Author(s)

Victoria Lubarsky, Jacalyn Rogers, Nataly Kuchik

Why was it done?

Accurate home medication history and admission reconciliation are critical during care transitions to prevent harm. In my hospital, the medication history team reviews over 85% of daily admissions, yet providers often face challenges with timely reconciliation. To address this, the pharmacy team proposed a dual-approach initiative: provider education to support reconciliation within 24 hours of admission, and a pharmacy-assisted process enabling pharmacists to reconcile select medications or collaborate with providers to finalize reconciliation.

What was done?

This initiative aimed to meet the hospital’s quality goal of achieving 90% completion of accurate admission medication reconciliations within 24 hours. A retrospective observational study was conducted over nine months in 2024. Data collected was quantitative, focusing on medication reconciliation completion rates, pharmacist interventions, and provider engagement. Descriptive statistics analyzed trends and measured improvements in reconciliation rates.

How was it done?

A dual-strategy approach was implemented: provider education and pharmacy-assisted workflow. A standardized flow sheet and enhanced EMR patient lists improved provider visibility. A new procedure and dashboard enabled pharmacists to identify incomplete medication reconciliations within 24 hours and intervene by reconciling select medication classes (e.g., OTCs, supplements, duplicates, long-acting meds), communicating via secure chat to resolve discrepancies, and documenting post-reconciliation additions in pharmacy notes. Prior to admission, home medication lists were reviewed by pharmacy technicians using the MARQUIS framework to support reconciliation accuracy.

What has been achieved?

A quantitative analysis using descriptive statistics was conducted to evaluate changes in medication reconciliation completion rates before and after implementing the initiative. • Overall reconciliation completion rates increased by 30 percentage points, from 52% to 82% over nine months • The pharmacy team’s consistent contribution accounted for 15% of the total improvement • Provider education accounted for an additional 15%, with 13% from pharmacy’s provider outreach and 2% from education initiatives and process awareness.

What next?

This initiative demonstrates the effectiveness of provider education and pharmacy-assisted processes in improving timely and accurate medication reconciliation outcomes and patient safety during care transitions. Future directions include expanding pharmacy-assisted hours and replicating the model across additional hospital sites to broaden impact and strategize best practices.

Author(s)

S. GAMBA1, M. FRANCHINA1, M. GIACONIA1, C. INTRA1, M. CASTIGNONE1, E. PANETTA1, G. D’ARENA1, C. PERASSO1, P. BARABINO1, G. SPIGA2.
1IRCCS GASLINI, HOSPITAL PHARMACY, GENOVA, ITALY.
2IRCCS GASLINI, CLINICAL GOVERNANCE, GENOVA, ITALY

Why was it done?

Paediatric galenic preparations are essential for neonates, patients with rare diseases, and those requiring highly individualised treatments or unable to swallow solid dosage forms, for whom no commercial alternatives exist. Despite widespread use, there is a significant need for accessible, user-friendly guidance to support correct home administration. Lack of clear instructions increases the risk of dosing errors—particularly during dose conversion or with multi-dose containers—a safety concern highlighted by regulatory bodies such as the Italian Medicines Agency (AIFA). To address this, the initiative aims to improve the safety and effectiveness of home administration through a personalised educational brochure for patients, caregivers, and healthcare professionals.

What was done?

A personalised brochure was created to guide patients and caregivers in the safe home administration of paediatric galenic medicines. It covers therapeutic indications, composition, storage, dosage and conversion, posology, management of missed doses, potential interactions and side effects, and instructions for medicine collection from the hospital pharmacy. A satisfaction questionnaire is distributed at dispensing to gather feedback for iterative improvements.

How was it done?

The brochure was developed collaboratively by pharmacists and prescribing physicians to ensure accuracy and consistency, so that all patients receive standardised information. Written in plain language and supported by icons, it is easy to understand. A QR code linking to a digital version allows continuous access via smartphone. Feedback from the questionnaire informs ongoing refinements.

What has been achieved?

This initiative reflects the evolving role of hospital pharmacies toward a clinical, patient-centred, and collaborative model. The brochure serves as both an informative resource and a practical tool for patient empowerment, improved communication, and enhanced care quality. In paediatrics—where treatments require heightened attention—this tool bridges the information gap, supporting patients and caregivers and increasing medication safety.

