EAHP represents over 30,000 hospital pharmacists across 37 member countries. EAHP represents and develops the hospital pharmacy profession within Europe in order to ensure the continuous improvement of care and outcomes for patients in the hospital setting. This is achieved through science, research, education, practice, as well as sharing best-practice and responsibility with other healthcare professional
The EAHP Board, elected for three-year terms, oversees the association’s activities. Comprising directors responsible for core functions, it meets regularly to implement strategic goals. Supported by EAHP staff, the Board controls finances, coordinates congress organization, and ensures compliance with statutes and codes of conduct.
The EAHP staff supports the Board in executing EAHP’s mission. The Staff assists in financial management, events organisations, policy activities and all EAHP projects. The EAHP staff works closely with EAHP’s members and ensures the effective communication all relevant stakeholders.
The first member countries were Belgium, Britain, Denmark, France, the Federal Republic, Germany, Italy and The Netherlands in 1972. EAHP has now 36 EAHP members and 2 Associate Members. EAHP is open to countries members of the Council of Europe and since 2022 to organisations representing the interests of hospital pharmacists from outside the Council of Europe (Associate Membership)
EAHP’s structure is also composed by different standing committes: EAHP Scientific Committee, EAHP Education Executive Committee and the EAHP CTF Steering Committee.
At EAHP, we are committed to transparency in our governance, ethical standards, and funding practices. This section provides open access to our foundational documents, including the EAHP Statutes, Code of Conduct, and Funding Sources. By sharing these resources, we aim to uphold accountability and foster trust with our members, partners, and the public.
Keep up with all EAHP’s events and webinars. Contact the team at info@eahp.eu should you have any questions about upcoming events or activities.
Here you can find all upcoming events organised by EAHP and by all its members and associate members. Do not hesitate to contact the events team at events@eahp.eu should you have any questions about the organisation of these events.
Hospital pharmacists conduct a critical role in the care of patients in hospitals. Learn more about what they do here and in all the pages under Hospital Pharmacy practice and Policy.
Self-Assessment
SILCC
Closed SIGs
EAHP brings together experts from many areas of hospital pharmacy practice providing and highlighting good local sustainable practices as that can be up-scaled and shared with other countries. The EAHP Working Group on Sustainability has the aim of reducing the environmental burden of the hospital pharmacy services.
The European Association of Hospital Pharmacists (EAHP), and its 36 member country platforms are creating a Common Training Framework for the hospital pharmacy education in Europe. The goal of this project is to allow the free movement of hospital pharmacists within the European Union.
The European Association of Hospital Pharmacists (EAHP) and the European Society of Clinical Pharmacy (ESCP) have collaboratively developed the Oath to Society. The Oath to Society is all encompassing and acts as a contract for excellence in providing compassionate patient care, working as part of the healthcare team and advancing the pharmacy profession, and showcasing how clinical and hospital pharmacists work every day
A day created to highlight the importance and to celebrate the work done by hospital pharmacies. This day celebrates all hospital pharmacy teams.
The Early Career Network aims to empower early-career pharmacists by sharing opportunities, insights, and success stories from across 25 member countries.
Together, we’re building a stronger, more connected hospital pharmacy community: one story, one country, one pharmacist at a time.
Catch up with EAHP’s press releases
Find all EAHP relevant publication like the EAHP Surveys, annual reports and the history books.
The European Journal of Hospital Pharmacy (EJHP) is the only official journal of the European Association of Hospital Pharmacists (EAHP) and is committed to advancing the science, practice and profession of hospital pharmacy. As the premier communication platform for hospital pharmacists worldwide, EJHP is a major source for continuing education as well as updates on advances in the practice and standard of pharmaceutical care for patients.
When EAHP and Hospital pharmacists appear in the news.
EAHP publishes a monthly EU monitor with updates about the latest EAHP initiatives and information relevant for the hospital pharmacy profession.
