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Author(s)

MARTÍNEZ LLIBERATO, A; COMPANY ALBIR, MJ; VICENTE ESCRIG, E; VALLEJO GARCÍA, R; RUBIO ORTOLÁ, L; GARCÍA MONTAÑÉS, S; BELLÉS MEDALL, MD; FERRANDO PIQUERES, R

Why was it done?

It was carried out to ensure the best monitoring, traceability and conservation of long-acting antiretroviral drugs, as well as to improve adherence and patient quality of life and reduce stigma in HIV patients.

What was done?

A program was developed for the administration and pharmacotherapeutic monitoring of patients who are candidates for long-acting antiretroviral treatment (LA-ART), coordinated with the infectious diseases unit (IDU) and the Hospital Pharmacy Outpatient Unit (HPOU).

How was it done?

After the inclusion of the drugs in the pharmacotherapeutic guide, the following program was designed:
1. Identification and communication to the HPOU by the IDU of patients who are candidates for LA-ART and electronic prescription.
2. Initial visit (week 0):
• Review and validation of the treatment by the pharmacist: indication, dosage regimen, interactions, contraindications.
• Planning of the annual administration calendar, providing two dates within the window period allowed by these drugs. Patients are scheduled for pharmaceutical care (PC) and administration on working Thursdays, in the HPOU Health Education Consultation agenda, which has a nurse.
• Information to the patient by the pharmacist, orally and in writing, about administration and adverse reactions. In addition, the annual appointment schedule is provided.
• Appointment of the patient for the first successive visit, if the patient accepts the start.
3. SMS sent the day before, to remind the patient of the follow-up visit. If the patient cannot attend the scheduled appointment, he/she will contact the HPOU to schedule an alternative date according to the calendar.
4. Successive visits (week 4 and every 8 weeks):
• PC
• Intramuscular administration by a nurse.
In all visits, the information is recorded in the patient’s computerized medical history.

What has been achieved?

Of 18 candidate patients in 18 months, 15 accepted ART after the initial visit. 89 PC and administration consultations have been carried out. Adherence was 100%, all reported local discomfort at the injection site between 1 and 7 days after administration and only 1 patient reported pyrexia.

What next?

A program applicable to all HPOU that have nursing and a Health Education consultation to implement adherence in these patients.

Author(s)

Michelle Ann Matzen, Linda Jeffery, Mette Juul-Gregersen, Bente Jonassen, Lene Juhl Biltsted

Why was it done?

At the regional hospitals in Horsens and Randers, the pharmacy helps mix selected intravenous (IV) antibiotics for patients admitted to inpatient wards (piperacillin/tazobactam, cefuroxime, and cloxacillin).
The mixing takes place centrally and is then distributed to the relevant wards.
Our electronic prescribing system does not help us to identify which/how many patients require these antibiotics so the number of prescriptions for each ward was manually counted before the mixing process.
To reduce medication waste, the manual counting was done every morning and noon, with an estimated time consumption of about 1 hour per day per location.
The goal was to move away from manual counting and towards an automated solution.

What was done?

The pharmacy assists wards in mixing IV antibiotics. There was a desire to digitize and streamline the workflow through development of a software robot.

How was it done?

The pharmacy assembled a team from two locations and reached out to the region’s robotic process automation (RPA) developers.
The pharmacy set requirements and expectations for the RPA solution with the developers.
Throughout the development, the programming was revised and adjusted several times to obtain the most accurate prescription data.
To verify the robot’s counting, manual counts were conducted multiple times during the process, leading to adjustments in the robot’s programming.

The development of the RPA solution spanned 9 months.

What has been achieved?

The fully developed RPA solution is now used at both locations. A report is emailed twice a day, after which antibiotics are mixed and distributed to the relevant wards.
Benefits:
• Frees up time for other tasks
• Data is more up-to-date regarding changes in patients’ medications
• Medication waste is minimized

What next?

There are plans to create a similar setup for a central mixing unit at Aarhus University Hospital, where the RPA solution can be implemented from the start.
There is potential for the RPA solution to be used at other locations/departments, with different medications. For example, monitoring of inhalation preparations or anticoagulant medications.

