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DEVELOPING A TERRITORIAL NETWORK TO ENHANCE HOME-HOSPITALIZATION CARE IN REMOTE MAUNTAINOUS REGIONS

European Statement

Selection, Procurement and Distribution

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.

IMPLEMENTATION OF AN ATYPICAL MEDICATION ROOM TO OPTIMIZE MEDICATION MANAGEMENT AND REDUCE WASTE AT HERLEV GENTOFTE HOSPITAL, DENMARK

European Statement

Clinical Pharmacy Services

Author(s)

Henrik Kjer, Christina Laustsen, Rasmus Riis, Caroline Rasmussen, Jeanette Bajrami, Christian Rubek, and Steffen Jørgensen

Why was it done?

An atypical medication room (AMR) was established at Herlev Gentofte Hospital, Denmark to centralize the storage and handling of medications not part of the standard assortment (i.e. atypical medication). The project aimed to improve the efficiency of medication management, reduce medication waste, and streamline workflows associated with the use of atypical medicines. To enhance the accuracy and efficiency of inventory control, the ScanPill technology was developed as a tool for digital tracking and updating of medication stock.

What was done?

Atypical medications are often stored across various departments with low turnover, leading to potential waste and time-consuming retrieval processes. Centralizing these medications in an AMR and using ScanPill aimed to reduce waste due to expiry, improve stock management, and simplify medication retrieval for healthcare professionals.

How was it done?

Atypical medications from multiple departments were collected and stored in the AMR. The ScanPill system was developed to facilitate the scanning of QR codes and barcodes on medication packaging, allowing for precise tracking of stock levels and easy updates to the atypical medication list. Staff were trained to use the AMR and ScanPill to ensure smooth transitions in retrieving, returning, and documenting atypical medicines. Regular inventory checks and updates were conducted to maintain an accurate database of available medications.

What has been achieved?

The AMR, supported by ScanPill, led to improved handling and management of atypical medications. The centralized storage reduced the need for duplicate stock across departments and enabled quicker access to necessary medications, reducing retrieval time and potential waste. The ScanPill technology improved inventory accuracy and streamlined the process of checking medication in and out, ensuring up-to-date records. Staff feedback has been positive, noting enhanced workflow efficiency and reduced medication waste.

What next?

Future steps include evaluating the economic impact of the AMR and its effectiveness in reducing medication waste. Efforts will be made to refine the use of ScanPill, enhance staff training, and explore potential applications of the AMR model across other departments. Continuous monitoring will ensure optimal performance and identify further areas for process improvement.

ASSESSMENT OF THE APPLICABILITY OF 3D-PRINTED MEDICINES IN A PAEDIATRIC WARD

European Statement

Clinical Pharmacy Services

Author(s)

M.S. Nielsen, The Pharmacy of the capital region of Denmark, Clinical Pharmacy Rigshospitalet, Copenhagen, Denmark
S.L. Otnes; The Pharmacy of the capital region of Denmark, Clinical Pharmacy Rigshospitalet, Copenhagen, Denmark
M.H. Clemmensen, The Pharmacy of the capital region of Denmark, Clinical Pharmacy Rigshospitalet, Copenhagen, Denmark
L.R. Duckert, The Pharmacy of the capital region of Denmark, non-sterile production, Herlev, Denmark
T. Schnor, The Pharmacy of the capital region of Denmark, production, Herlev, Denmark

Why was it done?

Paediatric medicine has limited availability of on-label, age-appropriate formulations. Drug-related challenges encompass variability in dosing, use of tube administration, and the necessity for child-friendly approaches, including formulation issues as well as taste and acceptability of medications.

What was done?

A clinical assessment of the applicability of 3D-printed medicines from a paediatric perspective, with the limitations of the chosen technique.
The aim of this project was to identify specific areas where 3D-printed medicines provide viable solutions to the complexities surrounding paediatric drug-related challenges.

How was it done?

To minimize the need for individual medicine manipulation, we identified key challenges by reviewing the manufacturer’s API list and comparing it with nationally available compounded products. This analysis offered historical insight on the shortcomings of commercial products in addressing patient needs. Additionally, consultations were held with nurses and doctors in selected paediatric wards for further input.

What has been achieved?

Three key areas were identified where 3D-printed medicines could benefit paediatric wards:
Dosage: 3D-printed medicines enable patient-specific doses or customizable low doses, assisting dose tapering and minimizing dosing errors. However, for APIs with a wide therapeutic index, the dose should be aligned with commercially available products. Patients or APIs that frequently require dose adjustments are better suited to a mixture formulation.
Logistics: Individual packaging and room temperature storage offer advantages for travel and storage compared to liquid mixtures, which often require cold storage and are produced in larger, less flexible containers. Additionally, existing options like mixtures increases the risk of losing the entire dose supply at once.
Patient related inappropriate drug form: The 3D-printed tablets can be chewed or partially dissolved, facilitating administration for patients with swallowing difficulties. Additionally, it allows for customizable flavors, offering more flexibility than commercial products.
However, the technique does not yet address the need for medication administration via tubes, as it requires heating of the tablets, which can be hazardous when handled by untrained parents. Highlighting that 3D-printing should complement, rather than replace, existing options.

