Author(s)

Collada VL1, Villamañán E1., Mallón S1., Laorden D2, Domínguez-Ortega J.3 García Lopez L1, Soto A1., Villaroya E1, Bueno S1, Herrero A1.
1. Pharmacy deparment. Hospital Universitario La Paz
2. Pneumology deparment. Hospital Universitario La Paz
3. Allergy deparment. Hospital Universitario La Paz

Why was it done?

The healthcare sector is responsible for 4–5% of global greenhouse gas emissions, with medications contributing up to 35%. pMDIs, widely used in asthma, contain hydrofluorocarbon propellants with high global warming potential. In Spain, 46% of inhalers prescribed in 2023 were pMDIs, with rescue therapies (SABAs) only available in this format. The aim was to explore substitution with lower-emission devices without compromising adherence or asthma control.

What was done?

An observational initiative was conducted in a severe asthma multidisciplinary group to evaluate the type of inhalers prescribed and their environmental impact. Prescription patterns, adherence and CO₂ emissions were analysed to identify opportunities for replacing pressurised metered-dose inhalers (pMDIs) with more sustainable alternatives.

How was it done?

The study included 223 adult patients with severe asthma followed during 2024. Inhaler prescriptions, adherence (medication possession ratio) and estimated CO₂ emissions were assessed. Barriers included lack of non-pMDI rescue inhalers and entrenched prescribing habits. These were addressed through multidisciplinary collaboration, identification of equivalent alternatives and education on sustainability.

What has been achieved?

Out of the 297 inhalers prescribed, 43.4% were pMDIs. Triple therapy (LABA–ICS–LAMA) was predominantly prescribed as pMDIs (66.7%). Acceptable adherence (>70%) was observed for both pMDIs and non-pMDIs, with no clinically significant differences. Over half of patients using rescue inhalers were high-frequency users, all of whom received SABA pMDIs (20–30 kg CO₂ per canister). For most maintenance prescriptions, non-pMDI equivalents with a much lower footprint (<2 kg CO₂ per canister) were available. These findings demonstrate that many pMDI prescriptions could be replaced without affecting treatment adherence.

What next?

This initiative shows that integrating environmental considerations into asthma care is feasible and clinically safe. It highlights the urgent need to introduce sustainable rescue inhalers and adopt new low-GWP propellants. The model can be scaled to other respiratory conditions and European healthcare systems, contributing to decarbonisation strategies while maintaining high-quality patient care.

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)

Martín Santamaria, A. López Fernández, A. Menchén Viso, B. Sanabrias Fernández de Sevilla, R. Folguera Olias, C. Guerrero Feria, I. Herrero Collado, L. De España Zaforteza, P. Pérez García, E. Sánchez Guerrero, A.

Why was it done?

Unnecessary disposal of high-cost injectables is often triggered by home storage errors, placing a burden on the public health system. The aim was to quantify avoidable expenditure through pharmacist review, and to identify opportunities for the education of targeted patients, prompted by these incidents.

What was done?

A pharmacist-led stability verification program for refrigerated medicines stored at home was implemented. When an out-of-fridge incident was reported, stability was assessed by a pharmacist and, when safe, continued use was authorised, avoiding replacement costs.

How was it done?

A retrospective analysis was conducted of incidents recorded in an Excel database from 2021 to 2024. For each case, the following variables were collected: active drug, units affected, units saved, and costs (potential replacement and avoided cost). Stability decisions were based on summaries of product characteristics (SmPCs), manufacturer information, and published temperature-excursion evidence (Stabilis database, Fridge Stability Tool by NHS) interpreted against the reported time/temperature exposure.

What has been achieved?

From 2021 to 2024, 115 incidents were recorded, involving 288 injectable units; 66 were authorized for continued use, avoiding 18.590€ in replacement costs. Savings by year and share of the total were: 6.922€ in 2021 (37,2%), 5.498€ in 2022 (29,6%), 4.012€ in 2023 (21,6%), and 2.159€ in 2024 (11,6%). By year, injectable units saved/affected were: 2021: 28/46, 2022: 19/150, 2023: 6/33, 2024: 13/59. The most frequently implicated drugs were adalimumab (38), etanercept (10), darbepoetin alfa (10), filgrastim (7), and golimumab (4). These drugs were also the most frequently consumed across this period. A substantial proportion of excursions were cleared for safe continued use through a structured pharmacist verification process.