The Sponsor Channel is designed to maximise visibility and engagement, allowing sponsors to connect with the hospital pharmacy community and partners in a dynamic and interactive environment. From product demonstrations to networking sessions, the Sponsor Channel offers a range of opportunities for sponsors to showcase their offerings and generate leads in the new EAHP Website.
Clinical Pharmacy Services
Charlotte Sørensen, Karin Aagot Møller Jørgensen, Anne Grethe Nørgaard Kyndi, Charlotte Lund Madsen, Line Scriver Poulsen, Charlotte Hjorth, Gitte Slyngborg Morbjerg, Janni Østergaard Jensen, Mette Juul-Gregersen, Rune Dalsenni Rask
A sustainability project in 2020 highlighted manual and time-consuming workflows when checking expiry dates in hospital medicine rooms. For example, manual reading, interpretation and notation of expiry dates in paper forms every half year. Therefore, a smartphone application was developed and implemented in a large university hospital in 2022. The application was a huge success and colleagues from other Clinical Pharmacy departments in other hospitals within the same region wanted to be part of the success of the initiative.
A smartphone application for managing expiry dates in medicine rooms was applied in one hospital in 2022 and in four other hospitals in 2023. The data-matrix of medicine packages is scanned with a smartphone camera and the application gives a sorted overview of medication near expiry. In the application you can register a medicine package as either used, discarded or released. By releasing medicine packages, the medicine is made available to colleagues in other medicine rooms.
The smartphone application was implemented in Clinical Pharmacy departments in four other hospitals, one by one from February 2023. After implementation the application is used in 373 medicine rooms.
Clinical Pharmacy staff are happy with the application. It takes significantly less time to check and scan expiry dates with the digital solution.
From February to September 2023 (five hospitals)
• 47491 packages were scanned
• 5251 packages were released (11%)
• 2664 packages were moved between medicine rooms to avoid medicine wastage (51%; 147000 €). Most activity (78%) was seen at the hospital that had been using the application since 2022. Most packages were moved between medicine rooms at the same hospital; however, in 215 cases (8%), medicines were exchanged between hospitals as well (20.000 €)
• 10918 packages were discarded due to expiry (743168 €; 0.5% of bought medicine).
The full potential of the digital solution remains to be achieved.
Pharmaconomists have to release medicine in the application a few months earlier than they do now. To go shopping in the application before ordering from the pharmacy, will probably also result in discarding less medicine. Sharing medication across hospitals to a greater extent will also be relevant to consider.
Patient Safety and Quality Assurance
Carla Noguera-Jurado, Alba Manzaneque, Gloria Molas, Genis Castells, Sandra Jara, Bernat Tenas, Jordi Nicolas
Bispecific antibodies (BA) have the ability to specifically bind two different antigens, thereby presenting specificity for two different cells. Among the toxicities associated with these drugs are cytokine release syndrome (CRS) and immunoeffector cell-associated neurotoxicity syndrome (ICANS), the management of which requires multidisciplinary action. The purpose of this circuit is to ensure adequate management of these toxicities to guarantee patient safety.
Creation of an action plan for haematological patients treated with bispecific antibodies for the detection and proper management of their toxicities.
A multidisciplinary team formed by Pharmacy, Haematology, Nursing, Intensive Care Medicine and Neurology was created and the healthcare professionals involved were specifically instructed. Moreover, an action circuit was implemented for the detection and management of these toxicities, and a specific protocol was created for the preparation and dispensing of tocilizumab. The protocol contemplated: centralisation of the preparation in the pharmacy department (within the pharmacy hours) or preparation in the hospitalisation ward by trained professionals using a kit previously prepared by the pharmacist (containing drug, serum and closed system dispositive for the preparation and administration of tocilizumab outside pharmacy hours).
From July 2022 to August 2023, a total of five patients have been treated with BA in our institution (elranatamab (4/5), and teclistamab (1/5)), including clinical trials and compassionate use, for Multiple Myeloma.
