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THE CLINICAL PHARMACEUTICAL SERVICE IT TEAM: ENHANCING MEDICATION WORKFLOWS AND PATIENT SAFETY IN EPIC

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European Statement

Patient Safety and Quality Assurance

Author(s)

Christina Theil Schnor and Saranya Loganathan.

Why was it done?

In 2018, hospitals in Region Zealand (RZ), Denmark, transitioned to the electronic health record (EHR) system, EPIC. Following this, hospital pharmacists faced repeated medication order challenges causing adverse events such as inappropriate medication orders, dispensing and administration errors, and insufficient workflow coordination. These issues resulted in complex, time-consuming workflows impacting quality and patient safety. Additionally, collaboration between corporate IT and clinical staff was challenged by a lack of understanding of practical issues. To address this, pharmacists of RZ established the Clinical Pharmaceutical Service IT Team (CPS IT Team) to build specialised knowledge of the EHR medication module, aiming to assure quality, optimise workflows, strengthen interdisciplinary coordination, and support safer and more efficient clinical use.

What was done?

CPS IT Team standardised workflows, enhanced coordination of medication order tasks, and created a forum to effectively utilise professional knowledge and networks across areas.

How was it done?

To address diverse Clinical Pharmacy challenges, CPS IT Team became the bridge between internal organisation (RZ Hospital Pharmacy and corporate IT) and external partners (EPIC and The Capital Region of Denmark (CRD)). For this reason, CPS IT Team was established with one team manager and two units: Internal and External unit. CPS IT Team continuously adapts to evolving Clinical Pharmacy needs.

What has been achieved?

The establishment of CPS IT Team has driven significant internal optimisation and standardised workflows. Acting as a coordinating unit, it optimises medication processes from ordering to dispensing and administration. Dialogue with IT has been strengthened, enabling more efficient, targeted communication across professional groups.

Collaboration with EPIC and CRD has enhanced quality assurance and optimised workflows. CPS IT Team efforts have helped prevent medication-related adverse events, improve workflows, and optimise medication processes. Interdisciplinary collaboration and professional consultation networks between regional clinics, hospital pharmacies, IT, and EPIC have been notably strengthened. These efforts have increased patient safety and fostered a safer, more coherent workflow in EPIC.

What next?

Fusion of RZ and CRD into Region Eastern Denmark will change CPS IT Team’s working conditions, opening new opportunities such as an expanded collegial network and broader range of tasks and needs. Systematic data use will support Hospital Pharmacy’s work, improving efficiency and quality in daily operations.

EMPOWERING PAEDIATRIC CAREGIVERS IN MEDICATION SAFETY: A CLINICAL PHARMACY INITIATIVE FOR WORLD PATIENT SAFETY DAY 2025

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European Statement

Patient Safety and Quality Assurance

Author(s)

Mengato D, Camuffo L, Todino F, Binanti ME, Sartori S, Benini F, Venturini F

Why was it done?

Medication errors in paediatrics often arise from incorrect handling or administration by caregivers. Strengthening their knowledge is essential to improve safety and adherence. The initiative aimed to raise awareness and assess caregivers’ understanding of safe medication use, storage, and the role of compounded (‘galenic’) medicines. It also intended to reinforce the visibility of clinical pharmacists as accessible medication experts for families.

What was done?

On 17 September 2025, during the World Health Organization’s World Patient Safety Day themed ‘Safe care for every newborn and every child’, the clinical pharmacy team of the Azienda Ospedale–Università Padova organised an awareness event within the Paediatric Department. The initiative included a pharmacist managed information desk, an interactive quiz for parents and caregivers, educational materials on safe medication practices, and gadgets for children to foster engagement. Pharmacists were available throughout the day to answer questions and provide individual counselling on paediatric medicines.

How was it done?

A voluntary anonymous quiz with 10 knowledge-based and 2 awareness questions was administered to parents visiting the department. Participants received a score (1–10) and tailored feedback: scores ≥8 indicated excellent knowledge, 5–7 good knowledge with room for improvement, and <5 the need for closer pharmacist or physician guidance. The event required coordination with paediatric staff and logistical support for educational materials and space allocation.

What has been achieved?

Thirty-two parents completed the quiz: 68.8% achieved ≥8 points (‘super-pharma-parents’), 28.1% scored 5–7, and 3.1% scored <5. Knowledge was strong regarding shaking suspensions (100%), completing antibiotic courses (96.9%), and proper disposal of expired drugs (96.9%). Gaps emerged in measuring tools (9.4% incorrect) and preparation environment (6.2% unsuitable). Awareness of galenic medicines was limited (18.7% misdefinition). The initiative was well received, stimulating high engagement and requests for future educational sessions.

