Author(s)

Sam Coombes
Cath Cooksey

Why was it done?

Re-Hale was launched in 2023 by a hospital pharmacist and technician to address the lack of a national inhaler recycling programme, despite a Parliamentary advisory recommendation in 2018. Over 73 million inhalers are dispensed annually, and their propellant gases account for an estimated 3–4% of the NHS carbon footprint. The initiative aimed to deliver a scalable recycling model aligned with the NHS Net Zero 2040 target.

What was done?

A logistics system was designed using existing medicines wholesaler infrastructure. Recycling bins were distributed alongside routine deliveries, then collected once full. Inhalers were transported to a depot and on to a recycling partner, where plastics were separated, aluminium canisters recycled, hydrofluoroalkane (HFA) gases captured, and medicines safely destroyed.

How was it done?

The programme embedded recycling into existing supply chains to minimise costs and disruption. Engagement was driven through posters, text messaging, social media, press releases, and a dedicated website where patients could locate drop-off points.

What has been achieved?

The pilot achieved record collection rates and significant stakeholder engagement
• 54% of community pharmacies
• 100% of acute hospital trusts
• 86% of dispensing GP practices
• 70% of all potential sites engaged
Over 40,000 inhalers were recycled during the pilot. With further funding, the scheme expanded across Kent and Medway (population 1.9 million, up to 400 sites). Since launch, more than 100,000 inhalers have been recycled.

What next?

Re-Hale has shown that inhaler recycling within pharmaceutical supply chains is feasible, cost-efficient, and effective. By capturing gases, recycling materials, and disposing of medicines safely, it reduces environmental impact. The model is replicable nationally and offers the NHS a practical route to cut inhaler-related emissions and support its Net Zero 2040 commitment.

Author(s)

Noe Garin Escriva, Borja Zarate Tamames, Unax Lertxundi Etxebarria, Jose Javier Martínez Simon, Rocio Tamayo Bermejo, Eguzkiñe Ibarra Garcia, Olaia Serna Romero, Anna Pelegri Pedret, Yolanda Torremorell Alos

Why was it done?

The GREEN BREATH Project aimed to reduce the environmental impact of inhaler use in Spain. It consisted of three components: (1) a sustainable inhaler prescription framework with a database on the environmental impact of inhalers, scenario projections to estimate benefits of alternative inhaler use and a decision-support algorithm for greener prescribing in Spain; (2) a nationwide patient education project across 40 hospitals focusing on proper inhaler disposal, assessing pharmacists interventions; and (3) a hospital pilot project for optimizing the disposal of used inhalers, reducing hydrofluorocarbon emissions.

What was done?

Inhalers contribute to global CO2 emissions, with over 15 million pMDIs used annually in Spain, generating 400,000 tonnes of CO2 equivalent. Prescription practices often ignore sustainability, and improper disposal exacerbates this problem. The project aimed to integrate environmental criteria into prescribing practices and raise awareness to improve disposal methods, without compromising patient care.

How was it done?

We contacted pharmaceutical companies to develop the carbon footprint database. The prescribing algorithm was designed by a multidisciplinary team. We used data from the Ministry of Health to calculate national projections. We also conducted a study across 40 hospitals focusing on asthma patients, using a questionnaire with a 3-month follow-up. Finally, we piloted an in-hospital inhaler waste management program in a single hospital.

What has been achieved?

The project demonstrated significant impact. We provided the first environmental database on inhalers in Spain. We estimate that shifting 10% of pMDI prescriptions could reduce CO2 emissions by 40,000 tonnes annually. Preliminary results show that over 50% of patients were unaware of inhaler disposal’s environmental impact, and that pharmacists interventions doubled proper inhaler waste disposal. Additionally, the hospital pilot project prevented up to 341 tonnes of CO2 emissions annually by optimizing inhaler waste management.

What next?

Educational resources have recently expanded to four languages used in Spain (Spanish, Catalan, Basque, Galician). We continue disseminating and collaborating with institutions to implement these and other activities. Additionally, sustainable prescribing should be integrated into electronic medical records to drive broader healthcare sustainability and reduce inhaler-related emissions. The project offers a replicable model for other healthcare systems.

Author(s)

LYG Lidia Ybañez García, VPG Virginia Puebla García, ERS Estefanía Rosón Sanchez, NSO Natalia Sánchez Ocaña, JCV Javier Corazón Villanueva, MTO María de la Torre Ortiz, TBG Teresa Benitez Gimenez.