Three patients presented grade 1 CRS in the first cycle of treatment, which was resolved with symptomatic therapy, with no need for tocilizumab administration in any case. In addition, one also presented grade 1 ICANS, which only required monitoring without treatment.
The availability of the toxicity management circuit, in addition to staff training, allowed toxicities to be detected and resolved early and, if tocilizumab had been needed, the circuit would have ensured its immediate availability.
The implementation of a multidisciplinary care circuit led by pharmacy and haematology guarantees the adequate management of toxicities associated with the treatment, ensuring the best quality of care for the patients and their safety.
Clinical Pharmacy Services
Afke van de Plas, Judith Baars-Timmermans, Hanneke Goossens, Ellen Frankfort
This initiative aimed to improve:
1. Personalized Healthcare and Patient Satisfaction: In the pursuit of strict regulatory compliance, pharmacy employees sometimes overlooked the pharmacy’s fundamental mission. With limited direct patient interactions, staff were often unaware of patients’ unique needs and preferences.
2. Employee Satisfaction: The program aimed to empower employees by reducing excessive regulations and allowing them to make decisions that aligned with the overarching mission, with the expectation that this would enhance their job satisfaction.
3. Enhancing Awareness of the Pharmacy’s Mission: By connecting all activities to the pharmacy’s core mission, the program attempts to improve personalized healthcare and patient and employee satisfaction.
Maastricht University Medical Centre’s hospital pharmacy introduced the “All Activities in Alignment with Underlying Aim” program.
The program’s implementation involved several key steps:
1. Defining the Underlying Aim and Key Principles: The program team identified the overarching aim as “Happy Patients and Employees” and established four key principles: “See the Person Behind the Patient,” “Focus on What Is Possible,” “Take the Lead Yourself,” and “From Rules to Self-Regulation.”
2. Employee Engagement: The new policy was presented and discussed in detail during a meeting with all employees.
3. Communication: Periodic newsletters and monthly team meetings were used to share illustrative examples and foster discussions about initiatives.
4. Evaluation: Customer and employee satisfaction were measured through surveys before and after program implementation.
The outcomes of the program were highly encouraging:
• The adoption of “Happy Patients and Employees” as the guiding aim resulted in numerous instances of personalized healthcare and enhanced collegiality.
• The four key principles empowered employees to align their actions with the program’s aim. The empowerment to decide in the patient’s interest increased from 58% to 73%.
• Surveys indicated improved customer and employee satisfaction.
• Enhanced awareness of the pharmacy’s mission (from 47% to 66%) led to stronger connections between activities and the overarching aim (from 73% to 85%).
The “All Activities in Alignment” program serves as a successful model for other hospital pharmacies seeking to elevate personalized healthcare, patient and employee satisfaction. Its simplicity and effectiveness make it a valuable initiative worth considering for broader implementation.
Selection, Procurement and Distribution
Elisabeth CESAR, Ludivine LECHEVRETEL, Adrien NIERENBERGER, Laurent DIETRICH, Anne FEGER-FALK
We decided to experiment this new solution on coronarography-packs, which presents the biggest rotation among surgery-packs (5,392 units estimated for 2,023), in order to improve working conditions of logistic workers, decrease musculoskeletal disorders (MSD) and optimise storage.
Pallet box have been implemented as a new logistic solution for surgery-packs in our hospital pharmacy on a proposal from one of our biggest suppliers. The aim of this comparative study between 52-pack pallet boxes and the previous storage solution by 4-pack boxes was to assess the potential benefit on handling work, storage, waste and its economic impact.
In order to compare these two solutions, we clocked the time and evaluated the cost of transport from delivery gate to storage room and healthcare-unit order-picking step (from picking up the first pack to cardboard flattening). We also estimated the amount of waste associated.
