the Pharmacy Intervention Team Hospital-based (PITH) for People Study: Effect on Clinical and Economic Outcomes

Inclusion Criteria: * \> three prescribed systemic drugs intended for chronic use at admission and discharge * an expected length of stay of 48 hours or longer * insured with the Dutch insurance company Agis/Achmea * patients or their carers are able to express themselves in Dutch or English Exclusion Criteria: * scheduled chemotherapy * radiation therapy * transplantation * transfer from another hospital * transfer from another non-eligible ward within the same hospital * no informed consent has been signed * a live expectancy less than 6 months * deceased during admission * inability to be counselled (e.g. cognitive dysfunction, language constraints) * discharge to a nursing home (presuming dependence on medication administration). Patients will only be included once.