INTEGRATION OF PHARMACEUTICAL CONSULTATION IN A PNEUMOLOGICAL DIAGNOSTIC CENTER
European Statement
Clinical Pharmacy Services
Author(s)
André Maia; Maria Teixeira; Ana Catré; Inês Margalho; Joana Duque; Marisa Costa; Marta Susana; Miguel Paulo; Tomás Sousa; Vânia Pereira; Teresa Pereira
Why was it done?
Tuberculosis(TB) is an infectious disease caused by Mycobacterium tuberculosis, typically transmitted through the airborne route. Despite being a curable disease, 1.5 million people die from tuberculosis each year, making it the leading cause of infectious death worldwide.[1,2] In Portugal, the most recent data from the National TB Program indicate a notification rate of 14.5 cases per 100,000 population in 2023. Regarding multidrug-resistant tuberculosis cases, the number of cases has doubled.[3] There was a need to restructure the anti-tuberculosis drug management circuit in the Pneumology Diagnostic Centers(CDP), creating a Personalized Distribution of Anti-tuberculosis Therapy (DPTB), to facilitate administration, improving adherence to therapy and therapeutic reconciliation.
What was done?
Pharmaceutical consultation was implemented in a pulmonological diagnostic center and the interventions performed during the Pharmaceutical Consultation (FC) were analyzed.
How was it done?
The pilot project began in collaboration between Pharmaceutical Services and the responsible Physician. Each month, the pharmacist visits the CDP and validates the medical prescription and prepares the DPTB for one month. During the FC, the information recorded by the physician in the previous consultation is verified, patient compliance is assessed, and therapeutic reconciliation is structured. A manual and tools to support healthcare professionals were developed, essential for improving the efficiency of TB treatment.
What has been achieved?
Between April and August 2025, 38 FC were carried out, in which a total of 11 patients with median age 59 years, 7 (64%) female and 4 (36%) male. The patients monitored were divided into: 5(45.5%) with latent TB, 3(27.3%) with active TB, and 3(27.3%) with atypical mycobacteria. The TB infection, 1(33.3%) case of pulmonary TB, 1(33.3%) of lymph node, and 1 (33.3%) of ocular TB. During the FC, 7 interventions were carried out: 1 drug interactions, 3 teaching and promotion of adherence to therapy, and 3 on adverse reactions (AE).
What next?
Pharmacists’ interventions in educating patients, counseling on AEs, monitoring and alerting them to risk situations significantly contribute to reducing treatment abandonment, one of the greatest challenges in tuberculosis control. In the future, we plan to conduct these in-person consultations in Primary Care settings for patients referred to by their physician.
REVOLUTION IN MEDICATION RECONCILIATION: DEVELOPMENT AND IMPLEMENTATION OF A DIGITAL TOOL TO PRIORITIZE PATIENTS IN RECONCILIATION.
European Statement
Clinical Pharmacy Services
Author(s)
Mireia Coll-Vinent Ollé, Alba Martin Val, Lidia Estrada, Adrián Vilariño Seijas, Ana Cia Hidalgo, Marlene Álvarez Martins, Clara Rodríguez González, Júlia Galí Fortuny, Raquel Gil Bardají.
Why was it done?
Care transitions are a major source of medication errors; therefore, therapeutic reconciliation plays an essential role in patient safety and treatment continuity. However, increasing workload and limited staff make it unfeasible to conduct thorough reconciliation for all patients systematically. The aim of this initiative was to develop a tool that enables prioritization of patients in therapeutic reconciliation and high-risk medication-related problems (MRPs) detection
What was done?
A digital tool was developed and implemented to prioritize patients for therapeutic reconciliation at hospital admission and discharge. This approach allows hospital pharmacists to focus on patients with the greatest need for reconciliation, optimizing available resources and improving care continuity. The tool integrates structured clinical data from multiple sources: hospital and primary care records, electronic prescriptions, laboratory results, and nursing documentation.
How was it done?