Author(s)

Arnela Boskovic
Gitte Stampe Hansen

Why was it done?

To ensure rational use of medicines during the acute phase of illness, an interdisciplinary group consisting of physicians, nurses, pharmacists, and the Hospital Pharmacy was initiated to determine if some medicines could be paused during shorter hospital admissions at The Medical Acute Care Unit, Bispebjerg Hospital.

What was done?

Patients in acute phase of illness may experience fatigue, nausea, swallowing difficulties, and cognitive challenges when faced with large amounts of oral medicine. Therefore, prioritizing life-critical medicines during hospitalization is essential, while non-critical medicines could temporarily be paused. Additionally, there is often medicine waste, where drugs are assumed to be administered but remain untouched on the bedside table. In acute care units with complex patients, optimizing nursing time, shelf space in the medicine room and managing costs is crucial for appropriate medication.

How was it done?

Information about the new practice was given via newsletters, oral presentations, and signs at the doctor offices and in the medicine room. The group identified statins, multivitamins and calcium supplements as non-critical, and these were hereafter removed from the shelves in the medicine room. The interdisciplinary division of roles were as follows; Physicians: Prescribe critical medicine and temporarily pause non-critical medicine; Nurses: Do not administer statins, multivitamins, or calcium supplements. If the prescription has not been paused, request the physician to do so; Pharmacists: Assist in pausing non-critical medicines; Hospital Pharmacy: Ensure availability of the correct medicine in the medicine room.

What has been achieved?

Temporarily pausing statins, multivitamins, and calcium supplements during short hospitalization led to minimizing medicine waste and freed up time for the nurses to do other nurse-specific tasks. Medicine administrations by nurses were reduced by 87-96%. It also resulted in optimized space in the medicine room, making space for more critical medicine such as medicines to treat epilepsy and Parkinson’s disease.

What next?

Expanding the list of non-critical medicine during short hospitalizations is in the pipeline. This will be done by interdisciplinary collaboration and will free up time for the nurses and doctors to focus on the acute care of the patient.

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.

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.

Author(s)

Yosr Trabelsi, Leila Achour, Ikram Fezaa, Samer Sahbi, Chema Drira

Why was it done?

Never events are serious incidents generally linked to human and/or practical errors, which should never happen. Most of these events are avoidable, and are the subject of specific recommendations for the implementation of appropriate protective measures. According to ANSM (French drug safety agency), potassium chloride (KCl) is among the drugs frequently implicated in Never Events.

What was done?

The aim of this study was to assess the prescription and administration practices of injectable KCL in our hospital.

How was it done?

We carried out a 1-month prospective audit between 1 and 30 September 2024. All the prescriptions of injectable KCL were collected and evaluated by a pharmacist using a data collection form. It was divided into 2 sections: preparation and administration. The reference guideline used for this study was the 2022 ANSM recommendations. The results were analyzed using excel.

What has been achieved?

Fifty-five prescriptions were included. The compliance percentage for prescriptions and administration practices was 31.4% and 30.5 %, respectively. Calculation of total intake was compliant and the total volume of diluent was mentioned in all the prescriptions. In 62% of the prescription, the correct specific units were used and in 38.2 % of cases the correct slow infusion rate was prescribed. Nevertheless, the use of the route was inappropriate since only the IV route was prescribed due to the shortage of oral KCl. For administration, final concentration (≤4g/L) of the KCL infusion was respected in 90.9% of cases and all the preparations were labeled.

What next?

The study revealed several non-conformities, leading to the development of an improvement report. Therefore, we decided to implement a training plan about injectable KCl use to ensure patient safety.

Author(s)

Margot DESCHAMPS, Nejib BORGAAOUI, Jimmy ROSE, Jennifer LE GRAND, Louise NICOLAS

Why was it done?

One of the clinical pharmacy activities in the thoracic oncology department is the analysis the interactions between chemotherapy and Complementary and Alternative Medicine (CAM). Cancer patients often seek alternative treatments which requires a rigorous evaluation of potential interactions. The goal of this study is to assess the methods used to analyze these interactions.

What was done?

