Improving access to medication review in high risk inpatients

Published 3 December 2019. Last updated 12 December 2019.

The Prince of Wales Hospital (POWH) is redesigning its clinical pharmacist services to prioritise medication review for inpatients most at risk of medication harm and ensure appropriate documentation of medication reviews.

View a poster from the Centre for Healthcare Redesign graduation, December 2019.

Improving Access to Medication Review [poster]


To increase the proportion of patient episodes that receive an 'allied health pharmacist intervention' (9555009) pharmacist documentation from 12% to 18% by December 2018. Then to further increase this to 25% by April 2020.


  • Use clinical pharmacist resources where they are most needed
  • Reduce risk of medication harm to hospitalised inpatients
  • Increase integration of pharmacists into multidisciplinary teams
  • Reduce staff stress levels
  • Provide pathways for referral of patients for a medication review


A patient’s experience of using medicines and their needs may change over time, especially during an admission to hospital. This means that medicines may need to be reviewed more than once during an episode of care.1

Organisations should ensure medicines use is optimised and medicine-related problems are minimised by conducting medication reviews and documenting the outcomes in partnership with patients.1

Medication reviews should be conducted with the objective(s) of:

  • reaching an agreement with the patient about treatment
  • optimising the impact of medicines
  • minimising the number of medication related problems
  • reducing waste.2

2018 POWH coding data indicates that 14% of hospitalised inpatients had a pharmacist review. Currently, the selection of patients for pharmacist review is ad-hoc and inconsistent. Pharmacists often review patients for the first time right before discharge. Due to current clinical pharmacist resources, not every patient is reviewed and there is a need to identify the patients who would most benefit from a medication review.

The lack of a systematic approach to patient prioritisation and the delay in performing medication reviews is predicted to result in an increased risk of medication related harm. POWH has high levels of medication harm. In hospital medication complications occur at double the rate of peer hospitals. There is a need to changes the way we practice, to reduce patients harm in patients most at risk.

A 2018 pharmacy services review revealed staff felt there are inconsistent and unclear goals for service provision which is resulting in high rates of staff burn out and dissatisfaction.

This project aims to engage staff and identify the best process to ensure that available resources are targeted to optimise patient care and minimise medication related harm.


Between November 2019 and March 2020, the following developments will be implemented.

  • Creation of learning packages for pharmacists for clinical documentation and medication review.
  • Approval from hospital patient safety committee and senior executive to trial new model of pharmacy service and patient prioritisation.
  • Development of risk minimisation discussions with departments in lower risk areas.
  • Improved eMR pharmacist consult functionality.
  • Development of eMR functionality to document medication review and track number of reviews that result in change to patient medication
    development of viewer to track coding data and results.
  • Use of intern pharmacists in supervised clinical roles.
  • Development of clinical lead pharmacist positions to promote specialist pharmacist care and mentoring of junior staff.


Implementation – The initiative is ready for implementation, is currently being implemented, piloted or tested.


  • Start: February 2019
  • Implementation: November 2019
  • Evaluation: March 2020

Implementation site

Prince of Wales Hospital


Centre for Healthcare Redesign


Evaluation will take place in February 2020, after three months of trial implementation.

The following evaluation measurements will be used for pre and post implementation.

  • A record of the percentage of acute admissions with pharmacist documentation present
  • Breakdown provided, by prioritised admission specialties and referral areas
  • Count of medication related hospital acquired complications
  • Staff satisfaction survey pre and post implementation
  • Proportion of pharmaceutical reviews that identify new medication related issues
  • A record of the percentage of pharmacist documentation that meets department requirements.

Lessons learnt

  • The stress caused by the climate and culture of the organisation can affect the ability to implement solutions. Multiple changes were taking place at the same time as this project and we constantly had to monitor priorities and limit the number of projects happening to ensure the organisation’s readiness to implement this solution.
  • Involving targets in the diagnostic, solution development and redesign process ensures buy-in and smoother, sustainable implementation.
  • Keep your scope small and focussed, ideally from the start. Our scope was huge when it started, with the belief that this would be reduced, yet that never happened, given the complexity of the project.
  • Clearly define the problem and scope before starting the project.
  • Sponsorship and executive engagement is essential to a successful project!


  1. Australian Commission on Safety and Quality in Healthcare. National Safety and Quality Health Service (second edition) Standard 4: Medication Safety, Criterion 4.10 Medication Review. Sydney. ACSQHC, 2017. (Accessed online 7/8/19).
  2. National Institute for Health and Care Excellence. NICE Guideline – Medicines Optimisation: the safe and effective use of medicines to enable best possible outcomes. UK: NICE; 2015. (Accessed online 7/8/19).


Adriana Chubaty
Senior Pharmacist Antimicrobial Stewardship
Prince of Wales Hospital
South Eastern Sydney Local Health District
Phone: 02 9382 2335

Carly Wills
Senior Pharmacist Medication Safety
Prince of Wales Hospital
South Eastern Sydney Local Health District
Phone: 02 9382 2335


Fill in our feedback form to find out more about this project or get in touch with the project manager.

Is this your project?

Fill in our feedback form to update your story or contact details.

Browse similar projects

Patient safetyMedicationSouth Eastern SydneyInpatientMetropolitanCentre for Healthcare Redesign
Back to top