Author(s)

JUDIT PERALES PASCUAL, ANA PÉREZ LÓPEZ, HERMINIA NAVARRO AZNAREZ, ELENA HERRANZ BAYO, MARIA PEREZ MORENO, CARLOS-IGNACIO DIAZ CALDERON HORCADA, Mª REYES ABAD SAZATORNIL

Why was it done?

In 2019 the UPEX attended a large volume of patients without a scheduled appointment, long waits were generated and the pharmacotherapeutic follow-up was complicated. The purpose was to implement an appointment management module to avoid crowds, excessive waiting times, allowing better organizational management of care and knowledge of patients in each type of consultation.

What was done?

An outpatient is a patient who goes to the outpatient unit of their Hospital Pharmacy Service to collect a drug for hospital use/diagnosis or foreign drug (it will be administered without health personnel intervention).

An appointment management system was implemented in accordance with the objectives of the SAMPA project (Service for Registration and Promotion of Adherence to Medicines for Elderly Patients), included in the European STOPandGo project.

How was it done?

Creating a cross-cutting system for the entire clinical circuit from prescription to dispensing involved a great deal computer involvement. Although it began to be used in November 2018, it was not used by the mostly part of prescribing doctors until the end of 2020.
Now, when the patient leaves medical consultation, he/she will go to the pharmacy and will be seen by a pharmacist. Besides, the program will propose a return appointment when it calculates that the patient has a week’s worth of medication, thus preventing the patient from running out of medication. The pharmacist will decide if the patient needs pharmacotherapeutic follow-up.

What has been achieved?

In 2019, 5 services cited patients while in 2020 it was 14; the percentage of patients attending pharmacy cited increased from 73.2%(2019) to 79.4%(2020).
Currently, the pharmacist knows in advance which scheduled patients he has and can establish a better organizational care management and determine in advance if the patient needs a close pharmacotherapeutic follow-up. Additionally, with this system an average waiting time of 03:55min was achieved (in 2019 appointments with waits >30min were recorded).

What next?

The implementation of the appointment management system has made possible to achieve better organizational management of care,avoid crowds,excessive waiting times, and provide better patient care and pharmacotherapeutic follow-up. The proposed solution can be extended to other hospitals.

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Author(s)

ROSARIO MORA-SANTIAGO, JOSE-LUIS ORTIZ-LATORRE, ELENA SANCHEZ-YANEZ, ANGEL JURADO-ROMERO, ISABEL MOYA-CARMONA

Why was it done?

During the health alert caused by Covid-19, home delivery was quickly implemented in our country to reduce attendance at the Hospital Pharmacy Service (HPS) to obtain their medications.
In our HPS we transform home delivery into telepharmacy program (TP) with chronic neurological patients, who suffering pathologies that decrease their autonomy, with the purpose to optimize clinical outcomes and reduce the risk of contagion.

What was done?

The main purpose was to design a telepharmacy program (TP) undertstood as the provision of pharmaceutical care by pharmacists through the use of telecommunications to patients located at a distance. Telepharmacy services include patient follow-up and clinical service delivery. In our case, home delivery is also included.

How was it done?

We design the TP stratifying stable chronic patients (more than 6 months of treatment) by level of autonomy, physical distance to our Hospital and high risk (due to immunosuppressive treatment). Inclusion in the TP was proposed to patients with multiple sclerosis (MS) and aminotrophic lateral sclerosis (ALS).

Telepharmacy appointments were recorded and scheduled within the outpatient care activity, they were recorded in the patient’s medical history, as a pharmaceutical clinical follow-up, reviewing adherence, interactions and possible adverse events. Later, home delivery was made, through an external logistics company. Patients gave their consent to transfer personal data for home delivery.

Data collected were: sex and age, first or second line treatment in MS patients, pharmaceutical form (pill or syrup ) in ALS patients and number of total deliveries made.

What has been achieved?

