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A hospital pharmacist’s role in concordance


Philip J Schneider
Clinical Professor and Director Latiolais Leadership Program
College of Pharmacy Ohio State University USA
Hospital Pharmacy Section
International Pharmaceutical Federation

The system of medications use after a prescribing decision is made is as important as the prescribing decision itself in assuring an optimal outcome for drug therapy. The starting point of this system will often be in the hospital where prescribed therapy is initiated, so strategies for addressing concordance in medicine use begin in the hospital setting.

Hospital pharmacists have developed several programmes with the intention of improving concordance with drug regimens, including medication histories, self-medication programmes and discharge counselling. Each of these actively involves the patient as a participant in the decisions related to their own medication use and fosters concordance.

Medication histories
Patients are often asked about the medications that they are taking upon admission to the hospital. The nurse, the physician, the pharmacist or more than one of these healthcare professionals can do this. The purpose of a medication history is to determine the prescription and nonprescription medications that the patient has taken or is taking, any drug allergies or previous adverse events that might have been caused by the medications, and the attitude and willingness of the patient to follow prescribed therapy (concordance).

It may be annoying to patients to have the same questions asked several times about their medication history. It may also be annoying for some health professionals to be asked NOT to ask patients about their medication history. Irrespective of these preferences, it is critical to adequately assess the medications the patient has taken, the effectiveness of the drug regimens and the concordance with medication therapy. This responsibility may be delegated to one member of the healthcare team to avoid redundancy, or subsequent interviews may simply review what has already been asked to confirm the important information (such as known drug allergies).

There is a case to be made for having a pharmacist assume responsibility for performing medication histories. Covington et al found that pharmacists were more effective in taking an accurate medication history, including the documentation of nonprescription medications, which are often not noted by physicians or nurses.(1) This is not to suggest that physicians or nurses are not qualified to take a medication history; rather, because of their regular work with all types of medications, pharmacists are more likely to get a complete history. Elements of a medication history should include:(2)

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  • Prescription medications taken in the past, including the dose, frequency and duration of therapy, dosage form and the time the last dose was taken.
  • Nonprescription medications taken in the past, including the dose, frequency and duration of therapy, dosage form and the time the last dose was taken.
  • Any free samples of medications that might have been provided directly in the doctor’s office.
  • Herbal and nutritional supplements that may not be considered medications by the patient.
  • A history of any allergies or other adverse events that the patient associates with the medication taken.
  • A candid, nonjudgemental discussion of the number of doses not taken and the reasons why they do not take medication.
  • How medications are stored in the home setting.
  • The patient’s general attitude towards the medications prescribed and those taken.

The history should be documented in writing with pertinent findings about the medication-related problems such as allergies, previous adverse drug events and concordance.

Self-medication programmes
There is often an overlooked opportunity to assess patient acceptance of therapy and concordance when medications are prescribed in the hospital. Besides assuring the desired clinical outcome of prescribed therapy, patients can be asked to begin assuming supervised responsibility for taking their own medications before they are discharged from the hospital and have to take them unsupervised. Explaining the rationale for each medication, showing the patient what each dose looks like and providing a properly labelled supply of medications to use under supervision can all improve concordance. Healthcare professionals can have more confidence that patients will accept their prescribed therapy and take their medications as directed if they participate in learning how to take doses properly and can discuss problems before they go home.

Examples of self-medication programmes that have been shown to improve concordance include: patients with spinal cord injuries in a rehabilitation hospital,(3) postsurgical patients at a thoracic surgery service,(4) elderly patients in hospitals or long-term care facilities,(5) and postpartum patients at an obstetric service.(6)

Discharge counselling
While self-medication programmes offer greater benefits to improving concordance, a final opportunity exists at the point of discharge to discuss medications with the patient.(7) Patients are often rushed at this point of care, but, if properly planned, discharge instructions about posthospital care, including medication, can be an important final step in their hospitalisation. Important elements to discharge counselling about medications includes:

  • The attitude about the medications that are being prescribed, including an assessment of patient response during the hospital stay.
  • Verbal instructions about the name, dose, schedule, duration and side-effects of each medication prescribed.
  • Asking for recall of the medication instructions and specific plans for how they will take their medication.
  • Plans for having the prescription filled (if a supply is not provided from the hospital pharmacy).
  • Plans for storing the medication while at home and travelling.
  • Written instructions to assure that patients receive complete, uniform information that is not dependent on memory.
  • Instructions about what to do if there are problems, including side-effects.

While it is not necessary for a pharmacist to counsel patients about their medications when they are discharged, it is likely that they will do this more completely than other healthcare professionals. At the very least, the hospital pharmacist can be helpful in providing properly packaged and labelled medications for the patient to take home, together with written instructions about the medications.

How patients use medications (concordance) is just as important as how drugs work when they are administered to patients (pharmacology). Both concordance and an appropriate pharmacological response are needed to derive benefit from medications. Since drug therapy is often initiated in the hospital, it is a good place to focus attention on concordance and the pharmacological response to prescribed treatment. Hospital pharmacists can be an important resource in optimising the use of medication through medication history, self-medication and discharge counselling programmes.


  1. Covington TR, Pfeiffer FG. Pharmacist-acquired medication history. Am J Hosp Pharm 1972;29:692-5.
  2. Rovers JP, Currie JD, Hagel HP, et al. A practical guide to pharmaceutical care. Washington DC: American Pharmaceutical Association; 1998. p. 48-9.
  3. Roberts CJ, Miller WA. Clinical pharmacy, self-administration, and technician drug administration in a 72-bed hospital. Drug Intell Clin Pharm 1972;6:408-15.
  4. Buchanan EC, Brooks MR, Greenwood RB. A self-medication program for cardiology patients. Am J Hosp Pharm 1972;29:928-34.
  5. Liblow LS, Mehl B. Self-administration of medications by patients in hospitals or extended care facilities. J Am Geriatr Soc 1970;18:81-5.
  6. Lucarotti RL, Prisco HM, Hafner PE, Shoup LK. Pharmacist coordinated self-administration program on an obstetrical service. Am J Hosp Pharm 1973;30:1147-50.
  7. Grissinger SE, Wolfe LW, Cohen MR. A protocol for consultation with discharged patients. Hosp Pharm 1973;8:175-83.

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