A multidisciplinary team composed of clinical pharmacists and data engineers was established to design and implement the tool. Intelligent algorithms were developed to detect predefined alerts related to pathological history, inappropiate medication, anticholinergic burden, MRPs, drug–diagnosis and drug–parameter interactions, and drugs increasing fall risk. The tool was first validated through a pilot project, after which the algorithms were redefined based on preliminary results. Obstacles such as data integration from different systems, synchronization, and resource constraints were addressed by close collaboration with IT teams, and practical application of the tool.
What has been achieved?
The tool successfully reduced the time required for reconciliation by automatically prioritizing high-risk patients. It facilitated early detection of MRPs, leading to timely interventions and preventing potential adverse drug events. It also strengthened communication between hospitals, primary care, community pharmacies, and social-health centers, and supported health-care continuity.
What next?
This initiative represents a scalable model of good practice. It can be expanded to other hospitals and care settings where provided clinical data are structured and IT integration is feasible. Its adoption in broader healthcare contexts could optimize therapeutic reconciliation processes, reduce errors, and enhance patient safety across systems.
IMPLEMENTATION OF A PHARMACOKINETIC MONITORING UNIT FOR PSYCHIATRIC MEDICATIONS IN A SPECIALIZED MENTAL HEALTH HOSPITAL
European Statement
Clinical Pharmacy Services
Author(s)
Ana Puebla Villaescusa, Elena Rodríguez del Río, Elena López Lunar, Sonia Fraile Gil, Eduardo Tejedor Tejada, José Diéguez Gómez, José Manuel Carrascosa Bernáldez
Why was it done?
Due to the high interindividual variability in response to psychiatric treatments (age, weight, comorbidities, polypharmacy, diet, addictions, genetic polymorphism), pharmacokinetic monitoring is essential to individualize and optimize drug dosages, improve clinical efficacy, and reduce adverse effects.
What was done?
A pharmacokinetic monitoring unit for psychiatric medications was established in a specialized mental health hospital.
How was it done?
• Design: Prospective study of plasma psychiatric drug levels in patients from a specialized mental health hospital between June and September 2025.
• Drugs monitored: valproic acid, lithium, clozapine, carbamazepine, risperidone+9-hydroxy-risperidone, olanzapine.
• Data collection: anthropometric and laboratory data, comorbidities, plasma levels, dosing history, drug interactions, addictions, dosage adjustment recommendations.
• Pharmacokinetic software: Bayesian and population pharmacokinetic models.
What has been achieved?
n= 129 patients (and 284 level measurements): 12 patients (9.3%) had levels above the established therapeutic ranges, and 35 (27.1%) had levels below range in at least one measurement.
• Valproic acid (n = 49): 5 (10.2%) above range (4 due to hypoalbuminemia); 14 (28.6%) below range. Among those, 5 using it as a mood stabilizer remained clinically stable without dose increase; 2 reduced their doses due to adverse effects while remaining stable. The rest had low levels due to different factors (drug interactions, clinical circumstances, poor adherence).
• Lithium (n = 34): 6 (16.7%) below range, half of them clinically stable; 1 (2.7%) above range due to an interaction with enalapril.
• Clozapine (n = 14): 9 (64,3%) below range due to several factors (poor adherence, adverse reactions that requires lower doses, possible genetic polymorphism). Despite below range, some patients remained clinically stable. The majority of patients were smokers, which significantly increases the drug’s metabolism, complicating dose adjustment without pharmacokinetic monitoring.
• Carbamazepine (n = 2): both within therapeutic range.
• Risperidone + 9-hydroxy-risperidone (n = 19): 2 (10.5%) below range; 7 (36.8%) above range, three of whom required monitoring for renal impairment, and the rest needed dose reductions to avoid supratherapeutic levels.
• Olanzapine (n = 9): 2 (22.2%) below range, one due to suspected non-adherence.
What next?
Ongoing optimization of pharmacokinetic monitoring of psychiatric medications, in which individualized dosage adjustment is required in a high percentage of patients to improve treatment efficacy and reduce adverse reactions in these patients.
DEVELOPMENT OF CLINICAL PHARMACY IN A HOME HOSPITALIZATION SERVICE: IMPLEMENTATION OF NEW ACTIVITIES.
European Statement
Clinical Pharmacy Services
Author(s)
D. AUDEGEAN, C. HAMELIN, C. CONTENT, C-H. BLANCHER
Why was it done?
