Author(s)

Christina Theil Schnor and Saranya Loganathan.

Why was it done?

In 2018, hospitals in Region Zealand (RZ), Denmark, transitioned to the electronic health record (EHR) system, EPIC. Following this, hospital pharmacists faced repeated medication order challenges causing adverse events such as inappropriate medication orders, dispensing and administration errors, and insufficient workflow coordination. These issues resulted in complex, time-consuming workflows impacting quality and patient safety. Additionally, collaboration between corporate IT and clinical staff was challenged by a lack of understanding of practical issues. To address this, pharmacists of RZ established the Clinical Pharmaceutical Service IT Team (CPS IT Team) to build specialized knowledge of the EHR medication module, aiming to assure quality, optimize workflows, strengthen interdisciplinary coordination, and support safer and more efficient clinical use.

What was done?

CPS IT Team standardized workflows, enhanced coordination of medication order tasks, and created a forum to effectively utilize professional knowledge and networks across areas.

How was it done?

To address diverse Clinical Pharmacy challenges, CPS IT Team became the bridge between internal organization (RZ Hospital Pharmacy and corporate IT) and external partners (EPIC and The Capital Region of Denmark (CRD)). For this reason, CPS IT Team was established with one team manager and two units: Internal and External unit. CPS IT Team continuously adapts to evolving Clinical Pharmacy needs.

What has been achieved?

The establishment of CPS IT Team has driven significant internal optimization and standardized workflows. Acting as a coordinating unit, it optimizes medication processes from ordering to dispensing and administration. Dialogue with IT has been strengthened, enabling more efficient, targeted communication across professional groups.
Collaboration with EPIC and CRD has enhanced quality assurance and optimized workflows. CPS IT Team efforts have helped prevent medication-related adverse events, improve workflows, and optimize medication processes. Interdisciplinary collaboration and professional consultation networks between regional clinics, hospital pharmacies, IT, and EPIC have been notably strengthened. These efforts have increased patient safety and fostered a safer, more coherent workflow in EPIC.

What next?

Fusion of RZ and CRD into Region Eastern Denmark will change CPS IT Team’s working conditions, opening new opportunities such as an expanded collegial network and broader range of tasks and needs. Systematic data use will support Hospital Pharmacy’s work, improving efficiency and quality in daily operations.

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?

A structured training programme was established to improve cytotoxic drug preparation in our hospital pharmacy. The initiative combined updated Standard Operating Procedures (SOPs), simulation sessions using non-hazardous substitutes, and debriefings focused on error prevention and occupational safety.

What was done?

Cytotoxic preparation carries significant risks: dosage errors compromise patient safety, while inadequate protective measures expose staff to hazardous drugs. Audits in our unit revealed inconsistent practices and insufficient adherence to safety protocols. A reproducible, safe method of training was needed to harmonise techniques and reduce risks.

How was it done?

The initiative was implemented through a structured program combining simulation sessions, observation checklists, and debriefing meetings. Teams were trained using standardized SOPs and dummy materials, allowing safe practice of aseptic techniques. Performance indicators were measured before and after simulation training to assess impact on safety and compliance.

What has been achieved?

More than 60 pharmacists and technicians have completed the programme. Error rates in cytotoxic preparations decreased by about 30%, and environmental monitoring showed a 25% reduction in contamination markers. Surveys confirmed improved confidence (92%) and adherence to protective measures (95%). The training is now part of our hospital’s continuous education system.

What next?

The programme will be extended to all new pharmacy staff and residents. Plans include developing e-learning modules and inter-hospital workshops to spread the model nationally and internationally.

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)

Sandra Oliver, Chief Clinical Information Officer, Pharmacy and Medicines.
Chris Green, Director of Pharmacy and Medicines Optimisation

Why was it done?

We describe how our hospital experienced a cyber-attack which resulted in the electronic patient record and other systems being taken offline, including our electronic prescribing system.

What was done?

We describe our response to the cyber-attack and the considerations necessary to replace an entire hospital’s electronic prescribing system with paper. We also describe the co-dependencies with other previously electronic departments and systems, and communications with partner organisations.

How was it done?

The conversion from electronic to paper prescribing was led by the pharmacy team. Initially, this was via a printed downtime solution from the electronic prescribing system, which then required transcription to a paper prescribing chart. This generated a number of logistic, practical and safety issues which were managed by the pharmacy team. We then describe how the hospital was converted back to electronic prescribing over the course of one day, and how the pharmacy team was pivotal to that.

What has been achieved?