We started on April 2020 with the program, six months later 56 patients were included, 48 with MS (total of MS patients attended by our HPS: 296) and 8 with ALS ( total of ALS patient attended by our HPS: 58). Median age: 45 years in MS group and 65 in ALS group. In MS group 37 patients received 1st line treatment and 10 second line. In ALS patients 6 received tablets and 2 syrup.
420 deliveries took place (average: 3,1 for patient).

What next?

The implementation of the TP was well accepted, avoiding longed displacement in patients with neurological pathologies. Our future target is to reach a greater number of patients that can be included in the program.

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Author(s)

Ana Pelaez Bejarano, Maria de las Aguas Robustillo Cortes, Pilar Villar Santos, Olalla Montero Pérez, Ignacio Garcia Gimenez

Why was it done?

Rheumatologic disorders carry increased risk of infection compared with the general population, so facilitate access to hospital medications is of vital importance.

What was done?

On 14 March 2020, the Spanish government declared a state of alarm to deal with the spread of COVID-19. Medication dispensing protocols were immediately established to deliver drugs to patients who could not come in person to the hospital pharmacy department. These measures were designed to benefit citizens who, due to age or physical fragility, were more vulnerable to contagion. We had the collaboration of community pharmacies actively practicing during the COVID-19 pandemic and a logistics service, with no extra cost to the public healthcare system.

How was it done?

Between 30 March and 1 September 2020, a circuit was designed as follows: First, patient request the delivery service in the community pharmacy of their choice, which sending the request of each patient to college of pharmacists. Later, this institution sending of applications received from all pharmacies to hospital pharmacy. Here, the hospital pharmacist reviewed the patient’s electronic medical record, checking that the medication requested was appropriate, modifying it if deemed necessary (change of drug, dose, and so on). A pharmaceutical cooperative sending antirheumatic drugs to the community pharmacies. Finally, the community pharmacist who received the package checked the medication and, with the patient, reviewed and reinforced the information on the treatment.

What has been achieved?

587 patients were included: 211 rheumatoid arthritis, 173 psoriatic arthritis, 121 psoriasis and 82 ankylosing spondylitis. The delivery service enabled us to provide antirheumatic drugs to patients in their immediate environment through a service that was free for both the patient and the hospital pharmacy service. This contributes to guaranteeing the achievement of the pharmacotherapeutic objectives established for these patients.

What next?

Further action is needed to identify which groups of patients require more intensive pharmaceutical care and, therefore, who could benefit most from telepharmacy, and not only the delivery service.

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Author(s)

ROCÍO TAMAYO BERMEJO, ARANZAZU LINARES ALARCÓN, CASILDA ORTEGA DE LA CRUZ, ISABEL MUÑOZ CASTILLO

Why was it done?

In the alarm state due to COVID-19 in March 2020, in order to reduce the number of visits to the hospital to outpatients who go to the Outpatient Pharmaceutical Care Area, a new Pharmaceutical Care and home delivery circuit is implemented.

What was done?

A circuit of Pharmaceutical Care and home delivery was implemented for outpatients in the alarm state due to COVID-19.

How was it done?

The needs, possibilities and resources of the Hospital were identified. Material resources were adapted: supply and stock management. A logistical solution was sought and a review of thermolabile drug stabilities was made. Human resources were restructured: definition of a new team, functions and responsibilities.
A new circuit was implemented with remote access. When the patient contacts, he´s attended by a pharmacist who performs the screening and interview (initiation/follow-up), who after reviewing the clinical records, validates the treatment and selects the dispensing process of the patient according to individualized. The preparation of shipments is organized through the use of a web resource, by a pharmacy technician and at a specific time, based on a list of shipments per day, dispensing sheets and personalized labels. Once the dispensations have been prepared, a double check is made by another pharmacy technician on a different shift.
Three phone lines and an email weren´t enough to attend to all concurrents demands in a period of less than 24 hours. To mitigate this situation, a multichannel information strategy was implemented to notify all patients.
Other limitations: incidents by the logistic operator, errors in addresses and incorrect dose shipments.

What has been achieved?

During two months (April-May), 1103 patients benefited from the new circuit, approximately 30% of the patients who collect medication in our Outpatient Pharmaceutical Care Area during this period.