The care of patients receiving home hospitalization is complex. These patients experience multiple transitions throughout the care process and are treated by many health professionals, both in hospitals and private practitioners. This increases the risk of losing important information.
What was done?
To improve safe medication management and make treatment delivery more efficient, new clinical pharmacy activities were implemented.
How was it done?
A medication review and a pharmaceutical consultation were added to pre-admission visits. Unintended discrepancies in patients’ treatment lists and the corresponding pharmaceutical interventions were identified and analysed. A French program, Patient Self-Administration of Medications, to support patients in managing their own medications was introduced following an initial assessment of autonomy by a clinical pharmacist. Information collected during these pharmacy activities was shared with community healthcare providers. The satisfaction of the home hospitalization medical team was also assessed.
What has been achieved?
Over six months, 41% (n = 34) of patients admitted to home hospitalization from our hospital received the new pharmacy service. A total of 38 medication reviews were done. At least one unintended discrepancy was found in 55% (n = 21) of these reviews. The most frequent problem was unintentional treatment omission. In total, 39 pharmaceutical interventions were made. Their clinical value was rated as “moderate” in 69% (n = 27) of cases. Most patients (47.5%) had an autonomy score of 0. Liaison letters were sent to community healthcare providers using secure messaging. All physicians (100%, n = 4) said they were “completely satisfied” with the new clinical pharmacy activities.
What next?
These new clinical pharmacy services helped ensure the safe use of medications in home care patients. Sharing information with community providers improved the link between hospital and community care and supported continuous medication management. However, current staffing levels do not allow all patients to benefit. Involving pharmacy technicians in medication reconciliation may help increase the number of reviews performed. The unanimous satisfaction of the medical team supports continuing these activities in the home hospitalization service.
USING ARTIFICIAL INTELLIGENCE TO TRAIN FUTURE PHARMACISTS : EVALUATION OF A CHATBOT DEVELOPED FOR THE ONCOLOGY PHARMACY UNIT
European Statement
Education and Research
Author(s)
P. BROUARD
C. JUTARD
C. COUSIN
E. COGET
Why was it done?
The Oncology Pharmacy Unit within the hospital pharmacy is experiencing a steady increase in activity. Medical teams are increasingly calling on pharmacy interns for technical and clinical questions.
What was done?
To enhance the training of pharmacy interns and improve responsiveness to medical inquiries, an artificial intelligence (AI) driven pharmaceutical chatbot pre-configured using a dedicated prompt. It was developed to deliver accurate, context-specific answers on clinical pharmacy, pharmaceutical technology, and organizational aspects of the oncology unit. This study aims to assess the relevance and quality of its responses to evaluate its potential as a support tool in intern training.
How was it done?
A total of 123 anonymized documents, including procedures, educational materials, and internal resources from the oncology unit of the hospital pharmacy, were integrated into a dedicated chatbot developed with ChatGPT-5. Forty questions reflecting eight key thematic areas of residents’ activities—clinical and technological validation, outpatient dispensing, controlled atmosphere areas, medical staff inquiries, software use, routine practice, and on-call situations—were submitted to the AI. Four experts pharmacists independently assessed each response using a standardized evaluation form with four levels of agreement (“Agree,” “Somewhat agree,” “Somewhat disagree,” “Disagree”).
What has been achieved?
Among the 160 responses received, a strong inter-rater consistency was observed, with 90% of evaluations showing concordance among at least three assessors and full unanimity in 20% of cases. Overall, 79% of chatbot responses were rated favorably (41% “Agree,” 38% “Somewhat agree”). The highest satisfaction rates were found in clinical pharmacy (95%), controlled atmosphere areas (95%), and software (90%). In contrast, lower agreement occurred in pharmaceutical technology (65% favorable, 30% disagreement) and particularly in on-call situations, where 55% of responses were considered unsatisfactory.
What next?
These findings confirm the educational potential of this tool, with most answers deemed relevant. Nonetheless, discrepancies underline its limitations regarding specific technical data, including occasional hallucinatory, incorrect, or incomplete responses that lack adequate reference to institutional procedures. Given its potential, we are working to improve this chatbot by refining the prompt, updating the database, and testing other non-hallucinatory AI models.