What next?

The experience improved caregiver awareness and strengthened collaboration between families and clinical pharmacists. This initiative, which is embedded with the Clinical Pharmacy Ambulatory, represents a reproducible model to enhance paediatric medication safety. Future steps include integrating similar educational events into routine hospital activities and developing digital tools to extend pharmacist-led counselling to the community.

BUILDING A ZERO-ERROR MEDICATION WORKFLOW THROUGH SMART DISPENSING SYSTEMS AND BIG DATA GOVERNANCE

European Statement

Patient Safety and Quality Assurance

Author(s)

Hui-Yu Chen, Kai-Cheng Chang

Why was it done?

Medication safety remains a cornerstone of healthcare quality, yet adverse drug events (ADEs) continue to cause preventable harm in hospitals. Traditional manual dispensing workflows, dependent on human memory and paper-based checks, are prone to errors, particularly in large medical centers with high prescription volumes.

What was done?

We launched the “Smart Dispensing and Data Governance Project,” aiming to transform the pharmacy workflow through digitalization and data-driven quality management.

How was it done?

A two-pronged strategy was adopted: (1) deployment of smart dispensing hardware and (2) establishment of a big data governance platform. The hardware featured personalized login for accountability, closed-loop barcode verification of both medications and prescription bags, LED guidance and voice feedback for real-time alerts, and final barcode validation before dispensing. Advanced automation such as real-time stock sensing, weight-based verification, and image-assisted accuracy checks further minimized human errors. A SAS Visual Analytics–based Business Intelligence dashboard visualized error trends and enabled continuous PDCA (Plan-Do-Check-Act) improvement cycles through near real-time feedback.

What has been achieved?

Implementation led to substantial quality improvements: the dispensing error rate decreased by 78.3% (0.023‰ to 0.0050‰, P < 0.05); data analysis time for error monitoring shortened from 4 hours to 10 minutes (-98.3%, P < 0.05); and pharmacist training time reduced from 10 days to 3 days (−60.0%). All indicators showed statistically significant enhancement in accuracy and efficiency. Integrating smart dispensing systems with big data governance effectively advanced medication safety and operational efficiency. This model established a scalable, data-driven, and high-reliability pharmacy workflow, transforming quality management from reactive correction to proactive prevention and serving as a replicable benchmark for digital hospital transformation.

What next?

We plan to apply AI algorithms to dynamically optimize drug storage locations based on usage and safety risk, and to digitalize all storage displays through an integrated electronic shelf–label system. These enhancements will further strengthen accuracy, reduce human-factor variability, and advance a highly reliable smart dispensing workflow.

ENHANCING DRUG COMPATIBILITY MANAGEMENT IN THE ICU: A COLLABORATIVE APPROACH BETWEEN CLINICAL PHARMACISTS AND MEDICAL STAFF

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European Statement

Clinical Pharmacy Services

Author(s)

Marco Gambera; Alessandra Grotto; Isabella Martignoni

Why was it done?

Periodic audits in hospital settings play a crucial role in identifying non-conformities and areas for improvement, ensuring that departments meet the required operational standards. During a routine inspection of the intensive care unit (ICU), the hospital pharmacy team discovered an outdated Y-site drug compatibility chart, which had not undergone prior review or approval. This non-conformity underscored the need for updated and reliable resources for managing drug compatibility in critical care settings. Addressing this issue became an opportunity to strengthen collaboration between the pharmacy and the ICU, with the aim of improving patient safety and clinical workflows

What was done?

The primary objective was to update and optimize the Y-site drug compatibility management in the ICU by revising the existing chart and educating the medical staff on real-time, evidence-based tools for accessing drug stability and interaction data integrating these tools into the daily practices of the ICU, ensuring that staff could access the most current information quickly and efficiently

How was it done?

ICU staff received dedicated training on using up-to-date software tools such as Stabilis, Micromedex, and Lexidrug. These tools provide real-time information on drug stability and interactions. Following the training, a comprehensive review of the ICU’s most frequently used medications was conducted and a new Y-site compatibility chart was developed, incorporating the latest stability data. The chart was tailored to meet the specific needs and operational practices of the ICU team, ensuring it was both practical and user-friendly

What has been achieved?

The revised chart and the associated training program significantly enhanced collaboration among healthcare professionals in the ICU, improving communication and awareness of each team member’s expertise. This project highlights the value of expanding the clinical role of hospital pharmacists, their expertise can directly improve patient care and support the management of complex drug therapies.

