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Why was it done?

OAM are widely used in the treatment of solid tumors and are administered orally in cycles that require self-administration at home. However, dose adjustments and discontinuations often lead to leftover medication which is discarded as waste. Therefore, the increasing use of expensive OAM comes with the downside of a financial and environmental burden. To reduce this waste, returned OAM to the pharmacy could be considered for redispensing to other patients providing guaranteed quality.

What was done?

We defined quality criteria for redispensing of oral anticancer medicines (OAM) in our hospital pharmacy. These criteria were laid down in a Standard Operating Procedure (SOP) to assess the eligibility for redispensing of returned OAM. This SOP was implemented in daily pharmacy practice.

How was it done?

A systematic risk analysis was conducted to determine eligibility of OAM for redispensing taking relevant guidelines and product information into account. The defined quality criteria were translated into a SOP and implemented in daily pharmacy practice. Over a year period, the number of returned OAM accepted for redispensing was quantified, and the reduction in financial waste and environmental burden calculated.

What has been achieved?

From the systematic risk analysis, four categories of quality aspects were identified: product presentation suitability (stability characteristics, storage requirements), physical condition (unopened or opened secondary or primary packaging, visual appearance), authentication (Falsified Medicines Directive, confirmation of initial dispense, recall), and additional aspects (remaining shelf life, period of storage under uncontrolled conditions). The first category identified that in principle, 75% of the licenced OAM (n=..products) dispensed at our institute is eligible for redispensing. From all combined quality aspects, a flow chart was created according to which each individual returned OAM is assessed . During the study period, 10,415 OAM dose units out of 13,210 returns (79%) were accepted for redispensing. The total value of OAM accepted for redispensing was €483,301, accounting for 0.9% of the total value dispensed during this period. Furthermore, the potential reduction in environmental burden was estimated at 1132.1 g of potent active pharmaceutical ingredient.

What next?

We established an easily implementable, comprehensive quality assessment of returned OAM for redispensing. Wide implementation of this approach would result in serious OAM cost and waste reduction.

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Author(s)

Sergio Portillo-Haro, Aída Rueda-Naharro, María Martínez-Pérez, Manuela Martínez-Camacho, David García-Marco

Why was it done?

Currently, multi-resistant microorganisms are a huge global problem of Public Health. In addition, this problem will be bigger in the next decades. The main strategy to face this threat is improve the use of antibiotics. DADA was born with this purpose. The app lets the Pharmacy Department manage a sizable number of inpatients using the time to analyse the results obtained by DADA. In other words, we have improved the efficiency in our use of time.
How was it done?
The app was developed in July 2022, and since then it has been updated multiple times to adapt it to our needs and expectations and the changes in clinical guidelines. Every Monday and Thursday, the app is started up. The results are analysed carefully by a pharmacist and afterwards the conclusions are transmitted to an Infectious Diseases Medician, who decides if modify the treatment.

What was done?

In July 2022, Pharmacy Department designed an app easy to use and comfortable in order to detect active antibiotic treatments that might be de-escalated. This app, DADA (Automated Antibiotic De-escalation) is fed with data of antibiotic treatments and microbiological cultures. DADA reads and understands every gap of information, and finally search results between the active treatments comparing it with theorical de-escalation sequencies, designed by Infectious Diseases Commission in our hospital and based in local epidemiological guidelines. In this way, DADA works with automatic decision algorithms. In addition, DADA also provides alerts of active treatments for resistant microorganisms to that antibiotic.

How was it done?

The app was developed in July 2022, and since then it has been updated multiple times to adapt it to our needs and expectations and the changes in clinical guidelines. Every Monday and Thursday, the app is started up. The results are analyzed carefully by a pharmacist and afterwards the conclusions are transmited to an Infectious Diseases Medician, who decides if modify the treatment.

What has been achieved?

Since August 2022 to March 2023, using DADA, the Pharmacy Department has made 25 proposals of antibiotic de-escalation, and 11 proposals were accepted (44.0%) by Medicians. In addition, the Department made two proposals of change for resistance to that antibiotic, both accepted by Medicians. This app has improved efficiency of time in the clinical team.

What next?

