Author(s)

Cliona Hayden
David Lumsden
Aidan Morris
Darren Walsh

Why was it done?

Clinical pharmacy services are vital for medication safety and patient-centred care. However, in Ireland, the absence of a national strategy has led to inconsistent service delivery across hospitals. This initiative was undertaken to evaluate and improve the clinical pharmacy service in a Model 4 hospital, addressing structural, process, behavioural, and cultural challenges. The goal was to enhance service integration, reduce variability, and align with international standards such as the European Statements of Hospital Pharmacy.

What was done?

A quality improvement project was launched using patient journey mapping (PJM) to visualise medication-related touchpoints across the inpatient care pathway. The initiative aimed to identify service gaps and opportunities for improvement. Key interventions included stakeholder engagement, SWOT analysis, and the development of tools to support prioritisation, documentation, and training.

How was it done?

The PJM approach followed a six-step methodology, including problem definition, stakeholder consultation, and data analysis. Engagement activities involved structured interviews with pharmacy staff, consultations with nursing and medical teams, and completion of the HSE Workpositive survey. These inputs were synthesised to assess organisational health and identify barriers to effective service delivery. The analysis focused on the interaction between structure, processes, behaviours, and culture.

What has been achieved?

The initiative identified critical gaps in medication reconciliation, discharge planning, and interprofessional communication. Outcomes to date include the realignment of the clinical prioritisation tool, clearer MPAR endorsement guidance, and a tailored training framework to address role ambiguity and knowledge gaps. Positive behaviours such as pharmacist autonomy and peer support were reinforced, while structural and process inefficiencies were targeted for improvement.

What next?

Next steps include embedding standardised processes, implementing electronic prescribing, and evaluating the impact of these changes on patient outcomes. Further work will explore the role of advanced specialisation in clinical pharmacy and strengthen interprofessional collaboration. Leadership will focus on aligning structure and culture to support sustainable, patient-centred service improvement.

Author(s)

A. GHORBEL, C. KONN, J. CATROUX, J. TISSERAND, P. ROCANIERES

Why was it done?

Polypharmacy and multimorbidity make medication safety a major challenge in geriatric medicine. Medication reconciliation and review are essential but time-consuming processes that cannot be systematically performed for all patients. Prior, we made a systematic review of the French literature which identified multiple prioritization approaches – empirical, statistical, and consensus-based – but no harmonized tool. Common criteria included advanced age, polypharmacy, psychotropic use, high-risk medications, and chronic diseases such as heart failure. Then, we aimed to translate these findings into a pragmatic, locally adapted prioritization grid to improve targeting and workflow efficiency.

What was done?

An initiative was developed in the geriatric department of a French University Hospital to introduce prioritization criteria for medication review (MR) at admission. The aim was to optimize pharmacists’ clinical activity by identifying high-risk patients most likely to benefit from a MR, given the limited available resources.

How was it done?

A prospective, observational, comparative study was conducted over 13 months (early June 2024 – end June 2025) in neuro-geriatrics and onco-geriatrics. During the 8 last months, pharmacists applied a prioritization grid daily based on clinical and pharmacological criteria (≥ 5 medications, renal impairment, psychotropics, high-risk drugs). Indicators before and after its implementation were compared using a two-sample Z-test (α = 0.05).

What has been achieved?

After implementation, 295 admission and 48 discharge MR were performed (vs 272 and 31 before prioritization). The initiative allowed the targeted inclusion of patients with a mean age of 87 ± 6 years and an average of 10 ± 4 chronic medications. The most frequent prioritization criteria identified were renal impairment, use of “never-event” drugs (methotrexate, insulin, colchicine, oral chemotherapy and anticoagulant drugs), antibiotic therapy, electrolyte disorders, and diabetes. Average MR time rose (113 vs 105 min; 89 vs 47 min), reflecting higher case complexity.

What next?

Defining common prioritization criteria could support national recommendations and enable the development of digital tools integrated into hospital information systems to automatically identify high-priority patients. In the future, it is planned to use these results to create decision rules from artificial intelligence software: it could generate dynamic prioritization models based on real-time clinical, biological, and therapeutic data, embedded into dispensing software to improve patient safety and optimize pharmaceutical care.

Author(s)

S. FIRULESCU, T.F. VRABIE, M.A. MIHAI, C.D. ROTARESCU, S.R. DILIMOT, F. PETRUC, D.E. DRANCA, C. ANDREI, S. NEGRES.

Why was it done?

