Author(s)

Lisa Wimmer, Beata Laszloffy, Tamara Clodi-Seitz, Doris Haider

Why was it done?

Antibiotic resistance poses a serious threat to global health, and Austria’s National Action Plan on Antibiotic Resistance (NAP-AMR) highlights the urgency of robust antibiotic stewardship, especially with the 2024 implementation of new antimicrobial quality standards. In response, a 700-bed hospital in Vienna has launched an ambitious initiative, forming a dedicated Antibiotic Stewardship (ABS) team. This interdisciplinary collaboration between physicians and clinical pharmacists is designed to revolutionize antibiotic use, curb resistance, and elevate patient care standards starting in the ICU and associated surgical units.

What was done?

The ABS team took decisive action by targeting one intensive care unit (ICU) and two surgical wards (64 beds in total) for weekly screenings. Infectious disease specialists and clinical pharmacists worked hand-in-hand, meticulously reviewing every patient’s case. This dynamic collaboration ensured not only the highest level of medication safety but also the relentless optimization of antibiotic use, pushing boundaries to meet and exceed best-practice standards.

How was it done?

The ICU and surgical wards—hotspots for antibiotic overuse—were strategically chosen for weekly reviews. In these high-risk areas, an interdisciplinary collaboration of physicians and clinical pharmacists joined forces, taking swift action to assess and fine-tune prescriptions. Pharmacists played a hands-on role, actively reviewing antibiotics and other medications, making recommendations, adjusting dosages, and halting unnecessary treatments. This collaboration was crucial in driving evidence-based decisions that directly elevated patient care to new heights.

What has been achieved?

After just four months, the project has already made significant strides, affecting a substantial number of patients. The majority of interventions have centered on refining antibiotic use, while additional recommendations on other medications have strengthened overall treatment safety. This close collaboration between physicians and pharmacists has directly improved adherence to national guidelines and sharpened prescribing practices.

What next?

Building on early successes, the ABS team will expand screening to additional departments, establishing a pivotal role for clinical pharmacists. This initiative serves as a model for other hospitals, demonstrating that significant improvements in antibiotic stewardship are possible, even with limited resources. The key takeaway: small steps can drive substantial gains in patient care and antibiotic use. As the program progresses, measurable effects on resistance patterns and antibiotic consumption are anticipated.

Pdf

Author(s)

Julen Montoya Matellanes, María Sánchez Argáiz, Pablo González Moreno, Sister Jacinta Wajinku, Ana Soler-Rodenas, Luis Ortega Valín, David Roca Biosca

Why was it done?

The goal of this initiative was to address the challenges faced in medicine management at the hospital, including low adherence to the HDF and the presence of numerous medicines not listed in the guideline. These issues hindered effective treatment options for patients and highlighted the need to improve compliance with national guidelines.

What was done?

We conducted a comprehensive review of the hospital drug formulary (HDF) in a rural Ugandan hospital to optimize pharmacotherapy and improve local access to essential medicines. This initiative involved assessing adherence levels to the HDF, identifying therapeutic needs, and evaluating drug availability.

How was it done?

A mixed-methods approach was used, combining qualitative and quantitative data. We compared the medicines available in the storage facilities s with those listed in the current HDF (published in 2016). Key indicators, such as adherence to the HDF and the number of available medicines not included in the guideline, were calculated. In addition, interviews with the responsible pharmacist provided insights into the causes of medicine shortages. We also compared the HDF with the 2023 Uganda Clinical Guidelines and the Essential Medicines and Health Supplies List for Uganda to identify therapeutic gaps.

What has been achieved?

The review revealed that out of 234 medications listed in the HDF, only 127 (54%) were available at the hospital pharmacy, while 107 (46%) were unavailable or out of stock. Adherence to the HDF was 63%, and 164 available medications were not included in the guideline. Ninety-nine potential therapeutic gaps were identified and it was highlighted that the main reasons for drug shortages included discontinuation of compounded drugs preparation and expiry of medicines due to low usage. This initiative provided a clear picture of the severity and causes of the issues related to access to medications.

What next?

To address these challenges, we recommend implementing staff training in medication management, systematizing stock and ordering processes, updating the HDF based on clinical and economic criteria, and reactivating the magistral formulation laboratory. With these measures we aim to improve medication availability and ensure better patient outcomes in this rural hospital. Additionally, the method employed can be standardized as a valid approach to assess drug availability in any hospital, with particular relevance in low-resource countries facing economic challenges and lacking electronic inventory control systems.

