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Provision of pharmacy services to hospital admission units in Wales

This study presents an audit in Wales of medicines reconciliation on admission to hospital, information sources of medication history used and staff time spent on activities

By R. J. Boldero, J. Gilberston, J. Goddard and S. J. Hiom

Pharmacy departments across Wales provide services to hospital admission units. However there is lack of clarity about how much time is being allocated, what activities are being carried out and what value in the care of patients is being provided through these services.

The need to demonstrate value in the care of patients is greater now than ever, with medicines reconciliation on admission to hospital being a pharmacy service that can contribute to this value. Our study presents an audit across 14 Welsh hospitals of medicines reconciliation on admission and the information sources of medication history used.

On admission units it is not only through medicines reconciliation that the pharmacy service can limit the harm occurring to patients. Focusing on more clinically oriented activities maximises the patient safety impact of pharmacists by using their time and expertise most effectively. Therefore in addition our study provides an investigation into the time spent and activities carried out by pharmacy staff on admission units across the 14 Welsh hospitals.


The study was undertaken at 14 hospital sites across Wales. The process and methodology were based on those used in a previous all-Wales study.

To ensure comparable data were collected, a uniform method was used. Preregistration trainee pharmacists undertook the data collection, which was centrally co-ordinated by a project steering committee.

Data were collected from the emergency/ unscheduled admissions unit within each hospital site and assessed against the following standard: 100 per cent of patients will have their medicines reconciled within 24 hours of admission.

Medicines reconciliation was defined to have occurred when the front of the medication chart had been signed to indicate the medication history check was complete, and any necessary actions had been implemented. The 24 hour period started when patient details were entered on the hospital’s electronic inpatient recording system.

To determine the medication history information source(s) used in the process of medicines reconciliation, the categories printed on the all-Wales medication chart were used. To ensure consistency of this data collection, standard definitions were provided across all data collection sites.

The data collected at each site were entered into an electronic database, collated and sent to the central data co-ordinator for analysis.


Pharmacy service provision to admission units For each day of the study there was an average of 21 beds seen per visit with an average time spent visiting each bed of 16 minutes. The average visit time per day for pharmacists was three hours and 10 minutes, and for technicians was three hours and 14 minutes.

Pharmacy service activities undertaken on admission units The most common pharmacist activities were reviewing current patients (18 per cent), undertaking medicines reconciliation (18 per cent) and obtaining a medication history (16 per cent).

For technicians the most common activities were ordering medicines (24 per cent), obtaining a medication history (23 per cent) and medicines reconciliation (15 per cent).

Medicines reconciliation within 24 hours Of all patients admitted, 55 per cent had their medicines reconciled within 24 hours of admission. This figure increased to 67 per cent when those patients with medicines not reconciled due to death, discharge or transfer to another hospital within 24 hours were excluded.

Number and type of medication history information sources used The most common medication history information source used to undertake medicines reconciliation was that of GP (38 per cent) with the patient (27 per cent), and patients’ own drugs (22 per cent) following. The GP source was used in 65 per cent of patients, and used as a single source in 26 per cent.


Throughout Welsh hospitals the pharmacy service is undertaking a variety of activities on admission units. Overall pharmacists undertake more clinically oriented activities while technicians focus more on technical roles. However our data indicate an overlap of some functions, such as medicines ordering and obtaining medication histories.

When staffing profiles permit, it is important that pharmacists spend as much time as possible on clinically oriented activities, with technicians undertaking all of the activities that their new and extended roles empower them to do. This will help to ensure the whole pharmacy service provides the best value in the care of patients. 

Across Wales the pharmacy service is achieving medicines reconciliation within 24 hours of admission for 55 per cent of patients.  Our study has shown that the rate is affected by patient factors, such as discharge, transfer to another hospital or death within the 24 hour data analysis period. These factors must be presented in any discussion and should be used to redefine the standard criteria. 

It is of note that a high number of patients had just one medication history information source used to undertake medicines reconciliation and that the most common category of information source used was “GP”.

This is of concern given that there are a number of limitations to “GP” as an information source. Raising awareness of and addressing these limitations would be appropriate given the high value that is currently being placed on this information source. 


Across Wales pharmacy departments are providing essential services in the care of patients on admission units through a variety of activities, including medicines reconciliation. However, a 100 per cent target for medicines reconciliation to be completed within 24 hours of admission is not being achieved for all adult patients.

A method of targeting services to the most appropriate patients should be considered. In the process of medicines reconciliation the lack of a gold standard medication history information source means current practice has its limitations. The continuing need for further development and optimisation of pharmacy services on admission units remains of paramount importance.


Authors: Welsh Pharmacists Project Oversight Group

Correspondence to: Richard Boldero (

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11121792

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