Infective endocarditis represents one of the most severe cardiovascular pathologies, with a mortality rate up to 30%, further complicated by rising antimicrobial resistance. The purpose of this study was to identify the most frequently encountered pathogens and to evaluate the influence of implantable cardiac devices or prosthetic heart valves. As clinical pharmacists, we also assessed treatment concordance with the European Guidelines for the management of endocarditis and hospital antibiotic policy.

What was done?

A retrospective analysis was conducted over the period January 2024-August 2025, by clinical pharmacists and residents of this specialty.

How was it done?

We evaluated patient records, focusing on the pharmacological treatment of infective endocarditis.

What has been achieved?

From a total of 104 hospitalized patients (67 males, 37 females), 66 patients were diagnosed with infective endocarditis as a primary diagnosis, while 38 patients had endocarditis as a secondary diagnosis. The patients were aged between 26 and 86 years, 60% of them being over 65 years old. Furthermore, the presence of implantable cardiac devices or valve prostheses represented a major risk factor, as it was also confirmed in this study (discovered at 55% of patients). The principal identified pathogens from blood cultures were Gram-positive cocci, such as Staphylococcus (67%) – mainly Staphylococcus aureus, both MSSA and MRSA (27%), Staphylococcus epidermidis (22%) – and Streptococcus (19%), mostly Streptococcus gallolyticus (7%). Other less common pathogens included Coxiella burnetii, Serratia marcescens, Enterococcus spp., and Stenotrophomonas maltophilia. The most commonly used antibiotics were: Vancomycin (56%), Ceftriaxone (53%), Ampicilin (42%) and Rifampicin (37%). In this study, antibiotics were used from all three AWaRe categories, as follows: 41% of patients received Access antibiotics, 41% Watch and 17% Reserve. Considering the used antibiotics and their posology, it could be estimated that in 65.4% cases, the recommendations of the current guidelines were strictly followed.

What next?

The evaluation of the guidelines concordance regarding the antimicrobial medication by clinical pharmacists as part of a multidisciplinary team is of the utmost importance for an optimized therapeutic management.

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Author(s)

Lærke Karner Overgaard, Daniel Pilsgaard Henriksen

Why was it done?

Multimorbidity and polypharmacy pose significant challenges for healthcare systems. In Denmark, general practitioners (GPs) play a crucial role in coordinating patient care but also rely on specialist support for complex cases. The aim of this intervention was to provide easily accessible multidisciplinary counseling on polypharmacy for GPs.

What was done?

A virtual polypharmacy outpatient clinic was developed to provide cross-sectional specialist counseling for GPs.

How was it done?

The intervention was developed through a multidisciplinary approach, involving specialists in clinical pharmacology, GPs, and healthcare planners. The service provides virtual consultations to GPs in the Region of Southern Denmark (1.2 million inhabitants), offering multidisciplinary specialist counseling for patients on five or more medications. The multidisciplinary team consists of clinical pharmacists, consultants in clinical pharmacology and consultants in geriatrics. The process includes referral, medication review, video conference, and follow-up.

What has been achieved?

The outpatient clinic received 376 referrals comprising 366 unique patients (median age 73 years, IQR 65-81; 61.2% female) over five years (March 2019 to February 2024). The median number of drugs per patient at referral was 17 (IQR 13-21). Referrals increased from a median of 3.5 (IQR 1-5) per month in 2019-2020 to a median of 9 (IQR 6-13) per month in 2023-2024. GPs from 21 of 22 municipalities in the Region of Southern Denmark referred patients. The median time from referral to video conference was 15 days (IQR 8-26). The three most common weekdays for video conferences were: Thursday: 96 referrals (25.5%), Monday: 71 referrals (18.9%), and Wednesday: 71 referrals (18.9%)
The service was well-received by patients and GPs and recognized by national health authorities as a valuable model for managing multimorbidity. The Telepharmacological outpatient clinic thus demonstrates a successful model for integrating specialist support into primary care management of polypharmacy.

What next?

The effects of the outpatient clinic on the health outcomes of referred patients will be evaluated in a scientific study. Future efforts will focus on sharing experiences with national and international stakeholders to further develop the intervention and inspire new research in rational pharmacotherapy.

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Author(s)

Steffy LEFAKOUONG, Mohamed MOSTEFA, Sarah BARBIEUX, Sophie VERNARDET, Isabelle LEFORT

Why was it done?

Institutional and multidisciplinary work has been carried out in the hospital since 2022 on reducing prescriptions of potentially inappropriate medications (PMIs) in older population (OP), in accordance with french recommandations.

What was done?

Our aim is to raise awareness among medical staff on the prescription of PMIs in OP through continuing education (CE) courses.

How was it done?