What next?

The pharmaceutical care and home delivery circuit has been shown to be safe, and has been able to meet the needs that are required in a alarm state. Also, it´s a circuit applicable to other Pharmacy Deparments since it doesn´t require a large investment in resources.

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Author(s)

Ignacio Salar Valverde, Maria García Coronel, Consolacion Pastor Mondéjar, Mayte Gil Candel, Iris Muñoz Garcia, Carles Iniesta Navalon, Elena Urbieta Sanz

Why was it done?

This project was carried out to avoid the possibility of contagion by SARS-CoV-2 when going to collect the medication. The circuit began at the end of March and the month of April 2020.

What was done?

Send the hospital dispensing medication to the patient’s home.

How was it done?

The first step was to specify the patient was considered at risk for SARS-CoV-2, in the end, patients over 65 years of age or immunosuppressed were considered at risk.
The second step was what order to follow to select and evaluate candidate patients for home delivery, for which the solution was simple, it was decided to follow the order of the pharmacy agenda for the collection of medication. The SELENE® electronic medical record program was used to evaluate the patient’s risk.
The third step was to contact him by phone, to check if there was a possibility of collecting the medication by a family member / caregiver, and if not, confirm a delivery address.
The last step was the preparation of the medication in the proper conditions of conservation and identified with the name and address of the patient. Shipments were organized from the pharmacy service. Patients were given an appointment in the pharmacy agenda for the next shipment.

What has been achieved?

There were 139 home deliveries of medication, 47 in March and 92 in April. Around 139 telephone calls were made, they are not counted, not all patients could be contacted in the first attempt, and up to three attempts were made per patient.
The majority, 124 shipments, were made through the service that the hospital made available to them, except for 13 that were made through the Red-Cross and 2 through Civil-Protection.

What next?

Although the delivery of medication at home and was already carried out in some pharmacy services, because of the pandemic it has spread to the rest of the hospitals in our country.
This service should be maintained, despite its cost, for patients who meet a series of criteria, which must be established and agreed upon. In addition, a telephone follow-up should be carried out on the patients that we send the medication to their home.

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Author(s)

Robert Baghdarsarian, Karin Hellström, Mattias Paulsson

Why was it done?

The health care providers at the Paediatric Emergency Ward discovered that when opening glass ampoules of morphine by snapping the top off, this did not result in the normal straight cut by the score. A close examination also revealed residual glue and the glass at the ampoule neck not being fully transparent. The sealed outer packaging also seemed manipulated for most of the morphine ampoules stored in the ward medication room. Simultaneously, staff discovered that one of the paediatric patients had not received the anticipated analgesic effect of the ordered morphine infusion.

What was done?

This case report describes how the compounding unit of Uppsala University Hospital (CU) was able to assist in analysing the contents of morphine glass ampoules and infusion solutions, in a case with suspected tampered containers

How was it done?

CU has invested in an easy-to-use spectrophotometer to check the concentration and identity of chemotherapy prepared in the clean rooms. The primary focus is to have an independent system to check preparations done by the chemotherapy robot e.g. in connection with software upgrades. This equipment was within hours adapted to be used for morphine analyses. The results clearly show that the infusion labelled 10 mg/mL was tampered with, containing only 0,4 mg/mL morphine. Samples were also sent to the Microbiological laboratory to check for risks for microbial exposure during infusion of tampered morphine.

What has been achieved?

CU was able to provide results of the contents of all ampoules, and the infusion solution administered to the patient, within a couple of hours and without any cost. The results showed that all ampoules had been emptied from its labelled contents and likely refilled with Sodium Chloride 9 mg/mL. The infusion solution given to patient was also likely prepared from a tampered ampoule. These results were crucial information in the conversation with parents about the incident, and the subsequent report to the police regarding the probable violence offence.

What next?

We recommend that all healthcare settings evaluate the possibility to collaborate closer with the hospital pharmacy, and in new ways.
Thanks to our CU being an integral part of the hospital with close interaction with wards, this rapid handling was possible to stage.

