THE CLINICAL PHARMACEUTICAL SERVICE IT TEAM: ENHANCING MEDICATION WORKFLOWS AND PATIENT SAFETY IN EPIC
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 specialized knowledge of the EHR medication module, aiming to assure quality, optimize workflows, strengthen interdisciplinary coordination, and support safer and more efficient clinical use.
What was done?
CPS IT Team standardized workflows, enhanced coordination of medication order tasks, and created a forum to effectively utilize professional knowledge and networks across areas.
How was it done?
To address diverse Clinical Pharmacy challenges, CPS IT Team became the bridge between internal organization (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 optimization and standardized workflows. Acting as a coordinating unit, it optimizes 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 optimized workflows. CPS IT Team efforts have helped prevent medication-related adverse events, improve workflows, and optimize 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.
OPTIMIZING DRUG THERAPY AND PATIENT SAFETY IN ILEOSTOMY: A BEST PRACTICE MODEL OF A CLINICAL PHARMACY–LED INTERPROFESSIONAL WORKING GROUP
European Statement
Patient Safety and Quality Assurance
Author(s)
S. Hehenberger, I. Lagoja,
Why was it done?
Metabolic complications as well as altered or reduced drug effects are common in patients with a stoma and require close interprofessional collaboration, particularly after an ileostomy. However, pharmacists are rarely involved in the care of stoma patients, and coordination or communication between the various disciplines is often suboptimal.
What was done?
An interprofessional working group was established to identify the most common metabolic complications associated with ileostomy based on current literature and clinical experience. Preventive measures were formulated and integrated into a structured scheme.
Of particular relevance from a clinical-pharmaceutical perspective:
* Ensuring optimal drug efficacy: A medication analysis framework was developed that addresses the specific challenges of drug therapy in ileostomy patients, followed by routine medication reviews for all inpatients with ileostomies.
* Development of a drug therapy algorithm for high-output stoma (HOS).
How was it done?
A recommendation for action was developed, which is now established and implemented as a standard operating procedure (SOP) throughout the hospital. An interdisciplinary STOMA outpatient clinic has been established to optimize medication, adverse drug reaction management, and the care of stoma patients, thereby improving their quality of life.
What has been achieved?
Through a clinical pharmacy approach involving an interdisciplinary advisory board, readmissions due to adverse drug reactions can be significantly reduced, leading to cost savings for the social system while simultaneously enhancing patients’ quality of life. In 70 reviews almost 400 drug problems (DRPs) were identified, of which more than 60% were stoma-related drug problems. All DRPs and pharmaceutical interventions were categorized and documented. Acceptance of the interventions was also recorded.
What next?
The diverse aspects of ileostomy patient care require interprofessional collaboration. The clinical pharmacist plays a central role in the team and contributes significantly to patient and medication safety and also to the quality of life of ileostomy patients. Measurement of drug levels in plasma further improve the data on drug absorption.
IMPLEMENTATION OF A PHARMACEUTICAL VALIDATION SUPPORT PROGRAM THROUGH AN ALERT SYSTEM INTEGRATED INTO THE ELECTRONIC HEALTH RECORD
European Statement
Patient Safety and Quality Assurance
Author(s)
Laura Rueda Montes, David Tomás González, Iker Muñoz Delgado, María Fernández-Vázquez Crespo, Jesús Airam Domínguez Cháfer, Rocío Manzano Lorenzo, José Carlos Tallón Martínez, Cristina González Pérez, María Ángeles Campos Fernández, Susana Sánchez Suárez, María Teresa Benítez Giménez
Why was it done?
One of the core responsibilities of hospital pharmacists is the validation of inpatient medication prescriptions. Our goal was to identify medication errors that could compromise patient safety, and to optimize and standardize pharmaceutical recommendations, ensuring consistent validation practices across pharmacists. This initiative serves as a tool for quality assurance and patient safety.
What was done?
Design and implementation of an automated alert system for pharmaceutical validation of prescriptions integrated into the Electronic Medical Record (EMR), which generates real-time pop-up alerts based on a database parameterized with clinical rules. During validation, the pharmacist decides whether the alert is appropriate and if accepted, a notification is added to the medical prescription, as well as a record of this intervention in the EMR.
How was it done?
Key pharmaceutical interventions (PIs) were established to optimize prescription validation, grouped into two categories:
• Drug-dependent interventions: 577 PIs classified into 9 groups: maximum dose, therapeutic duplication, drug interactions, gastroprotection, laxative prophylaxis with opioids, incorrect administration techniques, treatment duration, potentially inappropriate medications in older adults, and sequential therapy.
