Author(s)

Martin Torrente. A; Picaza Iturricha. E; Carmona Oyaga. P; Lombera Sáez. L; Gemio Zumalave. PR; Illodo Becerra. JA; Ibarra Barrueta. O.

Why was it done?

The Hospital Pharmacy Department developed a unit to dispense medications in individualized dosing systems for residents of health and social centers with the aim of improving pharmaceutical care. This initiative seeks to ensure safe, efficient and patient‑centred medication supply managementin centers.

What was done?

A structured survey was designed and distributed to healthcare professionals to evaluate the service provided.

How was it done?

The questionnaire was created through a collaborative brainstorming session with the pharmaceutical team following literature review of existing tools. Thematic domains were defined based on practical experience and service priorities. Each section was assigned to a different pharmacist to ensure clarity, relevance and consistency. The final 36‑item survey, generated using Google Forms, included two descriptive questions (nursing home name and respondent’s professional role) and 34 evaluative questions grouped into four thematic areas: 14 questions on satisfaction with medication deliveries (blister-packed and non-blistered), 6 on incident resolution, 8 on logistics of transport and 6 on overall perception of the impact on professional workflow and patient safety. The survey combines Likert scales, multiple-choice items and open-ended fields to gather both quantitative and qualitative feedback.

What has been achieved?

The survey captures satisfaction with deliveries and labelling, completeness of orders, incident management and logistics aspects such as punctuality, packaging condition and integrity. It also gathers overall perceptions of the service’s impact on workflow and patient safety. Open‑ended fields encourage reporting of problems, suggestions and observations to ensure a comprehensive view of performance.

What next?

The questionnaire will be distributed to health and social centers. Data will be analysed to inform service improvements. Cronbach’s alpha is used to assess internal consistency and p‑values to examine significant differences. Findings will identify strengths and areas for improvement in the pharmaceutical care model, inform training strategies and support future policy decisions.

Author(s)

Bennani I., Cherif Chefchaouni A., Alaoui S., Hajjaj S., El Deeb S., Boufaress S., Hafidi Y., El Merrakchi S., Moukafih B., Bandadi F., El Kartouti A.

Why was it done?

Despite their benefits, ADCs present critical vulnerabilities such as inappropriate overrides, stocking errors, look-alike/sound-alike (LASA) drug confusion, workarounds with barcoding, and incomplete profiling. These failures increase the risk of medication errors, stock mismanagement, and patient harm. A structured, universal improvement method was needed to mitigate risks and enhance sustainability.

What was done?

A safety improvement bundle (SAFE-6) was developed to address recurrent failures of Automated Dispensing Cabinets (ADCs) in clinical units. The approach targeted six critical areas: override governance, smart search and naming, barcode stocking verification, configuration hygiene, workflow integration with BCMA, and monitoring with downtime readiness.

How was it done?

A multi-step audit was performed to identify weaknesses in current ADC use. Root cause analysis guided the development of the SAFE-6 bundle. Each hospital unit implemented one improvement component at a time, followed by data collection and multidisciplinary feedback. Quantitative and qualitative indicators were monitored to evaluate safety gains and operational efficiency.

What has been achieved?

Implementation of SAFE-6 led to measurable safety improvements: reduction of inappropriate overrides, decreased inventory discrepancies through barcode verification, increased use of profiled dispensing linked to electronic prescribing, and reduction of LASA-related risks through smarter search functions. Staff acceptance improved with clear governance tools and training modules, and quality assurance indicators were integrated into routine audits.

What next?

The SAFE-6 approach will be expanded to intensive care and emergency departments, with inter-hospital benchmarking to validate scalability. Future steps include integration of advanced analytics to detect override anomalies and potential diversion signals, as well as collaboration with vendors to enhance user interfaces and standardisation of drug labelling.

Author(s)

C Gastalver Martin, O Serna Romero, I Escribano Valenciano, S Buendia Bravo, FJ Alonso Zazo, S Alvarez Atienza, D Garcia Gordillo, M Rubio Garcia, AM Iglesias Bolaños.

Why was it done?