A PMI-specialized team composed of 2 geriatricians, 1 pharmacist and 1 pharmacy intern was formed.
CE is planned in the form of a structured medication review describing clinical cases based on discharge prescriptions of hospitalized patients, selected according to several criterias: >75 years old, ≥1 PMI on the prescription.
These prescriptions are analyzed by the specialized team using various reference documents, with a relevance audit grid provided by the regional drug authority as a basis.
The first MR was presented to the doctors and residents of the establishment’s various departments during a joint session.
A satisfaction survey was created to assess the interest and relevance of the course.

What has been achieved?

For our first session, we selected 3 prescriptions : two containing 4 PMIs each and one containing 2 PMIs.
A detail of each PMI was carried out with a focus on two main themes : deprescribing long-acting benzodiazepines and proton pump inhibitors.
Besides PMIs, a comprehensive prescription analysis was done by mentioning inadequate prescriptions from a geriatric medical view.
In total, we have a participation of 100% of the pharmacists, 89% of the geriatricians and 100% of pharmacy residents. Among the other departments, only 3 other physicians participated in the course.
According to the survey, 100% of participants said they were satisfied with the session and 44% wanted more interactive training.

What next?

The high participation of pharmacists and geriatricians, 2 teams of interest in the process of deprescribing MPIs, highlights the usefulness of this CE among healthcare professionals.
The structure of the session encourages constructive and collaborative exchanges while comparing visions of different professionals.
Nonetheless, a reflection on our approach’s appeal is necessary in order to increase the participation rate of physicians and medical residents absent during the session.
The satisfaction rate remains encouraging, and pushes us to renew this training periodically.

Author(s)

Ana Helena Ulbrich, Amanda Fonseca, Catherine Isoppo, Henrique Dias

Why was it done?

The motivation behind NoHarm stemmed from the time-consuming nature of the prescription review process, which required clinical pharmacists to assess not only drug interactions but also factors such as appropriateness, effectiveness, safety, adherence, and affordability of drug therapies. NoHarm was envisioned as a solution to systematize the workflow and provide cross-referencing of essential drug and inpatient information, thereby addressing these issues.

What was done?

The NoHarm initiative was developed to address challenges faced by clinical pharmacy teams during the prescription review process in a hospital setting. This open-source intelligent system was introduced to enhance the medication review process. The initiative was executed in a 420-bed public hospital in Brazil over a 17-month period to evaluate its impact on prescription reviews.

How was it done?

The implementation of NoHarm involved integrating the system with the hospital’s electronic health records to collect and compute all inpatient data. NoHarm utilized a drug knowledge base and intelligent algorithms to identify and alert healthcare professionals about inpatient risks. The algorithms were designed to cross-reference patient laboratory results with drug thresholds, adjust for liver and renal function, analyze drug usage patterns at the hospital, and extract patient risk factors from clinical notes, including diseases, adverse events, symptoms, and biometric data.

What has been achieved?

The number of medications assessed increased dramatically from 17,000 to 2,643,957 within the 17-month period, all while maintaining the same team size. Improved prescription review rates, rising from 65% to 94%, demonstrate the effectiveness of the system. Furthermore, these improvements in prescription reviews resulted in better clinical pharmacy services and contributed to reducing medication errors and associated risks in patient care at the hospital.

What next?

NoHarm is an open-source solution and an example of good practice in healthcare due to its achievements in streamlining prescription reviews and enhancing patient safety. Its successful implementation led to increased efficiency, higher prescription review rates, and substantial cost savings, showing its potential as a model for other healthcare settings. Its prospective global applicability makes it a solution to address medication errors and elevate the standard of care in healthcare institutions worldwide.

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Author(s)

MARCELO DOMINGUEZ CANTERO, CARMEN MARIA DOMINGUEZ SANTANA, MARCELINO MORA CORTES, ESMERALDA RIOS SANCHEZ, JUAN MANUEL BORRERO RUBIO

Why was it done?

Patients who withdraw medication from outpatient pharmacies in Spanish hospitals are provided with pharmaceutical care and pharmaceutical care stratification tools in specific outpatient pharmacy consultations. These patients are usually multi-pathological with multiple drug interactions, contraindications, and important adverse effects. Therefore, during the hospital admission of these outpatients, it was appropriate to provide continuous care from the hospital pharmacy. Before the implementation of the protocol, there was no specific and systematic follow-up of hospitalized outpatients.

What was done?

Implementation of a protocol that provides pharmaceutical care to outpatients during hospitalization, ensuring continuity of care through the pharmacy service.

How was it done?

