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Author(s)

E. Bredenberg, M. Knuutila-Jerkku, P. Halonen, E.W. Gröndahl

Why was it done?

On the ward, attaching infusion lines to cytotoxic doses is performed alongside busy clinical work, often resulting in delays. Centralised attachment of infusion lines to patient-specific cytotoxic doses in the hospital pharmacy cleanroom streamlines the chemotherapy workflow. It also enhances medication safety by improving the quality of ready-to-administer doses compared to the previous attachment practices on the ward.

What was done?

In Turku, patient-specific cytotoxic doses are prepared for administration in the hospital pharmacy’s centralised compounding unit, located in EU GMP-compliant cleanrooms. This ensures aseptic preparation and emphasises occupational safety. As part of this project, we included Cytoset Line® infusion sets pre-filled with saline into patient-specific cytotoxic doses during the centralised compounding process in the cleanroom.

How was it done?

To improve medication safety in chemotherapy, we held a multidisciplinary review of the process, consulted other hospitals for their practices and experiences, and assessed the stability of pre-attached infusion lines compared to non-attached doses.

The process of filling Cytoset Line® infusion lines with saline was introduced to pharmacists. The integrity of the closed infusion system was tested by adding caramel colour dye to the infusion bag. The effect of clamp placement was tested by positioning it at different points along the filled line. Caramel colour leakage into the line indicated insufficient sealing.

What has been achieved?

Performing the line attachment in a Grade A cleanroom improves aseptic conditions and reduces the risk of microbiological contamination. Occupational safety is enhanced by minimising nurses’ exposure to cytotoxic agents. Centralised preparation optimises the use of personnel resources. Correct placement of the clamp below the infusion port is critical in preventing contamination.

What next?

Expansion of the practice to other hospital units

Assessing the feasibility of attaching infusion lines to doses intended for extended storage

Standardising processes: adopting uniform infusion lines across all oncology units (requirement for pre-attached infusion lines)

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.

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Author(s)

D. PROTZENKO (1) (2), Y. GONZALEZ (2), M. TASHAN (2), J. CARDI (2), A. PLAN (1) (2).

(1) CHICAS, CLINICAL PHARMACY, GAP, FRANCE.
(2) CHICAS, HOME-HOSPITALIZATION, GAP, FRANCE.

Why was it done?

Our service area spans four departments in France, encompassing numerous mountain valleys with weather-dependent access, making deployment challenging. Additionally, some patients are over two hours’ drive from our hospital.

What was done?

We developed a territorial network by integrating hospital and extra-hospital structures into our home-hospitalization logistics circuit. This integration allowed us to strategically place equipment storage points across our region, enhancing the speed of care in emergencies.

How was it done?

We utilized a computerized tool to map areas accessible within 30 minutes by car and identified strategic points (both hospital and extra-hospital) to maximize coverage with minimal investment.

To optimize operations and improve response times, we established equipment storage points with ready-to-use kits. These kits, created through multi-disciplinary meetings to address key emergency scenarios, are designed to address a range of situations, including post-operative treatments, pressure sores, and end-of-life care, which are particularly prevalent in our population. The variability of care settings—such as patients’ homes, short-term rehabilitation facilities, and long-term care facilities— is also considered. This approach ensures that nurses and doctors can access the necessary equipment at all time, regardless of their location or the specific care requirements. We formalized partnerships to ensure the presence of these kits at designated sites, which are now referenced on a map accessible to our team. Quality processes were implemented to maintain kit quality and prevent expiry.

What has been achieved?

Immediate deployment of equipment for home hospitalization is now possible, regardless of patient location or weather conditions.

What next?

We are expanding our network by recruiting additional partners to enhance our local coverage. This strategy will also apply to areas with shared medical and paramedical skills, improving our responsiveness, particularly in end-of-life care situations. We will also forge new partnerships to broaden our capabilities, enabling other hospitals to prepare patient materials or medications, or to be used as parcel delivery service.

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Author(s)

Christina Anastasiadou – Lead Pharmacist Acute & Emergency Medicine
Karen Dicks – Chief Pharmacy Technician Medicines Management
Radhika Patel – Pharmacy Technician MMS

Why was it done?