What next?

Ongoing feedback will be used to refine the brochure and digital resources. The initiative will expand to additional paediatric units and be adapted for other patient groups requiring complex or individualised therapies. Collaboration between healthcare professionals and families will continue to ensure accuracy, usability, and patient-centred design. Long-term monitoring will assess the impact on medication safety, adherence, and clinical outcomes, with potential wider application across other therapeutic areas and hospital settings.

Author(s)

E. WILLIAM1, K. TLILI1, L. WANG1, A. TARRE1, A. BENOMAR1, M. EL HUSSEINI1, S. OUABDELKADER2, I. DEBRIX1, F.FEDERSPIEL1
1 : HÔPITAL TENON, PHARMACIE À USAGE INTÉRIEUR, PARIS, FRANCE.
2 : HÔPITAL TENON, DIRECTION QUALITÉ ET GESTION DES RISQUES, PARIS, FRANCE.

Why was it done?

Medication reconciliation (MR) is a widely recognized process for preventing medication errors (ME). However, the step involving the preparation of the” Best Possible Medication History (BPMH) is a complex process, itself subject, like any production process, to potential errors. This means that inaccurate or incomplete BPMHs can be generated, in contradiction with the high level of reliability implicitly expected of the final product. However, to our knowledge, current recommendations do not describe a dedicated risk management model for this process, and published studies addressing ME potentially induced by MR itself are scarce.

What was done?

The aim of this work was to consider the BPMH preparation process as a full-fledged production process and, as such, to develop a dedicated safety model by identifying potential or previously described error risks, existing safety measures, and actions to be implemented within a continuous quality improvement framework.

How was it done?

A systemic analysis method, FMECA (Failure Modes, Effects, and Criticality Analysis) was chosen to collectively assess the relative criticality of each identified risk, with the aim of establishing specific safety principles for this process.

What has been achieved?

Seven analysis meetings took place over six months, bringing together 3 to 5 senior pharmacists, 1 to 3 junior pharmacists, and one quality manager. The analysis identified 49 generic hazards and 62 associated risks. The most critical risks were related to identity vigilance, the completeness and reliability of sources used, the specificity of high-risk drugs, data recording, and the pharmacotherapeutic consistency of the final BPMH. Discussions confirmed the role of common cognitive biases in the occurrence of potential, often overlooked errors. The proposed safety system therefore mainly focused on strengthening awareness of typical error risks during MR, formalizing a self- and double-check checklist, and developing a dedicated non-conformity reporting form.

What next?

This systemic analysis contributed to a collective awareness of the persistent risk of errors in a process that may appear, at first glance, to be well controlled. The analysis of non-conformities through a dedicated experience feedback committee (CREx) will confirm the value of a dynamic and collective approach in the more global management of errors in clinical pharmacy.

Author(s)

I. GUMIEL BAENA1, L. ARMENDARIZ PATIER1, P. RIOS ESTEBAN1, R. VIZCAYA CORTÉS1, S. SANTOS MUÑOZ1, R. SANABRIAS FERNANDEZ DE SEVILLA1, A. SANCHEZ GUERRERO

Why was it done?

Efficient management of clinical trial start-up is essential to ensure timely initiation and compliance with regulatory and operational requirements. Hospital pharmacy services play a central role in handling, preparation, and accountability of investigational medicinal products (IMPs). However, information provided by sponsors is often incomplete or inconsistent, leading to delays, miscommunication, and additional workload at trial initiation. To address these challenges, a standardized approach was needed to collect pharmacy-related requirements proactively and optimize communication with sponsors.

What was done?

A standardized electronic form was developed to collect critical information from sponsors prior to the initiation of a clinical trial. The objective was to anticipate logistical, technical, and operational needs of the pharmacy service and to improve coordination during the start-up phase.

How was it done?