The main problem with the implementation was the real-time detection of hospitalized outpatients. The development of a software tool to facilitate the location of patients provided an impetus for the implementation of the project. The computer tool selected patients who met the inclusion criteria (hospitalized outpatients with medication withdrawal in the outpatient unit in the last two months). Patients treated with erythropoietin and colony stimulants were excluded.

What has been achieved?

Seventy-nine patients were included in the study between April and September 2023; 62.1% were male. Main pathologies included 41.9% oncohaematologic diseases, 18.9% human immunodeficiency virus, and 17.7% immune-mediated inflammatory diseases.
The reason for admission was related to the pathology for which outpatient medication was withdrawn in 27 patients (34.2%), and six patients (7.6 %) were admitted due to an AE of the medication withdrawn in outpatients. Pharmaceutical interventions (PI) were performed in 21.5% of the patients reviewed, and 76.5% were accepted. PI reasons included discontinuation of treatment (64.7 %), modification (17.7 %), initiation (11.8 %) and monitoring (5.9 %).

What next?

With our protocol, we want to show that outpatients within the pool of patients admitted to a hospital are a priority target group. For these patients, the hospital pharmacist can improve treatment during hospitalization with a high degree of pharmaceutical intervention.

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Author(s)

Daniele Mengato, Laura Camuffo, Anna Zanin, Fernando Baratiri, Barbara Roverato, Franca Benini, Francesca Venturini

Why was it done?

PPC patients are children with chronic or terminal illnesses requiring a high intensity of care. Because of their criticality, a strict clinical monitoring is needed, as well as personalised therapeutic strategies.

What was done?

The paediatric palliative care (PPC) unit aims to provide paediatric patients with the best possible care in the management of their disease to ensure the optimal quality of life. The pharmacist has joined the interdisciplinary team with the aim of improving drug management in both acute inpatient and chronic therapies.

How was it done?

From August 2021, the clinical pharmacist joined the PPC staff with the aim of improving medicine management. The pharmacist, primarily, took charge of the medication review process. Individual therapies were periodically reviewed by the multidisciplinary team on the basis of admissions and clinical changes. In addition, a formulary manual for healthcare professionals was drafted, with the description of the crushability of the most commonly used pharmaceutical forms in clinical practice by collecting and keeping up-to-date information from national and international handbooks.

What has been achieved?

Over the past eight months, initial drug reviews have been carried out for all 169 patients followed by the PPC unit, with collegial re-evaluations cyclically carried out for the most critical patients (15). These patients had at least 10 drugs to take each day and therefore assessments were made to simplify treatment regimens by providing 37 suggestions to physicians with the aim of reducing the risk of interactions and facilitating home therapy management. With regard to the handling of pharmaceutical forms, many galenic formulations have been proposed in order to reduce the crushing of solid forms as much as possible. Most of the suggestions were discussed and accepted by the medical team.

What next?

Clinical pharmacist’s intervention is crucial in the management of terminal or chronic therapies for critically ill patients. Next step will be the analysis of caregivers’ care burden, through a specific questionnaire that has already been validated, so as to improve the home management of this particular category of patients.

Author(s)

Alina Shramko, Veronika Haziahmetova

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

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Author(s)

Pernille Printzlau, Nanna Skyttegaard Mortensen, Signe Kristensen, Troels Bygum Knudsen, Nathalie King Otoo

Why was it done?

When the pharmacists make medication reviews it is often a long, detailed review with several interventions. A tool that would quickly give the physician an overview of the interventions suggested by the pharmacist was needed. Furthermore, a tool was needed in the process of shared decision making between the physician and the patient regarding the possibilities of deprescribing.

What was done?

We made a tool to improve the interdisciplinary collaboration around medication reviews and to help the process of shared decision making. The tool categorises interventions suggested by the pharmacist in red-yellow-green boxes, indicating the order of the interventions recommended by the pharmacist.

How was it done?

The tool was developed and tested by using the Model of Improvement. The physician stated that the tool gave him the needed overview and, in his experience, furthermore added value by visualising the interventions to the patient. Patients were interviewed after the consultation to evaluate how they perceived the tool and whether they felt involved in the decision making regarding their treatment and deprescribing.

What has been achieved?

A manageable and operationalisable tool for the physician to get a quick overview of the interventions suggested by the pharmacist. Furthermore, the tool visualises the interventions to the patient and supports the process of shared decision making during the consultation.

What next?

At our hospital we have clinical pharmacists making medication reviews at several different wards. The next step is to distribute the tool to pharmacists at other wards to strengthen the interdisciplinary collaboration and ensure the largest profit of the pharmacist’s medication reviews. We are also working on developing a similar tool to categorise found side effects to help the physician when deprescribing.