DEPLOYMENT OF FLASH TRAINING SESSIONS ON HIGH-RISK MEDICATIONS IN CARE UNITS AS PART OF MEDICATION SAFETY
European Statement
Clinical Pharmacy Services
Author(s)
Cartaillac-Julien C.(1), Danjean S.(1), Demazière V.(1)
Why was it done?
As part of the 2026 HAS certification, the “Medication Safety” group launched short training sessions for nurses on high-risk medications. Designed by a pharmacy resident and validated by a nurse, these sessions were implemented despite limited resources and 12-hour shifts.
What was done?
To strengthen medication safety by maintaining a consistent level of knowledge among nurses through regular, unit-based sessions.
How was it done?
These 20-minute “flash” trainings, integrated into continuing education, are conducted by a pharmacy resident directly within care units to optimize staff time. An anonymous 12-question MCQ is completed before and after each session to measure impact. The interactive slideshow format promotes discussion, and participants receive a pocket summary of key points. Satisfaction questionnaires assess the program’s quality in line with QUALIOPI standards. The first module focused on anticoagulants, high-risk drugs frequently involved in “Never Events.” Developed from official and nursing references and reviewed by a frontline nurse, it covers indications, side effects, contraindications, interactions, interprofessional communication, and patient counseling.
What has been achieved?
Seventeen sessions were delivered across eight departments, involving 45 nurses. Small-group formats required several sessions per unit. Knowledge improved, with mean scores rising from 14.2/20 to 16.3/20 (+14.8%). The least-known topics were bleeding signs, indications, and management of missed doses.
Nurses valued the practical content and on-site format, which saved time. Opinions on duration were mixed—some found 20 minutes too short, others saw it as the only feasible format. Unit managers praised the pharmacy team’s adaptability. Participants requested new topics such as antibiotics, antidotes, insulins, potassium, and adverse drug effects, as well as stronger physician involvement.
What next?
These successful short trainings foster collaboration between nurses and pharmacists, standardize practices, and improve medication safety. The initiative will continue with additional modules and expanded participation from other professionals, contributing to a shared culture of safe medication use.
THERAPEUTIC SEQUENCING IN MULTIPLE MYELOMA: THE ROLE OF INNOVATIVE THERAPIES
European Statement
Clinical Pharmacy Services
Author(s)
Cristina Soares
Ana Margarida Dias
Inês Seabra
Patrocínia Rocha
Why was it done?
Multiple myeloma has evolved significantly, as reflected in the latest international guidelines from the International Myeloma Working Group, which underscore the incorporation of novel pharmacological classes—such as proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies, and T-cell redirecting therapies (e.g., CAR T-cell therapy, bispecific antibodies) which have revolutionized treatment paradigms.These therapeutic advances have led to: Improved progression-free and overall survival;Reduced toxicity profiles compared to conventional chemotherapy; Enhanced personalization of treatment, guided by cytogenetic and molecular risk stratification. The strategic sequencing and combination of therapies are now central to clinical decision-making.
What was done?
Following the clinical case of a 54-year-old male patient with IgA/K multiple myeloma, stage II (ISS), undergoing fifth-line therapy with a bispecific monoclonal antibody, the hospital pharmacist key responsibilities included: Therapeutic Optimization; Pharmacovigilance and Safety Monitoring; Support in Advanced Therapies; Collaborating in supportive care strategies; Patient Education and Adherence; Interdisciplinary Collaboration.
How was it done?
The hospital pharmacist played a key role in the validation of protocols, preparation of advanced therapies, pharmacovigilance, and documentation of the patient’s perspective. In this case, the first administration of talquetamab was conducted during hospitalization, following protocol guidelines. The patient developed cytokine release syndrome (CRS), which was successfully managed with two doses of tocilizumab, an anti–IL-6 agent. The pharmacist actively contributed to the preparation, administration, and monitoring of talquetamab, including dose escalation, and coordinated efforts to improve the patient’s quality of life. Additionally, the pharmacist provided counseling on treatment goals, administration routes, and adherence strategies, particularly in outpatient settings and during transitions between therapeutic lines, while serving as a liaison between hematology, pharmacy, and nursing teams.
