Author(s)

Dhorn Amnuayphonwiwat, Pharm.D.
Outpatient Pharmaceutical care unit, Outpatient Pharmacy Division, Department of Pharmacy, Faculty of Medicine Siriraj Hospital, Bangkok Noi, Bangkok 10700, Thailand

Why was it done?

Within this integrated heart failure (HF) clinic, A HF pharmacists collaborate with multidisciplinary HF specialists to optimize guideline-directed medical therapy (GDMT), increase GDMT usage, resolve drug-related problems (DRPs), reconcile medications, and educate patients. They also help patients adhere to therapies and thereby improve clinical outcomes.

What was done?

Optimizing GDMT in patients with heart failure with reduced ejection fraction (HFrEF) was suboptimal because many factors, such as patients being unable to tolerate side effects or having non-compliance, health care insurance was limited in access to GDMT and there was a lack of a multidisciplinary care team. Our objective was to optimize GDMT, enabling patients to achieve reach the target or maximally tolerated dose and to resolve DRPs, thereby improving therapeutic outcomes.

How was it done?

Pharmacists performed medication reconciliation, reviewed all medications including GDMT, optimized doses, and identified DRPs at each visit. They also provided relevant interventions to physicians. After physician consultation, pharmacists counseled patients on their home medications. All information was recorded in both the pharmacist’s database and the hospital database. We analyzed the data annually and continuously improved our interventions.
We created education tools for HF patients such as flipchart, booklets and animations for focusing on empowering patients’ GDMT knowledge and improving self-care monitoring.

What has been achieved?

Data on GDMT dosage optimization, usage, and DRPs were gathered from all patient visits between January 2020 and September 2023. Among 2907 patient visits over 4 years, the annual GDMT dose rates were 67% for beta-blockers, 93% for RAAS blockade, 41% for sacubitril/valsartan, 100% for MRAs, and 100% for SGLT2i. The proportion of visits achieving more than 50% of the GDMT dose was 68%, 80%, 46%, 100%, and 100%, respectively. At the one-year follow-up, these 79 patients showed significant improvements in left ventricular ejection fractions, New York Heart Association functional class and signs and symptoms of congestion such as orthopnea, paroxysmal nocturnal dyspnea, edema, and lung crepitation.

What next?

With more improvement in the HF pharmacist’s role, we aim to develop the program for calculating the GDMT dose in the individual level and design supportive tools to enhance patients’ adherence. Moreover, the HF pharmacist collaborates with multidisciplinary team to disseminate this education initiatives to the other hospitals for improving the HF patients’ standard care.

Author(s)

Mª Antonia Meroño Saura
Rebeca Añez Castaño
María García Coronel
Francisco Valiente Borrego
Elena Urbieta Sanz

Why was it done?

Prostate cancer patients are often elderly, frail, and chronically medicated. The introduction of new hormonal therapies has increased treatment complexity and the risk of drug-related problems. Despite evidence linking excessive polypharmacy to poor outcomes, structured deprescribing models are rarely applied in oncology. OPTIM-CP was introduced to address this unmet need by integrating validated stratification tools (Risk stratification model (EM) for the pharmaceutical care of oncology patients with solid or hematologic neoplasms (SEFH)) into routine practice to prioritize patients at highest risk and guide pharmacist-led interventions.

What was done?

The OPTIM-CP initiative was developed to improve the safety and quality of pharmacotherapy in patients with prostate cancer. It implemented a structured pharmaceutical care model based on clinical-pharmacological risk stratification and individualized deprescribing.

How was it done?

A multidisciplinary working group of clinical pharmacists reached consensus on the practical adaptation of the EM to prostate cancer patients, ensuring consistency and clinical validity. Eligible patients receiving oral hormonal therapy were identified and stratified during pharmaceutical care consultations in the Hospital Pharmacy Department through. According to their assigned risk level, follow-up intensity was adapted. Medication reconciliation was performed using the regional electronic prescribing system to ensure accuracy and coherence across hospital and primary care records.

What has been achieved?

The initiative achieved full integration into the hospital’s outpatient pharmacy circuit. A total of 111 patients were stratified during pharmaceutical care consultations. The mean age was 78,25 ± 9,6 years, and most were treated for hormone-sensitive metastatic disease. According to the ME, 4.5% were classified as high risk, 38.7% as intermediate, and 56.8% as low risk. Polypharmacy was present in 73% of patients, and 72% used at least one high-risk medication. Treatment-related variables were the main contributors to overall risk.
The implementation of the stratification model improved communication with patients, reduced medication discrepancies, and allowed prioritization of high-risk patients for closer follow-up.