• Patient-specific interventions based on lab data: 398 PIs classified into 7 groups: renal failure, electrylite (magnesium, potassium, and sodium) levels, neutropenia, thrombocytopenia, and anemia.
With support from the IT department, an algorithm was configured using a total of 975 rules that we established for 386 drugs. When a prescription meets any of these rules, an alert pops up in the EMR, displaying a predefined pharmaceutical recommendation tailored to the patient.
What has been achieved?
Implementation of the alert system in the pharmacist’s EMR profile in order to detect medication errors in patients who meet one or more of the rules set in the created algorithm.
Moreover, a dashboard was created displaying the number of interventions by prescribing department, drug, and type of intervention.
Since its launch in April 2025, a total of 3,547 PIs were made for 2,411 patients within six months.
What next?
Ongoing review of existing alerts based on feedback from the pharmacy team, along with the incorporation of new rules to maximize medication safety for hospitalized patients.
FROM RISK TO RELIABILITY: ADVANCING HEALTHCARE SAFETY INNOVATIVE WITH SEMI-IV PREMIXED
European Statement
Patient Safety and Quality Assurance
Author(s)
Naila Aljahdali, Hala Al-Buti, Rana AlKhanbashi, Afaf Almalki, Basem Elbehiry, Mohammed El-Kholi, Ahmed Albariqi, Sara Dabab
Why was it done?
Medication errors, particularly in intravenous preparation, delivery, and administration, pose a significant safety concern in healthcare settings. At King Fahd Armed Forces Hospital in Jeddah, delays in IV antibiotic preparation and delivery were identified as critical issues affecting patient outcomes and pharmacy services. The project aimed to decrease the turnaround time between the order and delivery of IV antibiotics to < 20 minutes by December 2025. Also, reduces medication errors and associated costs, and increases healthcare practitioners’ satisfaction with the new Inpatient/IV Pharmacy workflow.
What was done?
Key strategies included tracking short stability and fixed-dose IV antibiotic utilization, configuring the Health Information System for premixed diluent products, incorporating new stock numbers in automated dispensing cabinets, conducting comprehensive training for healthcare practitioners, and satisfaction surveys.
How was it done?
This project implemented semi premixed IV antibiotic bags from August 2023 to August 2025 in Obstetrics and Gynecology, Medical, and Surgical units for Cefazolin 1GM and Meropenem 1GM. Utilized Lean methodology and Plan-Do-Study-Act (PDSA) cycles to optimize workflows. Baseline assessments were conducted to evaluate order-to-delivery times, medication errors, and wastage cost pre/post intervention.
What has been achieved?
The intervention resulted in a significant reduction in turnaround times from an average of 48 minutes to 17 minutes. Medication errors decreased from an average of 47 to 17 incidents, and the number of returned IV medications dropped to zero. The estimated cost savings from reduced waste amounted to approximately 113,382.324 SAR.
What next?
The implementation of semi premixed IV antibiotics significantly improved turnaround time of the medication order and delivery, enhanced patient safety, and increased practitioner satisfaction. The successful application of Lean methodology underscores the potential for broader implementation of this approach across the hospital to further optimize healthcare delivery.
FROM COLLABORATION TO AUGMENTATION: INTEGRATING AN ARTIFICIAL INTELLIGENCE (AI)-POWERED DOSING TOOL INTO A PHYSICIAN–PHARMACIST COLLABORATIVE WARFARIN CLINIC (PPCC-AI MODEL) — A QUASI-EXPERIMENTAL STUDY AT TAKUAPA HOSPITAL, THAILAND.
European Statement
Clinical Pharmacy Services
Author(s)
daruni sitthikan
Why was it done?
Warfarin management is complex due to its narrow therapeutic index and wide interpatient variability. Although the physician–pharmacist collaborative clinic (PPCC) model has improved anticoagulation outcomes, genetic variability remains a key challenge, as pharmacogenomic (PGx) testing is rarely available in Thai hospitals. To overcome this, an AI-based dosing tool (WarfaWise web application) was developed to assist clinicians in personalizing warfarin therapy without genetic testing.
What was done?
To evaluate the effectiveness of an AI-assisted dosing tool (WarfaWise web application) integrated into the PPCC model (PPCC–AI Model) for optimizing warfarin therapy at Takuapa Hospital, Thailand.
