Author(s)

Virginie Deroche, Ilias Bensouna, Fanny Ponce, Karl-Dietrich Hatz, Nicolas Jauniaux, Amina Benomar, Isabelle Debrix, Florence Federspiel, Laure Raymond, Laurent Mesnard

Why was it done?

Within our hospital, exome sequencing is routinely performed for adults with unknown nephropathy or genetically-suspected Chronic Kidney Disease (CKD), offering not only molecular diagnosis but also underutilized PGx insights. Frequently polymedicated CKD patients could greatly benefit from PGx data to improve medication adherence and optimize their treatment proactively.

What was done?

We designed a pharmacogenetic (PGx) circuit to provide personalized care in nephrology and kidney transplantation.

How was it done?

Following nephrology medical examination and blood sampling, patients received medication reconciliation and counseling with a pharmacist to complete their current treatment list, and to gather past intolerance, adverse events, potential inefficiency and over-the-counter drugs. Meanwhile, a biologist and a bioinformatician analyzed their PGx profiles through exome sequencing data. A pharmacogenetic expert combined these data with medication reconciliation into a PGx report including dosing guidelines based on international recommendations (CPIC, DPWG guidelines). Patient cases were reviewed during multidiciplinary consultation meetings (MCM), to offer personalized treatment and ensure medication safety. MCM reports were integrated into eletronic health record and stored for later use.

What has been achieved?

Out of the 766 patients who underwent exome sequencing, 148 had a medication reconciliation. 88 patient cases were discussed during 27 MCM, which began in October 2024. 100% of these patients received at least one recommendation regarding drug dosing or contraindications, totaling 345 recommendations including immunosuppressants, analgesics and cardiovascular drugs.

What next?

To go further, we aim to efficiently share PGx information to healthcare providers including treating physician, to design a website to educate patient about PGx testing, and to deliver PGx results to patients during a dedicated consultation.

Author(s)

Noemi Tatti, Melania Rivano, Giacomo Bertolino, Valentina Mureddu, Raffaele Deidda, Arianna Cadeddu

Why was it done?

Patients are required to attend a follow-up visit every three months for viral load testing. A collaborative protocol has been implemented to facilitate treatment adherence, monitoring, and access to medication.

What was done?

Collaboration between the immunology department and the hospital pharmacy facilitated the management if drug therapy in HIV-positive patients, enhancing access to care and improving treatment adherence.

How was it done?

The visit schedule is shared monthly. Each patient is assigned an alphanumeric code to ensure anonymity. Any change in appointments, test results, visits, or therapy regimens is also communicated. Through the hospital’s electronic system, pharmacists can access each patient’s treatment plan, review the dates of medication pickups, and verify treatment adherence. In case of discrepancies, these are promptly reported to the physician before the patient’s next visit. Additionally, sufficient medication to cover three months of therapy is prepared in advance for each patient, simplifying the dispensing process and preventing unnecessary hospital visits.

What has been achieved?

This initiative has optimized adherence monitoring, which is particularly important for this category of patients. It has also facilitated the drug dispensing process. By reducing waiting times and hospital visits, it has improved treatment compliance and ensured the protection of their privacy. This project was implemented on 792 patients, and from 01/10/2024 to 01/10/2025, a total of 1,369 dispensations of antiretroviral drugs were carried out.

What next?

This approach has been used to improve the quality of care and overall experience of this patient group. We hope that it will soon be extended to all patients who collect their medication at our hospital.

Author(s)

Rossella Centola, Elisabetta D’Amico, Stefano Morabito, Maria Alfieri, Maria Giovanna Elberti, Lucilla Grisi, Giorgio Lilla, Amelia Filippelli, Francesco Sabbatino

Why was it done?

Precision Medicine (PM) in oncology remains a highly debated topic within Italian healthcare institutions. Currently, Next-Generation Sequencing (NGS) tests are not included in the Essential Levels of Care (LEA), and reimbursement policies vary across regions. Moreover, most targeted therapies based on mutational profiling are prescribed off-label.

What was done?

This study aimed to conduct a cost-effectiveness analysis of a personalized cancer therapy administered in an end-of-life setting.

How was it done?

Clinical and prescription data were collected for a targeted treatment with olaparib. Data were presented as a case report, and median progression-free survival (PFS) and overall survival (OS) were calculated in months. A cost-effectiveness analysis was performed comparing standard care with NGS-driven therapy, using company management software to estimate healthcare expenditure. The Incremental Cost-Effectiveness Ratio (ICER) was calculated and compared against a willingness-to-pay (WTP) threshold of €60,000, considering the rarity of the tumor.