Why was it done?

Dual antiplatelet therapy with clopidogrel and ASA is standard for acute coronary syndrome and post-stent patients. ASA hypersensitivity occurs in approximately 1.5–2.6% of coronary patients, requiring rapid desensitization. The previous capsule-based protocol involved up to 10 strengths in batches of 100 capsules, many of which were discarded.
A literature search identified only capsule-based protocols or preparations made from dispersible tablets at the ward. To minimize the risk of errors from bedside manipulation, we developed a pharmacy-prepared oral suspension from the active ingredient, allowing centralized, standardized, and safer compounding.

What was done?

A new ASA desensitization protocol was implemented using an extemporaneous pharmacy-prepared oral suspension. It replaced multiple-strength capsules, which were laborious to produce and generated considerable waste. The suspension allowed faster preparation, simplified administration of incremental doses (standardized in the protocol), and offered a more patient-centered approach. It also eliminated the need for ward-based dilutions from dispersible tablets, enhancing safety through centralized pharmacy preparation.

How was it done?

A bibliographic review (RUESA, PubMed, SEFH, Compounding Today, Trissel’s) and analysis of existing protocols were conducted. No suitable aqueous formulations were available, and oily preparations were discarded due to poor palatability. The suspension was prepared according to national pharmacy compounding and quality guidelines.
Composition: ASA 100 mg, glycerin 3 g, carboxymethylcellulose gel 1.5% (35 mL), and purified water q.s. to 100 mL (1 mg/mL). Stable for 24 hours, packaged in individualized oral syringes

What has been achieved?

Since 2017, thirteen patients (median age 83, eight males) have undergone desensitization using the oral suspension. All tolerated the process, allowing initiation of ASA therapy. Compared with the previous protocol, the new approach is faster to prepare and administer, reduces waste, simplifies the process, and maintains patient safety and treatment effectiveness. Centralized preparation eliminated bedside dilutions and enabled safe, standardized incremental dosing.

What next?

This initiative highlights the role of hospital pharmacists in developing practical solutions to optimize patient care. The approach is easily transferable to other hospitals facing similar challenges with ASA desensitization

Author(s)

Inês Carmo, Ana Parola, Inês Oliveira, Margarida Carvalho, Marta Carvalho, Ana Mirco.

Why was it done?

On April 28, 2025, a nationwide blackout affected Portugal, disrupting the national power grid and severely compromising the cold chain of vaccines in primary health care facilities, along with all forms of mobile communication. Given this event, the response by the Pharmaceutical Department (PD) of a Local Health Unit responsible for delivering vaccines to 38 Primary Health Care Facilities (PHCF) required evaluation due to major clinical, financial, and operational risks.

What was done?

Vaccines exposed to any temperature excursion during storage were identified and placed under quarantine, preferably using an alternative cold storage unit with an independent power source, when available, and distinctly labeled. Through a standardized notification form, each incident was promptly reported within 48 to 72 hours to the cold chain supervisor and PS. During the first week after the blackout, PS reviewed each report to determine the vaccine’s stability and possible return to the supply chain.

How was it done?

Hospital pharmacists collected key data such as temperature variations, time outside safe range, and affected vaccine batches. They consulted reliable sources (databases and Summary of Product Characteristics) and sought information from the supplier laboratory. Upon analyzing all data, PHCF received precise recommendations on suitability for ongoing use.

What has been achieved?

On April 28, 2025, 40 cold chain incidents were notified, affecting 12,442 vaccines units. After thorough analysis, 12,202 units were authorizes for use, reducing clinical and economic impact. Only 240 units were discarded, resulting in a loss of 6,018.50 € out of a total stock valued at 284 544, 60 €. Joint action by Pharmacist and PHCF assured continuity of patient care and vaccine safety, preventing disruptions to the National Vaccination Program.

What next?

The nationwide blackout exposed vulnerabilities in the PHCF cold chain, highlighting the need for more refrigerators, continuous electronic monitoring, backup generators, refrigerated vehicles, and standardized protocols between PS and PHCF.

Author(s)

Noemi Tatti, Melania Rivano, Giacomo Bertolino, Valentina Mureddu, Raffaele Deidda, Arianna Cadeddu

Why was it done?

Patients are required to attend a follow-up visit every three months for viral load testing. A collaborative protocol has been implemented to facilitate treatment adherence, monitoring, and access to medication.