What next?

An infographic will be developed to standardise patient counselling: correct home storage (fridge placement, do-not-freeze warnings, time-out-of-refrigeration windows by product), safe travel with injectables (cool bags/ice packs, temperature monitoring, air/rail travel tips, hotel-fridge checks), and recommended actions after an incident—product quarantine, time/temperature recording, and immediate contact with the hospital pharmacy (email/phone). The infographic will be provided at first dispense and after any excursion, and its impact will be evaluated through subsequent incident and saved units rates.

Author(s)

MARIA TERESA ESTEBAN ALONSO, ANA INFANTE CAMARERO, INES BAENA BOCERO, SARA ARNAIZ DIEZ, LAURA IZQUIERDO ACOSTA, OLGA ALAMO GONZALEZ, MARTA UBEIRA IGLESIAS, MPAZ ESPINOSA GOMEZ , AITOR AYASTUY RUIZ , NATALIA REVILLA CUESTA.

Why was it done?

A sustained rise in IVIG consumption, particularly related to new oncohaematologic therapies and off-label situations, raised concerns about clinical appropriateness, economic impact, and national supply shortages. The aim was to ensure rational, safe, and cost-effective use of this therapeutic resource in a context of increasing demand and the introduction of novel treatments such as bispecific antibodies.

What was done?

A collaborative strategy between the Pharmacy and Haematology Departments was developed to review and optimise the use of intravenous immunoglobulins (IVIG) in haematology patients.

How was it done?

All haematology patients treated with IVIG during a reference period were included. Prescriptions were jointly reviewed by pharmacists and haematologists, classifying cases according to clinical justification. A structured review of prescribing practices was required to ensure compliance with approved indications and clinical guidelines. Evidence-based indications were prioritised, while emerging scenarios associated with bispecific antibodies were carefully assessed. In cases lacking sufficient clinical support, treatment discontinuation or alternative management strategies were proposed in agreement with the clinical team. The process was formalised through a management objectives agreement linking clinical outcomes to expenditure control.

What has been achieved?

The initiative enabled early identification of unjustified prescriptions, preventing unnecessary treatments and contributing to significant cost containment. It also strengthened multidisciplinary collaboration and raised awareness among clinicians on the importance of preserving IVIG for evidence-based indications, thereby enhancing patient safety and sustainability

What next?

A joint Haematology–Pharmacy protocol defining priority indications and usage criteria for IVIG is planned, together with the expansion of this model to other specialties with high immunoglobulin consumption. This initiative represents a transferable and scalable example of good practice for hospital settings across Europe.

Author(s)

Rossella Centola, Elisabetta D’Amico, Stefano Morabito, Maria Alfieri, Maria Giovanna Elberti, Lucilla Grisi, Giorgio Lilla, Amelia Filippelli, Francesco Sabbatino

Why was it done?

Precision Medicine (PM) in oncology remains a highly debated topic within Italian healthcare institutions. Currently, Next-Generation Sequencing (NGS) tests are not included in the Essential Levels of Care (LEA), and reimbursement policies vary across regions. Moreover, most targeted therapies based on mutational profiling are prescribed off-label.

What was done?

This study aimed to conduct a cost-effectiveness analysis of a personalized cancer therapy administered in an end-of-life setting.

How was it done?

Clinical and prescription data were collected for a targeted treatment with olaparib. Data were presented as a case report, and median progression-free survival (PFS) and overall survival (OS) were calculated in months. A cost-effectiveness analysis was performed comparing standard care with NGS-driven therapy, using company management software to estimate healthcare expenditure. The Incremental Cost-Effectiveness Ratio (ICER) was calculated and compared against a willingness-to-pay (WTP) threshold of €60,000, considering the rarity of the tumor.

What has been achieved?

The case involved a 56-year-old male diagnosed with cholangiocarcinoma in 2017. After multiple treatments, an NGS test revealed a BAP1 gene mutation associated with a BRCA-like phenotype. Off-label treatment with olaparib 300 mg BID began in June 2019. The personalized therapy resulted in a PFS of 21 months compared to approximately 2 months with best supportive care (standard treatment), and an OS of 48 months versus 29 months, respectively. The cost-effectiveness analysis, conducted from the Italian National Health Service perspective, considered direct healthcare costs including disease management, drug administration, and management of serious adverse events. Personalized therapy showed a survival gain of 2.5 life-years (LY) compared to 1 LY with standard care. The resulting ICER was approximately €45,000 per LY gained—well below the €60,000 WTP threshold.