Until October 2023, the A&E department in Croydon University Hospital in London lacked a full-time pharmacy service, unlike other London trusts. This has contributed to suboptimal medicine management and a delay in the identification of prescribing errors. This has resulted in longer stays, missed medication doses, and a rise in patient safety incidences. At a hospital level this reduces flow and increases cost due to medication wastage. Ultimately, the aim is to improve the flow of patients within the hospital via timely medicines provision, early clinical pharmacy intervention and early discharge planning.

What was done?

We have obtained funding from the Better Care Fund for a period of 2 years. This funding is aimed at assisting local systems in effectively achieving the integration of health and social care in a manner that promotes person-centred care, sustainability, and improved outcomes for individuals and caregivers. Therefore, we introduced a full-time pharmacy service including one pharmacist and two medicines management technicians (MMTs)—one full-time and one part-time. This initiative was implemented as a 2-year trial period, using key performance indicators (KPIs) to evaluate its effectiveness.

How was it done?

Data has been collected against the below KPIS:
1) Number of drug histories completed on admission, before patient is allocated a ward (by MMT or pharmacist) per calendar month.
2) Number of medicines reconciliations completed (by pharmacist) per calendar month.
3) Number of clinical interventions completed by all members of the pharmacy team.
4) Savings secondary to the use of patient’s own drugs (PODs) brought from home for administration to reduce medicines wastage.
5) Savings due to the return of medicines to inpatient pharmacy for re-use from other patients when appropriate.
6) Time between request of medicines from pharmacy dispensary and medicine being dispensed, checked and released to A&E.
7) Review of stock lists in all areas in A&E.
8) Reduction in omitted doses.
9) Discharge medicines supply and screening from A&E to streamline discharge.
10) Number of patients counselled on their medicines and provided with patient-friendly information on them.
11) Number of referrals to community teams i.e allocated chemist via Discharge Medicines Service, Integrated Care Network (ICN) pharmacists or specialty teams (i.e anticoagulation clinic for newly initiated anticoagulant) to provide continuation of care.
12) Liaising with specialty teams within the hospital to expedite review and treatment in a time efficient and cost-effective way.

What has been achieved?

The current pharmacy team is fully integrated into the A&E service and has contributed significantly towards advancing patient experience, via early pharmacy engagement with patients. During the first 10 months of the project, we have data to show:
1) A 540% increase in drug histories and medicines reconciliation on admission.
2) A 19.525% increase in clinical interventions and early detection of medication errors.
3) We have completed 5 teaching sessions so far, in order to tackle common prescribing and medicines management inaccuracies and embedding solutions into nurses and doctors training.
4) We have contributed towards the reduction in omitted doses by 6%.

Positive contribution towards tackling medicines wastage has been shown too. Our team contributed towards saving £13.110 from April to September 2024 by using PODs for administration in hospital and £10.483 by returning dispensed medications to the inpatient pharmacy for recycling and use for other patients for the same time period.

In addition, the team has completed 66 referrals to the community pharmacy team for follow up on newly started medicines, stopped medicines, adherence concerns and polypharmacy. This is in order to provide continuous care and establish follow-up after discharge from hospital.

All in all, improved safe patients flow in and out of hospital.

What next?

Work towards a business case for a permanent pharmacy service in A&E, to continue further developing the above. Utilise all the skills our MMTs hold, in order to continue working on patient safety, improved flow and cost improvement plans. Introduce a pharmacist-prescriber who will be able to tackle arising problems as soon as possible and provide high quality care in liaison with doctors, nurses and advanced care practitioners.

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Author(s)

AGUILAR GUISADO, CAROLINA. PHARMACY SERVICE. EL ESCORIAL UNIVERSITY HOSPITAL
SANCHEZ SUAREZ , SUSANA.PHARMACY SERVICE. EL ESCORIAL UNIVERSITY HOSPITAL
GARCIA GIMENO, M MERCEDES.PHARMACY SERVICE. EL ESCORIAL UNIVERSITY HOSPITAL
OTERINO MOREIRA, IVAN.PHARMACY SERVICE. EL ESCORIAL UNIVERSITY HOSPITAL
FIORANTE EMILSE SILVANA. INTERNAL MEDICINE SERVICE.EL ESCORIAL UNIVERSITY HOSPITAL
BARCIA MARTIN M ISABEL.PHARMACY SERVICE. EL ESCORIAL UNIVERSITY HOSPITAL
SAAVEDRA QUIROS VIRGINIA.PHARMACY SERVICE. EL ESCORIAL UNIVERSITY HOSPITAL

Why was it done?