The main outcome is to improve the confidence of Medicians in this tool, in order to increase the percentage of acceptance in the proposals. Furthermore, the app can be more complete and interprets data, such as analytics parameters. In the future, other hospitals might use this tool to analyse their patients or in outpatients treatments.

Why was it done?

Benzodiazepines and derivatives (BZD) are often prescribed over a long time period among the elderly for anti-anxiety and hypnotic purposes leading the eldery to become addicted to their treatment. However, on the long term, BZD are less effectives and may cause dependence and adverse effects (AE). It is necessary to reassess the treatment to avoid them.

What was done?

This study evaluates patients’ dependence on BZD and reassesses the treatment after explaining the AE to patients.

How was it done?

A questionnaire for patients taking BZD at home, were developed: at first, the questions were about the reason of hospitalization, BZD’s indications, initiation date, occurrence of AE and attempts to stop treatment.

Then, the ECAB dependence test (cognitive scale of attachment to BZD) was proposed.

Eventually, explanations about BZD long term AE and an information sheet were given to patients. A substitution with short half-life BZD, dosage reduction or treatment discontinuation was proposed to the patient in collaboration with the geriatrician.

What has been achieved?

The questionnaire was completed by 34 patients. Of these patients, 44.1% came for falls and/or confusions, 27 had one BZD at home and 7 had two. About the prescribed BZD, 80.5% were for hypnotic purpose, 19.5% for anti-anxiety purpose, and 9.8% had long half-lives (not recommended for elderly).

Of 41 BZD, 46.3% had been prescribed for over 10 years.

Amid the patients, 79.4% reported AE, including 21 fall cases, 11 confusion cases and 7 somnolence cases.

Only 13 patients tried to stop the treatment.

There are 18 patients with an ECAB score greater than or equal to 6 which indicates that they are dependent on BZD (sensitivity: 94%; specificity: 81%).

Eventually, after presenting BZD AE, 6 patients switched to a BZD with shorter half-life, 10 agreed dosage reduction and 4 agreed stopping the treatment. In total, a positive result was obtained in 58.8%.

What next?

BZD are still widely prescribed and very few are re-evaluated despite the risk of AE among the elderly (often poly-pathological and poly-medicated). Given the positive results after providing an information sheet on BZD AE, it would be interesting to extend this practice to the entire hospital.

Author(s)

Lorenzo Di Spazio, Daniele Mengato, Andrea Ossato, Vera Damuzzo, Marco Chiumente, Giulia Dusi, Sabrina Trippoli, Andrea Messori, Maria Cecilia Giron, Maria Chiara Silvani, Francesca Venturini

Why was it done?

Pharmacist’s activities on MDs are mainly linked to governance, management and vigilance but little to clinical pharmacy practice. In order to study and develop interventions aimed at optimizing the use and compliance of medical devices on patients, a national survey was conducted to identify the clinical pharmacy experiences already consolidated in this field.

What was done?

Clinical pharmacy activities that demand specialized expertise in medical devices (MD) constitute a relatively uncharted territory for hospital pharmacists. Our aim, through a nationwide survey, was to delineate the clinical responsibilities overseen and handled by hospital pharmacists that necessitate a specific focus on MDs.

How was it done?

A 54-question survey, available from 1 October 2022 to 31 December 2022, was created by a pool of experts from an Italian scientific society (Italian Society of Clinical Pharmacy and Therapeutics – SIFaCT) and shared through Google Forms. The questions, divided into six sections, were related to five clinical areas defined by the working group: surgery room (SR), wound care (WC), vascular access management (VAM), patient education on diabetes treatment technologies (DTT) and MD in oncology and artificial nutrition (ON).
The questionnaire allowed us to define the state-of-the-art of clinical pharmacy on MDs, highlighting the activities and training needs of the participants.

What has been achieved?

We received 142 responses. In particular, emerged that 42% of participants adopted standard kits in the SR and 76% of them declared the pharmacist involvement.
A specific team for WC was created for 35% of participants, with the involvement of the pharmacist in 90% of cases, in particular as consultant role in 22%.
37% of participants declared the presence of a team dedicated to VAM, with the involvement of the pharmacist in 40% of cases and patient counselling in 9%. Finally, in DTT and ON the pharmacist was involved in 8% and 10% of the responses, respectively.

What next?