To ensure traceability of the analysis, a tracking table for requests was created. The requests, coming from doctors, nurses, or patients, are recorded with key information such as name, date of birth, and the purpose of the analysis. Five information sources were selected, including the Herbal Medicine section of MedlinePlus, the website of the Memorial Sloan Kettering Cancer Center (MSKCC), a database of plants and dietary supplements published by the French National Agency for Food, Environmental and Occupational Health Safety, a database from the European Scientific Cooperative on Phytotherapy, and a publication from the journal Medical Oncology (Vol 36, number 45, 2019).

How was it done?

In nine months, 25 interaction requests were processed, 70% of which were from doctors. The analysis took an average of 30 minutes and were completed within 24 to 48 hours. The interactions mainly concerned oral chemotherapies (n=18), particularly Osimertinib (n=13). The requests involved various CAM (essential oils, medicinal plants, dietary supplements), with an average of four products per request. Desmodium was the most frequently analyzed product (n=5). In total, for 24 CAM, including Desmodium, was not recommended for use after analysis due the drug interaction risk and modification of liver metabolism of chemotherapies.

What has been achieved?

It is difficult to prohibit CAM to patients, and most substances can be taken at recommended doses. However, determining the precise dosage at which an interaction with chemotherapy occurs is complex due to the lack of a single reference. Using various sources allows for cross-referencing expertise and obtaining complementary information. For instance, MedlinePlus offers a generalist approach, while MSKCC focuses on interactions in oncology. Using international sources broadens the analysis and fills geographical or cultural gaps.

What next?

For the future, we would like to develop a tool that compiles the five data sources in order to be exhaustive in our future analysis.

Author(s)

S. Arraki Zava (1), A. Kandel (1), S. Herioux (1), C. Monpagens (1), L. Capayrou (2), C. Tailhades (1), V. Grenouilleau (1), S. Ferrari (1)
(1) Pharmacy Department, Pau Hospital Center, 64000, France
(2) Quality Department, Pau Hospital Center, 64000, France

Why was it done?

In the current context of rising production of anticancer preparations (AP), our hospital has adopted the C-log® tool to improve the safety and traceability of AP administration.

What was done?

Evaluation of the integration of the C-log® solution into the AP administration circuit in the oncology day ward.

How was it done?

From June to September 2024, a risk mapping (RM) using FMEA (Failure Mode and Effect Analysis) for the AP administration circuit was conducted by a multidisciplinary team (quality and IT departments, hospital pharmacists, pharmacy technicians, logisticians, nurses, and healthcare managers). After evaluating the circuit, failures, their causes and effects were identified. A residual criticality score was calculated (C=F*S*M) for each failure, considering its frequency F, severity S, and level of control M, and classified into 3 categories: acceptable (C<4), vigilance (4≤C<10), unacceptable (C≥10). An action plan was developed with corrective measures (CM).

What has been achieved?

RM identified 39 failures: 34 acceptable, 4 unacceptable, and 1 classified as vigilance. First unacceptable risk was related to disruptive patient episode identifier (PEI) scanning due to wristband opacity. Another came from mismatches between the wristband PEI and that on the AP label, when patients had multiple administration days with different PEIs for each, while AP labels only contained the first PEI. Third one is related to nurse’s lack of training which led them to miss important administration information on the software. The last unacceptable risk was increased time to trace all protocol administrations (checkpoints, premedication, AP…). The vigilance risk was due to the inability to trace anticipated premedication intake on the software.
CM includes the use of clearer wristbands and permanent ID number instead of PEI solving unacceptable failures. We decided to use C-log® for AP administration traceability only, while CHIMIO® remains to trace all other protocol administrations. New training sessions for nurses will be scheduled.

What next?

RM highlighted C-log’s contribution to reinforce identity vigilance. It demonstrated the importance of nurse’s acceptance of the software and therefore the need for sufficient training time on the tool. Focusing on an entire protocol administration traceability, C-log® couldn’t replace CHIMIO® yet. Once all the CM are implemented, the RM will be re-evaluated to assess their impact.

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Author(s)

PAULA HERNANDO MARTÍNEZ, VIOLETA LAFARGA LAPIEZA, DAVID JAMES BOARDMAN GONZÁLEZ, GRACIA PICAZO SANCHÍZ, CARIDAD MARTÍ GIL, DOLORES BARREDA HERNÁNDEZ

Why was it done?

