Clinical Pharmacy and the Clinical Potential of the Pharmacist

Farmácia clínica Opuspac University

Clinical Pharmacy is an area of Pharmacy that focuses on the application of pharmaceutical knowledge to improve patient health. Clinical pharmacists engage in the assessment, prescription, and monitoring of pharmacotherapy with the aim of ensuring the safety, efficacy, and effectiveness of drug treatment.


Clinical pharmacy originated in the early 20th century in the United States. However, it was only in the 1960s that this field began to gain greater relevance with the development of new drugs and technologies. It started being practiced in hospitals, where pharmacists began to take a more active role in patient care. Currently, clinical pharmacy is also practiced in clinics, offices, community pharmacies, and other healthcare settings.

Pharmacists in the United Kingdom play a crucial role in ensuring the appropriate and effective use of medications for patients in hospitals. In recent decades, there has been a significant expansion of the pharmacist’s role, extending beyond simply dispensing medications to include pharmaceutical care. The latter focuses on treatment effectiveness and the reduction of side effects.

The development of clinical pharmacy in the United Kingdom has resulted in different service models. A survey of these services in the UK in 1994 confirmed this diversity. The lack of an authoritative body of evidence to support the claims of clinical pharmacists has hindered the adoption of successful local initiatives in conventional services. However, there is a strong belief among pharmacists that clinical pharmacy improves patient care and resource utilization. This has been recognized by the Department of Health, which issued guidelines to hospital managers on the clinical and economic benefits that could be achieved with the implementation of clinical pharmacy services.

The concept of “pharmaceutical care” gained prominence in the pharmaceutical scene during the 1990s, introduced in the US by Heppler and Strand. Defined as the “responsible provision of drug therapy with the goal of achieving defined outcomes that improve the patient’s quality of life,” it was quickly incorporated into the good practice guidelines of the Royal Pharmaceutical Society in the UK. Although the term has become common among pharmacists, its adoption has not been questioned regarding its suitability for the UK healthcare system, leading to criticism of unquestioned acceptance of a concept developed in a very different healthcare environment.

Clinical Pharmacist

The essential role played by clinical pharmacists within hospital institutions encompasses a range of multifaceted and vital activities for the quality of patient care. Clinical pharmacy is a crucial area in healthcare, and the clinical pharmacist plays a multifaceted and fundamental role within this field. This professional is the cornerstone of patient-centered care, prioritizing not only the effectiveness of medications but also the safety and well-being of those under care.

These activities exemplify the commitment of clinical pharmacists to ensuring optimized and personalized drug therapy, contributing significantly to the safety and effectiveness of treatment.

Some of the key activities of the clinical pharmacist in hospital institutions include:

– Thorough patient history assessment:

  Allows understanding the patient’s medical history, pre-existing conditions, and specific needs, aiding in the personalization of drug therapy.

– Medication reconciliation:

  Ensures the patient’s medication list is accurate and up-to-date, avoiding medication errors and reducing the risk of errors in the medication process.

– Analysis of medical prescriptions:

  Goes beyond simple prescription fulfillment, considering factors such as dosage, administration routes, and necessary adjustments based on the patient’s clearance.

– Dose adjustment considering patient clearance:

 Allows adapting the medication dose to the patient’s body’s ability to metabolize it, ensuring efficacy and safety.

– Identification of possible incompatibilities between medications:

Prevents adverse reactions or a decrease in the effectiveness of therapy due to negative interactions between different drugs.

– Identification of therapeutic duplications:

 Prevents unnecessary or duplicate use of medications, optimizing therapy and reducing the risk of side effects.

– Identification of potential harmful drug interactions:

 Benefits: Protects against interactions that could interfere with treatment, compromising efficacy or causing adverse effects.

– Pharmaceutical interventions and closer collaboration with the medical team:

 Allow immediate adjustments to therapy, ensuring a collaborative and coordinated approach to patient treatment safety and effectiveness.

– Identification and communication of allergies

Identifying and communicating allergies helps avoid the prescription or administration of medications that could trigger severe allergic reactions, promoting patient safety. Clearly and precisely communicating allergies to the healthcare team reduces the risk of errors in prescribing or administering medications, preventing potentially dangerous situations.

– Analysis of laboratory test results:

Personalization of therapy adjusts doses and medications according to the patient’s needs based on their laboratory test results. Early detection of issues: Identifies complications or negative trends in the patient’s health.

The risk reduction avoids adverse reactions to medications, adjusting doses according to physiological response; maximizing efficacy ensures that therapy achieves the desired goals. And interdisciplinary collaboration contributes to an integrated treatment plan.