What next?

OPTIM-CP is now being consolidated as a permanent part of routine care. The next phase focuses on the systematic deprescribing of potentially inappropriate medications identified during stratification, using validated decision-support tools (CheckTheMeds®) and shared decision-making with clinicians. Future steps include expanding the model to other oncologic populations.

Author(s)

Virginie Deroche, Ilias Bensouna, Fanny Ponce, Karl-Dietrich Hatz, Nicolas Jauniaux, Amina Benomar, Isabelle Debrix, Florence Federspiel, Laure Raymond, Laurent Mesnard

Why was it done?

Within our hospital, exome sequencing is routinely performed for adults with unknown nephropathy or genetically-suspected Chronic Kidney Disease (CKD), offering not only molecular diagnosis but also underutilized PGx insights. Frequently polymedicated CKD patients could greatly benefit from PGx data to improve medication adherence and optimize their treatment proactively.

What was done?

We designed a pharmacogenetic (PGx) circuit to provide personalized care in nephrology and kidney transplantation.

How was it done?

Following nephrology medical examination and blood sampling, patients received medication reconciliation and counseling with a pharmacist to complete their current treatment list, and to gather past intolerance, adverse events, potential inefficiency and over-the-counter drugs. Meanwhile, a biologist and a bioinformatician analyzed their PGx profiles through exome sequencing data. A pharmacogenetic expert combined these data with medication reconciliation into a PGx report including dosing guidelines based on international recommendations (CPIC, DPWG guidelines). Patient cases were reviewed during multidiciplinary consultation meetings (MCM), to offer personalized treatment and ensure medication safety. MCM reports were integrated into eletronic health record and stored for later use.

What has been achieved?

Out of the 766 patients who underwent exome sequencing, 148 had a medication reconciliation. 88 patient cases were discussed during 27 MCM, which began in October 2024. 100% of these patients received at least one recommendation regarding drug dosing or contraindications, totaling 345 recommendations including immunosuppressants, analgesics and cardiovascular drugs.

What next?

To go further, we aim to efficiently share PGx information to healthcare providers including treating physician, to design a website to educate patient about PGx testing, and to deliver PGx results to patients during a dedicated consultation.

Author(s)

Mireia Coll-Vinent Ollé, Alba Martin Val, Lidia Estrada, Adrián Vilariño Seijas, Ana Cia Hidalgo, Marlene Álvarez Martins, Clara Rodríguez González, Júlia Galí Fortuny, Raquel Gil Bardají.

Why was it done?

Care transitions are a major source of medication errors; therefore, therapeutic reconciliation plays an essential role in patient safety and treatment continuity. However, increasing workload and limited staff make it unfeasible to conduct thorough reconciliation for all patients systematically. The aim of this initiative was to develop a tool that enables prioritization of patients in therapeutic reconciliation and high-risk medication-related problems (MRPs) detection

What was done?

A digital tool was developed and implemented to prioritize patients for therapeutic reconciliation at hospital admission and discharge. This approach allows hospital pharmacists to focus on patients with the greatest need for reconciliation, optimizing available resources and improving care continuity. The tool integrates structured clinical data from multiple sources: hospital and primary care records, electronic prescriptions, laboratory results, and nursing documentation.

How was it done?

A multidisciplinary team composed of clinical pharmacists and data engineers was established to design and implement the tool. Intelligent algorithms were developed to detect predefined alerts related to pathological history, inappropiate medication, anticholinergic burden, MRPs, drug–diagnosis and drug–parameter interactions, and drugs increasing fall risk. The tool was first validated through a pilot project, after which the algorithms were redefined based on preliminary results. Obstacles such as data integration from different systems, synchronization, and resource constraints were addressed by close collaboration with IT teams, and practical application of the tool.

What has been achieved?

The tool successfully reduced the time required for reconciliation by automatically prioritizing high-risk patients. It facilitated early detection of MRPs, leading to timely interventions and preventing potential adverse drug events. It also strengthened communication between hospitals, primary care, community pharmacies, and social-health centers, and supported health-care continuity.