We were able to successfully take our hospital off electronic prescribing and initiate a paper-based downtime solution that ran over several days, and then return the hospital to electronic prescribing. Recovery efforts involved pairing prescribers with pharmacists across wards, establishing a pharmacy command centre, coordinating medication administration on ePMA, and communicating service updates across the Trust. Third-party services were reinstated, and recovery was prioritised by acuity, with the least acute wards addressed first. During the downtime period, we actively encouraged the pharmacy team to log patient safety concerns, or ideas to improve the downtime process which were reviewed and acted on in real time and as part of the post-recovery review.

What next?

We have learned several valuable lessons from the downtime experience which we have taken forward as part of our revised business continuity plan. This includes a review of specialist prescribing situations for example insulin, how we contact and work with partner organisations, the robustness of our downtime printer setup, and training material for clinical staff who at the time of the cyber-attack, had never used a paper based prescribing system. This case study serves as a valuable resource for healthcare organisations seeking to strengthen their cybersecurity and business continuity strategies.

Author(s)

Cristina Garcia Fernandez, Estela Alamino Arrebola, Bárbara Lopez Bautís, Carmen Gallego Fernandez, Begoña Tortajada Goitia.

Why was it done?

Patient safety in clinical trials relies on the correct management of both investigational and auxiliary/comparator medications. While investigational products are usually managed through automated systems (e.g., IWRS) ensuring traceability and standardization, auxiliary medications often lack similar oversight from sponsors. A preventable medication error in an oncology clinical trial—caused by the preparation of an incorrect drug concentration due to the absence of automated supply and harmonization—highlighted the need to analyze system gaps and implement corrective actions to strengthen patient safety and medication traceability.

What was done?

A Root Cause Analysis (RCA) was conducted following the detection of a medication error involving the preparation of hospital stock (20 mg/mL) instead of the clinical trial formulation (10 mg/mL). The objective was to identify systemic weaknesses and design a Corrective and Preventive Action (CAPA) plan aimed at preventing recurrence and improving management of auxiliary medication in clinical trials.

How was it done?

The RCA was performed in July 2025 using the “5 Whys” methodology, supported by:
-Document review, staff interviews, and chronological reconstruction of the event.
-Analysis of human, technical, communicative, and organizational factors.
-Classification of the incident (NCC MERP category D — no patient harm).
Corrective measures implemented included:
– Creation of a pre-trial pharmacy checklist to ensure drug availability and concentration verification.
– Mandatory pharmaceutical validation after any protocol amendment.
– Formal requests to sponsors to standardize drug concentrations across sites.
– Improved communication channels between sponsors, pharmacy, and clinical teams

What has been achieved?

-Identification of the main root cause: lack of automation in auxiliary drug supply requiring manual requests.
-Prevention of similar future events through harmonized pharmacy processes.
-Reinforcement of patient safety culture and traceability of clinical trial medications.
-Strengthened collaboration among hospital pharmacy, clinical teams, and sponsors.
-No patient harm resulted from the event, confirming the importance of early detection and system review.

What next?

-Extend IWRS automation and standardization practices to include auxiliary medications in all clinical trials.
-Share the initiative with other hospital pharmacies and sponsors to promote harmonization at institutional and multicenter levels.
-Continue monitoring the implemented CAPA and evaluate its impact on error prevention.
-Foster continuous improvement in pharmacy oversight and communication workflows for clinical research.

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Author(s)

A. HERREROS FERNÁNDEZ, P. FERNÁNDEZ-VILLACAÑAS FERNÁNDEZ, R. AÑEZ CASTAÑO, P. ORTIZ FERNÁNDEZ, M.A. MEROÑO SAURA, I. GARCÍA MASEGOSA, R. GUZMÁN LAIZ, P. SELVI SABATER, C. CABALLERO REQUEJO, L. RENTERO REDONDO, E. URBIETA SANZ.

Why was it done?

The preparation of sterile magistral formulas involves significant risks due to complex processes, material handling, and sterility requirements. A systematic risk assessment was essential to identify vulnerabilities, classify risk levels, and implement preventive measures to improve safety and compliance with regulatory standards.

What was done?

Sterile magistral formulas are personalized medications prepared in hospital pharmacy services to meet individual patient needs. In 2023, a risk matrix was implemented to systematically evaluate the risks associated with their preparation. This initiative aimed to enhance patient safety and ensure compliance with the “Guide to Good Practices for the Preparation of Medications in Hospital Pharmacy Services” (GGP).

How was it done?

Sterile magistral formulas prepared in the pharmacotechnics area of a hospital during 2023 were identified from a Microsoft Access® database. A Microsoft Excel® database was specifically designed to apply the GGP-based risk matrix, categorizing formulas into low, medium, or high risk. Each formula was evaluated across six key criteria: preparation process, route of administration, drug safety profile, number of units prepared, preparation vulnerabilities, and distribution process. Risk levels were assigned using a combination of letters (A-D) based on the matrix. Challenges included standardizing data collection and ensuring multidisciplinary collaboration to refine the matrix and ensure its applicability.