How was it done?
This quasi-experimental study included patients (≥18 years) who received warfarin for ≥3 months (January 2023–May 2025). The WarfaWise web-based AI dosing application was incorporated into the PPCC workflow to predict individualized weekly warfarin doses based on patient-specific parameters (age, sex, weight, comorbidities, concomitant drugs, adherence, and INR trends). The primary outcome was the percentage of Time in Therapeutic Range (%TTR). Secondary outcomes included dosing accuracy (Mean Absolute Error: MAE) and incidence of bleeding or thromboembolic complications. Statistical significance was set at p<0.05.
What has been achieved?
A total of 230 patients were enrolled. The AI-assisted PPCC demonstrated superior dosing precision (MAE=2.09±1.20 mg/week) and significantly improved mean %TTR (primary outcome) from pre-intervention 65.10±1.09% to post-intervention 71.4±8.6% (p<0.02). The incidence of minor bleeding decreased by 69.5%, and no major bleeding or thromboembolic complications occurred during the study period. Pharmacists also reported enhanced workflow efficiency and a reduction in dosing calculation errors. In conclusion, the study showed that the PPCC-AI model demonstrated superior dosing precision, enhanced INR control, and improved patient safety. This pragmatic digital innovation facilitates the scalable adoption of AI-assisted clinical decision-making tools in resource-limited settings where PGx testing is inaccessible, underscoring the evolving role of pharmacists in precision anticoagulation management.
What next?
To develop a mobile application that is easily accessible and free of charge, and can be used in hospitals at all levels.
DEVELOPMENT OF CLINICAL PHARMACY IN A HOME HOSPITALIZATION SERVICE: IMPLEMENTATION OF NEW ACTIVITIES.
European Statement
Clinical Pharmacy Services
Author(s)
D. AUDEGEAN, C. HAMELIN, C. CONTENT, C-H. BLANCHER
Why was it done?
The care of patients receiving home hospitalization is complex. These patients experience multiple transitions throughout the care process and are treated by many health professionals, both in hospitals and private practitioners. This increases the risk of losing important information.
What was done?
To improve safe medication management and make treatment delivery more efficient, new clinical pharmacy activities were implemented.
How was it done?
A medication review and a pharmaceutical consultation were added to pre-admission visits. Unintended discrepancies in patients’ treatment lists and the corresponding pharmaceutical interventions were identified and analysed. A French program, Patient Self-Administration of Medications, to support patients in managing their own medications was introduced following an initial assessment of autonomy by a clinical pharmacist. Information collected during these pharmacy activities was shared with community healthcare providers. The satisfaction of the home hospitalization medical team was also assessed.
What has been achieved?
Over six months, 41% (n = 34) of patients admitted to home hospitalization from our hospital received the new pharmacy service. A total of 38 medication reviews were done. At least one unintended discrepancy was found in 55% (n = 21) of these reviews. The most frequent problem was unintentional treatment omission. In total, 39 pharmaceutical interventions were made. Their clinical value was rated as “moderate” in 69% (n = 27) of cases. Most patients (47.5%) had an autonomy score of 0. Liaison letters were sent to community healthcare providers using secure messaging. All physicians (100%, n = 4) said they were “completely satisfied” with the new clinical pharmacy activities.
What next?
These new clinical pharmacy services helped ensure the safe use of medications in home care patients. Sharing information with community providers improved the link between hospital and community care and supported continuous medication management. However, current staffing levels do not allow all patients to benefit. Involving pharmacy technicians in medication reconciliation may help increase the number of reviews performed. The unanimous satisfaction of the medical team supports continuing these activities in the home hospitalization service.
TO IMPROVE TIMELY MEDICINES PROVISION AND ENSURE SAFE PRESCRIBING AS WELL AS SUPPORT EARLY DISCHARGE PLANNING TO IMPROVE FLOW INSIDE AND OUTSIDE AN NHS TRUST
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Christina Anastasiadou – Lead Pharmacist Acute & Emergency Medicine
Karen Dicks – Chief Pharmacy Technician Medicines Management
Radhika Patel – Pharmacy Technician MMS
Why was it done?
Until October 2023, the A&E department in Croydon University Hospital in London lacked a full-time pharmacy service, unlike other London trusts. This has contributed to suboptimal medicine management and a delay in the identification of prescribing errors. This has resulted in longer stays, missed medication doses, and a rise in patient safety incidences. At a hospital level this reduces flow and increases cost due to medication wastage. Ultimately, the aim is to improve the flow of patients within the hospital via timely medicines provision, early clinical pharmacy intervention and early discharge planning.
