Complex Inpatients Need Medication Experts: Optimizing the Pharmacists' Role on the Healthcare Team

In 90% of hospitals, pharmacists manage medication therapy for inpatients with complex and high-risk medication regimens in collaboration with other members of the healthcare team. (Previously Objective 1.3)

This tool kit illustrates how pharmacists and pharmacies can launch or expand a clinical pharmacy program. Information about how to implement a clinical service and which clinical pharmacy activities make a difference (as evaluated through the use of performance measures) are included.

The tool kit is designed to be used by most pharmacists and administrators in most clinical settings. Attempts were made to include information relevant both to those without clinical pharmacy programs aiming to launch a new program and to those wishing to expand existing clinical pharmacy programs. The information should be relevant to smaller community hospitals, as well as larger academic institutions, and encompasses the full scope of relevant hospital personnel, including front-line clinical pharmacists, coordinators of clinical pharmacy programs, pharmacy directors, and hospital executives.

CSHP members from across Canada contributed to the tool kit for objective 1.3.

There are 2 sections to this tool kit.

Implementation Plan

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When planning new or expanded clinical pharmacy services for managing medication therapy for inpatients, it is important to ensure the commitment of senior leadership. Framing the proposal in terms of institutional priorities such as accreditation standards may be a way to facilitate this commitment. A needs assessment should be carried out in collaboration with key stakeholders, and the value of the proposed clinical pharmacy service objectively demonstrated. Clearly defined vision, goals, scope, and outcomes for the clinical program should be communicated, and baseline data collected if possible. Common barriers to implementing such a plan include resistance on the part of physicians, “change fatigue”, lack of administrative support, and unreasonable complexity or breadth of the proposals. A business plan, outlining the resources needed to implement the program and any proposed cost savings, will likely be required. The resource list should cover labour, training, educational funding, and outcomes assessment.

Measuring our Impact through the use of Clinical Performance Measures

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In a 2006 systematic review, Kaboli and colleagues identified 5 categories of clinical pharmacy activities that had a positive effect on patients’ outcomes: “interacting with the health care team on patient rounds, interviewing patients, reconciling medications, providing patient discharge counseling and follow-up”. The CSHP 2015 tool kit working group for this objective assessed each of these 5 activities for practical application in both small and large hospitals nationwide and recommends 2 core measures:

  • Proportion of all admitted inpatients receiving formal documented medication reconciliation at the time of admission
  • Proportion of all inpatients receiving formal, documented medication education from a pharmacist at the time of discharge (also known as discharge medication

Note: Different core measures may be more appropriate in settings where these 2 core activities are not routinely carried out. The working group also determined that there is no consensus across Canada on the most appropriate core measures to employ for clinical pharmacy. The core measures presented here, although based on objective assessment of the available literature, should be considered the opinions of this Tool Kit Working Group.

Why the Objective Matters

A substantial amount of published evidence indicates that clinical pharmacy services (i.e., services related to managing medication therapy) for inpatients are associated with a positive impact on clinical outcomes, patients’ safety, patients’ knowledge about their medications, adherence with therapy, patients’ satisfaction, and patients’ quality of life. Most studies have also found that clinical pharmacy services are cost-effective.

Clinical pharmacists who manage medication therapy become experts in pharmaceutical care, sharing their knowledge to other members of the healthcare team, which ultimately improves the medication-use system. These benefits are particularly evident when pharmacists are involved in interprofessional teams and rounds. At sites where medical students and residents are trained, the clinical pharmacist is often a vital provider of medication education. This interaction between clinical pharmacists and medical trainees increases the appropriateness of prescribing and affects medication effectiveness and safety for the duration of the prescribers’ careers.

Hospital pharmacists value the time they are able to spend on clinical activities, and clinical work is generally associated with higher job satisfaction. Greater job satisfaction improves retention of employees and facilitates recruitment of new employees. And, the 2010 Accreditation Canada Qmentum standards require that pharmacists be part of an interprofessional team.1 Although the standards do not specifically state that pharmacists should manage medications, they do require that the effects of medications, including adverse effects, be monitored and documented in light of progress towards the patient’s treatment goals;1 pharmacists are generally understood to have a primary role in these monitoring activities.

The following literature review provides evidence to support the value of clinical pharmacists’ involvement in medication management, as described above.


Bond and his colleagues have published several studies supporting clinical pharmacy services. Notably, their reports have included data indicating that increasing both the number of clinical pharmacists in hospitals and their involvement in managing medications is associated with lower mortality rates. In the largest study to date from this group, a reduction in mortality rates occurred in association with 7 clinical pharmacy services: management of drug protocols, management of adverse drug reactions, participation on the cardiopulmonary resuscitation team, participation in medical rounds, provision of in-service education, drug-use evaluation, and admission drug histories.2

In a review of inpatient care provided by clinical pharmacists, improvements in patients’ outcomes were associated with the following activities: interacting with the healthcare team during rounds, interviewing patients, reconciling medications, and providing counselling and follow-up to patients at the time of discharge and beyond.3

In a more recent study, Chisholm-Burns, Lee, et al. found that the provision of direct patient care by pharmacists was associated with numerous improvements in patients’ outcomes including mortality, length of stay, readmission to hospital, visits to the emergency department, level of glycosylated hemoglobin ( A1c), blood pressure, and low-density lipoprotein.4