What has been achieved?

A total of 80 sterile magistral formulas were assessed. Of these, 38.75% were classified as medium risk, 36.25% as high risk, and 25% as low risk. Among medium-risk formulas, 67.7% included a “C” in the matrix, while 96.6% of high-risk formulas contained at least one “D.” The most frequent risk combinations were “BBAAAA” (11.25%) and “BBBAAA” (10%). The preparation process and administration route were the primary contributors to overall risk. Medium- and high-risk formulas, primarily intravenous mixtures of antibiotics and biological drugs, required preparation in a cleanroom environment, as recommended by the GGP.

What next?

This initiative demonstrated the value of a risk matrix in identifying and managing risks in the preparation of sterile magistral formulas. It represents a best practice model with significant potential for adaptation in other healthcare settings, enhancing patient safety and standardizing risk management in hospital pharmacy operations.

Author(s)

Joana Pinto, José Feio, Sebastião Silva, Francisco Machado, Ana Dinis, Margarida Abreu, João Peres, Mariana Guia

Why was it done?

Clinical decision support systems comprising information on DDI improve DDI risk detection, avoiding preventable patient harm. The resulting DDI alerts can change prescribers’ behaviour to benefit patient care. However, an excessive number of alerts can lead to alerts’ desensitisation by prescribers.

What was done?

We monitored the drug-drug interactions (DDI) alerts displayed in the prescription system through three subsequent homologous periods, occurring after the integration of a DDI database in the prescribing software system of a teaching hospital to assess its impact on the prescribing pattern.

How was it done?

We developed a DDI database – MedH® – to be integrated into the prescribing software system to support hard stop DDI alerts. only the higher clinical risk DDIs were included in this database in order to restrain the burden of alerts and warrant acceptance by health professionals.
Data of all inpatient hospital prescriptions over a 12-month period prior to MedH® implementation were extracted and intersected with MedH® DDI BD to identify the top 10 co-prescribed binomials at risk of severe DDI. The number of alerts for the same binomials was then monitored through three subsequent, post-implementation, homologous periods.

What has been achieved?

Considered the TOP10 observed in the pre-implementation period, the number of alerts for all binomials has consistently reduced over the three post-implementation periods analysed.
The integration of MedH® DDI BD into the prescribing system, resulted in changes in the prescribing pattern, translated by a decrease, between 67% and 100%, in the number of alerts for a sample of control risk binomials coinciding with the top 10 co-prescribed risk binomials observed in the pre-implementation period. These results reflect the good acceptance by the professionals and the didactic effect achieved by the exposure to alerts.
More importantly, these results are indicative of the effectiveness of the implementation of MedH® Alerts in reducing patient exposure to high-risk combinations of medicines, thus promoting patient safety.

What next?

It will be important to ensure that data from IDD alerts are rigorously analysed to recognise clinical situations in which the co-administration of risk binomials is justified, to ensure consistent application of recommended risk minimisation measures, and the availability of safer therapeutic alternatives whenever possible.

Why was it done?

This solution, an integrated module of our electronic health record (EHR) (Millennium Oracle Cerner), allows the computerised validation of the administration of medication in real-time at the patient’s bed by scanning a bar code identifying the medication or the infusion.

What was done?

The implementation of a solution allowing the secure administration of medication (oral or injectable) at the patient’s bed is one of the latest processes we have put in place to improve the security of the medication circuit and the quality of patient care within our establishment.

How was it done?

Our pharmacy has a robot for automated dispensing of unit forms of medication by over-packaging (PillPick Swisslog). A unique code of each oral medication is affixed to each sachet and this code, once scanned, will be used to verify the concordance between the physical medication in the hands of the nurse dispensed by the pharmacy and the medication prescribed in the EHR.
For infusions, a tool of our EHR makes it possible to generate a barcode label taking again information of the prescription as well as patient identity and that one is affixed on the infusion after reconstitution/dilution the barcode being scanned at the time of the installation.

What has been achieved?

In collaboration with the care services we have set up a Bluetooth barcode reader connected to the nursing cart for the scanning of the therapeutics and the patient. The process allows after scanning and verification of the patient’s identity, to scan all the drugs to be administered orally or by injection directly at the time of administration and their validation in the patient’s file at once.

What next?