Current antiretroviral therapies are effective, but adherence can be difficult for some patients, so innovation in parenterally administered antiretroviral treatments can help with adherence, as well as reducing the burden on patients with chronic HIV infection.

What was done?

Aim and Objectives: to implement a pharmaceutical care circuit for dispensing long-acting antiretroviral treatments in adult HIV patients.

How was it done?

Expected Improvements: Optimize antiviral use, enhance patient satisfaction, address adherence and maintain clinical effectiveness.
Circuit Design and Stages: In 2023, Pharmacy and Therapeutics Committee introduced intramuscular antiviral treatment with cabotegravir and rilpivirine, and established use criteria, in collaboration with the Internal Medicine service and Nursing consultation involved in the administration(NP):
1. Adults with undetectable Viral Load (VL) for at least 12 months
2. Treatment duration of 6-12 months
3. No prior resistance to non-nucleoside reverse transcriptase inhibitors or integrase inhibitors
4. Absence of HBV co-infection
5. Not pregnant or planning to conceive
6. Good treatment adherence
Pre-Treatment Circuit:
1. Medical Consultation: Clinical assessment and criteria evaluation.
2. Treatment Request: Physicians submit requests electronically.
3. Pharmacy Evaluation: Assessment of adherence to criteria with communication to the physician. Approved requests result in electronic prescriptions, ensuring correct dispensing.
In-Person Pharmaceutical Care Consultations (FCC):
• The first two visits confirm patient commitment and deliver dosing schedules.
• Medications are dispensed by pharmacy technicians and administered at Nursing practice
• From the third dose, consultations are conducted remotely to monitor adherence and effectiveness.
Nursing practice tasks:
• Confirm patient attendance the day before administration.
• Request medication from the pharmacy for the patient.
• Administer treatment and schedule future appointments based on the established calendar.
Implementation: The program began in November 2023.

What has been achieved?

8 patients were included, achieving 100% compliance from all services involved. Patient satisfaction is high, with undetectable VL maintained for 6-12 months post-treatment change. Mild flu-like symptoms were reported by 2 patients, and 2voluntarily discontinued due to mood concerns. 3 patients are awaiting treatment changes. All patients included underwent face-to-face FCC for the first and second doses, and telematic consultation for successive doses.
Limitations: small sample size.

What next?

This pharmaceutical care circuit can be adapted to various pharmacy services, providing a promising approach for HIV treatment adherence.The sample size needs to be enlarged for further studies.

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Author(s)

Lotte Borg

Why was it done?

In the home care team (HTC), it is often assistants, who may be unskilled workers, that administer the medication from a multi-dose compliance aid. The quality control they perform before administration involves verifying that the number of tablets and capsules for the designated time slot matches what is recorded in the HTC’s digital system.
The hospital may not have all the strengths in stock, and therefore a dose can be composed of multiple or fewer tablets.
If the number of tablets deviates from the HCT’s digital system, the assistant is not allowed to administer the medicine and must call on a nurse to make sure that the hospital has dispensed the correct medicine.
This is time consuming for the HCT and the patient may receive their medicine at a later time than prescribed with consequent health effects. Furthermore the phone call between the assistant and the nurse can be worrying for the patient to hear.

What was done?

Communication with the local HCT regarding deviations from the medication list was enhanced through the use of an existing digital discharge report (DDR).

How was it done?

A DDR was already in place, and the enhancement is that nurses and pharmacy technicians now use it to report any changes in the number of tablets and capsules dispensed when discharging a patient to the HTC. A nurse from the HTC then adjusts the quantity of tablets in the HTC’s digital system based on the number of days for which the hospital has dispensed medication to be administered by the HTC.
The implementation was initiated on May 1st, 2024, in two hospital wards.

What has been achieved?

