were the topics of clinical guidance that were subject to regular change. Public health programmes implementing novel therapies should ensure the provision of sufficient enquiry answering capacity.

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