An electronic form (Jotform®) was created and sent to sponsors before the initiation visit. It included the following sections: (1) general study data (title, phase, code, investigator, department, duration, and enrollment); (2) investigational and auxiliary medication (description, dosing, and supply details); (3) logistical requirements (storage, shipping, and custody); (4) preparation and dispensing (procedures, need for pharmacy compounding, and prescribing system details); (5) returns and expiry management; and (6) additional pharmacy tasks (e.g., completion of sponsor platforms). The form was completed electronically and returned before pharmacy service approval.

What has been achieved?

Implementation of the form improved communication with sponsors, ensured early identification of specific requirements (such as special storage conditions or sample conservation), and clarified responsibilities regarding delegated pharmacy tasks. The process allowed more efficient planning and reduced start-up delays associated with missing or inconsistent information.

What next?

The standardized form will be regularly updated based on user feedback and extended to additional hospital departments involved in clinical research. This experience demonstrates a replicable strategy that can be implemented in other hospitals to enhance efficiency and quality in clinical trial management.

Author(s)

S. FIRULESCU, T.F. VRABIE, M.A. MIHAI, C.D. ROTARESCU, S.R. DILIMOT, F. PETRUC, D.E. DRANCA, C. ANDREI, S. NEGRES.

Why was it done?

Infective endocarditis represents one of the most severe cardiovascular pathologies, with a mortality rate up to 30%, further complicated by rising antimicrobial resistance. The purpose of this study was to identify the most frequently encountered pathogens and to evaluate the influence of implantable cardiac devices or prosthetic heart valves. As clinical pharmacists, we also assessed treatment concordance with the European Guidelines for the management of endocarditis and hospital antibiotic policy.

What was done?

A retrospective analysis was conducted over the period January 2024-August 2025, by clinical pharmacists and residents of this specialty.

How was it done?

We evaluated patient records, focusing on the pharmacological treatment of infective endocarditis.

What has been achieved?

From a total of 104 hospitalized patients (67 males, 37 females), 66 patients were diagnosed with infective endocarditis as a primary diagnosis, while 38 patients had endocarditis as a secondary diagnosis. The patients were aged between 26 and 86 years, 60% of them being over 65 years old. Furthermore, the presence of implantable cardiac devices or valve prostheses represented a major risk factor, as it was also confirmed in this study (discovered at 55% of patients). The principal identified pathogens from blood cultures were Gram-positive cocci, such as Staphylococcus (67%) – mainly Staphylococcus aureus, both MSSA and MRSA (27%), Staphylococcus epidermidis (22%) – and Streptococcus (19%), mostly Streptococcus gallolyticus (7%). Other less common pathogens included Coxiella burnetii, Serratia marcescens, Enterococcus spp., and Stenotrophomonas maltophilia. The most commonly used antibiotics were: Vancomycin (56%), Ceftriaxone (53%), Ampicilin (42%) and Rifampicin (37%). In this study, antibiotics were used from all three AWaRe categories, as follows: 41% of patients received Access antibiotics, 41% Watch and 17% Reserve. Considering the used antibiotics and their posology, it could be estimated that in 65.4% cases, the recommendations of the current guidelines were strictly followed.

What next?

The evaluation of the guidelines concordance regarding the antimicrobial medication by clinical pharmacists as part of a multidisciplinary team is of the utmost importance for an optimized therapeutic management.

Author(s)

AMARA NIHED ; HAMDADOU DJAMILA ; TOUMI HOUARI

Why was it done?

This project was developed within the Pharmacovigilance Department, where identifying drug–drug interactions (DDIs) is essential but time-consuming due to the volume and complexity of pharmaceutical data. To address this challenge, a national collaborative project was initiated with the Computer Science Research Laboratory at Oran 1 University to design an intelligent and scalable system capable of predicting DDIs using artificial intelligence and improving prescription safety.

What was done?

The objective was to create an advanced Decision-Support System integrating machine learning and deep learning models to enhance DDI prediction accuracy. The system improves detection of clinically relevant interactions, optimizes prescription quality through an integrated recommendation engine, and provides a user-friendly dashboard for healthcare professionals. It classifies interactions by severity, synthesizes risk information, and remains adaptable to updates in pharmaceutical databases

How was it done?