Medications prescribed in hospital’s electronic prescribing programs are transferred to automated dispensing devices (ADDs) to prevent medication errors and increase patient safety. This allows nurses to withdraw drugs from ADDs according to the medical prescription, dosage and schedule. However, most intensive care units (ICUs) have their own prescribing systems, usually computerized vital signs charts, which operate independently from the rest of the hospital systems. This fact could be a risk for patient safety.
The objective of this project is to increase the safety of patients admitted to ICUs by integrating prescriptions recorded in the computerized ICU chart with medication withdrawals from the ADD, thereby reducing medication errors.
A secondary objective was to automatically detect medications prescribed in the ICU but not entered into the unit’s ADD, improving medication availability without the need for manual review of the ICU prescription by the pharmacist.

What was done?

This project increase the safety of patients admitted to the Intensive Care Unit by integrating prescriptions recorded in the automated ICU chart with medication withdrawals from the ADD.
This also permitted to detect automatically medications prescribed in the ICU but not available into the unit’s ADD, increasing medication availability without the need for manual review of the ICU prescription by the pharmacist.

How was it done?

This project was implemented in several phases:
1. Preparation Phase
a. Cleanup of the ICU chart medication database: review of standardized treatment lines, dose adjustments to medication presentations, and removal of duplicates.
b. Mapping of the medication database: assignment of the article codes contained in the ADD to the treatment lines in the ICU chart, so that both systems can communicate with each other.
2. Implementation Phase
a. Integration testing and troubleshooting.
b. Go-live.

What has been achieved?

The implementation of computer integration of medical prescriptions through automated dispensing devices increased patient safety and reduced medication errors.
It also decreased the need for manual review of the ICU prescription by the pharmacist to ensure medication availability in the ICU ADD.

What next?

Pharmaceutical validation of medical prescriptions for ICU patients remains essential to ensure the appropriate treatment of these patients

Author(s)

Andrea Piovanelli, Ivan Schimmenti, Enrico Almici, Paola Crosasso, Fabio Genestrone, Elena Toniato

Why was it done?

Medical devices’ traceability is a critical issue in hospital settings due to the high cost of devices and the need to associate item-patient-procedure. Standardized identification systems become fundamental to manage clinical risk, while addressing inefficiencies in inventory management, and minimizing waste from poorly monitored expiration dates. RFID-based solutions have been tested to implement identification and traceability with the promise of automating procedures and facilitating personnel activities, nonetheless their complexity and cost have limited their adoption so far. EU Regulation 2017/745 (MDR) introduced the requirement of native UDI (Unique Device Identifier) codes present on each medical device. As such, it is now possible to implement simple and cost-effective solutions for identification and traceability that do not require specific hardware or tedious relabeling procedures compared to RFID, and exploit 2D data carriers natively present on MDs.

What was done?

To implement a digital, end-to-end traceability system for medical devices using native UDI (Unique Device Identifier) codes, in compliance with EU Regulation 2017/745 (MDR). The objective is to improve patient safety, optimize inventory management, reduce operational costs, and ensure regulatory compliance without the need for relabelling and dedicated personnel.

How was it done?

The proposed solution leverages optical identification technologies and hands-free systems to automate device tracking from hospital entry to patient association. Smart cabinets manage inventory and access control, while smart baskets automatically link devices to patients. An AI-powered platform analyses data across all phases to support stock optimization, automatic reordering, structured reporting, and performance evaluation.

What has been achieved?

The system enables real-time inventory visibility, eliminates manual errors, improves device utilization. Avoiding costly, time-consuming and risky relabeling of MDs with RFID tags lowers implementation costs, minimizing environmental impact. Clinically, it enhances patient safety enabling rapid response to recalls and adverse events. Operationally, it streamlines logistics, reduces staff workload, and improves planning through AI-driven insights.

What next?

The adoption of an end-to-end UDI-based traceability system represents a significant advancement in medical device management. It delivers tangible benefits in terms of economic efficiency, clinical safety, organizational performance, and environmental sustainability. This innovative approach aligns with the digital transformation of healthcare and offers a scalable model for hospitals seeking to modernize their logistics and compliance processes

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Author(s)

BEATRIZ MONTERO LLORENTE, ELENA GEMENO LÓPEZ, CARMEN PALOMAR FERNÁNDEZ, ANA MARÍA ÁLVAREZ DÍAZ

Why was it done?