What was done?

Collaboration between the immunology department and the hospital pharmacy facilitated the management if drug therapy in HIV-positive patients, enhancing access to care and improving treatment adherence.

How was it done?

The visit schedule is shared monthly. Each patient is assigned an alphanumeric code to ensure anonymity. Any change in appointments, test results, visits, or therapy regimens is also communicated. Through the hospital’s electronic system, pharmacists can access each patient’s treatment plan, review the dates of medication pickups, and verify treatment adherence. In case of discrepancies, these are promptly reported to the physician before the patient’s next visit. Additionally, sufficient medication to cover three months of therapy is prepared in advance for each patient, simplifying the dispensing process and preventing unnecessary hospital visits.

What has been achieved?

This initiative has optimized adherence monitoring, which is particularly important for this category of patients. It has also facilitated the drug dispensing process. By reducing waiting times and hospital visits, it has improved treatment compliance and ensured the protection of their privacy. This project was implemented on 792 patients, and from 01/10/2024 to 01/10/2025, a total of 1,369 dispensations of antiretroviral drugs were carried out.

What next?

This approach has been used to improve the quality of care and overall experience of this patient group. We hope that it will soon be extended to all patients who collect their medication at our hospital.

Author(s)

Torres-Pérez, Andrés
Iglesias-Valín, Ana Rut
Mateos-Salvador, María
Fernandez-Gabriel, Elena
Feal-Cortizas, María Begoña
Fernandez-Diz, Clara
Gómez-Costa, Eva
Caeiro-Martinez, Laura
Margusino-Framiñán, Luis

Why was it done?

An individualized dosing procedure for Pegasys® (peginterferon alfa-2a) was implemented, using syringes adjusted to the prescribed dose. The primary aim was to guarantee continuous and safe patient treatment during the global shortage, while also optimizing the use of 90 µg vials.

What was done?

In 2024, a worldwide supply disruption of Pegasys® occurred, creating a risk of treatment interruption for hematology patients. Since many prescriptions were below 90 µg, direct vial use caused significant drug waste and aggravated the shortage. A fractionation system was developed, combining coordinated workflow and a risk-based stability assignment, to ensure continuity of care for all patients with the additional benefit of reducing economic impact. The project started on 21 October 2024 and remains ongoing.

How was it done?

A structured workflow between hematology and the hospital pharmacy was established. After each medical visit, the hematologist contacted the pharmacist responsible for the hematology outpatient clinic, who reviewed the prescription and informed the compounding pharmacists of the preparation schedule and updated doses. Syringes were filled under aseptic conditions, stored at 2–8°C protected from light, and delivered to the hematology pharmacy clinic the day before dispensing.
The 30-day stability was assigned according to the hospital’s risk assessment matrix, supported by published stability data from similar products. The process was internally validated in line with hospital compounding standards.

What has been achieved?

To date, the strategy has allowed treatment of 18 patients, with 332 syringes obtained from 90 µg vials, the majority of which corresponded to 45 µg or lower doses. This approach achieved a 51% reduction in the number of vials used, representing savings of €20,791.
Most importantly, no patient experienced treatment delays or interruptions, ensuring therapeutic continuity and safe handling during the global shortage. No stability issues or administration-related problems were reported.

What next?

The protocol will be maintained in our hospital and could be adapted by other centers facing similar shortages. This experience highlights the key role of hospital pharmacists not only in cost management, but above all in the guarantee of safe and continuous access to essential medicines.

Author(s)

Héctor Rodríguez-Ramallo, Nerea Báez-Gutiérrez, Alicia Melgar-Sánchez, José María Pastor-Martínez, Marta GÓNZALEZ-MARTÍNEZ, Jesus Francisco SIERRA-SÁNCHEZ.

Why was it done?

We designed and implemented a semi-automated method to estimate Days of Therapy for inpatient antibiotic use by leveraging routinely available Athos Prisma prescription exports. The workflow extracts daily prescription data and processes it with an automated script (Stata/Python/R) to generate DOT by antibiotic and hospital unit.

What was done?

DOT is a widely accepted measure of antibiotic exposure, and it is especially useful in paediatrics, where Defined Daily Doses (DDD) are unreliable due to weight variation across ages and heterogeneous “standard” dosing across centres.
Aim: to enable reliable, reproducible DOT measurement from data already available to all Athos Prisma users, facilitating stewardship dashboards and unit-level benchmarking.

