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Author(s)

Helge Ovesen

Why was it done?

In November 2022 St Olav’s hospital, a large university hospital, introduced electronic prescribing and closed loop medication for more than 700 beds. Oral medications are predominantly available as unit doses, other medications as barcoded packages. After go-live with the bedside scanning, data showed that a large part of the administrations and preparations did not happen with barcode scanning. The hospital needed to understand the reason for this in more detail.

What was done?

A team of pharmacists, nurses and IT personnel have analysed technical reasons why medications are not scanned at the patient’s bedside during administration or when doing preparation in the wards’ medicine room.

How was it done?

The group collected data on all scans that had failed and analyzed the input to the barcode scanner. In addition, the nursing staff lead was consulted to provide more information of the problems with the physical packages for the medication and how that affected the work process of achieving closed loop medication. Products that did not have a printed barcode at all were not included in the analysis.

What has been achieved?

Six different areas were identified when trying to describe the problems with closed loop medication and scanning of medicine:
1. Barcode printed on package but missing product code/GTIN in the system/national drug registry.
2. Barcode printed on package but with wrong implementation of ISO/GS1 encoding.
3. Barcode printed on package but hidden for the user on the package label.
4. Barcode only printed on the outer package that was removed when stored in the medicine room.
5. QR codes with links to training materials or other barcodes confused the nurse and the wrong code was scanned.
6. Barcode printed on package but contrast for the barcode scanning was not good enough (ex. dark vials with black barcodes).
The problems have been shared with drug manufacturers and competent authorities to raise awareness of how drug package design and correct/incorrect use of barcode printing affect implementation of closed loop medication.

What next?

Work together with national drug registries in Norway and drug manufacturers to create a national best practice for barcode printing on drug packages. The work should be coordinated with work on a European level.

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Author(s)

Andrés Sánchez Ruiz, Rocío Contreras Collado, Lucía Gutiérrez Lucena, Juan Jerez Rojas

Why was it done?

The programme began to be developed in March 2020 as an emergency solution to the COVID-19 pandemic, but over time it was refined due to the benefits seen in different areas, especially for pharmacy patients.

What was done?

A hospital drug dispensing programme was created with the collaboration of a community pharmacy and its pharmaceutical distributor. A daily delivery was conducted from the hospital pharmacy, covering the entire province, with a population area of 622,000 inhabitants and an area of 13,500 km2 that includes widely dispersed population centres with complicated communication.

How was it done?

Interlevel collaboration between hospital pharmacy, official college of pharmacists, pharmaceutical distributor and community pharmacy. After the first year, in which the process was more manual and marked by the pace of the pandemic, the programme began to develop. A web application with two-way communication hospital-community pharmacy was created. Hospital Pharmacy reviews and dispenses these requests, with daily shipments to all community pharmacies in the province through the distributor, which ensures safe transportation of the medication with adequate conditions of humidity and temperature.

What has been achieved?

A total of 57,130 dispensations have been made since 2020 (8,089 in 2020, 14,996 in 2021, 16,629 in 2022 and 17,416 in the first half of 2023). Pharmacy Service has dispensed at least once to 5,091 patients. Thanks to the reduction of individual trips (a total of 3,529,022 kms, 52,669 hours travel time, since 2020), it is estimated that the discharge into the atmosphere of 500 tonnes of CO2 in total has been avoided, which is equivalent to the emission of 500 round-trip Spain to Denmark flights (1,000 medium-sized trees are needed for 50 years to absorb that amount of CO2). Eighty-seven percent of private car use was estimated. We did not take into account movements of patients residing in the urban centre of the hospital. The development of ICTs will allow a more clinical approach and an improvement in patient care. We also expect the improvement of the process with the creation of Patient Reported Outcomes (PROs) protocols, already underway for migraine and psoriasis, and Patient Reported Experience Measures (PREMs) protocols.

What next?

The development of ICTs will allow a more clinical approach and an improvement in patient care. We also expect the improvement of the process with the creation of Patient Reportes Outcomes (PROs) protocols, already underway for migraine and psoriasis, and Patient Reported Experience Measures (PREMs) protocols.

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Author(s)

Catarina Diogo, Rui Caceiro, Maria Helena Duarte, Armando Alcobia

Why was it done?