What has been achieved?
This study demonstrates the importance of a clinical follow up in a patient with MM treated with a innovative therapy and added value of integrating a clinical pharmacist in a multidisciplinary healthcare team to optimize therapeutics outcomes and patient care.
What next?
The future of multiple myeloma treatment presents challenges in selecting innovative therapies, particularly in therapeutic sequencing, toxicity management, access and equity, and real-world data integration. These complexities underscore the essential role of the hospital pharmacist within multidisciplinary teams, ensuring safe, effective, and patient-centered care.
OPTIMIZATION OF PEGASYS® DOSING THROUGH SYRINGES IN THE HOSPITAL PHARMACY: ENSURING SUPPLY DURING A GLOBAL SHORTAGE
European Statement
Selection, Procurement and Distribution
Author(s)
Torres-Pérez, Andrés
Iglesias-Valín, Ana Rut
Mateos-Salvador, María
Fernandez-Gabriel, Elena
Feal-Cortizas, María Begoña
Fernandez-Diz, Clara
Gómez-Costa, Eva
Caeiro-Martinez, Laura
Margusino-Framiñán, Luis
Why was it done?
An individualized dosing procedure for Pegasys® (peginterferon alfa-2a) was implemented, using syringes adjusted to the prescribed dose. The primary aim was to guarantee continuous and safe patient treatment during the global shortage, while also optimizing the use of 90 µg vials.
What was done?
In 2024, a worldwide supply disruption of Pegasys® occurred, creating a risk of treatment interruption for hematology patients. Since many prescriptions were below 90 µg, direct vial use caused significant drug waste and aggravated the shortage. A fractionation system was developed, combining coordinated workflow and a risk-based stability assignment, to ensure continuity of care for all patients with the additional benefit of reducing economic impact. The project started on 21 October 2024 and remains ongoing.
How was it done?
A structured workflow between hematology and the hospital pharmacy was established. After each medical visit, the hematologist contacted the pharmacist responsible for the hematology outpatient clinic, who reviewed the prescription and informed the compounding pharmacists of the preparation schedule and updated doses. Syringes were filled under aseptic conditions, stored at 2–8°C protected from light, and delivered to the hematology pharmacy clinic the day before dispensing.
The 30-day stability was assigned according to the hospital’s risk assessment matrix, supported by published stability data from similar products. The process was internally validated in line with hospital compounding standards.
What has been achieved?
To date, the strategy has allowed treatment of 18 patients, with 332 syringes obtained from 90 µg vials, the majority of which corresponded to 45 µg or lower doses. This approach achieved a 51% reduction in the number of vials used, representing savings of €20,791.
Most importantly, no patient experienced treatment delays or interruptions, ensuring therapeutic continuity and safe handling during the global shortage. No stability issues or administration-related problems were reported.
What next?
The protocol will be maintained in our hospital and could be adapted by other centers facing similar shortages. This experience highlights the key role of hospital pharmacists not only in cost management, but above all in the guarantee of safe and continuous access to essential medicines.
DETERMINATION OF THE PH OF SELECTED ANTI-INFECTIVES FOR SAFE INTRAVENOUS ADMINISTRATION
European Statement
Clinical Pharmacy Services
Author(s)
L. Čermanová, V. Slezáková, J. Babiaková, D. Fábiánová, S. Porubcová
Why was it done?
Phlebitis is one of the most common complications of infusion therapy. Intravenous drugs with extreme pH values (9) may chemically irritate or damage the venous endothelium, triggering an inflammatory response. Understanding the pH of intravenous anti-infectives is essential for clinical decision-making to prevent infusion-related complications.
What was done?
The aim of this work was to determine the pH values of selected intravenous anti-infectives administered at the National Institute of Cardiovascular Diseases, Bratislava (NÚSCH, a. s.) due to their potential to cause endothelial damage.
How was it done?
A literature review was performed to collect available data on the pH of reconstituted and diluted anti-infectives used at NÚSCH, a. s. Sources included Summaries of Product Characteristics, ASHP Injectable Drug Information®, pharmaceutical recommendations of Hôpitaux Universitaires de Genève, and relevant scientific publications.