Pallet-boxes enable a 24% room saving (52 pallet-spots yearly (2 pallet-boxes piled on one spot) instead of 68) and a 31% global time saving (22 hours yearly (13h transport + 9h order picking) instead of 32 hours (17h transport + 15h order picking)). Time saving on order picking was 40%: picking step of one pack from a pallet box requires on average 6 seconds whereas 10 seconds were needed from 4-packs-boxes. Yearly 104 pallet-boxes (603 kg of empty cardboards) will be manipulated whereas 1,348 4-pack-boxes (1,213 kg) used to be handled resulting in a 2-fold decrease. Even though pallet-boxes halve cardboard-waste, they represent 1.5 times more wooden-pallets’ waste (104 versus 68). Furthermore the price of coronarography-packs are impacted by a 2% increase representing around 4,100€ yearly which is not balanced by savings on transport or order picking (10h ≈ 150€).
Logistic workers are unanimously satisfied in implementing pallet-boxes as it facilitates their work on many aspects: pallet transport, order picking, waste disposal. Despite being costlier, a decision has been made to implement pallet-boxes in the long-term in order to improve waste management and working conditions of logistic workers. Our hospital pharmacy is already thinking about extending pallet-boxes to other references in order to assess more precisely their impact on MSD in logistic workers.
Patient Safety and Quality Assurance
Irene Centeno López, Eva M Legido Perdices, Maria José Cano Cano, Salvador Benlloch Pérez, Federico Peydró Tomás, José Manuel Ventura Cerdá
Acetaminophen is the most used antipyretic and analgesic drug around the world. Intentional and non-intentional acetaminophen overdose is related to acute liver failure and it is important to start the treatment during the first hours after the intake to reduce liver injury. The main treatment to prevent liver failure is n-acetilcysteine (NAC) and it is administered depending on acetaminophen plasmatic concentrations using Rumack-Matthew nomogram during the first 24 hours. Variability in sampling time and duration of NAC administration was detected when acetaminophen intake was unknown or above the first 24h. Moreover, different NAC administration protocols were used in our institution.
An interdisciplinary team involving Hospital Pharmacy, Emergency, Gastroenterology Department and Critical Care Unit was created to establish an agreed protocol for the management of acute acetaminophen poisoning.
The interdisciplinary team agreed the following procedures:
– To change the traditional NAC protocol of three intravenous infusions (150 mg/kg over 1 h, 50 mg/kg over 4h and 100 mg/kg over 16h) to the SNAP protocol of two bags (100 mg/kg over 2h and 200 mg/kg over 10h) reducing duration of administrations from 21 to 12 h.
– To establish the sampling times for the determination of acetaminophen serum concentrations: the extraction will be 4h after the ingestion during the first 24h of the intake. When time is unknown or greater than 24h, two samples separated by at least 2h will be extracted to calculate acetaminophen half-life to assess the probability of liver damage (high probability when half-life (t1/2)>4h).
– Define NAC discontinuation when INR<1.3, transaminases are in normal range and acetaminophen concentration<10 mcg/ml. If one of these parameters remains altered, the last NAC perfusion must be repeated.
– Reduce the duration of NAC treatment in the Emergency and hospitalization rooms if all analytical parameters are normalised.
– Reduce the variability in the management of acetaminophen poisoning and sampling time.
– To perform a closer clinical follow up of intoxicated/over-medicated patients.
Measure the reduction of hospital admissions and safety improvement by modifying NAC administration protocol and therapeutic drug monitoring of acetaminophen.
Clinical Pharmacy Services
Jesper van Breeschoten, Chang Chui, Bert Storm, Grootswagers-Sobels Annemieke
After the introduction of new medications in a hospital, it is uncommon for local treatment and administration protocols to be reevaluated in light of the latest scientific evidence. Infusion units are facing numerous challenges today, including staffing shortages and a growing number of patients receiving intravenous treatments. It may prove beneficial to periodically conduct a comprehensive review of the current protocols, with the objective of minimizing the time patients spend in the infusion unit and to prevent unnecessary use of medication while upholding the delivery of high-quality care.
We performed an extensive review of treatment protocols for all medications administered at our infusion unit.