What next?

This case illustrates that applying PM in end-of-life care for a rare cancer can yield significant survival and economic benefits. These findings highlight the need for greater integration of PM into clinical trials, structured data-sharing networks, and the establishment of solid evidence-based and pharmacoeconomic frameworks.

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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.

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Author(s)

Arnela Boskovic
Gitte Stampe Hansen

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

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Author(s)

(NFR) Nathalie Fogh Rasmussen
(MS) Maja Schlünsen
(JHPR) Joo Hanne Poulsen Revell
(LJK) Lene Juel Kjeldsen

Why was it done?

Exchanging medication stocks between hospital wards is a common method for reducing pharmaceutical waste at hospitals. However, the impact of such systems is unclear. Therefore, we aimed to calculate the annual economic cost savings after the establishment of a medication exchange system at the University Hospital of Southern Denmark in Aabenraa.

What was done?

A medication exchange system at a Danish hospital was evaluated according to avoidance of medication waste and potential economic impact.

How was it done?

For two weeks in February 2024, pharmaconomists registered all medications that were exchanged between six hospital wards representing 147 of 302 hospital beds. The quantity of the excess medications when returned was registered and the amount of pharmaceutical waste was calculated. This was compared to the amount of waste incurred by ordering a whole package for the ward. Moreover, the economic cost was calculated based on the value per package and compared to the economic costs of purchasing whole packages.

What has been achieved?

In total, 244 exchanges were registered. The pharmaceutical waste was estimated to 13-26%. The Department of Pulmonary Diseases, followed by the Department of Gastrointestinal Diseases, caused the greatest waste. The exchanged medicine had an economic cost of 3,566 DKK (478 euro). In comparison, the cost of purchasing whole packages was estimated to 21,042 DKK (2,822 euro). Thus, the total cost saving was ((21,042-3,566 DKK)x(52/2 weeks)=454,376 DKK (60,935 euro), corresponding to ((454,376/147) x 302)= 933,480 DKK (125,146 euro) for the entire hospital. The results led to establishment of a physical medication room to store the excess medication available for other clinical wards. All medications are registered electronically to support optimal use of excess medication throughout the hospital.

What next?

The economic evaluation may be replicated for comparable medication exchange systems at other hospitals, and thus, generate evidence for the economic and environmental impact of the system.

Author(s)

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

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

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Why was it done?

Expenditure on medicines is increasing, mainly due to the availability of expensive, innovative medicines. The admission process for expensive medicines to the Dutch market is complicated and available medicines are not always (fully) reimbursed.
At the Martini Hospital, many different parties were involved in the expensive medicines file. However, mutual coordination was limited and there was a lack of direction, monitoring and feedback of information to the prescribers.

What was done?

In collaboration with all parties involved, the process for expensive medicines has been redesigned, from application to monitoring and feedback of information to the prescribers. Responsibilities for parts of the process have been explicitly assigned and a hospital pharmacist is in charge of the process.

How was it done?

Various sub-processes have been defined: contracting, prescription and distribution, screening for new substances/indications, financial handling and monitoring. Tasks and responsibilities have been identified for each process and it has been determined how monitoring takes place.
A digital procedure for applying for new expensive medicines or indications, compassionate use programs and authorizations for individual patients has been developed.
Specific reports have been developed for each group of prescribers and are sent periodically. These reports include, for example, compliance with agreements made about preferred substances, conversion to biosimilars, and correct completion of indication codes (which are required for reimbursement).

What has been achieved?

A clear method for requesting new expensive medicines or indications has been implemented. The average processing time for a new application has decreased significantly (exact figures will be available during the EAHP 2025)
All information regarding reimbursement of expensive medicines is centrally available and transparent to all parties involved.
Physicians’ awareness and knowledge of expensive medicines has increased, and this is reflected in their prescribing behavior.
The amount of unreimbursed medicine costs has been substantially reduced (exact figures will be available during the EAHP 2025)

What next?

Continuous evaluation of the process and further development of the reports to the prescribers.