What has been achieved?

The case involved a 56-year-old male diagnosed with cholangiocarcinoma in 2017. After multiple treatments, an NGS test revealed a BAP1 gene mutation associated with a BRCA-like phenotype. Off-label treatment with olaparib 300 mg BID began in June 2019. The personalized therapy resulted in a PFS of 21 months compared to approximately 2 months with best supportive care (standard treatment), and an OS of 48 months versus 29 months, respectively. The cost-effectiveness analysis, conducted from the Italian National Health Service perspective, considered direct healthcare costs including disease management, drug administration, and management of serious adverse events. Personalized therapy showed a survival gain of 2.5 life-years (LY) compared to 1 LY with standard care. The resulting ICER was approximately €45,000 per LY gained—well below the €60,000 WTP threshold.

What next?

This case illustrates that applying PM in end-of-life care for a rare cancer can yield significant survival and economic benefits. These findings highlight the need for greater integration of PM into clinical trials, structured data-sharing networks, and the establishment of solid evidence-based and pharmacoeconomic frameworks.

Author(s)

A Wagner, D Weixler, C Waidinger, M Josl

Why was it done?

A pharmacist, integrated in the palliative care team, reviewed preselected patients with advanced disease to identify potentially inappropriate medications (PIMs). When appropriate, a team of physicians deprescribed PIMs in accordance to patient preferences, clinical status and rationale. The initiative aimed to identify PIMs, reduce pill burden and align pharmacotherapy with individual treatment goals.

What was done?

Up to 96% of geriatric oncological palliative care patients experience polypharmacy (>5 medications) (1), with up to 70% receiving at least one PIM referring to Lindsay J et al. (2).
Deprescribing is considered appropriate in certain clinical situations, including for example:
– presence of polypharmacy
– patient’s wish
– shift in treatment strategy or goals
– limited life expectancy
– when potential harm outweighs benefits

How was it done?

– Weekly interdisciplinary meetings
– Eligible patients were identified by the palliative care physicians based on prognosis, symptom burden, medication profile (polypharmacy), and patient wishes
– Pharmacist reviewed medications using medical records, identified potential deprescribing opportunities and provided tailored deprescribing recommendations (what and how to deprescribe)
– Recommendations were collaboratively discussed and documented
– If deprescribing was implemented, follow-up was conducted at the next patient visit and was subsequently monitored during regular consultations

What has been achieved?

During observation period, three patients (all male, median age 80) received a structure deprescribing review. A total of 59 drugs were targeted, 20 PIMs have been identified.
Commonly deprescribed medication groups were gastroprotective drugs (A02B), urological agents (G04B, G04C) antihypertensives (C02A, C09A, C08C, C03C) and vascular or miscellaneous agents (C05B, N06DX, N07A). Typical reason for discontinuation included stable blood pressure, presence of indwelling urinary catheter, patient-driven deprescribing request, therapeutic futility.
Other drug classes such as psychotropics (N06A, N04B), cognitive enhancers (N06D) and bone-metabolism agents (M05B, A12A) were occasionally discontinued when adverse drug effects outweighed potential benefit or did not align with palliative goals (long-term preventive therapy). Main drivers for deprescribing were patient wishes to reduce pill burden, complex symptom management and avoidance of adverse effects.

What next?

The initiative demonstrated feasibility, safety, and transferability of pharmacist-supported deprescribing as part of a multidisciplinary team. Next steps could include the development of interprofessional training sessions and expansion to other clinical settings.

Author(s)

André Maia; Maria Teixeira; Ana Catré; Inês Margalho; Joana Duque; Marisa Costa; Marta Susana; Miguel Paulo; Tomás Sousa; Vânia Pereira; Teresa Pereira

Why was it done?

Tuberculosis(TB) is an infectious disease caused by Mycobacterium tuberculosis, typically transmitted through the airborne route. Despite being a curable disease, 1.5 million people die from tuberculosis each year, making it the leading cause of infectious death worldwide.[1,2] In Portugal, the most recent data from the National TB Program indicate a notification rate of 14.5 cases per 100,000 population in 2023. Regarding multidrug-resistant tuberculosis cases, the number of cases has doubled.[3] There was a need to restructure the anti-tuberculosis drug management circuit in the Pneumology Diagnostic Centers(CDP), creating a Personalized Distribution of Anti-tuberculosis Therapy (DPTB), to facilitate administration, improving adherence to therapy and therapeutic reconciliation.

