In-hospital pharmacotherapeutic stewardship: A paradigm shift towards interprofessional and safer prescribing practices

Prescribing errors are a leading cause of preventable harm in hospitals, contributing to adverse drug events, prolonged hospital stays and rising healthcare costs. Despite decades of interventions - such as computerised physician order entry, on-ward participation of pharmacists and medication reconciliation - their effectiveness in routine clinical practice remains limited. Hospital prescribing remains a complex, high-risk process characterised by individual performance knowledge gaps, systemic failures and organisational inefficiencies. This thesis introduces In-hospital pharmacotherapeutic stewardship (IPS) as a novel, interprofessional strategy to reduce prescribing errors and improve medication safety. IPS reframes prescribing as a shared clinical responsibility, requiring structured collaboration between prescribers, pharmacists and other healthcare professionals, supported by the wider hospital environment. Through systematic reviews, observational studies and ward-based interventions, this research identifies persistent causes of prescribing errors, including inadequate pharmacotherapy knowledge, excessive workload, unclear protocols and guidelines and underperforming digital systems. Fragmented care pathways and high-pressure contexts, such as the COVID-19 pandemic, further expose these vulnerabilities. A key outcome of this work is the development of 35 internationally validated quality indicators that provide a practical framework for implementing IPS in different hospital settings. These indicators define essential roles, team composition and measurable outcomes to guide and evaluate safe prescribing practices. IPS represents a paradigm shift in the approach to prescribing safety - moving beyond narrow error detection and individual accountability to a proactive, system-level strategy. Rooted in the Safety-II framework, IPS emphasises resilience, continuous learning and reinforcement of what goes right in clinical practice. By embedding pharmacotherapeutic expertise into daily workflows and promoting interprofessional collaboration, IPS transforms safe prescribing from the exception to the norm. More than just another intervention, IPS offers a scalable, evidence-based model for addressing the real-world complexities of hospital care and preventing medication-related harm. It provides a practical, sustainable pathway to safer, in-hospital prescribing