This first national survey shows that the pharmacist is often involved in multidisciplinary groups in the five analyzed areas, but less involved in patient’s counselling probably due to the sub-optimal training in the field of MDs. Indeed, almost all the participants declared the need to improve their knowledge in this field and create a network among colleagues.

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Author(s)

Beatriz Somoza-Fernández, Vicente Escudero-Vilaplana, Cristina Ortega-Navarro, Ana de Lorenzo-Pinto, Ana Herranz-Alonso, María Sanjurjo-Sáez

Why was it done?

HH units have experienced an extraordinary period of growth over the past few years and are already considered the preferred option of care model for most patients. However, its full potential is actually limited by some challenges both demanding and ripe with opportunities for pharmacy engagement, such as patient clinical complexity (usually elderly and chronic patients at greater risk of poor adherence and suffering from medication errors) and lack of medical staff physically available for monitoring patients’ evolution.

What was done?

We developed and implemented a comprehensive pharmaceutical care programme in a home hospitalisation (HH) unit.

How was it done?

The project was conceived by a multidisciplinary team (physicians, pharmacists, and nurses) that conducted a literature review and developed a new home medication management standardised operating procedure. The team worked in the design of a HH pharmaceutical care guideline and the implementation of an e-health care tool for remote patient monitoring.

What has been achieved?

1. HH pharmaceutical care guideline: it included the directions for the following measures: (1) a comprehensive pharmaceutical assessment and medication reconciliation, (2) standardised recommendations for optimising acute and chronic treatments at home, (3) daily interviews with patients or caregivers to explain medication changes, and (4) follow-up calls 7 days after discharge in order to assess medication adherence.
2. HH monitoring app: this new tool ensures pharmacotherapeutic monitoring by setting medication schedules and intake notifications. The platform includes a patient recording for vital signs, side effects, medication intake, and health status (functional status and quality of life). The system enables online access for pharmacists and physicians in real-time and continuous two-way communication.

What next?

Since our programme is easily applicable to any HH unit, we are working on implementing it in other hospitals in our country, in order to overcome HH medication management complexity nationally. We aim to conduct a multicentre study to evaluate its external validity in terms of increasing medication errors detected and optimising hospital resources.

Author(s)

Ana Helena Ulbrich, Amanda Fonseca, Catherine Isoppo, Henrique Dias

Why was it done?

The motivation behind NoHarm stemmed from the time-consuming nature of the prescription review process, which required clinical pharmacists to assess not only drug interactions but also factors such as appropriateness, effectiveness, safety, adherence, and affordability of drug therapies. NoHarm was envisioned as a solution to systematize the workflow and provide cross-referencing of essential drug and inpatient information, thereby addressing these issues.

What was done?

The NoHarm initiative was developed to address challenges faced by clinical pharmacy teams during the prescription review process in a hospital setting. This open-source intelligent system was introduced to enhance the medication review process. The initiative was executed in a 420-bed public hospital in Brazil over a 17-month period to evaluate its impact on prescription reviews.

How was it done?

The implementation of NoHarm involved integrating the system with the hospital’s electronic health records to collect and compute all inpatient data. NoHarm utilized a drug knowledge base and intelligent algorithms to identify and alert healthcare professionals about inpatient risks. The algorithms were designed to cross-reference patient laboratory results with drug thresholds, adjust for liver and renal function, analyze drug usage patterns at the hospital, and extract patient risk factors from clinical notes, including diseases, adverse events, symptoms, and biometric data.

What has been achieved?

The number of medications assessed increased dramatically from 17,000 to 2,643,957 within the 17-month period, all while maintaining the same team size. Improved prescription review rates, rising from 65% to 94%, demonstrate the effectiveness of the system. Furthermore, these improvements in prescription reviews resulted in better clinical pharmacy services and contributed to reducing medication errors and associated risks in patient care at the hospital.

What next?

NoHarm is an open-source solution and an example of good practice in healthcare due to its achievements in streamlining prescription reviews and enhancing patient safety. Its successful implementation led to increased efficiency, higher prescription review rates, and substantial cost savings, showing its potential as a model for other healthcare settings. Its prospective global applicability makes it a solution to address medication errors and elevate the standard of care in healthcare institutions worldwide.