The administration of medications through NGT is a common practice in the hospital setting. However, it cannot be assumed that this route of administration shares same properties as the oral route. Proper administration requires considering the pharmacokinetic and pharmacodynamic proper1es and adapting recommendations to the medication’s pharmaceutical form(PF). Incorrect manipulation can lead to undesirable effects, such as a reduction or loss of therapeutic efficacy, as well as an increase in adverse effects, toxicity or mechanical, metabolic, and/or infectious complications.
Despite the wide bibliography on this topic, there is a lack of knowledge among patients, caregivers, and hospital staff when there is not adequate training on the use and care of the NGT.

What was done?

Development of a pharmaceutical care project for patients with nasogastric tubes(NGT) to ensure the proper administration of medications through the tube and their correct handling.

How was it done?

In May 2024, a working group of pharmacists was formed in the Hospital Pharmacy Department (HPD) with the aim of creating a protocol for the adjustment of medications for administered through a NGT in hospitalized patients. A document was developed with general recommendations on maintenance, interactions with drugs, food and enteral nutrition, aimed at patients, caregivers and healthcare professionals to ensure the correct use of the tube. Additionally, a literature review was conducted on the various available manipulation guidelines (Technical sheets, dysphagia Guide from La Paz Hospital 2021 and the Guide for Drug Administration through Tubes Reina Sofía Hospital 2023), as well as validated apps such as (Deglufarm®, Medisonda®) which provide handling and administra1on instructions for each PF.

What has been achieved?

A daily search was conducted for hospitalized patients with nasogastric tubes to identify the need of instructions on medication handling. A fillable document was designed with the necessary recommendations for the handling of each prescribed medication during the hospitalization. During the pharmaceutical validation, patients with NGT were reviewed, and personalized reports were created according to the prescribed treatments.

What next?

To evaluate the level of patient sa1sfaction and including new needs. In addition, the aim is to implement this protocol upon discharge, in order to offer a personalized report with recommendations for the prescribed medications.

Author(s)

Luísa Álvares
Sara Brandão Madureira
Diana Monteiro
Patrocínia Rocha

Why was it done?

Lutetium (177Lu) oxodotreotide is indicated for treating subtype 2 somatostatin receptor-positive (SSTR2) gastroenteropancreatic neuroendocrine tumors, well-differentiated G1 and G2, progressive, inoperable or metastatic. This radiopharmaceutical targets cells with SSTR2 overexpression, emitting radiation that causes cell death.
Initially, the Summary of Product Characteristics (SmPC) included the gravity method for intravenous administration, using a system with two needles, one connected to a NaCl 0.9% solution, with or without a perfusion pump, using gravity to facilitate the flow of the radiopharmaceutical.
This method was adopted and optimized due to incidents during administration.

What was done?

Optimization of the administration method of lutetium (177Lu) oxodotreotide to maximize the administered radioactivity and enhance protection for healthcare professionals.

How was it done?

The first administration using the described method occurred in October 2022.
Subsequent treatments required transferring the radiopharmaceutical to a syringe and using a syringe pump due to incidents during administration.
A perfusion pump was later introduced to manage the flow of NaCl 0.9% solution.
In May 2024, a three-way stopcock was connected to the short needle.

What has been achieved?

Since October 2022, 23 administrations have been conducted. In the first, the percentage of remaining radioactivity in the vial was 2.19%.
The use of a syringe pump increased handling and exposure risks and was rejected due to the lack of protective barriers.
Adding a perfusion pump to the NaCl 0.9% line didn’t fully resolve perfusion issues. This was resolve by adding a three-way stopcock connected to the short needle. The additional third line allows for a syringe to be attached and force air into the system, promoting the radiopharmaceutical flow.
The average remaining radioactivity improved from 1.71% to 0.98% after final optimization.
No incidents, such as leaks or perfusion issues, occurred after optimization.
This optimization reduced the remaining radiopharmaceutical activity values, ensuring complete administration. It also minimizes professional exposure and contamination risks, as the radiopharmaceutical remains in the original vial, as indicated in the SmPC.

What next?

We aim to apply this optimized method in other treatments with the same radionuclide.