Background Medication counselling opportunities are key times for pharmacists and patients to discuss medications and patients’ concerns about their therapy. Communication Accommodation Theory (CAT) describes behavioural, motivational and emotional processes underlying communication exchanges. Five CAT strategies (approximation, interpretability, discourse management, emotional expression and interpersonal control) permit identification of effective communication. Objective To invoke CAT to investigate communication strategies used by hospital pharmacists during patient medication counselling. Design This was a theory‐based, qualitative study using transcribed audiorecordings of patients and hospital pharmacists engaged in medication counselling. Setting and participants Recruited pharmacists practised in inpatient or outpatient settings. Eligible patients within participating pharmacists’ practice sites were prescribed at least three medications to manage chronic disease(s). Main outcome measures The extent to which pharmacists accommodate, or not, to patients’ conversational needs based on accommodative behaviour described within CAT strategies. Results Twelve pharmacists engaged four patients (48 total interactions). Exemplars provided robust examples of pharmacists effectively accommodating or meeting patients’ conversational needs. Non‐accommodation mainly occurred when pharmacists spoke too quickly, used terms not understood by patients and did not include patients in the agenda‐setting phase. Multiple strategy use resulted in communication patterns such as “information‐reassurance‐rationale” sandwiches. Discussion and conclusions Most pharmacists effectively employed all five CAT strategies to engage patients in discussions. Pharmacists’ communication could be improved at the initial agenda‐setting phase by asking open‐ended questions to invite patients’ input and allow patients to identify any medication‐related concerns or issues.