**1.1 Definition**

The concept of pharmaceutical care (PC) emerged in the early 90's and has since evolved to become a recognised aspect of pharmacy practice. The philosophy of pharmaceutical care was introduced by Hepler and Strand in 1990 [1] and has been an important concept in every field of pharmacy practice in which patients are the focus. They have defined PC as 'the responsible provision of medical therapy for the purpose of achieving definite outcomes'. The process of

pharmaceutical care involves pharmacists working with other healthcare professionals to develop, implement and monitor a therapeutic plan designed to produce specific therapeutic outcomes. These functions are carried out through a comprehensive assessment of the patient's health and drug history, devising, implementing appropriate plans of care, monitoring and evaluating the efficacy and safety of drug therapy.

The American Society of Hospital Pharmacists (ASHP), United States (US) is of the opinion that PC represents a valuable new concept representing growth in the profession beyond clinical pharmacy as often practiced. It also goes beyond pharmacists' activities, including medication preparation and dispensing. In 1992, ASHP came out with a new definition of PC, which is an adaptation of the definition developed by Hepler and Strand. ASHP defined pharmaceutical care as 'the direct responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient's quality of life' [2]. The principal elements of PC by this definition are not only medication therapy but also decisions not to use medication therapy. The outcomes sought from PC are cure of a patient's disease, eradication, reduction in patients' symptoms, arresting or slowing of a patient's disease progression and prevention of a disease or symptoms.

The interest in the philosophy of PC is not only confined to the US where it was founded but also spread globally. While ASHP further elucidated the meaning of PC, the board of the Pharmaceutical Care Network Europe (PCNE) saw the need to redefine PC in 2013 for the purpose of having a single and certain definition in Europe. The redefinition reads 'pharmaceutical care is the pharmacist's contribution to the care of individuals in order to optimise medicines use and improve health outcomes' [3].

#### **1.2 Pharmaceutical care at tertiary level care**

PC is delivered through clinical pharmacy practice at primary, secondary and tertiary levels of care. With the ASHP PC definition that includes all medicationrelated problems, the practice has expanded, especially when it involves patients who are hospitalised. Pharmacists at tertiary care institutions incorporate pharmaceutical care through practices that include medication history-taking, drug regimen review and monitoring and reconciliation of medications.

Patients admitted at tertiary care centres are more critical due to the presence of co-morbidities and more drug-related problems that need urgent interventions. Studies have shown that there is a high prevalence of DRPs among patients who visited the emergency department or are admitted. An average of 1.25 (+1.23) drugrelated problems (DRPs) per prescription was observed in chronic kidney disease patients. The most common DRP was adverse drug reactions [4]. Patients (N = 109) admitted to the emergency department observed for a period of 6 months were identified with various DRPs of which 69.7% was due to ADR, 27.5% non-adherence, followed by subtherapeutic doses, untreated indication and overdosage (0.91%) [5]. Pharmacists in tertiary care institutions work as part of a multidisciplinary healthcare team to provide pharmaceutical care services. They also ensure that the interventions are tailored to the unique needs of the patient and ensure treatment effectiveness and patient safety. Thus, the purpose of PC is to ensure that DRPs are discovered and recognised by pharmacists, so patients receive the right care for them to achieve definite outcomes and quality of life.

### **2. Medication review**

#### **2.1 Introduction**

Medication review processes are changing in several countries as a result of pharmacists' increased involvement in drug history taking, medication reconciliation and medication review in their day-to-day work [6]. A medication review can be done independently or in tandem with other interventions such as medication reconciliation or personnel education. Although the clinical advantages of medication reviews, such as lowering hospital stay and mortality, have not always been demonstrated, medication management and multidisciplinary approaches have proven to be successful methods for reducing drug-related iatrogenic risks, inappropriate medication use and drug spending for elderly recipients [7].

An ageing population necessitates more medications and has a higher prevalence of multiple medical conditions. Age-related polypharmacy, which is the continuous use of five or more different medicines [8], is becoming more prevalent. There is ample proof that polypharmacy contributes to more problems with medication safety and a higher risk of adverse drug events (ADEs). The risk of drug interactions, drug toxicity, falls, delirium and non-adherence [9], as well as the possibility of readmission and mortality, have all been linked to polypharmacy [10]. The value of medication reviews by pharmacists for patients in community settings is becoming increasingly recognised through research [11]. The World Health Organisation (WHO) suggests giving patients who are taking numerous medications a medication review to lessen the risk of polypharmacy [12]. Medication reviews may lower the likelihood of polypharmacy, also known as the use of multiple medications, improper drug usage and medication costs in patients [13]. When a healthcare provider meets a patient and decides to prescribe or stop medication after going through an extensive and planned process that is supported by the patient's records, the process is known as a medication review [14]. The plan for discontinuing inappropriate therapy and achieving medication optimisation, therefore, incorporates a medication review [15].