The approach around this work and its deployment has allowed team work between the pharmacy, the care services and the IT services in charge of the EHR to achieve the rapid and sustainable implementation of this solution, fast learning and saving nursing time. It allows us to secure our circuit from the production of therapeutics by our robot to the administration to the patient and also to respect the 5B rule of the drug circuit.

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Author(s)

Carlos Santos Rodríguez, Silvia Irene Corrales Vargas, Maria de los Ángeles Peña Peloche, Alfredo Julian Jover Sáenz, Miguel Ángel Ramos Gil, Arturo Morales Portillo, Marta Mir Cros, Francisco Ignacio Torres Bondia, Lluis Marqués Amat, Joan Antoni Schoenenberger Arnaiz

Why was it done?

Beta-lactam antibiotics are the most commonly used group of antimicrobial drugs but are also the ones with the most significant induction of allergic reactions. However, it is known that many of these patients do not present reactions upon rechallenge or have false allergy warnings in the medical records.

What was done?

To assess the impact of a pharmacist-driven programme for active beta-lactam allergy warning removal in adults in collaboration with the Allergology service.

How was it done?

We identified adults with active beta-lactam allergy warnings among outpatients aged 35 to 45 years over 26 months.
Both in the hospital and primary care setting the pharmacist assessed the current information of the cases in the electronic medical records (EMR) and through personal interviews or by telephone. The following data were retrieved: year of allergy registration, type of reaction described, tolerance of beta-lactam antibiotics, and the existence of Allergology reports.
The pharmacist, previously trained by the Allergology service, could proceed to remove or confirm the allergy label, if applicable, or refer the patient to the Allergology service for allergy tests.

What has been achieved?

We reviewed a total of 1178 cases with active beta-lactam allergy warnings. The most frequently implicated beta-lactam drug was amoxicillin, with 170/1178 (14.4%) cases.
111/1178 (9.4%) of cases had an allergic reaction in childhood, and in 714/1178 cases (60.6%) EMR did not describe the symptomatology or treatment that justifies the allergy.
The allergy warning was directly removed in 93/1178 (7.9%) of patients, as they had previous reports of Allergology, had tolerated antibiotics after the allergic reaction, or did not present symptoms compatible with an allergic reaction.
The review confirmed allergic warnings in 43/1178 (3.65%) cases, according to the symptomatology and the information recorded in the Allergology reports.
One thousand and forty-two cases were referred for beta-lactam allergy test performance in the allergology service, of which 47% yielded a negative result.

What next?

The pharmacist is qualified to remove the warning in cases with a doubtful allergy to beta-lactam antibiotics after a thorough medical record review and informed consent. Moreover, the pharmacist can provide valuable information that allows the classification of warnings according to the detected risk and facilitates subsequent decision-making by the allergist.

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Author(s)

Linda Jeffery, Maria Grønkjær Abrahamsen, Anja Alrø Bøtkjær, Lotte Aggergaard, Ann Brit Andersen

Why was it done?

Our country has a national SMR for every citizen. The SMR shows the current medication that the citizen has been prescribed, from all sectors. All sectors can see the SMR, which is considered/ought to be the ‘truth’ about the patient’s medication. On discharge from the hospital the SMR is updated by the doctor. Afterwards, pharmacy technicians dispense medicines for discharge. The technicians, at this stage, often find discrepancies in the SMR compared to the medication prescribed and given during admission. The SMR is electronically updated but not adequately reconciled. False information in the SMR may ultimately lead to adverse drug safety events in the primary sector.

What was done?

The regional hospital pharmacy patient safety network studied how many patients do not have a reconciled electronic Shared Medication Record (SMR) at discharge, despite the doctor having electronically updated it.

How was it done?

The technician recorded the discrepancies found before contacting the doctor to get the SMR corrected.
Each discrepancy was reported into the national patient safety database.
The technicians do not dispense medicines to all discharged patients, so our results were extrapolated to all discharged patients in the time period (there was no reason to expect bias).
The study was carried out in the whole region (5 hospitals) during the same week in September 2022.

What has been achieved?

Preliminary data shows that 994 patients were discharged from the wards studied.
Technicians dispensed medicines to 278 patients. They found one or more discrepancies in 65 SMRs (23,4%).
Extrapolation of these results revealed that, in the period, there were potentially 232 patients with drug-related problems from these wards (and approx. 17,000/year in the region).

What next?

Our results showed that the SMR is not adequately reconciled in 23% of discharges, despite the doctor feeling that the task is completed. This gives drug related problems in the primary sector, often resulting in calls to the ward etc. that are time consuming and difficult to solve after discharge. Updating the SMR at discharge is essential for patient safety under transition of care. Our results will be brought to the hospital administrations, patient safety organisations and the regional medicines board for further discussion about the problem and possible solutions.