We performed an extensive review of treatment protocols for all medications administered at our infusion unit, drawing insights from the most recent literature. Our evaluation covered a range of factors, including premedication, infusion rates, observation periods, line flushing, administration routes, hydration strategies, and anti-emetic regimens. To provide additional data supporting protocol refinements, we utilized an electronic health record text mining tool known as CTcue, which facilitated the collection of retrospective patient information. Subsequently, these protocol modifications received unanimous approval from both pharmacist and attending specialist.
Treatment and administration protocols of 17 medications were optimized. We decreased infusion times for atezolizumab, bevacizumab, carboplatin, doxorubicine, durvalumab, folinic acid, irinotecan, panitimumab, vinblastine and vincristine. Vital sign assessment during infusion were omitted from protocols. Premedication and anti-emetic medication were converted to oral administration. Intravenous administration was converted to subcutaneous administration for abatacept, daratumumab, infliximab, tocilizumab, trastuzumab + pertuzumab and vedolizumab. Observation time after infusion was omitted for daratumumab, infliximab and vedolizumab. Based on the current literature, hydration schemes of cisplatin were shortened from 20 hours to 4 hours. The implementation of all optimization measures resulted in a reduction of ± 6000 hours of bed occupancy by patients annually. Based on our estimation, this has resulted in a reduction of approximately 16% in total time that beds were occupied.
We aim to periodically review our treatment and administration protocols and share our experiences with other hospital pharmacists. Other infusion units that also face challenges in shortness of staff may copy this blueprint to mitigate these problems.
Selection, Procurement and Distribution
Andrés Sánchez Ruiz, Rocío Contreras Collado, Lucía Gutiérrez Lucena, Juan Jerez Rojas
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.
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.
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.
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.
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.
Clinical Pharmacy Services
Patricia Van den Bemt, Thijs Oude Munnink
Healthcare is responsible for an important part of the carbon footprint and medication production and use contribute substantially to this footprint. In line with Green Teams being established in all layers of society at the moment, the UMCG departments were also starting to implement such teams. The CPP was among the first departments establishing such a Green Team in order to reduce the footprint of medication use.
The department of Clinical Pharmacy and Pharmacology (CPP) is responsible for providing pharmaceutical patient care to all hospitalised and ambulatory patients of the University Medical Centre Groningen (UMCG) in tThe Netherlands. Two years ago, the department has established a Green Team, dedicated to making this pharmaceutical care as sustainable as possible.
The Green Team CPP started in June 2021 with a brainstorm on potential subjects. As the main focus we chose to ‘contribute to sustainable medication use and to reduce disposal’. The team consists of representatives of all CPP sub-departments. Proactive measures and projects were defined, but increasingly the Green Team is being consulted by doctors and nurses regarding issues on sustainable medication use. Department-wide awareness is fuelled by a periodic newsletter.
Three projects were conducted: 1) Switching from paracetamol intravenous therapy to oral/rectal therapy (based on doctor’s question); 2) Patient’s own medicine use combined with self-administration of medication (POM/SAM project; based on nurse question); 3) Exploring oral anticancer drug waste by patient interviews (in preparation of improvement measures; proactive Green Team project). The results of these projects are of interest to all European hospital pharmacists and can inspire others to establish Green Teams to contribute to sustainable pharmaceutical care.
Given the success of the paracetamol project, we will expand this to other intravenous medications. The pilot project on POM/SAM has inspired us to implement POM/SAM within all nursing departments of the UMCG. And the results of the interviews on oral anticancer waste form a solid justification of the necessity of implementation of re-use of medication. In addition, we will continue to perform new proactive projects, aimed at deprescribing (by performing medication reviews), improving medication adherence, optimising the logistics of medication (reducing the amount of medication being dispensed, implementing of ready to administer medication, implementing of pharmacy IV service), reducing medication and financial waste using vial rounding, and proper disposal of medication. We will also continue to be the expert group to which doctors and nurses can direct their questions on sustainable medication use.