What next?

A prioritized and condensed list of APIs will be conducted based on the identified key areas and assessed by pharmacists, doctors, and nurses.
Appropriate wards will be selected for the pilot implementation of 3D-printed medicines.

TO IMPROVE TIMELY MEDICINES PROVISION AND ENSURE SAFE PRESCRIBING AS WELL AS SUPPORT EARLY DISCHARGE PLANNING TO IMPROVE FLOW INSIDE AND OUTSIDE AN NHS TRUST

European Statement

Clinical Pharmacy Services

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.

IMPLEMENTATION OF A PHARMACEUTICAL CARE CIRCUIT FOR LONG-ACTING ANTIRETROVIRAL TREATMENTS IN HIV PATIENTS IN A REGIONAL HOSPITAL

European Statement

Patient Safety and Quality Assurance

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.

THE USE OF A DIGITAL DISCHARGE REPORT PROVIDING INFORMATION ON DISPENSED MEDICATION TO IMPROVE THE INTERFACE BETWEEN SECONDARY AND PRIMARY CARE

European Statement

Clinical Pharmacy Services

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.

REDUCING MEDICATION WASTE IN HOSPITALS: DATA-DRIVEN SOLUTIONS AT THE SOURCE

European Statement

Selection, Procurement and Distribution

Author(s)

Minke Jongsma, hospital pharmacist, Tjongerschans Hospital, Heerenveen, The Netherlands
Marja Bogaards, hospital pharmacist, Haaglanden Medisch Centrum, Den Haag, The Netherlands
Annemiek Zwetsloot, ICT consultant, Panacea Informatics, Oosterbeek, The Netherlands
Folkert Botma, ICT consultant, Panacea Informatics, Oosterbeek, The Netherlands

Why was it done?

A significant proportion of valuable medications, often produced far from where they are used, ends up discarded without ever being administered. Due to limited visibility into actual medication use, hospitals face challenges in understanding which drugs contribute to waste.
Analyzing internal data allowed us to gain insight into different aspects of medication waste. Addressing these aspects successfully improved sustainable use of medication.

What was done?

We developed a medication waste dashboard to promote sustainable decision-making across medication policies, purchasing, prescribing, distribution, administration, and waste management.

How was it done?

Daily, hospital pharmacies register all medication orders and dispensations (to patients or for stock), while nursing staff document actual administrations. The discrepancy between dispensed and administered drugs provides useful insight into unnecessary medication waste.

What has been achieved?

We integrated dispensing and administration data into a dashboard, offering real-time visibility at the organizational, departmental, ward, and drug group levels. This tool allows our multidisciplinary team to conduct trend analyses and implement greener practices. Key outcomes include: 1) reduction of medication waste, 2) preventing excessive stock accumulation, 3) optimizing internal processes, and 4) maximizing reuse. Additionally, these data supports effective management during drug shortages and provides critical insights into missing opioids.

What next?

Utilizing data allows us to retrospectively analyze trends and project future scenarios, unlike traditional waste-bin audits. This data-driven approach empowers us to make proactive adjustments, guiding hospitals toward long-term medication waste reduction and facilitating benchmarking across healthcare institutions.

DOSE-DISPENSED MEDICINE IN SECTOR TRANSITIONS BETWEEN HOSPITAL AND HOME

European Statement

Patient Safety and Quality Assurance

Author(s)

Anette Thomsen, Sarah Mejlvang, Maria Grønkjær

Why was it done?

Automatic multidose Dispensing System (ADS) was implemented in April 2024 in the Hospital Pharmacy Central Denmark Region.
Before the implementation, new software functionalities were developed in the medication module (MEM) of the electronic patient record. The development included creation of new workflows in the wards and in the Pharmacy. A new functionality makes it possible for nurses and pharmaconomists at the hospitals to manually order dose-dispensed medicine (DDM) to patients who are discharged from the wards. The orders are sent from MEM to the ADS on one patient for a given time period. Medication can be ordered hourly until noon.

What was done?

Medicine for 1-5 days of use can be dose-dispensed (DD) for the patients ready for discharge, which gives the following advantages:
-Improved patient safety. The transition from hospital to home now uses a concept regarding DDM that is known in the primary healthcare sector.
-Increased time for the patient to buy new medication at a local pharmacy after discharge.
-Extra time for newly added/removed drugs to be incorporated in future DDM from local pharmacies.
-Less time spent by nurses dispensing medicine for patients who are being discharged.

How was it done?

To support patients in the transition between hospital and home it has been important to make an easy way to order and dispense medication. Following developing tasks has been made:
-Identification of needed functionalities
– Identification of necessary IT-support
– Requirement for ADS
-Developments in MEM Development and implementation of new workflows in the clinic
All points were created in collaboration between doctors, nurses, IT specialists and pharmacy staff.
The development took around one year

What has been achieved?