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Author(s)

Rosalia Fernández-Caballero, Virginia Collados Arroyo, Clara Herranz Muñoz, Araceli Henares López

Why was it done?

Every month, an average of 700 patients receive pharmaceutical care in the outpatient consultation (OC) of our first-level hospital. Given the mobility restriction measures applied by the spanish government during the pandemic, access to this consultation was difficult for some patients. The aim of this program is to ensure the access to medication for all patients and prevent them and professionals to virus exposure. Telepharmacy program consists of providing pharmaceutical care based on available means of communication and access to medication through home drug delivery.

What was done?

During the COVID-19 pandemic, we designed and implemented a telepharmacy programm to ensure access to medication for all patients.

How was it done?

Once weekly, the pharmacist contacted the listed patients during the following week in OC by telephone or via the hospital’s electronic platform, to offer the possibility of participating in the program. During teleconsultation, pharmacist provided the same attention as in face-to face consultation: administrative situation of the patient, adequate medical follow-up, assessment of adherence, review of interactions and adverse events and treatment changes. Moreover, we e-mailed the patient’s consent for home drug delivery by and external company. In case the patient didn’t have a web mail, we requested verbal consent. Once a week, one pharmacy technician prepared the medication and the selected company performed the home delivery in guaranteed storage conditions. To minimize the burden of work, the medication was sent for two months per patient. Oncohematological patients, who came to their doctor’s appointment every month, were excluded from this program.

What has been achieved?

Between March 20 and October 9, we have included 595 patients in this program and conducted 1190 teleconsultations and 872 home drug deliveries with a great satisfaction of outpatients.

What next?

Our next step is to improve the web system for sending alerts through our electronic platform to automate the home delivery process and thereby to reduce the logistic burden of the pharmacist and to increase the pharmaceutical care given to patients.

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Author(s)

Olga Nedopilkova, Stanislav Gregor

Why was it done?

The project was created to increase quality and maintain continuity of a health care provided in the Czech Republic and to prevent any discontinuity which could endanger the patient. Emergency dispensing of a drug is enabled by new functionality which is the patient’s drug record (PDR) which was only launched in the CZE in June 2020. Last but not least it is about expanding existing competencies of pharmacists and strengthening pharmacists’ position in the healthcare system.

What was done?

The Association of Young Pharmacists, with support of the Czech Chamber of Pharmacists, created a project which is focusing on a possibility of dispensing a chronically used prescription drug in case a patient cannot obtain a prescription for various reasons (“emergency dispensing of a drug”). In hospital pharmacies in the Czech Republic (CZE), it is possible to dispense medicines to the public. A concept has been developed that describes all the essentials that must be followed.

How was it done?

A project proposal describing specific situations when the pharmacist can proceed to emergency dispensing, rules of the actual implementation and also cost analysis has been prepared). A search for experience from abroad has been conducted as well. Subsequently, a survey among pharmacists was conducted. The purpose of the survey was to determine whether pharmacists are interested in this competence and have comments on it. Then a comprehensive concept was submitted to the Ministry of Health. Specific legislative changes will now be needed.

What has been achieved?

Among pharmacists in the CZE, a considerable agreement was reached with the draft. According to the survey 94% of pharmacists agree with the prepared proposal, 3.2% disagree, and the remaining 2.8% agree with minor modifications to the request. Furthermore, we managed to develop a concept that describes detailed conditions for dispensing drugs in emergency mode. The concept was submitted to the Ministry of Health, with which the details of this proposal will now be gradually negotiated.

What next?

This project represents only one of the new competencies that pharmacists could achieve. We want to follow up on this step with another project that would enable pharmacists to prescribe chronically used drugs under specific conditions even outside emergency situations.

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Author(s)

VIRGINIA SAAVEDRA QUIRÓS, BELÉN ESCUDERO VILAPLANA, ELVIRA SANTIAGO PRIETO, MARÍA BELLA CORREDERA GARRUDO, INÉS GUMIEL BAENA, MARÍA DOLORES GARCÍA CEREZUELA, AMELIA SÁNCHEZ GUERRERO

Why was it done?