What next?

This initiative represents a scalable model of good practice. It can be expanded to other hospitals and care settings where provided clinical data are structured and IT integration is feasible. Its adoption in broader healthcare contexts could optimize therapeutic reconciliation processes, reduce errors, and enhance patient safety across systems.

Author(s)

Victoria Lubarsky, Jacalyn Rogers, Nataly Kuchik

Why was it done?

Accurate home medication history and admission reconciliation are critical during care transitions to prevent harm. In my hospital, the medication history team reviews over 85% of daily admissions, yet providers often face challenges with timely reconciliation. To address this, the pharmacy team proposed a dual-approach initiative: provider education to support reconciliation within 24 hours of admission, and a pharmacy-assisted process enabling pharmacists to reconcile select medications or collaborate with providers to finalize reconciliation.

What was done?

This initiative aimed to meet the hospital’s quality goal of achieving 90% completion of accurate admission medication reconciliations within 24 hours. A retrospective observational study was conducted over nine months in 2024. Data collected was quantitative, focusing on medication reconciliation completion rates, pharmacist interventions, and provider engagement. Descriptive statistics analyzed trends and measured improvements in reconciliation rates.

How was it done?

A dual-strategy approach was implemented: provider education and pharmacy-assisted workflow. A standardized flow sheet and enhanced EMR patient lists improved provider visibility. A new procedure and dashboard enabled pharmacists to identify incomplete medication reconciliations within 24 hours and intervene by reconciling select medication classes (e.g., OTCs, supplements, duplicates, long-acting meds), communicating via secure chat to resolve discrepancies, and documenting post-reconciliation additions in pharmacy notes. Prior to admission, home medication lists were reviewed by pharmacy technicians using the MARQUIS framework to support reconciliation accuracy.

What has been achieved?

A quantitative analysis using descriptive statistics was conducted to evaluate changes in medication reconciliation completion rates before and after implementing the initiative. • Overall reconciliation completion rates increased by 30 percentage points, from 52% to 82% over nine months • The pharmacy team’s consistent contribution accounted for 15% of the total improvement • Provider education accounted for an additional 15%, with 13% from pharmacy’s provider outreach and 2% from education initiatives and process awareness.

What next?

This initiative demonstrates the effectiveness of provider education and pharmacy-assisted processes in improving timely and accurate medication reconciliation outcomes and patient safety during care transitions. Future directions include expanding pharmacy-assisted hours and replicating the model across additional hospital sites to broaden impact and strategize best practices.

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Author(s)

JR ROMA, A RIZO, N POLA, B LOPEZ, A GARCIA, E BRAGULAT, M SANCHEZ, D SOY

Why was it done?

Several studies had been published claiming that the figure of a clinical pharmacist could improve the quality and safety of the medicines prescribed in the ED. However, little information has been published regarding its clinical impact when the pharmacist is physically present at the ED, which could enhance communication with clinicians and ED staff.

What was done?

A clinical pharmacist was included into the multidisciplinary team of the Emergency Department (ED).

How was it done?

The pharmacist performs their duties on-site from 8:00 a.m. to 11:00 a.m., Monday through Friday, joining the medical team located in the short stay unit (SSU) of the ED. The project was focused on validating and reconciling the medications of SSU patients who require short-term treatment, observation or reassessment of their initial ED treatment prior to discharge. Additional activities include logistical tasks, risk management and medication-related safety issues, with the identification of medication errors (MEs) during the pharmaceutical review. These errors are defined as any medication-related error, regardless of whether or not the patient experiences adverse effects.

What has been achieved?

During the first six months (December 2023–May 2024), 1904 clinical histories (patients) were reviewed (Mean day: 16 patients). MEs were found in 14.8% of the patients (282 patients), with a total of 338 MEs. Of these, 30.5% were reconciliation errors, 28.1% were overdosing errors, 15.1% were therapeutic duplicities and 8.9% were underdosing errors. Other identified MEs included: incorrect posology (3.8%), analytical value adjustments errors (3.0%), drug interactions (2.4%), incorrect duration (2.4%), adverse effects (2.1%), wrong administration route (1.8%), incorrect presentation (1.0%) and allergies (0.9%). The most common pharmacological class involved was antimicrobials (40.6%), followed by anticoagulants (13.2%), immunosuppressants (9.3%), and antihypertensives (7.8%).