The core objective of healthcare institutions is to ensure patient safety and maintain the highest quality of care throughout every medical procedure.
This principle must extend to the drug circuit as well. Within our hospital, pharmaceutical services have a dedicated route for producing injectable ophthalmic medications, serving 795 patients and yielding 3720 solutions, in 2022. However, the existing paper-based procedure for medication management is laborious, time consuming and error-prone, demanding full-time constant pharmacist involvement to ensure the secure progression of these medications.

What was done?

A software application was developed on the Power Apps platform to streamline medication management for injectable ophthalmic medications. This application aimed to replace manual paper-based procedures with digital solutions, enhancing efficiency, reducing errors, and providing a comprehensive platform for patient registration, prescription tracking, schedule management, and oversight of injectable solutions’ production.

How was it done?

Over two months, needs of pharmaceutical and ophthalmology services were assessed, soliciting input from pharmacists, ophthalmologists, nurses and administrative personnel. Subsequently, a software application was developed featuring four distinct interfaces, customised for each professional group involved. This application enables patient registration, medical prescription, schedule management and monitoring the injectable solutions’ production – prescription and agenda validation, batch management and generation of identification labels.
This project is presented, therefore, as a customised digital solution, the result of a multidisciplinary collaboration.

What has been achieved?

It is the authors’ belief that this software has allowed for the development of a safer, more efficient, and integrated workflow, as an alternative to paper – which is more prone to errors. In this manner, from a pharmaceutical perspective, it simplifies the workflow, freeing the pharmacist to focus on other important tasks and optimizing personnel management. Furthermore, it is also valuable for ophthalmologists, enabling prescription repetition and access to patient history, as well as for administrative staff, streamlining schedule management. In conclusion, this software is set to transform our injectable ophthalmic medication circuit.

What next?

Further studies confirming its advantages are needed. Its validation would establish its potential and applicability across healthcare settings.

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Author(s)

María Isabel Sáez Rodríguez, Marta Eguiluz Solana, Marta Miranda Magaña

Why was it done?

Shortages are common in our setting. Having a list of critical and must-have drugs (CMHD) specifically designed for our centre allows us to reduce risk of complications due to delays in drugs administration.

What was done?

Monitoring and mitigating potential shortages of critical medicinal products and medical devices by redacting a list of critical pharmacy and health products to have in our centre.

How was it done?

First, we conducted bibliographic research, finding official list of CMHD by FDA, EAHP, and AEMPS.
Afterwards, we crossed those lists with the pharmacotherapeutic guide (PTG) in our centre, identifying those drugs that are considered CMHP, and checking their stock.
Discrepancies between the list provided by official agencies and our PRG were evaluated by the clinical pharmacist, taking into account our centre complexity and surroundings, nearby hospitals and type of patients attended.
With our findings, we redacted a list of CMHP specifically designed for our centre.

What has been achieved?

During our revision, we found discrepancies between our PTG and the official lists of CMHD:
• Some medicines, like certain antidotes, were not considered CMHD. These drugs were included in our list, according to intoxications incidence in our area.
• Lack of stock of must-have products in the official list. Some of them, like coagulation factors, were not considered a CMHD in our centre due to their availability in nearby hospitals. Others, like albendazole, were not included due to low incidence of disease they treated.
Evaluating each drug necessity helped us identify certain health emergencies we may come across in our centre, and prepare for them accordingly. Also, stock revision showed us which medicines have suffered from shortages in the past.
Finally, we achieved our main goal of having a specifically designed list CMHD for our centre.

What next?

Doing a revision of must-have products and adapt it to the centre’s situation enables us to have a better stock control, and serves as a back-up in case of shortages. Our CMHD list must be periodically revised, making sure it adapts to any potential changes in our centre’s situation.

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Author(s)

Viviana Andrea Pinzon Garcia, Paula Camila Murcia Jaramillo, Reinaldo Grueso Angulo

Why was it done?