How was it done?

Baseline capability: Athos Prisma supports DDD estimation but not DOT.
Data discovery: We identified a standard, centre-agnostic daily prescription export that contains the fields needed to compute DOT.
Processing pipeline: A one-click script parses the daily file, standardises drug names, groups by patient/day, and outputs DOT by antibiotic and unit.
Obstacles & solutions:
• DOT function is not integrated in Athos Prisma → built an external script that any site can run.
• Manual file export burden → consolidated to a single daily export; runtime <1 minute.
• Availability: The code is available on request and can be used by any Athos Prisma-using unit after minor local configuration.

What has been achieved?

We achieved a working code pipeline and measured DOT from June–September 2025 across the hospital. Highlights below:
Antibiotic DOTs Share of total DOT (%)
Amoxicillin/clavulanic 2608 9%
Ceftriaxone 4033 14%
Cefepime 611 2%
Piperacillin 3507 13%
Meropenem 1858 7%
Ciprofloxacin 970 3%
Levofloxacin 1495 5%
Cotrimoxazole 2443 9%
Cloxacillin 207 1%
Cefazolin 993 4%
Linezolid 751 3%
Daptomycin 678 2%

What next?

• Normalize to DOT per 100 patient-days at hospital and unit level.
• Automate the export (scheduled job) and publish weekly dashboards to stewardship teams.
• Set guardrails: prospective alerts for sustained increases in broad-spectrum DOT.
• Validate against a manual audit sample and report inter-method agreement.
• Share pack: provide a turnkey bundle to other centres.

Author(s)

Clarisse Laurent, Carole Metz, Clara Debaisieux, Romain Lestel, José Carreira, Muriel Maison, Valérie Friser, Nathalie Miranda, Mélanie Hinterlang, Carole Fouteau, Sylvain Choquet, Lamia Hassani, Nabih Azar, Marie Antignac, Fanny Charbonnier Beaupel.

Why was it done?

Chimeric Antigen Receptor-T cells (CAR-T), an innovative therapeutic option, have shown remarkable clinical efficacy. However, their pathway from production to infusion requires new multidisciplinary expertise. The Mario CAR-T Project was designed to train both paramedical and non-medical hospital staff in this process.

What was done?

The project took place over two days in January 2024. The program lasted 3 hours and included 6 20-minute workshops. To measure knowledge acquisition, a test was developed and validated with input from multiple disciplines. The test contained 20 questions, each rated with a certainty score from 1 to 5. Professional categories were also recorded (paramedical : nurses, social workers, nursing students, hospital pharmacy technicians and non-medical : call center staff and medical-administrative assistants).

How was it done?

Participants completed the test at three time points: (A) before the course, (B) immediately after the course, and (C) two months after the course. Data were analyzed using PRISM® (GraphPad). Median scores were compared using the Kruskal–Wallis test (alpha = 0.05).

What has been achieved?

A total of 79 participants were enrolled: 60 answered test A (51.6% paramedical vs. 48.4% non-medical), 54 answered test B (61.1% vs. 38.9%), and 6 answered test C. The median grade of A was lower than that of B (p < 0.0001). Question-by-question analysis showed better results in domains related to collection, reception, storage, and thawing of CAR-T cells (median of A : 8.5 versus B : 11.25 ; p < 0.05). Across all professional categories, scores improved between time A and B for social workers (median of A : 8.5 versus B : 11.25 ; p <0.05 ) and nurses (median of A : 13.0 versus B : 14.5 ; p< 0.001).

What next?

This study shows that the Mario CAR-T Project enabled the acquisition of new knowledge for staff involved in CAR-T cell care. However, no progress was observed on questions about lymphodepleting chemotherapy or CAR-T administration, indicating the need to adapt training. Due to the low number of follow-up responses, long-term knowledge retention could not be assessed. An annual session is planned to update and maintain staff knowledge.

Pdf

Author(s)

RBH, Rie Bager Hansen (presenting author), rie.bager.hansen@regionh.dk
ALK, Annabel Lee Krarup
The Capital Region Pharmacy, Hvidovre, Denmark and Department of Orthopaedic Surgery, Amager og Hvidovre Hospital, Copenhagen

Why was it done?