The system architecture relies on a central web server hosting all functional modules. A dedicated database constructed via web scraping stores drug identifiers, SMILES molecular structures, and Morgan fingerprints. The learning module manages preprocessing, model training, and validation, while the AI prediction module automatically detects DDIs. Additional modules support database maintenance, prescription validation, and user-interface rendering. The interface integrates LLAMA-based models for generating structured medical summaries.

What has been achieved?

key features such as interaction prediction (via a CNN), medication management, and automatic report generation (integrating LLaMa) demonstrate the system’s comprehensive approach. The screenshots illustrate an intuitive interface, enhancing the usability of the solution.

What next?

PharmaDDI therefore enables advanced interaction prediction, real-time prescription optimization, automated synthesis generation, and improved clinical decision-making. Although available since June 2025, deployment is currently delayed due to computer performance limitations. The system is undergoing expert evaluation before full integration into pharmacovigilance practice

Author(s)

Hui-Yu Chen, Kai-Cheng Chang

Why was it done?

Medication safety remains a cornerstone of healthcare quality, yet adverse drug events (ADEs) continue to cause preventable harm in hospitals. Traditional manual dispensing workflows, dependent on human memory and paper-based checks, are prone to errors, particularly in large medical centers with high prescription volumes.

What was done?

We launched the “Smart Dispensing and Data Governance Project,” aiming to transform the pharmacy workflow through digitalization and data-driven quality management.

How was it done?

A two-pronged strategy was adopted: (1) deployment of smart dispensing hardware and (2) establishment of a big data governance platform. The hardware featured personalized login for accountability, closed-loop barcode verification of both medications and prescription bags, LED guidance and voice feedback for real-time alerts, and final barcode validation before dispensing. Advanced automation such as real-time stock sensing, weight-based verification, and image-assisted accuracy checks further minimized human errors. A SAS Visual Analytics–based Business Intelligence dashboard visualized error trends and enabled continuous PDCA (Plan-Do-Check-Act) improvement cycles through near real-time feedback.

What has been achieved?

Implementation led to substantial quality improvements: the dispensing error rate decreased by 78.3% (0.023‰ to 0.0050‰, P < 0.05); data analysis time for error monitoring shortened from 4 hours to 10 minutes (-98.3%, P < 0.05); and pharmacist training time reduced from 10 days to 3 days (−60.0%). All indicators showed statistically significant enhancement in accuracy and efficiency. Integrating smart dispensing systems with big data governance effectively advanced medication safety and operational efficiency. This model established a scalable, data-driven, and high-reliability pharmacy workflow, transforming quality management from reactive correction to proactive prevention and serving as a replicable benchmark for digital hospital transformation.

What next?

We plan to apply AI algorithms to dynamically optimize drug storage locations based on usage and safety risk, and to digitalize all storage displays through an integrated electronic shelf–label system. These enhancements will further strengthen accuracy, reduce human-factor variability, and advance a highly reliable smart dispensing workflow.

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Author(s)

Adina Elihu, Claudia Wunder

Why was it done?

In Austria, there is growing recognition of the vital role clinical pharmacists play in healthcare teams. However, the current structure of the Austrian healthcare system does not adequately support the establishment of sufficient clinical pharmacist positions. Consequently, it is imperative to strategically integrate the limited available resources into patient-centered medication processes and fully harness their potential to enhance drug therapy safety.
The initial project was conducted in 2018/2019, and the present retrospective study was completed in 2022.

What was done?

This study explores the efficient integration of clinical pharmaceutical services across various medical disciplines, including both surgical and conservative fields. It specifically addresses how the integration of clinical pharmacy in surgical settings differs from that in conservative settings, and what success factors and obstacles need to be considered.

How was it done?

Through a retrospective analysis of outcomes from a comprehensive polypharmacy project, coupled with surveys of participating pharmacists and physicians, we delineate the procedures and methodologies essential for effective implementation.

What has been achieved?

It was demonstrated that a “one size fits all” approach, or a single process for all departments, is not practical. The study highlights specialty-specific considerations, such as the necessity for written communication on surgical wards and the inappropriateness and appropriateness of accompanying ward rounds in some cases.
Groundbreaking considerations for the approach were developed, including preparation, differences in approaches between surgical and conservative specialties, information sharing, communication pathways, necessities in the implementation phase and prerequisites for de-escalation.
The initiative paved the way for the introduction of electronic consultation systems to improve information transfer and documentation.