All clinical wards that receive DDM can now manually order DDM for patients who are on their way home. This is a great help in the clinics.

What next?

Extending the timespan in which it is possible to order DDM to patients who are being discharged is planned.
Qualitative studies in patient safety for patients receiving dose dispensed medicine in the transition between Hospital and home is considered.

OPTIMISING PATIENT ADHERENCE IN HEART TRANSPLANTATION: A PHARMACIST-LED EDUCATIONAL APPROACH

European Statement

Clinical Pharmacy Services

Author(s)

Lucie Malečová, Daniela Seberová, Blanka Zelená, Markéta Hanulíková, Kornélia Chrapková, Stanislav Gregor, Michal Hojný

Why was it done?

Adherence to immunosuppressive medication is crucial for long-term graft survival. Patients receive substantial information from various healthcare professionals regarding new medications and lifestyle choices during hospitalisation and post-discharge. Frequent non-adherence indicated that the existing educational approach led by physicians was insufficient. Our objective was to create optimal conditions for providing these instructions to patients before discharge.

What was done?

In collaboration with the cardiology department, hospital pharmacists created and implemented a new educational project to improve adherence among heart transplant patients. The main activity involves hospital pharmacists conducting educational visits at the patient’s bedside, supported by new educational brochures, materials, and questionnaires.

How was it done?

We created a questionnaire and collected baseline data by assessing the knowledge of transplant patients educated by the existing educational approach. Afterwards, we designed and implemented a six-visit educational program and prepared new educational materials and brochures. A new record system was integrated into the hospital information system to facilitate communication between doctors and pharmacists, documenting educational visits and questionnaire results. The initial three visits, scheduled during hospitalisation, cover the correct use of immunosuppressants and other medications, their interactions, and potential adverse effects. Guidance on recommended lifestyle changes post-transplantation, such as hygiene, diet, and infection prevention, is also included. The remaining three visits occur within one year post-discharge to assess patient knowledge with the previously mentioned questionnaire and adherence to the treatment plan with BAASIS©. During these visits, the pharmacist conducts a comprehensive review of adherence, addresses any drug-related issues, and guides medication changes.

What has been achieved?

Since the project’s initiation, 120 visits have been completed, involving more than 30 patients. The education significantly improved patient knowledge, with educated patients scoring an average of 94% correct answers on the knowledge questionnaire compared to 59% correct answers of patients educated by the existing educational approach. Only three educated patients were non-adherent, with the most common type of non-adherence being failure to take medication at the prescribed time.

What next?

As more patients participate in the project, we aim to correlate their knowledge and adherence with tacrolimus levels and the incidence of rejection. Additionally, we intend to extend this educational initiative to other departments within the hospital.

EVALUATION OF PROFESSIONAL PRACTICES: CLINICAL AUDIT OF DRUG PREPARATION AND ADMINISTRATION IN A NURSING HOME

European Statement

Patient Safety and Quality Assurance

Author(s)

Gulseren Lafci
Magali Ferro
Valerie Chaminant

Why was it done?

In accordance with french legislation concerning the quality of drug management in healthcare establishments, an assessment of professional practices was carried out within our nursing home. The aim was to study the compliance of drug preparation and administration methods with good practice in our nursing home.

What was done?

A clinical audit has been set up in our nursing home. It was carried out by 2 hospital pharmacists over 3 half-days to consider the preparation of weekly doses, daily doses, and an administration.

How was it done?

One of the 4 sectors of the nursing home was randomly selected. The medication management of all its residents was evaluated. The evaluation criteria were divided into 2 main parts: “drug preparation” and “drug administration”. The part on drug preparation was divided into 4 sub-sections (person in charge of preparation, room and hygiene, preparation, conditioning). The part on drug administration was also divided into 4 subsections (concordance between prescription and administration, identitovigilance, administration, traceability).

A criterion was defined as compliant if all the responses to the items were in line with the procedure, and as non-conforming if only one of the responses was not.

A conformity rate was defined for the entire audit (overall conformity), for each part (partial conformity) and sub-part (average conformity).

What has been achieved?

The care of the 19 residents in the sector was assessed (23.4% of nursing home residents).

The overall conformity rate of our clinical audit was 38.6%. Partial conformity of the “drug preparation” part was 32.3% (the average conformities of sub sections were: 50% for “person in charge of preparation”, 25% for “premises and hygiene”, 22.5% for “preparation” and 56.25% for “packaging”). Partial conformity of the “drug administration” part was 47.8% (the average conformities of sub-sections were: 100% for “concordance prescription/administration” and “identitovigilance”, 27.3% for “administration” and 42.8% for “traceability”).

What next?

The majority of non-conformities were due to a lack of human and material resources. In addition, a lack of knowledge was observed for substitution equivalence and galenic. The results were presented and proposals for improvement, such as raising staff awareness and providing resources, were made to the hospital’s medical committee.

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