What next?

Further support measures will be implemented, such drug-specific tables outlining stability, interactions, storage, and handling instructions. These tables align with recommendations on medication management and provide an essential resource for clinical decision-making. The initiative not only enhanced the quality and safety of medication administration but also fostered a culture of continuous professional development and collaboration, ultimately benefiting the ICU’s clinical operations and patient outcomes

DESIGN OF AN ANTI-HAEMORRHAGIC AGENTS PROTOCOL FOR AN INTENSIVE CARE UNIT (submitted in 2019)

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European Statement

Clinical Pharmacy Services

Author(s)

Mercedes Gómez-Delgado, Marta Valera-Rubio, Margarita Carballo-Ruiz, José Luis Ortiz-Latorre, Isabel Moya-Carmona

Why was it done?

Blood coagulation factors and their adequate use can be of particular importance in the treatment of massive haemorrhage, especially in the ICU. This initiative was taken in order to improve uptake and to avoid errors in the administration, which can be difficult in emergency situations.

What was done?

To define an emergency procedure that ensures correct management in cases of massive bleeding in an intensive care unit (ICU).

How was it done?

The development of drug use protocols for emergency situations is a simple task that facilitates health workers to manage them. Prioritising the drugs to be included in a protocol by a previous survey in a multidisciplinary setting is important to consider the different points of view. We carried out a review of the pharmacy service to the ICU needs of antihaemorrhagic drugs. ICU staff (doctors and nurses) were informed to reach an agreement about eligible drugs for being included in the protocol. ICU staff requested the inclusion of four drugs in the protocol according to the prevalence of use and the difficulty of administration: human fibrinogen, tranexamic acid, eptacog alfa and human prothrombin complex. We created a protocol with four information sheets, one of each drug, made of schematic information about: 1. Physical location (fridge or room temperature, number of shelf) and minimum safety stock (3 units of human fibrinogen, 4 units of tranexamic acid and 3 units of human prothrombin complex). 2. Indications and dosage according to the clinical situation and the patient characteristics (dosage adjustment according to renal or hepatic impairment, weight or age when applicable). 3. Recommendations for intravenous administration (flow rate, bolus, loading dose, dilution, mixture stability).

What has been achieved?

Mapping the information and dividing it into sections is essential for its rapid understanding in a high-stress work environment. The implementation of this protocol was well embraced by all the staff involved, since it allowed a more efficient health care circuit for the ICU staff. It also optimises the consumption of this type of more monitored drugs.

What next?

We will monitor the compliance with this protocol, as well as possible updates that may be beneficial for a better understanding of the forms of administration.

HIGH-ALERT MEDICATIONS, A STEP FORWARD TO IMPROVE PATIENT SAFETY

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European Statement

Patient Safety and Quality Assurance

Why was it done?

The implementation of safe medication practices plays a key role to prevent medication errors (ME) in the hospital setting. High-alert medications (HAMs) are those that bear a heightened risk of causing significant patient harm when they are used in error. Institutions such as the Joint Commission requires that hospitals define institution-specific HAMs and implement good processes.
Our objective was to ensure safe medication hospital practices and to eliminate medication errors that may cause harm, which is a priority to achieve patient´s safety goals.

What was done?

A program for identifying and handle high-alert medications in a terciary hospital has been implemented.

How was it done?

The project was carried out in different stages:
-First of all, it was consulted the updated list (published in 2012) by the Institute for Safe Medication Practices. Therefore, a total of 186 drugs were HAMs.
-The second step was identified them using auxiliary red colour labels to warn health professionals of their potential danger.
-Finally, we defined general and specific strategies to take up with HAMs. In general strategies, plant kits were reviewed to remove unnecessary stock and limiting access to HAMs. It was also standardized HAM handling practices. In this way, specific strategies focused on: methotrexate, insulin and heparin. Regarding methotrexate administered orally, it was distributed a fact sheet indicating rules to promote it proper administration. Regarding insulin, a working group was formed to determine the available presentations, reserving the insulin pen for diabetic debuts. For the unfractionated heparin, a procedure for standardized dilution of 5% heparin was performed being the 1% heparin restricted to certain services.

What has been achieved?

A total of 186 medications were identifyed as HAMs and different strategies to prevent ME with those was defined. The main objective we have accomplished is becoming aware of their potential danger in case of error.

What next?

In the near future, our main objetives are asses the long-term impact of the implemented strategies, monitor ME involving HAMs and reassess the current list of HAMs to promote a needed safety culture in the hospital setting.