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Author(s)

BEATRIZ TORROBA-SANZ, CRISTINA ORTEGA-NAVARRO, ANA DE LORENZO-PINTO, CARMEN REDONDO-GALAN, JUAN ANTONIO ANDUEZA-LILLO, MARTA SANCHEZ-CELAYA POZO, ANA HERRANZ-ALONSO, MARÍA SANJURJO-SAEZ

Why was it done?

Almost half of the patients discharged from the ED receive incomplete information at discharge and they forget approximately 60% of the medical information received when they leave the hospital. All these hinders the proper management of medication at home, generating anxiety to patients and favoring the appearance of adverse events and new visits to the hospital.

What was done?

We have designed, implemented and evaluated a tool to resolve pharmacotherapeutic queries of patients discharged from the Emergency Department (ED).

How was it done?

Patients with doubts about the pharmacological treatment prescribed upon discharge can contact FarmaCenter through the instructions included in the discharge report (telephone/email). The pharmacist will then analyze each query, gathering information from the clinical history and, if necessary, contact the care-team for resolution. Finally, the pharmacist will contact the patient, resolve the query and offer the opportunity to complete a satisfaction survey.

What has been achieved?

766 consultations were received (November 2022- 31 August 2023), mean age was 49.8 years and 49.3% were men. The majority (96%) contacted by telephone and the mean time of resolution was 1.5 hours. Half of the cases (53.7%) were resolved by the hospital pharmacist without the necessity of contacting the rest of the healthcare team. The main reasons for consultation were: medication not prescribed (28.3%), drug administration (8.7%), management of adverse reactions (6.9%), shortages (6.8%), dosage (5.9%) and duration of treatment (5.7%). 15.5% of consultations were not related to medication. The satisfaction survey was sent to 288 patients and 40% responded. The overall rating was 4.9/5 and the most highly valued aspects were the individualized attention, fast resolution of the query and the pharmacist’s kindness. In addition, 95% of patients considered that FarmaCenter had helped them to avoid a visit to a healthcare center.

What next?

Developing improvement strategies to reduce the number of patients with medication-related concerns from the ED.

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Author(s)

Stine Hygum Sørensen, Henrik Nielsen, Ulla Kloster, Anne Grethe Nørgaard Kyndi, Maja Vad Mortensen, Dorthe Ludvigsen

Why was it done?

The concept of medicine at Gødstrup Hospital is based on Patient involvement in the medicine process. Consequently, the patients bring their own medicine, which is stored in the patient’s room, and additional medicine is supplied in original packages. Medicine dispensing is performed in the patient’s room to allow patient participation. The medicine rooms at the hospital are quite small, because the majority of the medicine is with the patient, but it also makes medicine rooms unsuited for on-site training of new nurses.

What was done?

Virtual Reality (VR) technology was applied for introduction of newly hired nurses to medicine rooms at the hospital.

Newly hired nurses are given a four hour introduction to the concept of medicine at Gødstrup Hospital, Denmark. The introduction is given by an interdisciplinary team of a clinical pharmacist, a pharmacologist and an experienced nurse. The introduction is given in collaboration with the Centre for Research and Education (NIDO) once a month. This ensures that newly hired nurses are given the same, relevant introduction when needed.

Introduction to medicine rooms is part of the training for nurses in introductory positons. Using VR newly hired nurses are given a different and exciting introduction to medicine rooms.

How was it done?

In collaboration with the simulation unit at NIDO we made a VR-video to enable up to 20 new nurses to see the same introduction at the same time. Hospital Pharmacy staff is featured in the VR recording and guides viewers to specific parts of the medicine room, explaining important topics such as waste disposal, hygiene and anatomical therapeutic chemical (ATC) groups.

What has been achieved?

The participants are positive and give the following feedback to the VR segment of the introduction: “It was significantly easier to deal with as a newbie”. “It was very visual as being there in reality”. “There was time to learn in a calm environment”, “It worked fine as a lesson” and “It is a good change from backboard teaching.”

What next?

The monthly introductions continues and further collaboration with NIDO will result in lessons with topics such as pharmaceutical formulations and drug calculations. Perhaps VR will be included in this too.