It is not technically feasible to generate a report of all the DDRs where this improvement has been implemented; however, the HCT has indicated that each time deviations are noted in the DDR, they will save a significant amount of time.

What next?

If a DDR is available and the hospital wards and clinical pharmacy department can reach an agreement on its usage and timing, there is no reason not to utilize it, especially if it can enhance patient safety during transitions in care.

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Author(s)

Mélanie Hinterlang, Mona Assefi, Pauline Glasman, Delphine Brugier, Meriem Charfi, Fanny Charbonnier-Beaupel, Marie Antignac, Carole Metz

Why was it done?

Clinical trials in critical care sometimes demand swift inclusion and administration, often occurring at any hour of the day or night. To enhance patient care, the experimental drug may be provided in a non-nominative manner directly from the pharmacy unit to the care unit for storage before any inclusion as a stock. This dispensing pathway is considered less secure than the conventional named dispensing but can be necessary. The objective of this risk analysis for this dispensing process was to identify the risks, determine the number of them with unacceptable criticality, and propose actions to reduce criticality of these risks.

What was done?

A risk analysis of non nominative dispensation of experimental drugs process was conducted to streamline, secure, optimize, and standardize this dispensing process.

How was it done?

Following a preliminary investigation, three pilot services were chosen: surgical intensive care, post-interventional recovery room (SSPI), and cardiology. The Failure Mode, Effects, and Criticality Analysis (FMECA) method was applied to the non-nominal dispensing circuit of experimental drugs from reception at the pharmacy unit to the administration of the drug to patient. Investigators, clinical research associates, nurse, and pharmacists participated.

What has been achieved?

Following the FMECA, 281 risks were identified. The majority were either acceptable (123 or 44%, 110 or 39%, 147 or 52%) or tolerable (139 or 49%, 148 or 53%, and 130 or 46%) for the intensive care, SSPI, and cardiology services, respectively. Unacceptable risks numbered 19 (7%), 23 (8%), and 4 (1%) for intensive care, SSPI, and cardiology services, respectively. The process identified as most critical for all three services was communication. After risk prioritization, a plan comprising 17 actions was implemented.

What next?

This risk analysis demonstrated that control over the non-nominal dispensing circuit is achievable. Once the actions are in place, a reduction in criticality is anticipated due to a decrease in the frequency. Theoretically unacceptable risks are now at 0%. In the long term, this project has the potential to participate to improve the care of patients enrolled in emergency clinical trials and boost research in the concerned units.

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Why was it done?

All errors, whether involving medication or not, are required to be reported and classified in the hospital reporting system. However, the system is poorly adapted for medication management and lacks the relevant terms. This results in the same type of error being classified in various ways, making systematic quality improvement difficult. A pilot study confirmed the system’s shortcomings, after which a new medication management process was developed and evaluated.

What was done?

The existing process for classifying medication errors was supplemented with a new process in which hospital pharmacists reclassified medication errors detected in the reporting system. The reclassification was based on a predefined medication management process.

How was it done?

A medication management process was developed in collaboration with specialist nurses and in accordance with applicable regulations and policies. The process consisted of the following activities: 1) Prescription, 2) Ordering/Delivery, 3) Storage/Narcotics Control, 4) Preparation, 5) Handover/Administration, 6) Medicines information in transitions of care, 7) Follow-up of treatment, and 8) Miscellaneous. The process was validated by having four hospital pharmacists independently classify 176 medication errors. Consistency in the assessment was evaluated, and the process was corrected as needed. All medication errors classified as medication-related in 2022 or containing the word “medication” in free text were thereafter exported from the reporting tool to Microsoft Excel and then into a data processing and performance monitoring tool for further analysis.

What has been achieved?

A total of 756 medication errors were identified in the reporting tool, distributed across 65 different activities. Hospital pharmacists identified an additional 305 errors through free-text searches that had not been reported as medication-related. A total of 1,061 medication errors (756+305) were reclassified and grouped into eight activities. The highest risk of errors was associated with the preparation (19%), followed by storage/narcotics control (18%), and prescription (17%). The new process, involving hospital pharmacists in classification, creates conditions for a more systematic approach to medication errors. The pilot project was presented at the hospital’s themed day for World Patient Safety Day 2022.

What next?