It has been demonstrated that implementing a medication review effort, which allows identifying many underlying risk factors and coordinating explicit measures to lessen the effects of each can lower the incidence of inpatient falls by 20–30% [12]. Falls are a common and increasing concern to older people's both immediate and longterm health and functional independence [16]. In addition, falls are the most reported safety occurrence among adult inpatients [17]. A physical injury occurs in 30–50% of falls, and fractures happen in 1–3% of cases. Establishing effective fall prevention strategies, such as appropriate multifactorial interventions, is crucial due to the burden associated with fall injuries from both an individual and a societal standpoint. A medication review with the goal of carefully deprescribing certain medications is an essential component of a multifaceted approach to preventing falls [18].

#### **2.2 Process**

The requirement for criteria for competency has become clear as pharmacists' adoption of medication reviews has increased [19]. The criteria were developed based on Clyne et al.'s suggestion of three degrees of review comprehensiveness: prescription review, medication review and comprehensive medication review (CMR) [20].

The common medicine dispensing procedure includes an immediate review of the medication list known as a prescription for the medication. Whenever technical and

therapeutic issues with the medication list may be resolved based on the information provided in the prescriptions, such as dosage and indication, they are considered in the prescription review.

Medication reviews, which evaluate the appropriateness of a prescription and identify and address therapeutically important medication-related issues, can be observed as a different service offered to the patient. It is advised that the medication review be carried out in a multidisciplinary setting along with the patient being informed of the drug of choice findings and adjustments. Checking proper medication use, adherence and self-management forms a component of medication review.

Compared to a medication review, a comprehensive medication review (CMR) is a more comprehensive assessment. Collaboration with the attending physician and other members of the care team will be utilised to address any clinically significant issues relating to the medication or medical condition. The patient is informed of significant medication observations and modifications. CMR involves ensuring that every medication is appropriate for consumption while considering the patient's illness and overall health. Upon CMRs, pharmacists collaborated with doctors and patients to manage medical conditions through patient education and motivational interviewing, medication adjustments and care coordination [21].

#### **2.3 Importance**

A medication review in combination with medication reconciliation, patient and professional education and transitional care is linked to a reduced chance of readmissions to the hospital [22]. Hospitalisations can have a negative impact on older patients' prognosis. Older patients are vulnerable to problems such as delirium, falls, functional degeneration, and future confinement or readmission following hospitalisation [23]. Readmissions due to medication are common, especially in elderly patients. Optimising medication appropriateness may lower medication-related issues and the frequency of hospital readmissions.

Medication reviews performed by clinical pharmacists' aid in the identification and prevention of medication errors and have been demonstrated to improve patient safety and reduce the risk of medication errors by up to 50% [24]. The annual incidence of preventable adverse drug events (ADEs) caused by medication errors in hospitalised patients is estimated to be 400,000 occurrences or approximately one medication error per patient each hospital day [25]. During all transitions of the hospital stay (admission, transfer of care, and discharge), the medication review process is described as verifying medication use, discovering discrepancies and resolving any medication-related difficulties [26].

Medication review by a clinical pharmacist can help older individuals with polypharmacy use their medications more effectively, especially when combined with cognitive functioning and depression screening [27]. Polypharmacy in the elderly commonly leads to medication therapy issues such as interactions, drug toxicity, falls with injury, delirium and non-adherence [9].

### **3. Medication reconciliation**

#### **3.1 Introduction**

The report 'To Err Is Human' by the Institute of Medicine has highlighted medical errors as a substantial cause of patient harm [28]. The statistics on medical *Delivery of Pharmaceutical Care at Tertiary Level: From Admission to Home Care DOI: http://dx.doi.org/10.5772/intechopen.112503*

errors consistently present startling figures and are often alarming. A recent WHO report and Cochrane review indicate that during hospitalisation, specifically at the transition of care, a significant proportion of patients (ranging from 25 to 80%) encountered at least one medication discrepancy or experienced a failure to communicate changes in their medication regimen [29, 30]. In the context of the delivery of pharmaceutical care at the tertiary level, medication reconciliation is a pivotal measure that should be undertaken to ensure medication safety in the inpatient setting. Recently, the original concept of medication reconciliation has transformed resulting in the establishment of a patient-centred system that supports optimal medication management [31].