Pdf

Author(s)

Arnela Boskovic
Gitte Stampe Hansen

Why was it done?

To ensure rational use of medicines during the acute phase of illness, an interdisciplinary group consisting of physicians, nurses, pharmacists, and the Hospital Pharmacy was initiated to determine if some medicines could be paused during shorter hospital admissions at The Medical Acute Care Unit, Bispebjerg Hospital.

What was done?

Patients in acute phase of illness may experience fatigue, nausea, swallowing difficulties, and cognitive challenges when faced with large amounts of oral medicine. Therefore, prioritizing life-critical medicines during hospitalization is essential, while non-critical medicines could temporarily be paused. Additionally, there is often medicine waste, where drugs are assumed to be administered but remain untouched on the bedside table. In acute care units with complex patients, optimizing nursing time, shelf space in the medicine room and managing costs is crucial for appropriate medication.

How was it done?

Information about the new practice was given via newsletters, oral presentations, and signs at the doctor offices and in the medicine room. The group identified statins, multivitamins and calcium supplements as non-critical, and these were hereafter removed from the shelves in the medicine room. The interdisciplinary division of roles were as follows; Physicians: Prescribe critical medicine and temporarily pause non-critical medicine; Nurses: Do not administer statins, multivitamins, or calcium supplements. If the prescription has not been paused, request the physician to do so; Pharmacists: Assist in pausing non-critical medicines; Hospital Pharmacy: Ensure availability of the correct medicine in the medicine room.

What has been achieved?

Temporarily pausing statins, multivitamins, and calcium supplements during short hospitalization led to minimizing medicine waste and freed up time for the nurses to do other nurse-specific tasks. Medicine administrations by nurses were reduced by 87-96%. It also resulted in optimized space in the medicine room, making space for more critical medicine such as medicines to treat epilepsy and Parkinson’s disease.

What next?

Expanding the list of non-critical medicine during short hospitalizations is in the pipeline. This will be done by interdisciplinary collaboration and will free up time for the nurses and doctors to focus on the acute care of the patient.

Pdf

Author(s)

Jose Luis Sánchez Serrano, Ana Valladolid Walsh, Andrea Drodz Vergara, Carolina Andrés Fernández, Laura Navarro Casado

Why was it done?

Due to a reorganization of health professionals in our hospital, we identified an opportunity to include in our clinical services the preparation of pharmacokinetic reports for all drugs for which blood levels were carried out both at the hospital and external laboratories.

What was done?

We have implemented a multidisciplinary pharmacokinetic-pharmacogenetic unit with the Laboratory Department in our hospital. Until the end of 2023 we participated in the preparation of pharmacokinetic reports for a limited number of drugs in inpatients, basically in haematological and critical patientes. After this, we have included this clinical service for all drugs for which levels were carried out at the hospitalization and outpatient level.

How was it done?

The first step was to present a joint project to the hospital management to reorganize this activity and meet with medical departments to identify their needs and areas of improvement.
At the same time we acquired and implemented a specific software to assist us with the elaboration of recommendations.
We included training sessions in pharmacokinetics for pharmacists in the Pharmacy Department´s annual training program, in addition to offering an external course on Pharmacogenetics Course for staff pharmacists.
As to the clinical services offered, the project has gone through two stages:
• First stage (1 month duration): We reviewed all requests for drug levels obtained both from hospital and primary care level.
• Second stage (10 months duration): The pharmacist monitors all drug serum levels of narrow therapeutic margin and monoclonal antibodies both at the hospitalization and outpatient level. We have updated the available catalogue of drug serum concentrations tests in our center including Voriconazole, Linezolid, Ustekinumab, Adalimumab and Infliximab.

What has been achieved?

We have improved the whole process from ordering tests to sample extraction, serum level determination, and making recommendations in both inpatients and outpatients.
An average of about 160 pharmaceutical interventions per month are done with a 95% acceptability.

What next?

Our future objectives include updating the available pharmacogenetic testing in this unit in order to include recommendations based on test results.