What was done?

Pharmaceutical consultation was implemented in a pulmonological diagnostic center and the interventions performed during the Pharmaceutical Consultation (FC) were analyzed.

How was it done?

The pilot project began in collaboration between Pharmaceutical Services and the responsible Physician. Each month, the pharmacist visits the CDP and validates the medical prescription and prepares the DPTB for one month. During the FC, the information recorded by the physician in the previous consultation is verified, patient compliance is assessed, and therapeutic reconciliation is structured. A manual and tools to support healthcare professionals were developed, essential for improving the efficiency of TB treatment.

What has been achieved?

Between April and August 2025, 38 FC were carried out, in which a total of 11 patients with median age 59 years, 7 (64%) female and 4 (36%) male. The patients monitored were divided into: 5(45.5%) with latent TB, 3(27.3%) with active TB, and 3(27.3%) with atypical mycobacteria. The TB infection, 1(33.3%) case of pulmonary TB, 1(33.3%) of lymph node, and 1 (33.3%) of ocular TB. During the FC, 7 interventions were carried out: 1 drug interactions, 3 teaching and promotion of adherence to therapy, and 3 on adverse reactions (AE).

What next?

Pharmacists’ interventions in educating patients, counseling on AEs, monitoring and alerting them to risk situations significantly contribute to reducing treatment abandonment, one of the greatest challenges in tuberculosis control. In the future, we plan to conduct these in-person consultations in Primary Care settings for patients referred to by their physician.

Author(s)

Mireia Coll-Vinent Ollé, Alba Martin Val, Lidia Estrada, Adrián Vilariño Seijas, Ana Cia Hidalgo, Marlene Álvarez Martins, Clara Rodríguez González, Júlia Galí Fortuny, Raquel Gil Bardají.

Why was it done?

Care transitions are a major source of medication errors; therefore, therapeutic reconciliation plays an essential role in patient safety and treatment continuity. However, increasing workload and limited staff make it unfeasible to conduct thorough reconciliation for all patients systematically. The aim of this initiative was to develop a tool that enables prioritization of patients in therapeutic reconciliation and high-risk medication-related problems (MRPs) detection

What was done?

A digital tool was developed and implemented to prioritize patients for therapeutic reconciliation at hospital admission and discharge. This approach allows hospital pharmacists to focus on patients with the greatest need for reconciliation, optimizing available resources and improving care continuity. The tool integrates structured clinical data from multiple sources: hospital and primary care records, electronic prescriptions, laboratory results, and nursing documentation.

How was it done?

A multidisciplinary team composed of clinical pharmacists and data engineers was established to design and implement the tool. Intelligent algorithms were developed to detect predefined alerts related to pathological history, inappropiate medication, anticholinergic burden, MRPs, drug–diagnosis and drug–parameter interactions, and drugs increasing fall risk. The tool was first validated through a pilot project, after which the algorithms were redefined based on preliminary results. Obstacles such as data integration from different systems, synchronization, and resource constraints were addressed by close collaboration with IT teams, and practical application of the tool.

What has been achieved?

The tool successfully reduced the time required for reconciliation by automatically prioritizing high-risk patients. It facilitated early detection of MRPs, leading to timely interventions and preventing potential adverse drug events. It also strengthened communication between hospitals, primary care, community pharmacies, and social-health centers, and supported health-care continuity.

What next?

This initiative represents a scalable model of good practice. It can be expanded to other hospitals and care settings where provided clinical data are structured and IT integration is feasible. Its adoption in broader healthcare contexts could optimize therapeutic reconciliation processes, reduce errors, and enhance patient safety across systems.

Author(s)

Ana Puebla Villaescusa, Elena Rodríguez del Río, Elena López Lunar, Sonia Fraile Gil, Eduardo Tejedor Tejada, José Diéguez Gómez, José Manuel Carrascosa Bernáldez

Why was it done?

Due to the high interindividual variability in response to psychiatric treatments (age, weight, comorbidities, polypharmacy, diet, addictions, genetic polymorphism), pharmacokinetic monitoring is essential to individualize and optimize drug dosages, improve clinical efficacy, and reduce adverse effects.

What was done?

A pharmacokinetic monitoring unit for psychiatric medications was established in a specialized mental health hospital.

How was it done?