Patient and family education at hospital discharge:

Helps and guides patients and families to understand prescribed medications, their purposes, doses, and possible side effects, ensuring correct adherence to treatment after discharge, providing the patient with a better understanding of drug therapy.

Effective education can reduce the likelihood of hospital readmission due to complications caused by poor understanding or improper administration of medications, reducing hospital readmissions. Read more about readmissions: “Unveiling Hospital Readmission.”

– Antimicrobial management – Stewardship Program:

The management and control of antimicrobials, also known as stewardship, is one of the key areas where the clinical pharmacist stands out. These professionals lead efforts to ensure the proper use of these medications and collaborate with healthcare teams to ensure the judicious use of antibiotics, antivirals, and antifungals. Their involvement ranges from evaluating antibiotic prescriptions to recommending the most effective and targeted therapy for infectious diseases.

They analyze the pharmacokinetics and pharmacodynamics of antibiotics and guide antibiotic de-escalation strategies, preventing the development of bacterial resistance, one of the major global health challenges. Ensuring that antimicrobials are used more precisely, increasing their efficacy in combating infections, and reducing the risk of therapeutic failures, avoiding unnecessary or prolonged use of antimicrobials, reducing the risks of side effects and adverse reactions in patients, and saving hospital resources by avoiding prolonged or inappropriate treatments, directing medications where they are most needed, optimizing healthcare resources. Contributing to the reduction of hospital infections and the spread of resistant organisms, improving patient safety.

Providing education to healthcare professionals and patients about the rational use of antimicrobials, promoting a broader understanding of the importance of correct use of these medications. Facilitating communication among different healthcare teams, including doctors, nurses, and pharmacists, for more effective and coordinated use of antimicrobials.

These activities together provide comprehensive and personalized pharmaceutical care, promoting the safety and efficacy of treatment, minimizing the risks of adverse events, and maximizing benefits for the patient, placing the patient at the center of their care. With the necessary information, cohesive medical and multidisciplinary teams aim to provide the patient with a positive and high-value experience.

Participation in Hospital Committees

The active participation of clinical pharmacists in hospital committees, such as the Pharmacy and Therapeutics Committee, Infection Control Committee, Parenteral Nutrition Committee, Oncology Committee, among others, is vital. By participating in these committees, these professionals ensure safety and greater effectiveness in patients’ drug therapy. They collaborate with medical and multidisciplinary teams, contributing to the implementation of care protocols, such as pain protocol, VTE prophylaxis, surgical antimicrobial prophylaxis, pressure ulcers, falls, bronchoaspiration, among others, ensuring compliance with institutional protocols and promoting quality and safe care.

Applications of Clinical Pharmacy

– Evaluation of patient pharmacotherapy to identify problems related to medication use (PRMs), including medication errors, drug interactions, medication allergies, among others.

– Reduction of medication errors by identifying and correcting them, thus preventing adverse events.

– Improvement of treatment adherence, assisting patients in adhering to their treatment, enhancing clinical outcomes.

– Optimization of pharmacotherapy, enhancing the safety, efficacy, and effectiveness of treatment.

– Pharmacist prescription, with proper authorization.

– Monitoring patient pharmacotherapy to ensure safety, efficacy, and effectiveness of treatment.

– Pharmaceutical education of patients on the safe and effective use of medications.

Advantages for Physicians:

– Improved patient safety by identifying and resolving PRMs, contributing to the prevention of adverse events.

– Enhanced treatment efficacy by assisting physicians in choosing the most suitable medications for each patient and monitoring treatment response.

– Reduced workload, as clinical pharmacists can take on some tasks, such as adjusting medication doses for patients with renal impairment, providing guidance and education to patients on their entire drug treatment, choosing the safest, most adherent medication with a convenient dosage, among other actions, freeing physicians to focus on clinical care.

Advantages for Patients:

– Better care by providing more individualized and comprehensive patient care.

– Improved quality of care by identifying medication interactions that the physician may not have noticed, preventing serious adverse events.

– Assistance in developing a personalized treatment plan that meets the patient’s needs and preferences.

– Monitoring treatment response to ensure the patient is receiving the correct treatment.

– Support and education for patients to manage their illness effectively.

– Non-pharmacological counseling on important issues such as smoking cessation, guidance to avoid self-medication, encouragement for a healthy diet, recommendations to avoid alcohol consumption, encouragement for supervised physical activities, and suggestions to reduce excessive stress.

– Collaboration in managing chronic diseases, improving the patient’s quality of life and reducing the risk of complications.

– Help patients save money on medication purchases by finding pharmaceutical assistance programs.

– Contribute to improving the patient’s quality of life, such as helping a patient with chronic pain find a medication or treatment that reduces pain and improves their ability to function.