What next?

Considering the overall satisfaction regarding the ED pharmacist figure in this setting, its work day in ED has been extended from 8:00 a.m. to 4:00 p.m. More research is needed in order to clarify if the role of the ED pharmacist working on-site at the ED can improve healthcare outcomes.

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Author(s)

Carmen Redondo Galán, Cristina Ortega Navarro, Ana de Lorenzo Pinto, Beatriz Torroba Sanz, Cecilia Martínez Fernández-Llamazares, Silvia Manrique Rodríguez, Álvaro Narrillos Moraza, Carmen Rodríguez González, Ana Herranz Alonso , María Sanjurjo Sáez

Why was it done?

Transitions of care put the patients at risk for medication error as a result of poor communication and information loss. Treatment beginnings, complex treatment and medication reconciliation errors are an important cause of morbidity and have a predominant role in chronic complex patients (CCP). In this sense, collaboration and effective communication between hospital and community pharmacy are considered essential elements to guarantee continuity of patient care, obtaining better health results in terms of safety, effectiveness and efficiency.

What was done?

Create and implement a collaborative network with direct communication between the Hospital Pharmacy Service of a tertiary hospital and the community pharmacies responsible for patient follow -up.

How was it done?

A multidisciplinary group of hospital pharmacists dedicated to different clinical areas was created: three pharmacists from the Emergency Department, two from the Paediatrics Department, one from the Neurology Department and one from the Outpatients area. They selected and contacted by telephone the 40 community pharmacies responsible for 25% of patient prescriptions in the area. Periodic meetings were scheduled and possible strategic lines of collaboration were shared. The following priority groups were identified: Group 1: CCP (paediatric patients and fragile elderly patients) and Group 2: patients treated in the hospital emergency department. We addressed logistical aspects (supplies and preparation of formulations), pharmacotherapeutic monitoring (adherence, adverse drug reactions and collaboration in the management of CCP). The main limitations were small population and short follow-up time.

What has been achieved?

From March 2023 to September 2023, the hospital Pharmacy Service has received 50 consultations on 45 patients from community pharmacies: 85% were classified as group 1 and 15% group 2. Pharmaceutical interventions were related to medical shortages (28%), reconciliation errors at discharge (22%), information about formulations (20%), information about new treatments (15%), prescribing errors (12%) and adverse drug reactions (3%). Community pharmacists appreciated accessibility and value of information provided by hospital pharmacists. 50% of patients avoided a hospital visit to solve their queries.

What next?

Our first results show the importance of pharmacist interventions with patients and other healthcare professionals.This collaborative network can be applicable to all services that work with community pharmacies to guarantee greater coordination and integration in the different healthcare settings.

Author(s)

Ugo CARRERE, Charles-Henri BLANCHER, Julien ARCIZET, Serge BENETEAUD, Caroline ALLIX-BEGUEC, Benoit LE FRANC

Why was it done?

EDs are the main entry point for hospitalizations. Medication errors are a major threat to patients safety. They are exacerbated by the high flow of patient admitted, the increase in polypharmacy in eldery patients, lack of knowledge of medication and time constraints.

What was done?

We have implemented proactive medication reconciliations (MR) for eldery patients in our emergency department (ED). Retroactive MR was performed in downstream departments (DD) for similar patients. Goals were to save physicians’ and nurses’ times, to improve patient safety.

How was it done?

A pharmacist provided MR in the ED unit three half-days per week. In agreement with the emergency physicians, we targeted patients aged 75 years and over and/or 65 years and over with multiple medications remained hospitalized. Pharmacists collected patients’ medication history and shared the information to ED prescribers. The drug assessment was recorded in a prescription support software. Prescribers, in the DD, could use it to prescribed without transcription and save time.
Our study was based on the comparison of the two groups : the proactive MR group in the ED and the control group with retroactive MR in downstream departements. Discrepancies were recorded and rated as intentional and unintentional in the two groups.

What has been achieved?

Between February and April 2021, 139 medication reconciliations were performed (proactive group n=61 ; retroactive group n=78). The age (about 83 years) and mean number of drugs per patient (about seven) of the two groups were not statistiquely different. We observed a statistically significant reduction in the number of unintentional discrepancies with proactive reconciliation in the ED (7% in the proactive group versus 20% in the retroactive group, p-value = 0.0034). Drugs for the nervous system and the cardiovascular system were the most affected by discrepancies. These discrepancies were mainly detected in prescriptions for patients taken care in the orthopedic surgery, the hepato-gastrology and the polyvalent medicine departments.