It is important to provide continuous training to all professionals working in the healthcare system, especially when staff turnover is frequent, and when their job is directly related with drugs management, where a failure in the chain of drug utilization can have an impact on patient health.

What was done?

We developed a technology-training strategy of the Pharmacy Department to improve the training resources of the professionals working in it, through the support of information and communication technologies (ICTs), in order to achieve the highest quality in our actions.

How was it done?

The initiative was targeted at the nursing assistant staff of the Pharmacy Department, in the dispensation process to in-bed patients. The development period was between March and April 2017, focusing on activities related to the management, conservation, storage and dispensing of medicines.
This information-training material was developed as follows:
‐ By editing video-tutorials, which would be accessed after recognizing an associated QR code.
‐ Through the preparation of summary sheets in poster format that reflect in a schematic, concrete and visual way those key aspects in each of the processes.
After its implementation, a user satisfaction survey was conducted to evaluate the initiative.

What has been achieved?

Five training video-tutorials were made on different subjects: preparation of unit-dose dispensing carts, preparation of medication from automated dispensing systems (ADS) in Pharmacy, order reception, replenishment ADS in the wards and preparation of medication “on demand”. The average duration of the videos was 5 minutes 45 seconds.
In addition, 7 summary sheets were designed for the management of other types of activities: returns, expirations, special orders, priorities in normal situation – critical situation, management of medicines not included in pharmacotherapeutic guide, interhospital medication loans and calls procedure in the Unit-dose dispensing area.
Satisfaction surveys conducted by nursing assistants have positively valued the initiative.
The strategy developed allows the integration of ICTs in staff training, helping to manage the information of the Pharmacy Department, achieving a better optimization of available resources.

What next?

The degree of satisfaction of the users was good for what we consider important to promote this practice, making it extendible to the other areas and members of the Pharmacy Department.

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Author(s)

Charlotte Ménage, Mickaël Le Barbu, Adrien Borowik, Christine Housset, Sandrine Voisin, Florence Lémann, Jean-Michel Descoutures

Why was it done?

An audit of the medication storage cabinets was performed in 2015 in 19 care units. Over a three month period, more than 5000 inappropriate medecines were found which are likely to alter the process of pillboxes prepation by the nurses. Our objective was to develop a training program for nurses to identify and avoid near miss events during the medication administration process.

What was done?

A simulation learning program for nurses was implemented to secure the drug pillboxes preparation.

How was it done?

A multiprofessional team (i.e., pharmacist, physician, pharmacist resident, head nurse, risk manager, hospital hygienist) collaboratively developed a simulation-based workshop. Two mobile cabinets were designed. They were composed of 28 medicine boxes, a patient pillbox and a laptop with a mock prescription. They included the use of a simulation scenario with errors (e.g., expired tablets, damaged blister packs, mixed pharmaceutical forms or dosages, non-formulary drugs). The nurses had to prepare the patient’s pillbox for one day and then were asked to solve five questions about good practices. A validated assessment grid was filled in by two team members, and finally discussed with the nurse about the successes and pitfalls as an education purpose. At the end of the simulation program, nurses had to answer a satisfaction survey.

What has been achieved?

47 nurses experienced the simulation-based workshop. It took 40 min for each nurse on the same week. 89% removed the deteriorated tablets remaining in the pillbox and did not unpack any unit dose. However, 81% were unable to prepare the right medicine, the right dose, the right route for the right patient at the right time, because of a lack of patient identification on the pillbox. Some critical procedures were considered not appropriately followed: i.e., detecting acetaminophen prescription duplicate (only 26%), throwing away medicines in the right disposable bin (21%), checking the tablet expiry dates (70%), using a drug for which the patient was not allergic (62%). The 47 nurses were all together satisfied (100%) with this workshop.

What next?

The simulation based program was adopted by the hospital department of nurse care. It is now integrated in the yearly re-assessment skills program of all nurses.