In 2018, concerned with the opioid crisis in USA, the pharmacy and therapeutic committee began to work on safer opioid use; an initial diagnosis showed an increase in the use of in hospital opioids and a lack of protocol for the disposal of the resultant remnants. Standard single-dose syringes (SSDS) were devised to avoid remnants, subsequently noticing that the strategies to be used should involve the whole medication order cycle (MOC). This gave rise to the OSP, which involves physician’s pain management and prescribing practices, pharmacy preparing and dispensing process, nurse’s custody, administration and disposing protocols.

What was done?

An Opioid Stewardship Programme (OSP) led by a multidisciplinary team: scientific direction, pharmacy and pain clinic, was implemented to ensure adequate and safe opioid prescription, dispensation, administration and disposing practices in San Ignacio University Hospital (HUSI), a tertiary level hospital in Bogota, Colombia.

How was it done?

Institutional pain practice guidelines were assessed, unifying the titration doses with SSDS and developing disposal protocols in which care staff is constantly being trained ever since. To trace the impact of the OSP, indicators for IV opioid consumption, SSDS prescription, naloxone use and guideline adherence were created.
Main obstacles on SSDS: <10% prescribing adherence, availability failures and dose expiration. In response, the whole ampoule prescription was narrowed to only pain specialists to face SSDS expiration costs and avoid shortage.

What has been achieved?

SSDS prescription proportion above 70% by July 2022, decreased milligram morphine equivalent (MME) consumption per hospital discharge (January 2019: 37, January 2020: 47, January 2021 (COVID 2nd surge): 39, January 2022: 25, July 2022 (COVID 3rd surge):16) and monthly costs decrease in 1997 USD, between 2019 and 2022.
An opioid shortage during the COVID surges, deepened in Colombia due to a hydromorphone recall, was avoided.

What next?

The OSP initiative could be replied in healthcare institutions considering our achievements. To keep working in a safer opioid MOC, our OSP has formulated new strategies with an active role of pharmacists, pain specialists and nurses oriented to: remnants disposal protocol, prescribing policies, medication error detection and healthcare staff and patient education.

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Author(s)

Easter Mark

Why was it done?

Medicines storage was low tech in a new high tech Private Finance Initiative (PFI) hospital and security was operationally heavy on nursing teams. The trust was on a journey to Electronic Patient Records (EPR). What was needed was a solution that bought both challenges together – how we implement improved medicines storage that fully leverage the power of a hospital EPR system.

What was done?

Trust-wide implementation of Automated Dispensing Systems, initially to drive safer and legislative compliance with storage. Since implementation, we have improved management of medicines during shortages, taken waste out of operational delivery around supply of medicines, informed teams around medicines safety during heat waves, and we are on a journey to closed loop medicines administration.

How was it done?

A business case recognising the reputational impact of poor Care Quality Commission (CQC) assessment of security, nurse led audit work recognising the impact of medicines handling on Time to Care and recruiting enthusiasts to support the programme.

What has been achieved?

All wards and departments have automated dispensing systems for medication storage – 72 units, including two in pharmacy for controlled drugs and after-hours support.
Medication Safety officer (MSO) used live view to track high risk medicines throughout Covid-19 and beyond. Never missed a dose of high risk medicines by utilising this technology over the Covid period.

Temperature monitoring gives an overview of real time temperature of all stock areas to support informed decision-making during hot and warm weather. Digital ordering by automated dispensing systems has reduced nurse time handling medicines by using pharmacy team time saved from ordering medicines redeployed to fill cabinets instead of nurses.
Increasing breadth of stock holding as top up thrice or more weekly rather than just weekly across Trust.

What next?

Planning benefits of integrating a robot dispensing system and hospital information system next spring. Robotic storage supporting real-time medicines management from stock to temperature all with enhanced security and removes process waste from process especially when combined with other digital initiatives. Trust Go-Live with Cerner in spring 2023 and use of cabinets to support closed loop administration.

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Author(s)

Louise Stilling Rasmussen, Lene Juhl Biltsted, Majken Nørskov Petersen

Why was it done?

To implement EAHP statements on Patient Safety and Quality Assurance the hospital pharmacist carried out the intervention in one of the largest psychiatric clinics in the region. The following challenges were observed: Lack of transparency for healthcare professionals. Inflexible and time consuming workflow which did not accommodate the needs in the medical treatment at the clinic. The workflow caused waste of medicine. Changes in the medical treatment, which caused medicine being surplus and ended up expiring. The distribution was expensive and not sustainable.