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Author(s)

Hilde Omestad, Maria Grønkjær Abrahamsen, Fatima Afif Mouaanaki, Charlotte Mosbæk Dybdahl, Anne Wulff Petersen, Emil Dalsgaard Züricho, Philip Hojrizi, Charlotte Arp Sørensen

Why was it done?

The sustainability strategy of the Central Denmark Region include less consumption and less waste. Our Pharmacy delivers an increasing amount of high-cost homecare medications, requiring refrigerator storage. In case of an accidental temperature exposure, patients may ask whether their medicine can be used or not. There may be a delay during transport or a breakdown of their refrigerator at home. During these medicines’ shelf-lives, most products can be kept at room temperature for days, weeks or months. When SmPC and the insert package leaflet says that the product should not be returned to the refrigerator, high-cost medicines sometimes are wasted, only because of this warning, instead of giving them a shorter shelf-life. When we hesitate to return packages to the refrigerator, time can elapse while waiting for the manufacturer’s or pharmacist’s answers to the patient’s questions after storage incidents.

What was done?

The Hospital Pharmacy categorized 47 Blood Coagulation Factors and Monoclonal Antibody Products requiring storage at 2-8 °C if Summary of Product Characteristics (SmPC) had any warning of returning a product to the refrigerator or not, after an unwanted time at room temperature

How was it done?

We asked manufacturers if a return of their product to the refrigerator would cause any harm. Should their product be disposed of because it has been put back into a refrigerator after being left out? Our findings were documented in a local guideline and in the Danish national information database (SAID).
Drug Information Pharmacists discussed several cases of real-world handling situations to be more confident to reduce medicine wastage.

What has been achieved?

Being aware of the reasons for these warnings, reduced medicine wastage in certain cases of incidental storage. The pharmacists have been given tools for pharmaceutical professional assessments in cases of temperature challenges.

What next?

Spread the good news. Improve communication between manufacturer and pharmacy, because manufacturer can’t be responsible for storage different from their SmPC. Inspire manufacturers to improve their storage warnings in SmPC

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Author(s)

Charlotte Sørensen, Karin Aagot Møller Jørgensen, Anne Grethe Nørgaard Kyndi, Charlotte Lund Madsen, Line Scriver Poulsen, Charlotte Hjorth, Gitte Slyngborg Morbjerg, Janni Østergaard Jensen, Mette Juul-Gregersen, Rune Dalsenni Rask

Why was it done?

A sustainability project in 2020 highlighted manual and time-consuming workflows when checking expiry dates in hospital medicine rooms. For example, manual reading, interpretation and notation of expiry dates in paper forms every half year. Therefore, a smartphone application was developed and implemented in a large university hospital in 2022. The application was a huge success and colleagues from other Clinical Pharmacy departments in other hospitals within the same region wanted to be part of the success of the initiative.

What was done?

A smartphone application for managing expiry dates in medicine rooms was applied in one hospital in 2022 and in four other hospitals in 2023. The data-matrix of medicine packages is scanned with a smartphone camera and the application gives a sorted overview of medication near expiry. In the application you can register a medicine package as either used, discarded or released. By releasing medicine packages, the medicine is made available to colleagues in other medicine rooms.

How was it done?

The smartphone application was implemented in Clinical Pharmacy departments in four other hospitals, one by one from February 2023. After implementation the application is used in 373 medicine rooms.

What has been achieved?

Clinical Pharmacy staff are happy with the application. It takes significantly less time to check and scan expiry dates with the digital solution.
From February to September 2023 (five hospitals)
• 47491 packages were scanned
• 5251 packages were released (11%)
• 2664 packages were moved between medicine rooms to avoid medicine wastage (51%; 147000 €). Most activity (78%) was seen at the hospital that had been using the application since 2022. Most packages were moved between medicine rooms at the same hospital; however, in 215 cases (8%), medicines were exchanged between hospitals as well (20.000 €)
• 10918 packages were discarded due to expiry (743168 €; 0.5% of bought medicine).

What next?

The full potential of the digital solution remains to be achieved.
Pharmaconomists have to release medicine in the application a few months earlier than they do now. To go shopping in the application before ordering from the pharmacy, will probably also result in discarding less medicine. Sharing medication across hospitals to a greater extent will also be relevant to consider.