What next?

By identifying pitfalls and essential success factors, this initiative stands as a model for establishing clinical pharmacy services across various medical specialties, particularly in the context of limited personnel resources. It provides valuable guidance for colleagues involved in establishing these services.

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Author(s)

Sebastian Philip, Andreas Lundgaard

Why was it done?

The screening aimed to ensure the rational use of antibiotics, contributing to the fight against antibiotic resistance and potentially shortening hospital stays by optimizing treatment.

What was done?

A systematic screening of antibiotic treatments for patients was conducted as part of the daily tasks performed by clinical pharmacists at The Medical Acute Care Unit, Bispebjerg Hospital.

How was it done?

For each patient receiving antibiotic treatment in the emergency department, the chosen therapy was systematically reviewed against regional antibiotic guidelines, considering factors such as allergies, resistance profiles, renal function, clinical indication and overall condition of the patient. Recommendations of adjustment of treatment were discussed with the attending physician for potential changes in therapy, including changes to dosage, frequency, route of administration, alternative antibiotic drug, or discontinuation of treatment. All interventions were documented, including the details of the therapy, the recommendation, and whether the attending physician approved the suggested changes.

What has been achieved?

A large dataset has been collected, detailing the number of patients receiving antibiotic treatment, the number of interventions conducted, the specific antibiotic treatment each patient received, the type of intervention performed and its indication, and whether the intervention was approved or rejected by the responsible physician.
The project has laid the groundwork for understanding the clinical pharmacist’s role in enhancing rational antibiotic pharmacotherapy.

What next?

It is planned to analyze the collected data to determine the types of changes in therapy most commonly recommended by clinical pharmacists and to which degree the interventions were approved or denied by the attending physician.
This will provide insights into the pharmaceutical contributions to more rational antibiotic use, highlighting commonly observed ‘areas for improvement’ that could potentially be addressed through education.

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Author(s)

Vera Hoebregts, Evert-Jan Boerma, Mark Reinders

Why was it done?

The initiative was introduced to address the complex medication needs of bariatric surgery patients, particularly those using risk medication. More and more research is available about the effect of bariatric surgery on medication. Before this initiative, there was a gap in personalized medication management for this patient population. The aim was to optimize medication regimens, enhance patient safety and create awareness about the influence of bariatric surgery on specific medication among bariatric patients.

What was done?

In response to the growing need for personalized care among bariatric surgery patients, Zuyderland Medical Center and the Dutch Obesity Clinic South initiated consultation sessions with a pharmacist for patients scheduled for bariatric surgery using risk medication. A scoring list was developed to identify patients eligible for these consultations. Additionally, a survey was conducted to assess patient perceptions of the consultation’s usefulness.

How was it done?

Our developed risk medication screening list for bariatric patients was used to identify patients eligible for pharmacist consultations. Notable medications on the list included lithium, oral antipsychotics, antiepileptics, direct oral anticoagulants, levothyroxine, and tamoxifen. Approximately 10% of bariatric patients met the consultation criteria. Eligible patients were informed by their surgeon during pre-operative consultations and subsequently scheduled a session with the pharmacist. These consultations centered on discussing the patient’s specific risk medications and how bariatric surgery might impact their efficacy or toxicity. If relevant, issues such as medication-related weight gain, ingestion challenges, and compliance were addressed. Pharmacists’ recommendations were shared with the patient’s physician or other relevant healthcare professionals (e.g. a neurologist regarding a patient with epilepsy).

What has been achieved?

Increased awareness about the effect of bariatric surgery on medication is created both among staff and patients. Patients reported high satisfaction levels (average score of 9,3 out of 10 (n=20)) with the consultations, mentioning enhanced understanding of their medication regimens. Furthermore, an increased confidence in managing their health postoperatively was precepted. Patients found this consultation of added value.

What next?

This initiative serves as an exemplary model of personalized care delivery in bariatric surgery settings. Its success underscores the value of pharmacist involvement in optimizing medication therapy for complex patient populations.