What was done?

By changing the handling and distribution of medication for psychiatric patients who are entitled to free medicine from the hospital, we now have an agile, streamlined, patient-safe and transparent workflow that ensures patient safety by accommodation of the seven rights, increases the flexibility and availability of medicine to the patient’s current treatment and gives a more sustainable handling of medicine. Furthermore, resulted in direct and indirect financial savings (estimated direct savings 8%, DKK 250,000).

How was it done?

A medication room was reorganised by the pharmacist according to ATC codes, shelf fronts, active ingredients and expiry date.
Establishment of a computer and scanner, linked to the national Shared Medication Record containing all patients’ prescriptions.
Medicine is ordered online from the hospital pharmacy.

What has been achieved?

New modern quality assured medication room with electronic registration of medicines dispensed to the patients. This provides transparency of the medical treatment across the healthcare sector. The medicines are stored correctly, and the integrity is maintained until immediate use and permit correct administration. Elimination of medication waste and reduced time consumption for healthcare personnel gave an estimated direct savings of approx. DKK 250,000 plus an uncalculated saving of staff time. Finally, a more sustainable management of medicines and reduced the risk of errors regarding medical distribution was achieved.

What next?

The results of this project have scaling potential. A presentation for decision-makers about implementing the solution elsewhere is ongoing. The handling and distribution has been changed from patient-labelled medication to secure digital registration of the medication dispensing from the medicine room, which now allows complete traceability of all medicines dispensed by the pharmacy.

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Author(s)

BEATRIZ MONTERO LLORENTE, ELENA GEMENO LÓPEZ, CARMEN PALOMAR FERNÁNDEZ, ANA MARÍA ÁLVAREZ DÍAZ

Why was it done?

To avoid stock breaks of medication due to unforeseeable fluctuations in their regular consumption. To reduce claims to the Pharmacy Service (PS) for medication shortages in automated dispensing systems (ADS) and other dispensing circuits. To achieve economic savings by avoiding unnecessary loans. To manage these loans in the morning when needs are detected in advance, with the consequent reduction in the time it takes for the pharmacist to manage it during on-call hours (approximately 2 hours per loan).

What was done?

We designed and implemented a tool to control in advance the stock of medication dispensed to hospitalisation and outpatient units and thus be able to forecast needs based on current prescriptions and associated habitual consumption.

How was it done?

1. An Excel file was developed in which the information on automated storage systems (ASS), ADS and prescriptions were integrated. It included maximum, minimum and current amount, and estimated coverage (in days) according to the consumption forecast associated with current prescriptions. We established the minimum amount based on a coverage threshold of 7 days.
2. Basic drug needs were studied (adjustment of maximum and minimum in the ASS and ADS, a dynamic process periodically reassessed according to demand).
3. The order information was added: order status, request date, last receipt date, order number and laboratory. These items allowed us to quickly locate old orders so we could address the reason for the delay in procurement.
4. We included medications stored externally to the ASS to control their stock electronically.

What has been achieved?

Loans requested annually from other hospitals were quantified as an indicator of improvement in acquiring medicines stored in the ASSs.
We obtained an annual reduction in the number of loans of 34.4% between 2019 and 2020 (125 loans vs 82) and 56.1% between 2020 and 2021 (82 loans vs 36). This result represented an average decrease in the time to manage loans of approximately 7 hours/month between 2019 and 2021.

What next?

The tool can be applied to all PS with ADS and ASS, intending to have the necessary medication available at the necessary time and thus avoid possible clinical damage to patients’ health derived from the delay in their treatment.

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Why was it done?

Due to the COVID-19 lockdown, many patients could not attend to hospital pharmacy for medication supply. To ensure treatment effectiveness, tolerance and therapeutic adherence, we developed this new model of medication dispensing as well as additional routes of patient follow-up, such as the use of mobile Health (mHealth).

What was done?

In 2024/03 we started to approach hospital medication (mainly onco-haematology oral treatments, subcutaneous monoclonal antibodies and clotting factors) to the patient’s home. We developed an alternative model of medication supply through the collaboration with community pharmacies (CPs) and a logistics partner.