– Collaborate with patients to live longer, for example, helping a patient with diabetes control their condition, reducing the risk of serious complications such as heart disease, stroke, and blindness.

Advantages for Healthcare Institutions:

– Cost reduction, contributing to the reduction of healthcare costs through the prevention of adverse events and optimization of medication use.

– Improvement of safety, enhancing the safety of patients and healthcare professionals.

– Enhancement of safety and quality in patient care and healthcare professional practices.

Contribution of Clinical Pharmacy

The influence of clinical pharmacists on medical prescriptions in hospitals is significant due to their therapeutic knowledge and frequent contact with prescribers. Strategies, such as the development of hospital policies and postgraduate training for individual pharmacists, are used to influence improvements in prescriptions and enhance their therapeutic skills. They play an increasing role in patient education on the correct use of medications.

The implementation of formulary policies has shown improvements in prescription and cost reduction, although challenges such as lack of flexibility and insufficient feedback have been faced. Despite the recognized clinical and economic benefits of clinical pharmacy services, the widespread adoption of electronic prescription systems remains a challenge, despite potential benefits. However, the integration of these systems into electronic patient records is expected to improve patient safety.

Training programs have been crucial to empower clinical pharmacists, and their role in patient education has the potential to improve the appropriate use of medications. Although there is recognition of the benefits, the role of pharmacists in systematically quantifying drug-induced diseases is still limited.

Pharmaceutical Practice

Pharmaceutical practice has undergone a remarkable transformation in the last century, recognizing the profession’s contribution to improving patient outcomes. The growing recognition of clinical pharmacy is reflected in national reports and important legislations, such as the Institute of Medicine (IOM) report ‘To Err is Human,’ which highlighted morbidity and mortality associated with medication errors.

Innovations over time have marked the evolution of clinical pharmacy, from pharmacists’ participation in hospital rounds to the establishment of medication management systems. Many significant milestones have been established, such as the creation of the University of Iowa Drug Information Service (IDIS), the Ninth Floor Pharmaceutical Services Project in San Francisco, CA, and the initiation of teaching safe and effective medication use to medical students and residents.

The expansion of clinical pharmacy services in hospitals was notable from 1989 to 2006, recognized as an effective strategy in reducing medication errors. In hospitals with large populations of Medicare patients, clinical pharmacy services have been shown to directly reduce the medication error rate.

Legislations such as the Medicare Prescription Drug Improvement and Modernization Act of 2003 and reports from the IOM and the National Quality Forum recognized the authority and responsibility of pharmacists in managing drug therapies, driving the expansion of systems such as electronic prescribing and clinical decision support.


Education continues to evolve to prepare future pharmacists for practice in interprofessional teams and the use of information technology to enhance patient care. Interdisciplinary learning environments and educational innovations, such as ‘flipped classrooms,’ have proven essential in training a workforce prepared for advanced clinical practice.

The future of clinical pharmacy is dynamic and promising. With technological advancements and the evolution of medical practices, clinical pharmacists are taking on more proactive roles, not only in educating patients about the correct use of medications but also in seeking new therapeutic approaches.


The role of the clinical pharmacist is invaluable in the contemporary hospital setting. Their expertise, attention to detail, and commitment to patients not only ensure effective drug therapy but also contribute significantly to the quality and safety of healthcare. The clinical pharmacist is the architect of patient-centered care, integrating science, technology, and empathy to promote better health for all.

It is essential to continue imagining and propagating innovations in pharmaceutical practice to further advance the profession and the quality of patient care. The clinical pharmacist is an essential member of the multidisciplinary healthcare team, contributing significantly to the improvement of health and the quality of life of the patient through more humane care. For this, they must be at the bedside for the practice of safe, economical, and effective clinical pharmacy.

Learn more: Watch the free course Clinical Pharmacy Presentation *

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Bibliographical References

  • Institute of medicine (IOM). Errar é humano: construindo uma cultura de segurança no sistema de saúde. Washington, DC: National Academies Press; 2000.
  • American College of Clinical Pharmacy (ACCP). A posição do ACCP sobre a prática clínica de farmácia: 2023. J Clin Pharm Ther. 2023;48(3):336-345.
  • World Health Organization (WHO). The role of the pharmacist in improving patient outcomes. Geneva: WHO; 2022.
  • Bates DW, Leape LL, Cullen DJ, et al. Reducing the frequency of errors in medicine. Qual Saf Health Care. 1998;7(2):185-191.
  • Bardsley M, Jones M. The history of clinical pharmacy in the United States. Am J Hosp Pharm. 1995;52(10):1557-1567.
Clinical Pharmacy and the Clinical Potential of the Pharmacist
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