To avoid stock breaks of medication due to unforeseeable fluctuations in their regular consumption. To reduce claims to the Pharmacy Service (PS) for medication shortages in automated dispensing systems (ADS) and other dispensing circuits. To achieve economic savings by avoiding unnecessary loans. To manage these loans in the morning when needs are detected in advance, with the consequent reduction in the time it takes for the pharmacist to manage it during on-call hours (approximately 2 hours per loan).

What was done?

We designed and implemented a tool to control in advance the stock of medication dispensed to hospitalisation and outpatient units and thus be able to forecast needs based on current prescriptions and associated habitual consumption.

How was it done?

1. An Excel file was developed in which the information on automated storage systems (ASS), ADS and prescriptions were integrated. It included maximum, minimum and current amount, and estimated coverage (in days) according to the consumption forecast associated with current prescriptions. We established the minimum amount based on a coverage threshold of 7 days.
2. Basic drug needs were studied (adjustment of maximum and minimum in the ASS and ADS, a dynamic process periodically reassessed according to demand).
3. The order information was added: order status, request date, last receipt date, order number and laboratory. These items allowed us to quickly locate old orders so we could address the reason for the delay in procurement.
4. We included medications stored externally to the ASS to control their stock electronically.

What has been achieved?

Loans requested annually from other hospitals were quantified as an indicator of improvement in acquiring medicines stored in the ASSs.
We obtained an annual reduction in the number of loans of 34.4% between 2019 and 2020 (125 loans vs 82) and 56.1% between 2020 and 2021 (82 loans vs 36). This result represented an average decrease in the time to manage loans of approximately 7 hours/month between 2019 and 2021.

What next?

The tool can be applied to all PS with ADS and ASS, intending to have the necessary medication available at the necessary time and thus avoid possible clinical damage to patients’ health derived from the delay in their treatment.

Pdf

Author(s)

Marinos Petrongonas, Maria Fragiadaki, Eleni Rinaki, Leonidas Tzimis

Why was it done?

HPs were facing challenges related to:
• Stuff shortages in a high risk environment with increasing uncertainty
• Implementation of Directive 2001/83/EC on Falsified Medicines; deadline for Greece is 2025
• Medicines’ shortages for which optimal inventory management procedures are needed • Patient safety and quality of pharmaceutical services: quality assurance processes, medicines’ traceability, monitoring expiration dates and respond-time to ward’s requests

What was done?

During the last 2 years, hospital pharmacists (HPs) actively participated in the supply, installation and functional integration of the first Automated (Robotic) Dispensing System (ADS) in Greece, in Chania General Hospital (CGH). It is a centralised distribution system installed in the pharmacy department which receives, stores and distributes packages of medicines.
It has a storage capacity of approximately 20,000 packages, including one robotic arm, three distribution exits, two loading ways (semi- and fully-automated), with software comprised. Speeds range from 200 to 900 for loading and 350 to 760 packages/hour for unloading. Under HPs’ direction, medicine management procedures were modified to ensure ADS’ functionality.

How was it done?

Since Pharmacy department of CGH was the first to install an ADS, a new route had to be inaugurated, concerning how HPs:
• Developed the proposal
• Documented and justified such a supply to be prioritised in funding
• Performed market research in Europe, as no such national market existed
• Drafted technical specifications, to assure the best system supplied
• Participated in an international tendering procedure (budget 130,000 euros)
• Planned and supervised installation and functional integration of the system
• Managed interoperability between ADS’ software and the pharmacy’s Information System
• Faced issues related to different barcodes on medicines’ packages

What has been achieved?

After 3 months of use:
• 50% of medicines’ codes and 35% of total packages are dispensed with ADS monthly
• 1.4 full-time pharmacy assistants equivalent is saved
• Response time to requests decreased
• Traceability and quality are better assured
• Falsified medicines’ check can run automatically
• Storage space is saved

What next?