How was it done?

The collaboration with CPs was coordinated by the Barcelona College of Pharmacists, who developed a new digital platform to manage and track delivery orders. A pharmaceutical wholesaler delivered these medications to CPs in 48–72 hours. In case of requiring a faster dispensation, we used a logistics operator which guaranteed a delivery time to the patient’s home of 24 hours.
Considering that our hospital pharmacy attends more than 8,000 patients, we prioritised this service to those with a complex socio-functional situation or who lived far from the hospital.
Pharmacy technicians were the key managers in this process. Through a telephone interview, they detected possible medication related problems (adverse effects, administration errors, inadequate dose/route of administration/duration of therapy and lack of treatment adherence). They also checked for in-person medical appointments that could justify dispensing direct to the patient. If any incident was detected, the technician referred the case to the pharmacist for further assessment and resolution.
Additionally, for some health conditions (heart transplant, colorectal and breast cancer, haematopoietic stem cell transplant, chronic migraine or HIV infection), we developed a mHealth programme in which patients were empowered by using a smartphone and tablet app to promote self-care management and contact with their healthcare professionals.

What has been achieved?

In 2020, 4,793 shipments were made to 1,814 patients. This meant 12.4% of the total hospital pharmacy dispensations (N=38,527). Of these shipments, 61.0% went to CPs and 39.0% to patients at home. In 2021, there were 4,171 shipments to 1,248 patients, 90.0% of which were sent to CF, which implies a decrease of the shipments of 12.9% compared to the previous year.
In our setting, mean time of virtual dispensing was 10 minutes versus 3 minutes of in-person dispensing. This additional time was due to the preparation of drug shipments and tracked delivery orders. The assessment of this model was positive for both patients and pharmacy staff. However, it was not exempt from some incidents, such as delivery delays or errors in package identification.
As for telepharmacy follow-up, 257 patients are using mHealth applications. In 2021, they performed 4,387 consultations with the pharmaceutical team.

What next?

The COVID-19 pandemic forced us to rethink the care model for outpatient care in hospital pharmacy services. Our assessment is positive and we believe that this model should continue in the future for a selected group of patients.

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Author(s)

Lone Møller Deleuran, Bitten Abildtrup, Sofie Pedersen, Ulrik Wøldike, Nina Winther Müller

Why was it done?

Amgros is committed to make its mark on the sustainability agenda regarding medicine – both nationally and internationally. Thereby improving access to medicines for patients in a more sustainable way – this project serves as a first step in this direction.

What was done?

In 2021, the Danish procurement organisation Amgros I/S issued the first national pilot tender for hospital medicines in which environment was an important award criterion along with price. Amgros procures 99% of the pharmaceuticals used at public hospitals. The pilot project was conducted to gain knowledge and experience about planning and executing future tenders with environmental criteria. The pilot tender was limited to the hormonal therapeutic area.

How was it done?

The chosen environmental criteria were environmental management, packaging (plastics and paper/cardboard), transportation and social responsibility.
It was a long process, including external help from consultants (The Technical University of Denmark), legal consultation, market dialogue with feedback, developing and adjusting the criteria to comply with national procurement legislation. Hence assuring the evaluation of the offers could be conducted in a meaningful, simple, and structured manner during the subsequent evaluation phase.
As a part of the final tender, a questionnaire was attached consisting of multiple choice questions concerning the environmental criteria. In the evaluation, the price weighed 80%, whereas the environmental criteria weighed 20%.

What has been achieved?

Amgros received 85 offers from 19 suppliers of which 76 offers contained the questionnaire about environment. Sixteen (84%) of the bidding suppliers completed the questionnaire. Three suppliers won the tender solely due to their environmental capability.
The tender with environmental criteria did not seem to discourage suppliers from bidding nor resulted in increasing price levels.
The pilot tender has created a great deal of awareness among the suppliers about the importance of environment and sustainability in production, distribution, and sales of medicine.

What next?

The experience obtained from this pilot tender is paving the way for the future broader implementation of more sustainable medicines in all tenders. Furthermore, the results will be shared nationally and internationally. Hopefully, the results will encourage other countries to incorporate environmental criteria in future medicinal tendering processes.