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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.

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Author(s)

S Hurel, H Benoist, N Guesdon, S Niemczyk, A-P Gaumon, A Perdriel, E Labbe
Hospital Center of Falaise, Falaise, FRANCE
sylvelie.hurel@orange.fr

Why was it done?

Implementation of a local cooperation protocol (LCP) to enable pharmacists to renew and adapt prescriptions within the hospital.

What was done?

In France, a decree published in February 2023 allows pharmacists working in hospital pharmacies to renew and adapt therapies (RAT) in a concerted manner (RATC) or directly (RATD). Previously, pharmacists could not intervene directly in prescriptions, but could only recommend changes to the prescriber, which were often time-consuming and never made. The aim of setting up this protocol was to improve patient care and optimise pharmacist and medical time.

How was it done?

The LCP was implemented on 8 July 2024 in a 600-bed hospital on three long-term geriatric test units (100 beds) following validation by the hospital medical committee in June 2024. A prospective study was carried out over three months on seven indicators: number of patients included, RATCs, RATDs, physician acceptance rates, adverse event (AE) and serious AE rates, and pharmacist and physician satisfaction rates. The indicators were collected in real time using a dynamic cross-tabulated Excel table, and satisfaction was assessed using a survey comprising five multiple-choice questions.

What has been achieved?

The number of patients included over the three months implementation period was 58. A total of 153 RATs were performed, including 53.6% (n=82) RATDs and 46.4% (n=71) RATCs. The main interventions concerned drugs prescribed but not referenced in hospital (n=38), inappropriate treatment durations (n=23) and supra-therapeutic dosages (n=18). The acceptance rate by doctors was 100% (n=153). There were no AEs or serious AEs reported. The satisfaction rate of doctors (n=3) and pharmacists (n=2) showed an overall satisfaction rate of 100% (n=5).

What next?

This three-month feedback showed that healthcare professionals were completely satisfied with the service provided by this LCP and the indicators have proved that this protocol can be applied safely. Thanks to this results, the LCP will therefore be continued in the three test units before being rolled out to other departments. Implementing this LCP in departments such as surgery will make it possible to secure prescriptions in a partnership between doctors and pharmacists.

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Author(s)

V. Mureddu, G. Ledda, G. Adamu, M. Rivano, A. Cadeddu. Hospital Pharmacy Department, Azienda Ospedaliero Universitaria, Cagliari.

Why was it done?

Mifepristone and misoprostol are provided for Voluntary Pregnancy Interruption (VPI) and Spontaneous Miscarriage (SM) according to different reimbursement schemes, based on different gestational age. According to Summary of Product Characteristics (SPC), the use of mifepristone and misoprostol is approved only within the first 63 days of pregnancy. Recently, access to treatment for VPI and SM has been extended by the Italian Medicines Agency by the I trimester of pregnancy. VPI within the first 49 days of gestation, the use of mifepristone and misoprostol is authorized according to SPCs. From 50th to 63th days is guaranteed under the law 649/96, that allows and reimburses the use of medicines for off-label indications. From 63th to 90th is considered an off-label prescription. Regarding SM, mifepristone and misoprostol can be used within the I trimester under the law 648/96. All these different reimbursement schemes are used as part of the Italian pricing-reimbursement system.

What was done?

To ensure appropriateness, a specific prescription form has been drafted to support clinicians in prescribing according to the correct reimbursement scheme gestational age, therapeutic indication and dosage must be reported in the prescription form.

How was it done?

The development of the prescription form required a deep knowledge of both the law under which the right of abortion is guaranteed and Italian reimbursement schemes. The prescription form was introduced in October 2022.
Prescriptions of all pharmacological treatments are ordinarily made through electronic software; therefore the prescription form was uploaded. Prescriptions from 01/01/2024 to 30/06/2024 were collected and retrospectively analyzed.

What has been achieved?