HPs are ready to share nationally and internationally their experience in developing and installing an ADS with colleagues interested in adopting similar solutions. Hospitals from the same region have already shown their interest.

Author(s)

Louise Refsgaard, Linda Skovsted, Nina Bøggild

Why was it done?

The medical supply vending machines were implemented during 2021 as a way of direct-to-patient distribution of medicine with more flexibility. The aim was to offer 24-hour access to collect medicine at a location that suits the patient, e.g. close to the patient’s home.

What was done?

Medical supply vending machines were implemented in the Capital Region of Denmark. The vending machines allow patients to collect their medicine whenever and wherever it suits them. It is the patient’s healthcare professional that controls and orders the medicine. The hospital pharmacy staff consults the prescription and labels, dispenses and records the medicine and places it in the vending machine for collection.
Patient and staff satisfaction was surveyed.

How was it done?

The implementation of this new direct-to-patient distribution method was carried out by the Capital Region Hospital Pharmacy in close collaboration with the region’s hospitals and outpatient departments. Installing the machines was fast but a full implementation requires that the clinical staff rethink their practice and accept that dispensing is no longer their responsibility. This has been the biggest obstacle along with creating patient safe procedures.

What has been achieved?

7 medical supply vending machines were installed centrally in hospitals in the Capital Region of Denmark. The machines are now used to distribute medicine to some of the region’s outpatients.
The patient satisfaction survey showed that the patients are very satisfied with the vending machines: 100 % are either ‘highly satisfied’ (86 %) or ‘satisfied’ (14 %) with the new service, and 97 % would like to use it again. The staff was also satisfied with the new service.
Additionally, the quality of medicine dispensing is increased due to hospital pharmacy staff dispensing the medicine rather than nurses.

What next?

In order to offer flexibility to patients and increase the quality of dispensing of medicine, we aim to increase the number of patients that collect their medicine from the vending machines by using the current machines in their full capacity and installing more machines. We also aim to collaborate with Denmark’s other 4 regions, so that patients, who are treated outside their home region, can collect their medicine in a vending machine closer to their home.

Pdf

Author(s)

Theodora Steindl-Schönhuber, Gittler G.

Why was it done?

Medication dispensing is a time-consuming, labour-intensive, error-prone process in the daily routine on the wards. The project was triggered by the tight personnel situation during the Coronavirus pandemic: In November 2020 three wards with COVID-19 patients (91 beds) were integrated into our Unit Dose blister service to assist the nursing staff. A multidisciplinary effort (management, IT-department, doctors, nursing staff, pharmacy holding a GMP-manufacturer´s certificate) and long-established electronic patient records including medication data enabled fast realisation.
After transformation back to a chirurgical, an internal and a geriatric ward the service was continued and extended to the neurological unit (49 beds) due to positive feed-back. We wanted to study the observed positive effects of Unit Dose supply in more detail.

What was done?

In our hospital medication distribution has been switched from manual dispensing by ward staff to automated Unit Dose blister packaging by the pharmacy. Our study investigates the impacts of this change on medication safety, staff satisfaction, time and drug resources.

How was it done?

The percentage of pharmacy-blistered drugs, time gain for nursing staff, employee satisfaction, medication consumption and erroneous blister fillings were investigated.

What has been achieved?

Unit Dose in hospitals is not standard for many countries and is so far unique in Austria. Therefore, we would like to share our experiences and findings with our colleagues: Solid, oral dosage forms could be supplied by 99% via Unit Dose. Time for manual drug dispensing was reduced by 75%. A survey showed high employee satisfaction with the supply process as well as the quality and correctness of the blisters. Consumption of blisterable drugs and stocks on the ward were reduced by 44% and 78%, respectively. Errors in blister fillings in our setting amount to 0,006%. When compared to literature references on error rates for manual medication dispensing (up to low double-digit rates), patients benefit from increased drug therapy safety. On the basis of these results our initiative was granted the Austrian Patient Safety Award 2021 in the field of medication safety.

What next?

We plan to extend Unit Dose to the remaining wards and to investigate patient satisfaction with the blisters, cost-efficiency and distribution of high-cost medications.