What was done?
We have obtained funding from the Better Care Fund for a period of 2 years. This funding is aimed at assisting local systems in effectively achieving the integration of health and social care in a manner that promotes person-centred care, sustainability, and improved outcomes for individuals and caregivers. Therefore, we introduced a full-time pharmacy service including one pharmacist and two medicines management technicians (MMTs)—one full-time and one part-time. This initiative was implemented as a 2-year trial period, using key performance indicators (KPIs) to evaluate its effectiveness.
How was it done?
Data has been collected against the below KPIS:
1) Number of drug histories completed on admission, before patient is allocated a ward (by MMT or pharmacist) per calendar month.
2) Number of medicines reconciliations completed (by pharmacist) per calendar month.
3) Number of clinical interventions completed by all members of the pharmacy team.
4) Savings secondary to the use of patient’s own drugs (PODs) brought from home for administration to reduce medicines wastage.
5) Savings due to the return of medicines to inpatient pharmacy for re-use from other patients when appropriate.
6) Time between request of medicines from pharmacy dispensary and medicine being dispensed, checked and released to A&E.
7) Review of stock lists in all areas in A&E.
8) Reduction in omitted doses.
9) Discharge medicines supply and screening from A&E to streamline discharge.
10) Number of patients counselled on their medicines and provided with patient-friendly information on them.
11) Number of referrals to community teams i.e allocated chemist via Discharge Medicines Service, Integrated Care Network (ICN) pharmacists or specialty teams (i.e anticoagulation clinic for newly initiated anticoagulant) to provide continuation of care.
12) Liaising with specialty teams within the hospital to expedite review and treatment in a time efficient and cost-effective way.
What has been achieved?
The current pharmacy team is fully integrated into the A&E service and has contributed significantly towards advancing patient experience, via early pharmacy engagement with patients. During the first 10 months of the project, we have data to show:
1) A 540% increase in drug histories and medicines reconciliation on admission.
2) A 19.525% increase in clinical interventions and early detection of medication errors.
3) We have completed 5 teaching sessions so far, in order to tackle common prescribing and medicines management inaccuracies and embedding solutions into nurses and doctors training.
4) We have contributed towards the reduction in omitted doses by 6%.
Positive contribution towards tackling medicines wastage has been shown too. Our team contributed towards saving £13.110 from April to September 2024 by using PODs for administration in hospital and £10.483 by returning dispensed medications to the inpatient pharmacy for recycling and use for other patients for the same time period.
In addition, the team has completed 66 referrals to the community pharmacy team for follow up on newly started medicines, stopped medicines, adherence concerns and polypharmacy. This is in order to provide continuous care and establish follow-up after discharge from hospital.
All in all, improved safe patients flow in and out of hospital.
What next?
Work towards a business case for a permanent pharmacy service in A&E, to continue further developing the above. Utilise all the skills our MMTs hold, in order to continue working on patient safety, improved flow and cost improvement plans. Introduce a pharmacist-prescriber who will be able to tackle arising problems as soon as possible and provide high quality care in liaison with doctors, nurses and advanced care practitioners.
72-HOUR TREATMENT RESPONSIBILITY AFTER DISCHARGE: CHARACTERIZATION OF MEDICATION-RELATED CALLS
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Daniel Rasmussen* and Morten Baltzer Houlind
Why was it done?
72-hour treatment responsibility (72H-TR) after hospital care is established to create a safe transition for the patient between hospital treatment and their home. After the implementation of 72H-TR, Copenhagen University Hospital, Amager and Hvidovre (AHH), experiences many calls from the municipalities related to patients’ medications. The purpose of this was to characterize calls related to medication in relation to 72H-TR.
What was done?
We reviewed logs from incoming calls made by Copenhagen and Høje-Taastrup municipalities regarding 72H-TR.
How was it done?
Calls related to patients discharged from the orthopedic or pulmonary medicine departments from AHH during the period from September to November 2023 were included. Further, two senior clinical pharmacists assessed whether calls related to medication was potentially preventable. In case of disagreement, consensus was reached between the reviews.
What has been achieved?
The results showed that 27 out of 50 (54%) calls were medication-related, and 22 out of 27 (82%) were potentially preventable. Of the medication-related calls that were potentially preventable, suboptimal communication was responsible for 11 out of 22 cases (50%), lack of a prescription accounted for 8 out of 22 cases (36%), and incomplete medication reconciliation accounted for 3 out of 22 cases (14%).