Prescription forms analysis showed that a total of 83 women were treated. In 53 cases the treatment was used for VPI and in 30 for SM. In 27% of cases, prescriptions were considered as per in-label. In 66% cases, prescriptions were allowed according to Law 648/96. In 7% of cases, prescriptions were off-label.

What next?

According to the development of reimbursement schemes, the prescription form will be implemented. Italy provides universal coverage for all citizens and residents; keeping it sustainable is one of the hardest challenges of these day. The contribution of hospital pharmacists in monitoring prescriptions has a pivotal role in making equal access to these treatments.

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Author(s)

Margot DESCHAMPS, Nejib BORGAAOUI, Jimmy ROSE, Jennifer LE GRAND, Louise NICOLAS

Why was it done?

One of the clinical pharmacy activities in the thoracic oncology department is the analysis the interactions between chemotherapy and Complementary and Alternative Medicine (CAM). Cancer patients often seek alternative treatments which requires a rigorous evaluation of potential interactions. The goal of this study is to assess the methods used to analyze these interactions.

What was done?

To ensure traceability of the analysis, a tracking table for requests was created. The requests, coming from doctors, nurses, or patients, are recorded with key information such as name, date of birth, and the purpose of the analysis. Five information sources were selected, including the Herbal Medicine section of MedlinePlus, the website of the Memorial Sloan Kettering Cancer Center (MSKCC), a database of plants and dietary supplements published by the French National Agency for Food, Environmental and Occupational Health Safety, a database from the European Scientific Cooperative on Phytotherapy, and a publication from the journal Medical Oncology (Vol 36, number 45, 2019).

How was it done?

In nine months, 25 interaction requests were processed, 70% of which were from doctors. The analysis took an average of 30 minutes and were completed within 24 to 48 hours. The interactions mainly concerned oral chemotherapies (n=18), particularly Osimertinib (n=13). The requests involved various CAM (essential oils, medicinal plants, dietary supplements), with an average of four products per request. Desmodium was the most frequently analyzed product (n=5). In total, for 24 CAM, including Desmodium, was not recommended for use after analysis due the drug interaction risk and modification of liver metabolism of chemotherapies.

What has been achieved?

It is difficult to prohibit CAM to patients, and most substances can be taken at recommended doses. However, determining the precise dosage at which an interaction with chemotherapy occurs is complex due to the lack of a single reference. Using various sources allows for cross-referencing expertise and obtaining complementary information. For instance, MedlinePlus offers a generalist approach, while MSKCC focuses on interactions in oncology. Using international sources broadens the analysis and fills geographical or cultural gaps.

What next?

For the future, we would like to develop a tool that compiles the five data sources in order to be exhaustive in our future analysis.

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Author(s)

VC Lamprecht, J Pont, SD Brugger, M Dunic, T Stutz, AR Burch

Why was it done?

The preparation of parenteral medication on wards pose a hygienic challenge. It is however imperative that parenteral solutions remain aseptic, as they evade the primary barrier of the human immune defense.
The bioburden of non-preserved parenteral medications after manipulation depends on the setting. Therefore, manufacturers cannot provide guidelines on microbial stability after manipulation and hence limit the retention period to immediate use.
National recommendations concerning this issue range from cautious to restrictive, but often allow exceptions e.g. for emergency medication. These recommendations, are difficult to implement universally due to the non-transferable framework conditions from one hospital to another.

What was done?

A practical framework for the determination of retention time of manipulated parenteral medication was developed, as economic and ecological perspectives stand in contrast to the hygienic ideal.

How was it done?

International recommendations were sighted. Recommendations of the German Commission for Hospital Hygiene and Infection Prevention (KRINKO), as well as the American Society of Anesthesiologists (ASA) and The Society for Healthcare Epidemiology of America (SHEA) were used as references, as well stated sources.

What has been achieved?

Key points were identified to create a directory that enables clinical professionals to use standardized cornerstones while adapting to their individual clinical setting.
The following are indicators for the retention period in which the parenteral medication may be used: (1) primary packaging; (2) type of manipulation; (3) physicochemical properties and (4) storage temperature.