Pdf

Author(s)

Francesca Baldi (1), Irene Bosoni (1), Sofia Filippini (1), Annamaria Valcavi (1), Gradellini Federica (1)
Alessia Rondini (3), Monica Salsi (3), Silvia Tanzi (2), Sara Alquati (2), Corrado Bacchi (3)
1. Pharmacy Department, Azienda USL-IRCCS, Reggio Emilia, Italy.
2. Palliative Care Unit, Azienda USL-IRCCS, Reggio Emilia, Italy.
3. Hospice Unit, Azienda USL-IRCCS, Reggio Emilia, Italy.

Why was it done?

Palliative care (PC) involves a network of hospitals and healthcare facilities supported by teams of nurses, specialists, general practitioners, and pharmacists. Off-label drugs are used to manage symptoms that do not respond to standard therapies, as permitted by law when no alternatives are available and under medical supervision. The National Health Service reimburses these drugs, but their use requires authorization based on proven safety and efficacy, potentially limiting patient access. Identifying essential drugs for symptom management is crucial to ensure a good quality of life.

What was done?

The AUSL of Reggio Emilia – IRCCS developed the “Local formulary of Palliative Care in Adult Patients” to support pharmacological management in PC. This formulary outlines key symptoms and provides evidence-based pharmacological options derived from scientific literature and clinical guidelines.

How was it done?

A multidisciplinary team of pharmacists, palliative care specialists, and nurses developed the formulary, defining essential treatments for palliative care across various local care settings. First published in 2019 and updated in 2022, the formulary specifies for each drug the indication, dosage, main side effects, and route of administration. Besides, it clarifies whether the use is in-label or off-label, based on the latest studies, accredited guidelines, and Italian legislation on off-label drug use. Off-label treatments are included to address multiple clinical needs when no approved therapeutic options exist, reducing empirical prescribing practices.

What has been achieved?

The formulary covers 16 symptoms, 99 drugs, and 30 active ingredients, ensuring continuity of care across the PC network. It allows PC specialists to prescribe listed medications, facilitating patient access to necessary therapies. This evidence-based system supports off-label use when approved options are unavailable, ensuring both patient safety and legal protection for healthcare providers. The tool is accessible to healthcare professionals through an electronic prescribing and administration system and in the company’s intranet section, promoting information sharing and continuity of care in hospital, community and home settings.

What next?

Clinical pharmacists play a critical role in ensuring appropriate prescribing and the proper implementation of the electronic system. Future steps include updating the formulary and expanding pharmacist training in palliative care

Pdf

Author(s)

M.S. Nielsen, The Pharmacy of the capital region of Denmark, Clinical Pharmacy Rigshospitalet, Copenhagen, Denmark
S.L. Otnes; The Pharmacy of the capital region of Denmark, Clinical Pharmacy Rigshospitalet, Copenhagen, Denmark
M.H. Clemmensen, The Pharmacy of the capital region of Denmark, Clinical Pharmacy Rigshospitalet, Copenhagen, Denmark
L.R. Duckert, The Pharmacy of the capital region of Denmark, non-sterile production, Herlev, Denmark
T. Schnor, The Pharmacy of the capital region of Denmark, production, Herlev, Denmark

Why was it done?

Paediatric medicine has limited availability of on-label, age-appropriate formulations. Drug-related challenges encompass variability in dosing, use of tube administration, and the necessity for child-friendly approaches, including formulation issues as well as taste and acceptability of medications.

What was done?

A clinical assessment of the applicability of 3D-printed medicines from a paediatric perspective, with the limitations of the chosen technique.
The aim of this project was to identify specific areas where 3D-printed medicines provide viable solutions to the complexities surrounding paediatric drug-related challenges.

How was it done?

To minimize the need for individual medicine manipulation, we identified key challenges by reviewing the manufacturer’s API list and comparing it with nationally available compounded products. This analysis offered historical insight on the shortcomings of commercial products in addressing patient needs. Additionally, consultations were held with nurses and doctors in selected paediatric wards for further input.

What has been achieved?