What next?

Clinical, economic and organizational scoring of unintentional discrepancies will be performed by a physician-pharmacist pair (CLEO scale of the French Society of Clinical Pharmacy)
Downstream departments with the most UD will be encouraged to use medication reconciliation.
A satisfaction survey will be conducted among the teams.

Author(s)

Alina Shramko, Veronika Haziahmetova

Why was it done?

Based on the results of the analysis, it is possible to answer the question whether it is advisable to spend financial resources, using the example of one healthcare facility; what steps should be taken to rationalize drug procurement; which drugs should be considered first of all for inclusion/exclusion from the procurement list.

What was done?

Currently, ABC/VEN analysis is one of the most effective pharmacoeconomical methods recommended by WHO for the use in the healthcare system. The use of pharmacoeconomic methods is carried out in accordance with the inherent effective use of drugs, and is carried out strictly in accordance with the principles of evidence-based medicine.

How was it done?

The ABC/VEN analysis was conducted based on data from the pharmacy of the LPI containing the costs of purchasing medicines during 2020. The VEN category was determined after a thorough review of the evidence available to us about the effectiveness, safety and cost of drugs.

What has been achieved?

The cost of drug provision to healthcare facilities in 2020 amounted to 62 943 951,38 rubles. The number of international generic name purchased and used was 355. About 35% of the funds were used for a group of vital medicines. The cost of the necessary medicines amounted to 43% of the funds – this corresponds to WHO recommendations.
In accordance with the ATX-classification, drugs affecting blood formation and blood are in the lead in terms of the volume of costs – 40.9% of all costs.
The drug is enoxaparin sodium, the leader in terms of costs in 2020. It is a direct anticoagulant (low molecular weight heparins with a molecular weight about 4500 daltons), which has an antithrombotic effect (2.38% of the total budget).
Also, the top ten leaders in terms of costs included saline sodium chloride solution – 6.1% of the annual budget, which probably indicates irrational excessive use of infusion therapy.

What next?

The application of pharmacoeconomical methods and principles of evidence-based medicine allowed us to assess the feasibility of drug procurement and serves to rationalize the use of medicines.

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Author(s)

Marguerite VAILLANT, Sophie GUILMIN CREPON, Benoit BRETHON , Julie ROUPRET-SERZEC

Why was it done?

In order to obtain a safe patient care pathway, we wish to implement proactive and/or retroactive DR for patients followed in the Hemato-Immunology Department of the University Hospital Center Robert Debre.

What was done?

Formalise and integrate drug reconciliation (DR). Evaluate the feasibility of the project, the impact of DR on the safety of patient care and the satisfaction of patients and health professionals.

How was it done?

Prospective cohort study. The different steps are: identification of eligible patients, collection of information on the patient’s drug history and ongoing treatments from the health partners involved in his or her care, entry drug reconciliation (EDR) during the entry pharmaceutical consultation, conciliation of exit drugs during the return pharmaceutical consultation, transmission of information to the local center and pharmacist or home hospitalisation, evaluation of stakeholder satisfaction and the impact of the intervention.

What has been achieved?

Thirty patients included between August and October 2019, or 30 conciliations performed. Concerning the EDR: all hospitalisation reports and previous prescriptions are consulted (100%), 6 EDR (20%) take place in pro-active mode, the average duration of an EDR is 43 minutes. Concerning the discharge drug reconciliation (DDR): 30 DDR (100%) take place in pro-active mode, the average duration of a DDR is 52 minutes, all prescriptions and intake plans are sent to community centres and pharmacists or home hospitalisation (100%). Of all the conciliations performed: 4 sources of information used by conciliation, 11 drugs prescribed on average per prescription, 8 intentional and 6 unintentional discrepancies identified by prescription. Concerning the evaluation of satisfaction: all community centres are satisfied (100%), 26 city professionals (87%), 21 hospital professionals (70%), 27 patients (90%).

What next?

In order to ensure that DR is permanently included in the service, a communication and information tool must be developed. This, made available to the entire team, will serve as a traceability support, decompartmentalise practices and improve patient care.