Patients undergoing acute orthopaedic surgery experience significant pain. The choice of pain-relieving treatment is based on national guidelines and regulatory actions. Considering the U.S. Opioid Crisis and the risk of opioid addiction, it was in 2022 politically decided by the Capital Region of Denmark to focus on consumption patterns of opioids within the region’s hospitals. Morphine is considered an opioid with a lower risk of misuse and was recommended as the first-line opioid. At the start of 2022, the Department of Orthopaedic Surgery at Hvidovre Hospital accounted for approximately 30% of the total oral opioid consumption with oxycodone being the preferred opioid. Thus, a strategy was initiated to shift opioid use towards morphine.

What was done?

The Department of Orthopaedic Surgery initiated a strategy to shift opioid use in hospitalised patients towards morphine. The strategy included including education, revision of guidelines and technical modifications to promote appropriate prescribing practices.

How was it done?

Opioid consumption was continuously monitored and evaluated. At the same time, administration of the antidote naloxone was recorded. The initiative included 1) education about the risk of opioid misuse, 2) e-mail follow-up to clinicians reinforcing that morphine was the first-line opioid, 3) revision of pre-filled electronic prescription packages used at the ward and operating room, 4) publication and implementation of a regional guideline specifically aimed at acute pain management in the orthopaedic surgery setting, and 5) ongoing support from pharmacists to facilitate appropriate selection of opioids.

What has been achieved?

Opioid consumption effectively shifted towards morphine, with the proportion of patients receiving oral morphine increasing from about 40% to approximately 80% of patients administered oral opioids. Moreover, the shift has remained stable for the past 10 months following the last intervention and there has been no trend toward increased usage of naloxone.

What next?

Future efforts will aim to identify reasons behind patients being prescribed non-morphine opioids and to investigate the specific circumstances under which naloxone is administered. This will enable further refinement of opioid prescribing practices and enhance patient safety.

Author(s)

Lanzone E. (1), Baldessarelli D. (2), Tinebra A. M. (1), Albini E. M. E. (1), Panarotto A. (1), Rossi C. (1) – (1) SC Farmacia Ospedaliera ASL Novara, (2) Scuola di Specializzazione Farmacia Ospedaliera Novara.

Why was it done?

A comprehensive analysis of systemic antibiotic use in hospitals during the first half of 2024 was conducted, revealing a significant increase in the consumption of WATCH class drugs, specifically carbapenems (ATC J01DH) and fluoroquinolones (J01MA). This prompted the implementation of rigorous monitoring for prescriptions of these drug classes.

What was done?

These antibiotics are key targets of the National Plan Against Antimicrobial Resistance (PNCAR 2022-2025), which mandates a reduction of at least 10% in consumption by 2025 compared to 2022. The initiative aimed to address the rising consumption and enhance antibiotic stewardship.

How was it done?

Data were extracted from the regional IT system, with consumption expressed in Defined Daily Doses (DDD) per 100 patient days. The project monitored the use of systemic antibiotics (ATC J01), focusing on carbapenems and fluoroquinolones. Motivated requests received by the Hospital Pharmacy (FO) were reviewed for therapeutic indications, dosage, treatment duration, and the availability of an antibiogram. All requests were recorded in an Excel sheet for effective data analysis and management.

What has been achieved?

In the first half of 2024, the Hospital Pharmacy received a total of 277 motivated requests for antibiotic prescriptions. Among these, 177 requests were aligned with the objectives of the PNCAR. Specifically, there were 54 requests for fluoroquinolones, including 35 for ciprofloxacin and 19 for levofloxacin. Within this subset, 16 requests included an antibiogram, while 27 were based on empirical data. Additionally, there were 6 requests for surgical prophylaxis, 1 for continuation of therapy, 1 accompanied by a positive urine culture, and 3 that were incorrectly filled out.
The analysis of requests also highlighted a significant number related to carbapenems, with a total of 123 submissions. Of these, 120 were for meropenem, 2 for imipenem in combination with cilastatin, and 1 for ertapenem. Notably, 80 of these requests included an antibiogram, with 74 deemed appropriate based on the established criteria.

What next?

Based on the collected data, modifications to the personalized motivated request form were proposed, introducing stricter criteria for empirical use of these antibiotics. This aims to limit their use to serious and well-defined cases, representing a significant step toward more effective antibiotic therapy and improved clinical outcomes while reducing the risk of resistance. The new form specifies that ciprofloxacin and levofloxacin requests can only be made under certain conditions, and carbapenems are restricted to cases of hemodynamic instability or severe respiratory failure.