Medication reconciliation is a formalised and standardised process that entails cross-referencing the medications presently consumed by a patient with any newly prescribed medications at transitions of care such as admission, discharge or transfer with standard health care [32]. The primary objective of medication reconciliation is to identify and rectify any inadvertent discrepancies, omissions or duplications in medication orders, thereby fostering safe and accurate management of medications for the patient's well-being according to the standards of medication frequency, route, dose, combination and therapeutic purpose [33].

#### **3.2 Process**

Multiple initiatives are being implemented during patient care transitions to promote medication. Extensive measures have been adopted across all healthcare providers and several international patient safety organisations to guarantee the precise and consistent transfer of medication information for patients throughout the transition of care.

Medication reconciliation plays a vital role as a key service during care transitions and has been proven with remarkable effectiveness in mitigating potential medication error risks. National Institute for Health and Care Excellence (NICE) guidelines recommended medication reconciliation to be performed within 24 hours or earlier if deemed medically necessary within the transition of care [34].

In general, medicines reconciliation comprises three primary steps (**Figure 1**) [29].

**Figure 1.** *Medication reconciliation process.*

#### *3.2.1 Creating the best possible medication history (BPMH)*

At each juncture of care transitions, the identification of a patient's pre-transition medication regimen is paramount. BPMH is a comprehensive list of the current medications that a healthcare provider obtains from various sources of information prior to the care transition to capture essential medication information [31].

To gain this information, a systematic process is employed, ensuring that no critical information is overlooked. This process involves tapping into primary sources for obtaining an accurate medication history. The main sources for obtaining a medication history may include engaging in open and effective communication with the patient or their relatives. By accessing the electronic medical record (EMR) system within the institution, a wealth of up-to-date patient data, including medication profiles may also be obtained ensuring the completeness and accuracy of the BPMH. In addition, the medication profile provided by a third party can also serve as a valuable resource in the creation of BPMH [35].

By utilising these diverse sources of information, healthcare providers can piece together a comprehensive and accurate BPMH. This facilitates the seamless transition of medication information, promotes patient safety and optimises the quality of care provided during the care transition process. This step emphasises the significance of gathering accurate and up-to-date information regarding a patient's medication history to inform the subsequent medical decision-making process [36].

### *3.2.2 Comparing the BPMH with medicines prescribed on admission, at in-patient transfer or patient discharge and identifying discrepancies*

During this crucial step, a comprehensive assessment is conducted for both prescribed and non-prescribed medications. Within the clinical context, two primary models, the proactive and retroactive models or a combination thereof can facilitate the medication reconciliation process [37].

In the proactive model, BPMH is established prior to formulating admission medication orders. By obtaining a comprehensive understanding of the patient's current medication regimen, potential drug interactions, allergies and other pertinent factors, healthcare providers can proactively address any discrepancies or potential risks to patient safety [38].

On the other hand, the retroactive model involves generating admission orders before creating the BPMH. Challenges in completing a BPMH due to delays in receiving the initial medication history from the prescriber in the retroactive model of medication reconciliation were particularly prominent in the critical care setting. Possible reasons for these delays included the challenges of approaching families during high-acuity situations and the lower priority given by physicians to medication reconciliation when engaged in acute patient care [39]. While this approach differs in sequence, it still necessitates a thorough reconciliation between the BPMH and the admission orders. This reconciliation step serves as a critical mechanism for identifying any disparities, inconsistencies or omissions that may exist between the documented medication history and the prescribed medications.

Regardless of any model employed, the reconciliation process bridged between the BPMH and the admission orders to ease the identification and rectification of any discrepancies. By comparing the patient's medication history with the prescribed medications, healthcare providers, such as pharmacists, can pinpoint potential issues such as drug interactions, duplicate therapies, incorrect dosages or the omission of crucial medications [40].

*Delivery of Pharmaceutical Care at Tertiary Level: From Admission to Home Care DOI: http://dx.doi.org/10.5772/intechopen.112503*

*3.2.3 Reconciling discrepancies by classifying them as intentional or unintentional and by taking the appropriate action and documenting intervention*

Once the discrepancies have been identified, they undergo a comprehensive and thorough analysis within the clinical context to ensure a detailed understanding of their nature and implications. This analysis allows for further classification of the discrepancies into two distinct categories: intentional and unintentional [41]. Intentional discrepancies arise from conscious decisions made by either the patient or the healthcare provider such as intentional adjustments to the medication regimen based on specific considerations. In contrast, unintentional discrepancies encompass instances where changes in the medication history occur without a conscious decision being made. These can manifest as both omission errors, where a medication is unintentionally left out or not properly documented and commission errors, where a medication is unintentionally added or administered incorrectly. Paediatric patients are a highly vulnerable population identified with unintentional discrepancies during the transition of care [42].