The criteria used to select anti-infectives for pH analysis were a complete lack or insufficient information on the drug’s pH, reported pH values approaching the extreme thresholds of 5 or 9, and excessively wide pH ranges exceeding these limits.
Subsequently, the pH of 21 selected drugs was measured at 37 commonly administered concentrations (including ready-to-use formulations) using a glass-electrode pH meter (XS pH 7 Vio portable pH meter; electrode CHS ChemFlex). The diluents used were 0.9% sodium chloride solution, 5% glucose solution, and water for injection.
What has been achieved?
A table summarising selected anti-infectives at commonly administered concentrations, along with their mean pH values (± standard deviation) was compiled. Dilution volumes used in clinical settings with either 0.9% sodium chloride or 5% glucose solution for extremely acidic or alkaline medications did not appear to significantly modify pH in a way that would affect vascular access choice.
The pH values enable the identification of anti-infectives with a higher potential risk of phlebitis and support the selection of the most appropriate vascular access device.
What next?
The results will be applied in developing institutional recommendations for the dilution and administration of anti-infectives, supporting safer infusion practices and the prevention of chemically induced phlebitis across NÚSCH, a. s. wards. They will also inform staff training and may contribute to the reduction of medication errors.
MAKING ANTIBIOTIC DAYS OF TREATMENT ESTIMATION HAPPEN IN UNCOOPERATIVE SYSTEMS: TURNING ROUTINE DATA INTO STEWARDSHIP METRICS
European Statement
Clinical Pharmacy Services
Author(s)
Héctor Rodríguez-Ramallo, Nerea Báez-Gutiérrez, Alicia Melgar-Sánchez, José María Pastor-Martínez, Marta GÓNZALEZ-MARTÍNEZ, Jesus Francisco SIERRA-SÁNCHEZ.
Why was it done?
We designed and implemented a semi-automated method to estimate Days of Therapy for inpatient antibiotic use by leveraging routinely available Athos Prisma prescription exports. The workflow extracts daily prescription data and processes it with an automated script (Stata/Python/R) to generate DOT by antibiotic and hospital unit.
What was done?
DOT is a widely accepted measure of antibiotic exposure, and it is especially useful in paediatrics, where Defined Daily Doses (DDD) are unreliable due to weight variation across ages and heterogeneous “standard” dosing across centres.
Aim: to enable reliable, reproducible DOT measurement from data already available to all Athos Prisma users, facilitating stewardship dashboards and unit-level benchmarking.
How was it done?
Baseline capability: Athos Prisma supports DDD estimation but not DOT.
Data discovery: We identified a standard, centre-agnostic daily prescription export that contains the fields needed to compute DOT.
Processing pipeline: A one-click script parses the daily file, standardises drug names, groups by patient/day, and outputs DOT by antibiotic and unit.
Obstacles & solutions:
• DOT function is not integrated in Athos Prisma → built an external script that any site can run.
• Manual file export burden → consolidated to a single daily export; runtime <1 minute.
• Availability: The code is available on request and can be used by any Athos Prisma-using unit after minor local configuration.
What has been achieved?
We achieved a working code pipeline and measured DOT from June–September 2025 across the hospital. Highlights below:
Antibiotic DOTs Share of total DOT (%)
Amoxicillin/clavulanic 2608 9%
Ceftriaxone 4033 14%
Cefepime 611 2%
Piperacillin 3507 13%
Meropenem 1858 7%
Ciprofloxacin 970 3%
Levofloxacin 1495 5%
Cotrimoxazole 2443 9%
Cloxacillin 207 1%
Cefazolin 993 4%
Linezolid 751 3%
Daptomycin 678 2%
What next?
• Normalize to DOT per 100 patient-days at hospital and unit level.
• Automate the export (scheduled job) and publish weekly dashboards to stewardship teams.
• Set guardrails: prospective alerts for sustained increases in broad-spectrum DOT.
• Validate against a manual audit sample and report inter-method agreement.
• Share pack: provide a turnkey bundle to other centres.