What next?

A collaboration with the Department of Infectious Diseases and Hospital Epidemiology of the University Hospital of Zurich was established to record the hospital specific conditions and to subsequently adapt the clinical practice as well as evaluate cost-effectiveness and patient safety.
Further collaborations with Swiss hospitals are being sought.

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Author(s)

Laura Camuffo (1), Daniele Mengato (1), Monica Bettio (1), Francesca Venturini (1)
1) Hospital Pharmacy Department, Padua University Hospital

Why was it done?

A pre-admission clinical pharmacy service for best possible medication history (BPMH) collection was developed and implemented at an Italian university hospital for selected surgery patients.

What was done?

In the surgery setting, studies have shown that pre-admission medication histories are more accurate when collected by pharmacists compared to other usual standards of care [1]. At Padua University Hospital, promising results were obtained performing an observational study in which pharmacist-led BPMHs were collected for patients admitted to the pre-admission outpatient clinic of a General Surgery Department [2]; a pre-admission clinical pharmacy service, however, had yet to be implemented and officially recognized.

How was it done?

The following steps were considered for service implementation: 1) Patient’s selection: patients undergoing major elective surgery, with polytherapy (5 or more concomitant drug) or taking relevant perioperative medications (eg. anticoagulants, antiplatelets) were selected as target patients; 2) Standardization of BPMH collection: a standardized interview with the patient (or caregiver) was carried out in order to collect BPMHs; all pharmacists involved underwent specific training; 3) Definition of setting and timing for BPMH collection: the interview was conducted by phone call a few days before patient’s surgical pre-admission visits; 3) Reporting of BPMH: all collected BPMHs were directly inserted by the pharmacists in the patient’s electronic health record (EHR).

What has been achieved?

In January 2023 the pre-admission clinical pharmacy service was implemented for three main surgery departments. During 2023, 772 patients undergoing major elective surgery were interviewed and a total of 791 pre-admission BPMHs were collected. Patients’ median age was 72 years old (IQR: 65, 80) and median number of concomitant medications was 7 (IQR: 4, 10). 230 patients (29.08%) underwent general surgery, 478 (60.43%) underwent urologic surgery, 77 patients (9.73%) underwent orthopedic surgery and 6 (0.76%) underwent another type of major surgery. All BPMHs were inserted by the pharmacists in the patient’s EHRs.

What next?

The next objectives of the service will be to offer a complete patient’s pre-admission pharmaceutical assessment, also conducting, in addition to BPMH collection: pre-admission medication reconciliation, drug discontinuation, bridging, replacement and deprescribing [3].

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Author(s)

Ranz Ortega P; Martín Barbero ML; Escudero Vilaplana V; Lobato Matilla E; Carrillo Burdallo A; Del Barrio Buesa S; Herranz Alonso A; Sanjurjo Sáez M.

Why was it done?

The EXPREM project aimed to enhance the patient experience for individuals with Multiple Sclerosis (MS) undergoing pharmacotherapeutic follow-up at our hospital.The project involved designing a Patient Journey Map,conducting patient interviews at key touchpoints,and identifying strategies to improve service quality and patient satisfaction.

What was done?

Due to the chronic and complex nature of MS,patients often fase challenges throughout their healthcare journey.The fluctuating symptoms and long-term treatment regimens require frequent interactions with healthcare providers,making the patient experience a critical component of disease management.This project aimed to identify gaps in pharmaceutical care,improve service efficiency,and create a more patient-centered healthcare environment.

How was it done?