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Author(s)

Serdar Kaya, Ulker Sener

Why was it done?

Despite medical devices and supplies are often high-cost products, they are often sub-optimally managed by hospitals. The objectives of the installation were the optimization and the automation of the inventory, and the charge management workflows, to comply with JCI (Joint Commission International) standards and address current challenges as safety, labor, stock-outs, space, costs and charges accountancy, traceability.

What was done?

An integrated Inventory Management and automation solution was implemented at Amerikan Hospital Istanbul (BD Pyxis™ SupplyStation™ system). 83 automated dispensing cabinets, a central management system, and a data analytics solution, are serving the 278-beds hospital.

How was it done?

The workflows for medical devices/supply inventory, and for patients charge management were mapped pre-installation and major challenges identified. Based on these needs, the decision to automate the hospital supply management was made. The cabinets were installed in the whole hospital but in particular in operating rooms, emergency rooms and intensive care units.

What has been achieved?

The impact of automation was measured one-month pre and one-month post installation, and five major areas of improvements have been identified:
1) Significant decrease in workload: -8% for nurses; -30% for charge secretaries
2) Missing charge rate reduced from 2.5% to 0.1%
3) Improved use of space and material organization
4) Inventory optimization: 0% stock-out, -16% expired items; – 45% on-hand inventory
5) Improved materials and patients’ safety, ensuring that supply were managed in the right way by the right staff. Patients are now protected by the risk of being provided with the wrong device.
All the nurses (n>50) were interviewed, reporting great satisfaction and ease of use with the new system. Furthermore, a positive return on investment was achieved in 4 years.

What next?

Due to legal regulations (MDR Regulation/ UDI Tracking requirements) the hospital is planning to leverage the automated system to achieve a full compliance and traceability of critical medical devices throughout their hospital.
The decision of investing in automation demonstrated important benefits in terms of safety and efficiency, with a positive impact on the hospital’s economy as well.

Pdf

Author(s)

MARINA RODRÍGUEZ MARÍN, HILARIO MARTÍNEZ BARROS, MARÍA DEL ROSARIO PINTOR RECUENCO, BEATRIZ MONTERO LLORENTE, ANA MARÍA ÁLVAREZ DÍAZ

Why was it done?

It was done in order to optimize opioids stock to meet the needs of COVID-19 patients and protocolize the correct quarantine without modifying the computerized registration in the 39 ADS.

What was done?

A procedure was implemented to optimize the stock and manage the quarantine of opioids in Automatic Dispensing Systems (ADS) during and after their use in hospital units hosting COVID patients.

How was it done?

As hospitalization units were being adapted to host COVID-19 patients, opioids stock had to be modified to meet their new demands. Reversely, when hospitalization units were recovered to host their usual type of patient, the opioids had to be replaced and quarantined for ten days, according to our Preventive Medicine Unit. All these movements were recorded.
We followed this process:
1. Physical and computerized unloading of opioids without dispensing in recent months and emptying of the returned drawer (storage space for opioids withdrawn from the ADS which were not used).
2. Relocation to hospitalization units hosting COVID-19 patients,
3. Replacement of all (minidrawers) where opioids were kept with clean ones
4. Quarantine in the Pharmacy Service, for the drugs unloaded which were unable to be immediately relocated.
5. Cleaning and sanitizing of the removed minidrawers from COVID-19 hospitalization units’ ADS to be used in the next conversion.

What has been achieved?

29 ADS of the 39 available in the hospital were optimized.
Given the decreased in COVID-19 admissions during May, the hospital made a schedule to return to normality which allowed to leave 5 ADS in quarantine without the need to unload or replace any drug,. The other 24 ADS had to be cleaned and disinfected,. It led to the physical unloading of 182 specialties (a total of 1,519 units), the physical and computerized unloading of 124 specialties (850 units) and the emptying of the returned drawers (18 specialties and 20 units). 504 minidrawers were replaced by other cleaned and disinfected ones and 298 specialties (2,080 units) were replaced.

What next?

Enhancing our protocol to allow us to spend more time with the patients in Covid’s further waives.