Three key areas were identified where 3D-printed medicines could benefit paediatric wards:
Dosage: 3D-printed medicines enable patient-specific doses or customizable low doses, assisting dose tapering and minimizing dosing errors. However, for APIs with a wide therapeutic index, the dose should be aligned with commercially available products. Patients or APIs that frequently require dose adjustments are better suited to a mixture formulation.
Logistics: Individual packaging and room temperature storage offer advantages for travel and storage compared to liquid mixtures, which often require cold storage and are produced in larger, less flexible containers. Additionally, existing options like mixtures increases the risk of losing the entire dose supply at once.
Patient related inappropriate drug form: The 3D-printed tablets can be chewed or partially dissolved, facilitating administration for patients with swallowing difficulties. Additionally, it allows for customizable flavors, offering more flexibility than commercial products.
However, the technique does not yet address the need for medication administration via tubes, as it requires heating of the tablets, which can be hazardous when handled by untrained parents. Highlighting that 3D-printing should complement, rather than replace, existing options.

What next?

A prioritized and condensed list of APIs will be conducted based on the identified key areas and assessed by pharmacists, doctors, and nurses.
Appropriate wards will be selected for the pilot implementation of 3D-printed medicines.

Pdf

Author(s)

Sergio Mezzadri(3), Sofia Filippini(1), Annamaria Valcavi(1), Alessandra Ferretti(1), Simone Filippi(1), Francesco Marchi(1), Lucrezia Manghi(1), Marco Massari(2), Alessandra Fonto(3), Federica Violi(3), Alberto Gandolfi(4), Lina Bianconi(4), Elena Casini(4), Valentina Pinna(4), Marcellino Bardaro(5), Giuseppe Russello(5), Paola Nardini(5), Laura Cavazzuti(6), Davide Maria Lucchesi(7), Lidia Fares(1), Federica Gradellini(1), Cinzia Gentile(8)
1- Pharmaceutical Department, Local Health Authority of Reggio Emilia
2- Infectious Diseases, Local Health Authority of Reggio Emilia
3- Primary Care Department, Local Health Authority of Reggio Emilia
4- General practitioner, Local Health Authority of Reggio Emilia
5- Microbiology, Local Health Authority of Reggio Emilia
6- Medical Direction, Local Health Authority of Reggio Emilia
7- Emergency Medicine, Local Health Authority of Reggio Emilia
8- Health Management, Local Health Authority of Reggio Emilia

Why was it done?

The overuse and misuse of antibiotics in Italy has led to the development of bacterial resistance. To minimise the emergence of antimicrobial resistance it is essential to improve best practices for antibiotic use in a “one health” approach.

What was done?

Guidelines for antibiotic prescriptions in the community to support general practitioners in the diagnosis, management and treatment of common bacterial infections in adults. The project aims to promote the use of narrow-spectrum antibiotics, encouraging the prescription from “Access” group (based on the AWaRe classification).

How was it done?

Guidelines were developed for respiratory, urinary, gastroenteric, and cutaneous infections based on local resistance patterns, literature evidences and local organization. For each antibiotic, a fact sheet with pharmacological and safety indications is available.
• The writing involved a multidisciplinary antibiotic management team (pharmacists, general practitioners, infectious disease specialists, microbiologists and emergency department physicians).
• The review was conducted by Primary Care Units (NCP).
• The documents were discussed during training events and published on a dedicated webpage.
• The effectiveness of the project was measured using drug-consumption indicators, training participation and webpage access.

What has been achieved?

A total of 21 protocols and 16 drug fact sheets were created, presented during training events from October 2023 to May 2024 (8 sessions), with 100% participation of NCP. The results of the first semester of 2024 show an increase in access to the web page, with a monthly average of 496 accesses among 238 users (78% of all general practitioners). Comparing the first semester of 2024 to the same period in 2023, there was a decrease in antibiotic use (11,11 vs. 11,51 defined daily dose per 1000 inhabitants), with a more significant reduction in the first quarter of the year, despite the trends in the 2023-2024 flu season (11,29 vs. 13,16 defined daily dose per 1000 inhabitants).

What next?

The second phase of the project will involve the creation of an app and leaflets for patients. In the meantime, antibiotic consumption data will continue to be monitored and discussed with general practitioners. The expected outcomes also include a more selective referral of patients to the emergency department and greater attention to reports of suspected adverse drug reactions by general practitioners.

Pdf

Author(s)

JR ROMA, A RIZO, N POLA, B LOPEZ, A GARCIA, E BRAGULAT, M SANCHEZ, D SOY

Why was it done?