The project was conducted in five phases from January-April 2024:
1.Defining the pharmaceutical care process:a detailed map was designed to outline the pharmaceutical care process,including:before arriving at the pharmacy service(PS), patient visit and post-visit
2.Patient Interviews:three MS patients receiving treatment—one newly diagnosed,one with stable chronic treatment,and one with a recent medication change—were interviewed by a pharmacist in semi-structured,open-ended conversations to capture their perceptions and experiences with the Pharmacy Service
3.Direct Observation(SAFARI Method):the pharmacist working group simulated the patient experience to understand what patient hear,see and feel during their journey, identifying areas for improvement in the facility
4.Designing the Patient Journey Map:information from interviews and observations was used to create the Patient Journey Map,highlighting key areas for enhancement
5.Proposals for Improvement:based on the findings,specific actions were proposed to improve the patient experience

What has been achieved?

The project identified areas for improvement, such as:
Before arriving at PS
•The need for a digital appointment management system to reduce waiting times and and improve medication dispensing efficiency.
•Improvements in the physical infrastructure ensuring privacy,better signage,accessible facilities and developing health education programs,such as audiovisual health material for waiting times.
Patient visit and follow-up
•Expanding the use of health apps,videoconsultation to improve real-time communication and ensure the efficacy and safety of medication at home
•Home medication dispensing to save time and reduce costs for patients

What next?

The methodology will be shared with other pharmacy services for broader implementation and the impact of these improvements on patient satisfaction and health outcomes will be systematically evaluated

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Author(s)

Lucie Malečová, Daniela Seberová, Blanka Zelená, Markéta Hanulíková, Kornélia Chrapková, Stanislav Gregor, Michal Hojný

Why was it done?

Adherence to immunosuppressive medication is crucial for long-term graft survival. Patients receive substantial information from various healthcare professionals regarding new medications and lifestyle choices during hospitalisation and post-discharge. Frequent non-adherence indicated that the existing educational approach led by physicians was insufficient. Our objective was to create optimal conditions for providing these instructions to patients before discharge.

What was done?

In collaboration with the cardiology department, hospital pharmacists created and implemented a new educational project to improve adherence among heart transplant patients. The main activity involves hospital pharmacists conducting educational visits at the patient’s bedside, supported by new educational brochures, materials, and questionnaires.

How was it done?

We created a questionnaire and collected baseline data by assessing the knowledge of transplant patients educated by the existing educational approach. Afterwards, we designed and implemented a six-visit educational program and prepared new educational materials and brochures. A new record system was integrated into the hospital information system to facilitate communication between doctors and pharmacists, documenting educational visits and questionnaire results. The initial three visits, scheduled during hospitalisation, cover the correct use of immunosuppressants and other medications, their interactions, and potential adverse effects. Guidance on recommended lifestyle changes post-transplantation, such as hygiene, diet, and infection prevention, is also included. The remaining three visits occur within one year post-discharge to assess patient knowledge with the previously mentioned questionnaire and adherence to the treatment plan with BAASIS©. During these visits, the pharmacist conducts a comprehensive review of adherence, addresses any drug-related issues, and guides medication changes.

What has been achieved?

Since the project’s initiation, 120 visits have been completed, involving more than 30 patients. The education significantly improved patient knowledge, with educated patients scoring an average of 94% correct answers on the knowledge questionnaire compared to 59% correct answers of patients educated by the existing educational approach. Only three educated patients were non-adherent, with the most common type of non-adherence being failure to take medication at the prescribed time.

What next?

As more patients participate in the project, we aim to correlate their knowledge and adherence with tacrolimus levels and the incidence of rejection. Additionally, we intend to extend this educational initiative to other departments within the hospital.

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Author(s)

Tea Stiplošek, Alenka Kovačič

Why was it done?

The growing misuse of antimicrobials, resulting in resistant microorganisms and more adverse reactions, has been identified as a significant concern. To tackle this issue, a system was put in place to systematically monitor the hospital’s dispensing and use of reserve antimicrobials.

What was done?

We established a system where each reserve antimicrobial prescription in the hospital is reviewed by a pharmacist, who decides whether to dispense the drug or suggest therapy adjustments. The dispensation of antimicrobial drug to the patient is then recorded in the patient’s medical documentation.

How was it done?