• Design: Prospective study of plasma psychiatric drug levels in patients from a specialized mental health hospital between June and September 2025.
• Drugs monitored: valproic acid, lithium, clozapine, carbamazepine, risperidone+9-hydroxy-risperidone, olanzapine.
• Data collection: anthropometric and laboratory data, comorbidities, plasma levels, dosing history, drug interactions, addictions, dosage adjustment recommendations.
• Pharmacokinetic software: Bayesian and population pharmacokinetic models.

What has been achieved?

n= 129 patients (and 284 level measurements): 12 patients (9.3%) had levels above the established therapeutic ranges, and 35 (27.1%) had levels below range in at least one measurement.
• Valproic acid (n = 49): 5 (10.2%) above range (4 due to hypoalbuminemia); 14 (28.6%) below range. Among those, 5 using it as a mood stabilizer remained clinically stable without dose increase; 2 reduced their doses due to adverse effects while remaining stable. The rest had low levels due to different factors (drug interactions, clinical circumstances, poor adherence).
• Lithium (n = 34): 6 (16.7%) below range, half of them clinically stable; 1 (2.7%) above range due to an interaction with enalapril.
• Clozapine (n = 14): 9 (64,3%) below range due to several factors (poor adherence, adverse reactions that requires lower doses, possible genetic polymorphism). Despite below range, some patients remained clinically stable. The majority of patients were smokers, which significantly increases the drug’s metabolism, complicating dose adjustment without pharmacokinetic monitoring.
• Carbamazepine (n = 2): both within therapeutic range.
• Risperidone + 9-hydroxy-risperidone (n = 19): 2 (10.5%) below range; 7 (36.8%) above range, three of whom required monitoring for renal impairment, and the rest needed dose reductions to avoid supratherapeutic levels.
• Olanzapine (n = 9): 2 (22.2%) below range, one due to suspected non-adherence.

What next?

Ongoing optimization of pharmacokinetic monitoring of psychiatric medications, in which individualized dosage adjustment is required in a high percentage of patients to improve treatment efficacy and reduce adverse reactions in these patients.

Author(s)

Pons Maria, A; Fernández Huertas, L; Samblas Ruiz, M; Hernandez Silveira, L; Barceló Sansó, F; Juez Santamaria, C; Luque Mesa, JA

Why was it done?

This case describes a 23-year-old patient admitted with acute kidney injury (AKIN III) of unknown origin. Due to poor clinical progression, along with symptoms of scalp itching and redness, and the presence of calcium oxalate crystals in urine, glyoxylic acid poisoning was suspected. Glyoxylic acid is a component found in certain hair straightening products. The potential use of fomepizole as an antidote was considered, prompting a pharmaceutical intervention.

What was done?

A literature review was conducted on the use of fomepizole in poisonings caused by glyoxylic acid and ethylene glycol, considering that glyoxylic acid is an intermediate metabolite in the toxic pathway of ethylene glycol.

How was it done?

The mechanism of action of fomepizole was analyzed as a competitive inhibitor of the enzyme alcohol dehydrogenase, assessing its ability to block the conversion of glyoxylic acid into toxic metabolites such as oxalic acid, which is responsible for renal damage. To evaluate the feasibility of using the antidote, the National Institute of Toxicology was consulted. After reviewing the case, and given that more than 72 hours had passed since exposure to the toxin, its administration was ruled out. Supportive treatment already initiated was continued, including fluid therapy, bicarbonate, thiamine, and pyridoxine. The patient showed progressive improvement in renal function without requiring dialysis.

What has been achieved?

The multidisciplinary approach enabled the identification of the toxic etiology and helped prevent major complications. The case highlighted the key role of the hospital pharmacist in the evaluation of antidotes.

What next?

Similar poisoning scenarios—both uncommon and typical—will be reviewed to establish well-defined clinical pathways that allow for rapid and coordinated action in case antidotes such as fomepizole need to be used. This review will help improve the preparedness of both pharmacy and clinical teams for toxicological situations not currently covered by existing protocols.

Author(s)

Brian Gatungu (Lead Biosimilar and High Cost Medicines Pharmacist)
Dita Valentinaviciute (Senior Biosimilar Pharmacy Technician)
Hershey Antipuesto (Senior Biosimilar Nurse)
Usha Hawker (Lead Specialty Medicine Pharmacist)

Why was it done?