Clinical Pharmacy Services
Marta Anghilieri, Francesco Guidoni, Vito Ladisa
The new DNA sequencing techniques, globally defined “Next Generation Sequencing (NGS)”, allow the parallel sequencing of many samples producing in short times a big amount of data. To enable comprehensive analysis of the data and develop new specific and clinically useful therapies, we have introduced the approach of evaluating the data by the MTB, which includes pharmacists as experts in drugs and their use.
Hospital Pharmacists (HPs) are integrated into the Molecular Tumour Board (MTB), a multidisciplinary group, to select the most appropriated therapy for oncology patients, ensure and facilitate patient access, and demonstrate therapeutic appropriateness found by MTB analisys.
MTB members, including HPs, perform DNA sequencing on each patient using NGS to identify known/unknown alterations. These data are entered into a database available to all MTB members and are the basic tool for selecting potential target therapy. The MTB meets once a week to discuss and integrate the observed DNA alterations with the patient’s clinical history. In this way, the most appropriate target therapy for the patient can ultimately be selected. The HPs then provide the patient with access to medications.
In this study, 208 patients affected by Non-Small Cell Lung Cancer were evaluated. DNA sequencing of patients identify 117 altered genes. After an extensive literature search, 15 genes were highlighted as potential targets for available drugs. They marked 116 patients potentially tractable with target therapy, of which 47 patients were candidates to a target therapy already in clinical practice and 69 to a target therapy not in clinical practice. Comparing the two groups, among candidates for drugs in clinical practice, treatment was started in 65% and continued in 53%; among those treated with drugs not in clinical practice, treatment was started in 23% and continued in 69%.
The inclusion of HPs in MTB allows for more deliberate use and better selection of drugs. HPs provide valid support to select drugs and facilitate access to them: HPs individualise the applicable therapy for a larger number of patients through MTB, they analyse the therapeutic outcome (MTB-selected therapy has a bigger chance to last longer) and the cost impact on the NHS.
Patient Safety and Quality Assurance
LUCIA SOPENA, ALBERTO FRUTOS, VICENTE GIMENO, OLGA PEREIRA, RAQUEL FRESQUET, ARITZ MERCHAN, REYES GARCIA, PAULA GOMEZ, ALBERTO APESTEGUIA, MARIA ANGELES ALLENDE, TRANSITO SALVADOR
The growing technological development of pharmacy services involves the coexistence of traditional warehouses with automated medicine dispensing systems controlled by different computer programs. The information is split into different systems and databases giving rise to possible errors due to the greater complexity. This is a threat but also an opportunity for the hospital pharmacist to lead the development, review, and improvement of medicine use processes and the use of health technologies to improve quality of care, patients’ safety and reduce costs. KNIME data analysis covered the need of our Pharmacy Service to blend data from any source in a single file simplifying the process.
The Pharmacy Service of a university hospital has implemented Konstanz Information Miner (KNIME) data analysis and develop successful treatment project to optimise the stock management of several medicines.
An initial algorithm was designed by the union of seven files and can be executed at any time to obtain the updated data.
This file provides up-to-date information about the stocks, stock-outs, consumptions, orders and purchasing data of all medicines (average price, laboratory, date and number of orders, units to be received).
In addition, KNIME calculated the coverage time in days and months from weekly and monthly consumption, and the current stock in the warehouses, obtaining a global vision of highest turnaround pharmaceuticals drugs.
The program also allows to link and merge data of the list for shortages of medicines, supply disruptions and restocking time, and to improve the storing, delivering and administering of COVID-19 vaccines.
KNIME program has been especially important in our Pharmacy Service to get better care outcomes and more precise medication ordering, which allows significantly higher patient safety.
KNIME is a tool that could be successfully implemented and appropriately generalised as recommended to all Pharmacy Services that use different data sources and want to have a generalised view of the information. KNIME represents an advance in the stock and purchase management of medicines specialties to work more efficiently, which improve patient care and safety. Digital medication management also contributes to greener pharmacies by preventing unnecessary overstocking and thus excessive disposal arising from expired medications.