Discussions have been initiated with system developers to improve the reporting tool. Discussions with hospital management will be initiated with the goal of creating a structure in which hospital pharmacists have an active role in the hospital’s work on patient safety related to medication.

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Author(s)

Douwe van der Meer, Peder Nygard

Why was it done?

In our hospital 30% of the daily distributed medication for individual patients was not administered. Reasons for not administering were for example lack of need because of patients clinical performance, discontinuation of prescriptions or early discharge. Because of safety concerns, like mix-ups, our standard procedure was to discard all returned medication. This resulted in a waste of about 220.000 pills annually.

What was done?

We reduced medicine waste by 90% by reusing returned medication from our medical wards. With this result we made an important step for our hospital to meet the national sustainability goals in the Dutch ‘Healthcare Green Deal (3.0)’.

How was it done?

Reusing returned medication brings multiple safety concerns. By performing a prospective risk analysis we identified three major risks: mix-ups, expired medication and accepting non-qualitative packages (like slightly opened blisters or incomplete labels). With these risks identified we redefined our distribution process on four key elements: 1) Every medication has a barcode on unit level and if not, is labelled by our team through duplicating the ‘Falsified Medicine Directive’-barcodes to small 2D barcode labels which includes expiration date. 2) All returned medication is checked by a pharmacy employee on major quality aspects. 3) Returned medication is placed in a separate ‘return-box’ in front of the original stock inside the distribution cabinet. 4) Expiration dates are checked more frequently and are checked upon distribution and administration through barcode scanning.

What has been achieved?

The new distribution process was implemented in all of our eight distribution cabinets and resulted in saving 90% of the returned medication; witch amount to 200.000 pills and 70.000 euro savings annually. On average we work with 6 employees daily, who need 15 minutes extra per person per day to process returned medication.

What next?

Our goal is to save all returned medication that meets our quality standards. 5% of the returns that are not reused are medicines not included in the assortments of the specific distribution cabinet, so extra logistic and administrative steps are needed to place them back in the pharmacy stock. We are exploring new ways to make this next step in reducing medication waste further.

Author(s)

Maria Gregori, Eva Legido, Marta Bellver, Inmaculada Seguí, Amando Mengual, Jose Manuel Ventura

Why was it done?

In Spain hospital pharmacy services dispense specific medications to outpatients. Nevertheless, some patients have difficulties in getting to the hospital due to disabilities, displacement problems or work reconciliation. In this sense, the objectives of the programme were as follows: Improve patient access to healthcare professionals and reduce visits to the hospital. Promote patient autonomy, responsibility, and participation in decision making regarding pharmaceutical care and dispensing of medicines. Increase patient satisfaction with the healthcare provided. To expand the portfolio of services of the OPCUs. Promote the integration and continuity of pharmaceutical care between the OPCU and CP.

What was done?

Implementation of a programme in the Outpatient Pharmaceutical Care Unit (OPCU) that includes telematic pharmaceutical care (telepharmacy) as well as the dispensing of hospital medications in proximity through our health structures (primary care centres) or community pharmacy (CP).

How was it done?

We took the following steps:
– Establish inclusion and prioritisation criteria for the selection of patients who are candidates to participate in the telematic pharmaceutical care and proximity dispensing programme.
– Establish the procedures for the development of telematic pharmacotherapeutic follow-up: telephone consultation at the beginning of inclusion and successive ones prior to each dispensation.
– Establish the processes, procedures, and resources for the performance of drug dispensing in CP.
– Coordination of all participants in the process.
– Establish indicators and variables to measure and improve the results obtained.
– Guarantee patients’ rights in terms of confidentiality, authorisation, and information.

What has been achieved?

From January 2022 to August 2023, a total of 376 patients have been included in the programme, which translates to 2,041 telephone consultations and 2,306 dispensations of medication from hospital to CPs or primary care centres. A total of 36 incidences were resolved.
Of these patients, 68% were included because of having reduced mobility or dependence, 18% due to work-life balance, and 14% due to distance or problems getting to the hospital.

What next?

– Inclusion of at least 15-20% of patients from face-to-face modality to telepharmacy and proximity program.
– Evaluate indicators and detect opportunities for improvement in the processes.
– Determination of patient reported outcomes.