Figure 1 illustrates the fluctuation in the number of medication reconciliations, ranging from 296 to 715, with an average of 466 per month. The pattern of medication reconciliations followed an expected trend, with a higher number occurring during hospital admission, followed by hospital discharge and service transfers within the hospital. Of the total of 5593 medication reconciliations evaluated, clinical pharmacists identified only 25 discrepancies. In 2020, a study assessing medication reconciliation in 100 patients showed a discrepancy rate of 71%. This finding suggests that the PFUU can enhance their medication reconciliation process to be more comprehensive and resourceful in identifying discrepancies.
It is essential to improve the number of medications reconciliations to achieve the required 100% coverage, aligning with medication safety practices like the Joint Commission International guidelines. This study demonstrated that the PFUU covered 96% of the medication reconciliation evaluations during hospital admission and 58% at hospital discharge. The time to complete the medication reconciliation evaluation following a transition of care was not assessed in this study, considering that some guidelines recommend completing it in the first 12 to 72 hours, but stricter guidelines require finalising it before administering the first prescription to the patient. The High 5s Project emphasises that medication reconciliation must be performed during the first 24 hours of hospitalisation. Measuring the time to coplete medication reconciliation can be considered a supplementary evaluation.

Both the pharmacotherapeutic profile and prescription suitability evaluation had a similar pattern, with a decrease in the number of evaluations observed. This decline could be attributed to the presence of pharmacy students in the department and the implementation process of these evaluations, which required adjustments. As expected, prescription suitability outnumbered pharmacotherapeutic profile evaluations. This trend was observed throughout the study period, except from January to June 2022. This deviation could be due to the lack of clinical pharmacists in the second afternoon shift, highlighting the need for clinical pharmacists across all shifts. The most prevalent medication errors were related to frequency, suggesting a lack of standardisation in clinical guidelines for patient treatment. A comprehensive strategy is needed to address this issue. It should involve reviewing and updating the guidelines and implementing modifications that have a clinical impact.
Figure 3 illustrates the trend of pharmacist interventions and the relationship between clinical pharmacists and the multidisciplinary healthcare team. It shows a decrease in RRPI from November 2021 to April 2022, which could be attributed to the incorporation of new pharmacy students who began their training in the department in January 2022; additionally, the decrease in RRPI observed in April 2022 corresponds to the incorporation of new medical residents in March 2022. This pattern can be explained by the adjustment between the new medical residents and pharmacy students during their professional practices. It is expected to observe this behaviour every year, reflecting the learning process of both healthcare professionals.
Several studies have reported varying acceptance rates of pharmacist interventions, ranging from 71% to 81% and reaching as high as 88%. This results of this study revealed an acceptance rate of 40.49% and an RRPI average of 40.23%. Despite being relatively modest, this acceptance rate is a promising starting point towards the established goals of enhancing medication safety. The PFUU comprises three trained clinical pharmacists and pharmacy student trainees. An improvement in the RRPI is expected with the incorporation of additional trained clinical pharmacists and the implementation of this process on a broader scale.
The Ghana health system operates at different levels: from the CHPS compounds being the lowest, to health centres, polyclinics, district and private hospitals, regional and tertiary hospitals being the highest. The services that are provided differ at each level and becomes more sophisticated as the level rises. Although the gate-keeper referral system is proposed by the MOH in collaboration with NHIS in a number of circumstances self- referral takes place because some of the facilities are not well re-sourced. The results revealed that most participants with hypertension and diabetes in the rural communities sourced medicines from the health centre while in the urban communities, the participants’ source of medicines was from the hospital. This compares with a study conducted in Brazil where medications were mainly obtained with a medical prescription at the pharmacy or hospital. In South Africa, chronic dispensing units are set up as the main sources of medications for stable patients with chronic conditions. This practice is different from what pertains in Ghana, where patients with chronic diseases do not have designated places for medicines. Participants with hypertension and diabetes in both communities also obtained medicines from health institutions in the public sector, presumably, when they go for regular follow up visits. Most of the participants with hypertension and diabetes are enrolled on the NHIS and hence are entitled to free medicines for the management of hypertension and diabetes when they go on follow–up visits. Access to medicines plays an important role in the health care delivery system. It serves as an input that should be available for an efficient and effective service delivery. It has been found that health systems are usually strengthened when adequate structures are in place to ensure equitable access to good quality medicines. In the rural communities there was no significant association between predisposing and enabling factors and source of medicine by participants after multinomial analysis. In the urban communities however, increasing age was associated with a more likelihood to source medicines from the Over the Counter Medicine Shop (OTCMS) than the pharmacy and an equal likelihood to obtain medicines from the hospital as pharmacy. Participants with hypertension and diabetes in the urban communities have more access to pharmacies than in the rural communities; likewise, also they are able to obtain medicines from the hospital as well. This finding compares with a study that identified age as a predisposing factor among others that influences health service utilization. Essential medicines have been found to be a foundation of almost all public health programmes that aim at reducing morbidity and mortality. Access and source of medicines therefore form part of the essential services that should effectively be accomplished to ensure improved health outcomes. The multinomial logistic regression analysis indicated that there was no significant association between the enabling factors of sourcing of medicines in the rural communities. However, in the urban communities, participants within low socioeconomic status were less likely to source medicines from the hospital than the pharmacy. This practice was observed since participants, especially those enrolled on NHIS could obtained their medications at the pharmacy. This finding is similar to a study conducted in Cambodia where it was found that the social health systems in place ensured that persons with hypertension and diabetes had access to medicines appropriate for the management of disease conditions. Availability of medicines alone however does not ensure improved health outcomes.