Several studies had been published claiming that the figure of a clinical pharmacist could improve the quality and safety of the medicines prescribed in the ED. However, little information has been published regarding its clinical impact when the pharmacist is physically present at the ED, which could enhance communication with clinicians and ED staff.

What was done?

A clinical pharmacist was included into the multidisciplinary team of the Emergency Department (ED).

How was it done?

The pharmacist performs their duties on-site from 8:00 a.m. to 11:00 a.m., Monday through Friday, joining the medical team located in the short stay unit (SSU) of the ED. The project was focused on validating and reconciling the medications of SSU patients who require short-term treatment, observation or reassessment of their initial ED treatment prior to discharge. Additional activities include logistical tasks, risk management and medication-related safety issues, with the identification of medication errors (MEs) during the pharmaceutical review. These errors are defined as any medication-related error, regardless of whether or not the patient experiences adverse effects.

What has been achieved?

During the first six months (December 2023–May 2024), 1904 clinical histories (patients) were reviewed (Mean day: 16 patients). MEs were found in 14.8% of the patients (282 patients), with a total of 338 MEs. Of these, 30.5% were reconciliation errors, 28.1% were overdosing errors, 15.1% were therapeutic duplicities and 8.9% were underdosing errors. Other identified MEs included: incorrect posology (3.8%), analytical value adjustments errors (3.0%), drug interactions (2.4%), incorrect duration (2.4%), adverse effects (2.1%), wrong administration route (1.8%), incorrect presentation (1.0%) and allergies (0.9%). The most common pharmacological class involved was antimicrobials (40.6%), followed by anticoagulants (13.2%), immunosuppressants (9.3%), and antihypertensives (7.8%).

What next?

Considering the overall satisfaction regarding the ED pharmacist figure in this setting, its work day in ED has been extended from 8:00 a.m. to 4:00 p.m. More research is needed in order to clarify if the role of the ED pharmacist working on-site at the ED can improve healthcare outcomes.

Pdf

Author(s)

MC. SÁNCHEZ ARGAIZ, A. TRUJILLANO RUIZ, E. MÁRQUEZ FERNÁNDEZ, M. GALLEGO GALISTEO, E. CAMPOS DÁVILA

Why was it done?

A multidisciplinary approach is essential for addressing chronic pain from multiple perspectives, ensuring that treatment is personalized and effective for each patient. This structure enables faster, more coordinated solutions for patients whose chronic pain is difficult to manage.

What was done?

The Pain Management Unit(PMU) is a multidisciplinary team responsible for the comprehensive treatment and management of patients with chronic pain. The team includes: anesthesiologists, traumatologists, rehabilitation specialists, rheumatologists, internists, primary care physicians, and now a clinical pharmacist.

How was it done?

When a physician is unable to adequately manage a patient’s chronic non-oncologic pain, the patient is referred to the PMU. The unit holds weekly meetings to discuss cases and propose medical solutions, including interventional procedures such as injections or nerve blocks. The clinical pharmacist plays a key role in this process by reviewing the patient’s current analgesic therapy and chronic medications in advance, assessing their appropriateness, potential drug interactions, and considering alternative analgesic strategies. Additionally, the pharmacist provides recommendations on the temporary suspension of antiplatelet and anticoagulant therapy for patients scheduled for procedures. On a quarterly basis, the pharmacist also identifies patients with chronic non-oncologic pain who are prescribed high-dose opioids, facilitating a review by the treating physician to promote safer and more rational opioid use.

What has been achieved?

-Optimization of analgesic therapy: Through collaborative reviews with the team, analgesic treatments have been more precisely adjusted, reducing unnecessary opioid use and favoring safer, multimodal approaches.
-Prevention of hemorrhagic and thromboembolic complications: Timely recommendations on the suspension of antiplatelet and anticoagulant therapy before invasive procedures have minimized risks.
-Promotion of safe opioid use: The quarterly identification and review of patients on high-dose opioids has reduced the risk of overdose, dependence, and adverse effects, ensuring safer pain management.

What next?

The integration of the clinical pharmacist into the PMU has shown a clear positive impact on the safety and effectiveness of chronic pain treatments. Moving forward, it would be beneficial to evaluate, at six-month intervals, the interventions proposed by the pharmacist and accepted by the medical team. This evaluation would provide valuable insights into the long-term benefits of pharmacist involvement and help refine the collaborative approach to pain management.

Pdf

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.