Several studies have indicated that pharmacists’ participation in interdisciplinary rounds decreases the frequency and severity of adverse drug events.3,5,6,7 In addition, several specific clinical pharmacy services have been linked to reductions in medication errors, including provision of drug information, management of drug protocols, management of adverse drug reactions, and drug admission histories, as have increases in clinical pharmacist staffing and decentralization of pharmacists.8 In a recent systematic review, Chisholm-Burns, Lee et al. found that direct patient care provided by pharmacists was associated with improvements in numerous patient safety outcomes, including adverse drug events, adverse drug reactions, and medication errors.4


As the prevalence of chronic diseases and associated medication use increases, the healthcare system will be required to adopt more cost-effective models of care. Most reviews and meta-analyses evaluating the cost-effectiveness of clinical pharmacy services have concluded that clinical pharmacy services are generally cost-effective; however, additional well-designed studies are needed. In a review of 93 studies published between 2001 and 2005, Perez et al. concluded that for every dollar invested in clinical pharmacy services, $4.81 in cost savings could be achieved.9 In another large-scale review, only 21 of 314 studies met the authors’ inclusion criteria, but the results from the selected cost–benefit analyses suggested that clinical pharmacy interventions were associated with cost savings.10 Chislom-Burns, Graff Zivin et al. found that of 126 studies meeting their inclusion criteria, 20 (15.9%) revealed a favourable economic impact, 53 (42.1%) had mixed results, 6 (4.8%) had no effect, and 47 (37.3%) had unclear results.11 The majority of the studies were limited by incomplete cost analyses, poor study design, lack of sensitivity analysis, inadequate discounting, or lack of verification of robustness.11

Patients’ Experience

Managing medications includes educating and engaging the patient, both of which facilitate increased involvement of patients in their own pharmaceutical care. When patients take more responsibility for their own healthcare, there are fewer potential gaps in addressing medication needs, and medication effectiveness and safety increase. And, when pharmacists interact with patients, patient satisfaction increases, which in turn improves the patient’s overall experience with the healthcare system.

In a recent review and meta-analysis, Chisholm Burns, Lee et al. found that the provision of direct patient care by pharmacists was associated with improved knowledge and adherence with medication therapy on the part of patients and improved patient satisfaction and quality of life.4 Notably, these authors found that for humanistic outcomes, there was more variability and a less consistent positive impact of pharmacists, relative to therapeutic and safety outcomes.4

Pharmacists’ Job Satisfaction (Recruitment and Retention)

According to Jorgenson, “A fulfilling and satisfying job that allows pharmacists to use their skills and expertise to improve the health of patients is the key to retaining staff”; if pharmacists are not given opportunities to use the skills they were trained for they will either seek employment elsewhere or they will lose their skills and become dissatisfied employees.12

Accreditation Standards

The 2010 Accreditation Canada Qmentum standards (see do not specifically indicate that pharmacists should manage medications, but the standards do require that patients’ medications be managed in the following ways:1

Standard 1.1 “Pharmacists are part of the interdisciplinary team.”
Standard 20.0 “The organization monitors clients following medication administration.”
Standard 20.1 “Staff and service providers monitor and document the effects of medication on progress towards the client’s treatment goals.”
Standard 20.2 “Staff and service providers monitor clients for possible and actual adverse drug events.


  1. Managing medications standards. In: Qmentum program 2010. Ottawa (ON): Accreditation Canada; 2009.
  2. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy 2007;27(4):481-493.
  3. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006;166(9):955-964.
  4. Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care 2010;48(10):923-933.
  5. Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med 2003;163(17):2014-2018.
  6. Etchells E. Do pharmacists’ presence on rounding teams reduce preventable adverse drug events in hospital general medical units? CMAJ 2004;170(3):333 Note: A commentary on Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med 2003;163(17):2014-2018.
  7. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug event in the intensive care unit. JAMA 1999;282(3):267-270.
  8. Bond CA, Raehl CL. 2006 national clinical pharmacy services survey: clinical pharmacy services, collaborative drug management, medication errors, and pharmacy technology. Pharmacotherapy 2008;28(1):1-13
  9. Perez AP, Dolorexc F, Hoffman JM, Meek PD, Touchette DR, Vermeulen LC, et al. Economic evaluations of clinical pharmacist services: 2001–2005. Pharmacotherapy 2008;28(11):285e-232e.
  10. De Rijdt T, Williams L, Simoens S. Economic effects of clinical pharmacy interventions: a literature review. Am J Health Syst Pharm 2008;65(12):1161-1172.
  11. Chisholm-Burns MA, Graff Zivin JS, Lee JK, Spivey CA, Slack M, Herrier RN, et al. Economic effects of pharmacists on health outcomes in the United States: a systematic review . Am J Health Syst Pharm 2010;67(19):1624-1632.
  12. Jorgenson D. Should clinical pharmacist resources be equally distributed across an institution to ensure a consistent level of clinical service for all patients? The “con” side. Can J Hosp Pharm 2007;60(3):205-206.

Link to Crosswalk and Supporting Literature

The CSHP 2015 Crosswalk is a document listing the CSHP 2015 goals and objectives in a tabular format, with links to philosophically aligned Canadian health initiatives. Also included are links to supporting literature, such as primary research papers and guidelines. (The CSHP 2015 Crosswalk can be found at: CSHP 2015 Crosswalk)