A special prescription form has been prepared, used exclusively for ordering reserve antimicrobials from the pharmacy in our hospital, separate from other medications. The form is reviewed by a pharmacist, who calculates the patient’s creatinine clearance, examines inflammatory markers, checks the alignment of treatment with the antibiogram, and reviews potential interactions with other therapies before deciding whether to dispense the drug. If necessary, the pharmacist suggests modifications to the antimicrobial treatment. Each time the antimicrobial is dispensed, it is recorded in the patient’s medical documentation for easier treatment tracking.

What has been achieved?

This approach has established systematic control over the prescription of reserve antimicrobial drugs, with a clinical pharmacist introducing an additional prescription checkpoint. Analysis of data from our work between 2020 and 2023 shows that during this period, we dispensed 16,464 courses of reserve antimicrobials, with pharmacists recommending therapy adjustments in 2,211 cases (13.6%). On average, we recommended dose reductions in 43.5% of cases due to impaired kidney function and dose increases in 23.5% due to improved kidney function or the need for appropriate dosing for specific indications. Pharmacokinetic monitoring (TDM) interventions, including those for vancomycin, amikacin, and gentamicin, accounted for 29.75% of the interventions, while 3.35% of our recommendations involved therapy changes due to inappropriate treatment based on antibiograms or the patient’s impaired kidney function.

What next?

We are digitizing the ordering system, allowing departments to request antimicrobial drugs directly through the hospital information system. We are also developing an application to calculate kidney function and verify the correct antibiotic dosage for each patient, all in one place.

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Author(s)

E. Volpi (1), F. Panizzi (2), B. Mastrelli (2), G. Lo Surdo (1), S. Tonazzini (1), S. Alduini (1), M. Mangione (3), S. Baratta (4), M. Baroni (5), S. Biagini (1)
1. Hospital Pharmacy, Ospedale del Cuore, Fondazione Toscana Gabriele Monasterio
2. Postgraduate School of Hospital Pharmacy, University of Pisa
3. Information systems and information technologies, Fondazione Toscana Gabriele Monasterio
4. Nursing, Technical and Rehabilitation Service, Fondazione Toscana Gabriele Monasterio;
5. Clinical Risk Manager, Fondazione Toscana Gabriele Monasterio

Why was it done?

Medication safety practices are a cornerstone for reducing medication errors and patient harm.
Hospital pharmacist has been recognized as one of main healthcare providers that can support the physicians and the nurses in this item.
The computerized labeling of multidose medicines when they were opened is a good practice for safe medication use which is performed from the Fondazione Toscana G. Monsaterio (Italy) since 2022.

What was done?

The routine control activity of the department’s drug stocks includes the verification of drugs expiration date and the timely removal of drugs before they have expired their validity.
In the case of opened multidose medicines, this operation is more complex as their validity is often reduced.
Our aim was to provide to all healthcare professionals a quick and safe computerized labeling tool, which is constantly updated by the pharmacist based on availability of drugs in the hospital wards.

How was it done?

A multidisciplinary team (pharmacist, nurse and computer scientist) developed a multidose drug labeling system linked to the patient’s medical record which allows the generation of a label every time a prescription for a multidose drug is presented, before patient administration. The team discussed the content of the label and selected the categories of drugs that needs to be included.

What has been achieved?

The categories of drugs included in our program are syrups, oral suspensions, ophthalmological and otological preparations and oral drops. We used a computerized program to fill the information about the validity after opening such as days and storage temperature and indicating the source of the information.
The new system allows to easily check the validity after opening for all multidose drugs, before administration to the patient. This implementation not only guarantees patient safety, but also offers support to all nurses or physicians for any subsequent administration of the same drug and simplifies deadline checking operations of the department’s drug stocks.

What next?

We will continue to keep the labeling program updated by including new drugs available in our hospital. We would like that the information on post-opening shelf life was always included in drug SmPCs and that the good practice of computerized labeling was diffused also in other hospital settings.