What next?
The next step will involve cross-sectoral and interdisciplinary workshops to identify barriers and facilitators and optimize the discharge process. We will also continue improving the online medication discharge reports available to municipalities to eliminate any ambiguities.
Development of a hospital pharmacist led re-evaluation of medication errors
Pdf
European Statement
Patient Safety and Quality Assurance
Why was it done?
All errors, whether involving medication or not, are required to be reported and classified in the hospital reporting system. However, the system is poorly adapted for medication management and lacks the relevant terms. This results in the same type of error being classified in various ways, making systematic quality improvement difficult. A pilot study confirmed the system’s shortcomings, after which a new medication management process was developed and evaluated.
What was done?
The existing process for classifying medication errors was supplemented with a new process in which hospital pharmacists reclassified medication errors detected in the reporting system. The reclassification was based on a predefined medication management process.
How was it done?
A medication management process was developed in collaboration with specialist nurses and in accordance with applicable regulations and policies. The process consisted of the following activities: 1) Prescription, 2) Ordering/Delivery, 3) Storage/Narcotics Control, 4) Preparation, 5) Handover/Administration, 6) Medicines information in transitions of care, 7) Follow-up of treatment, and 8) Miscellaneous. The process was validated by having four hospital pharmacists independently classify 176 medication errors. Consistency in the assessment was evaluated, and the process was corrected as needed. All medication errors classified as medication-related in 2022 or containing the word “medication” in free text were thereafter exported from the reporting tool to Microsoft Excel and then into a data processing and performance monitoring tool for further analysis.
What has been achieved?
A total of 756 medication errors were identified in the reporting tool, distributed across 65 different activities. Hospital pharmacists identified an additional 305 errors through free-text searches that had not been reported as medication-related. A total of 1,061 medication errors (756+305) were reclassified and grouped into eight activities. The highest risk of errors was associated with the preparation (19%), followed by storage/narcotics control (18%), and prescription (17%). The new process, involving hospital pharmacists in classification, creates conditions for a more systematic approach to medication errors. The pilot project was presented at the hospital’s themed day for World Patient Safety Day 2022.
What next?
Discussions have been initiated with system developers to improve the reporting tool. Discussions with hospital management will be initiated with the goal of creating a structure in which hospital pharmacists have an active role in the hospital’s work on patient safety related to medication.
Medication reconciliation practice at transitions of care: a new challenge or opportunity for the clinical pharmacist?
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Elisabetta Volpi, Giuseppa Lo Surdo, Sara Tonazzini, Stefania Alduini, Maurizio Mangione, Umberto Paradossi, Monica Baroni, Sergio Berti, Stefania Biagini
Why was it done?
Several data suggest that pharmacists and physician collaboration, direct pharmacist interaction with patients or caregivers through medication reconciliation and discharge counselling decreases the number of adverse drug events (ADEs) and plays an overall positive role in transitional care. Our aim is to demonstrate the constant necessity of pharmacist led medication reconciliation in order to maintain a high standard of care and safe medication use.
What was done?
Medication reconciliation at hospital discharge is essential for the prevention of medication discrepancies and patient harm. Hospital pharmacists are recognised as one of main healthcare providers that can support the physicians in this activity.
Since 2016, the medication reconciliation process has been performed by physicians and clinical pharmacists before home discharge from the Heart Hospital, Fondazione Toscana G.Monsaterio in Italy.
How was it done?
We analysed the medication reconciliation activity performed in our hospital over time and we observed that the number of unintentional discrepancies was always around 20%.
A shared pre-discharge prescription review programme has been activated with all doctors, so when the final lists of drug prescriptions are ready, the pharmacist examines them and suggests improvements or corrections to the doctor before the discharge letter is delivered to patients. Among the unintentional discrepancy observed, the most frequent were omissions of chronic therapy, lack of information about suspension for low molecular weight heparin or antibiotics.
What has been achieved?
A strong collaboration between physicians and clinical pharmacists has been achieved as we shared the results of this improvement. The same activity has been required and extended to the paediatric ward where the demand of simple, clear and complete information is even more crucial given the particular inter-individual variability and fragility of this population.
What next?
We would like to improve the prescription review programme also at admission in order to minimise drug omissions and at transition between different wards or different hospitals with the aim of improving communication between health care settings.