The transition from Adalimumab originator biologic to biosimilars, such as the Adalimumab biosimilar Yuflyma, offers a valuable opportunity to reduce healthcare costs while still providing effective treatment for patients. Biosimilars are designed to be highly similar to the original biologic medications and are cost effective, which can ease financial pressures on healthcare systems. However, despite these clear benefits, successfully switching patients from established Adalimumab originator drug to biosimilars is not always straightforward.

One of the main challenges is that patients often have concerns or fears about the new medication, which can lead to anxiety or perceived adverse effects after switching. These concerns sometimes result in patients wanting to revert back, or “switch back” to their original biologic treatment. This reluctance undermines the cost saving potential of biosimilars and may disrupt patient care. Additionally, it can be difficult for healthcare providers to determine whether a patient’s symptoms are due to a true disease flare or other factors, such as incorrect administration of the drug or anxiety related symptoms.

Because of these challenges, it is important to find ways to maintain high biosimilar switch rates while ensuring patients safety and confidence in their treatment. The implementation of the Biosimilar Switch Team, comprised of a pharmacist, pharmacy technician and nurse, has helped to sustain successful transitions to Yuflyma. By offering close clinical monitoring, patient education and personalised support, this team aimed to address patient concerns, provide accurate assessments and ultimately encourage continued use of the biosimilar.

What was done?

The project centered on improving and sustaining the transition from the originator Adalimumab biologic to the biosimilar Yuflyma across multiple specialties at The Royal London Hospital and Mile End Hospital. This initiative recognised the financial and clinical benefits of biosimilars, offering comparable efficacy at a lower cost, but also acknowledged the barriers often encountered during implementation. These barriers include patient apprehension, misconceptions about biosimilar safety, and clinical uncertainty surrounding therapeutic equivalence. In response, the hospitals established a dedicated Biosimilar Switch Team specifically to manage and support this transition process.

This team, composed of a pharmacist, pharmacy technician and a nurse, was responsible for coordinating and overseeing switches to Yuflyma in Gastroenterology, Rheumatology, and Dermatology. Their duties included patient education, assessment of clinical outcomes, and ensuring the maintenance of therapeutic efficacy. They provided a central point of contact for clinicians and patients, thereby enhancing communication and consistency across departments. The inclusion of such a specialised team ensured that patient concerns were addressed promptly, minimising disruptions to care and promoting sustained adherence to the biosimilar.

The core aim of the intervention was not merely to facilitate the initial switch, but to maintain a high long term transition rate while safeguarding patient safety and satisfaction. By embedding the Biosimilar Switch Team into the multidisciplinary team (MDT), the project sought to establish biosimilar use as a normalised, routine aspect of care rather than an isolated substitution event. In doing so, the Biosimilar Switch Team provided a sustainable model for biosimilar implementation that balanced economic efficiency with clinical excellence.

How was it done?

When patients reported adverse effects or expressed concerns, the Biosimilar Switch Team conducted a structured review of their case. They evaluated disease activity scores, patient reported outcomes and the timing and nature of symptoms. In many cases, the team identified non-inflammatory causes such as poor injection technique, misunderstanding of self administration procedures, or psychological discomfort with changing medication. In such instances, they provided personalised education sessions, including practical demonstrations on injection technique, reassurance about biosimilar efficacy and guidance on managing anxiety related to treatment changes.

Decisions regarding whether a patient should switch back to their previous treatment were made collaboratively, involving consultants, the pharmacist and the nursing staff. This collective decision making process ensured that switchbacks were only approved when clinically justified, minimising unnecessary reversions to originator products. The team also offered ongoing follow up to ensure patient confidence and adherence. Through this hands on, case by case management strategy, the Biosimilar Switch Team embedded a culture of patient centred, evidence based practice into biosimilar adoption.

What has been achieved?

The implementation of the Biosimilar Switch Team yielded highly positive outcomes across all involved specialties. Out of 944 patients transitioned to Yuflyma 96.7% successfully remained on the biosimilar, indicating both the clinical viability of the product and the effectiveness of the team’s support model. The total switchback rate of only 3.3% highlights the significance of the Biosimilar Switch Team in sustaining biosimilar use even in the face of patient hesitations and reported adverse experiences. Moreover, switchback rates varied minimally across specialties, with the lowest in Gastroenterology (0.37%), followed by Rheumatology (3.44%)  and the highest in Dermatology (6.45%).

Importantly, the team’s assessments revealed that most switchback requests were not due to true disease flares but rather to modifiable non-inflammatory factors such as administration difficulties or anxiety. By identifying and addressing these issues through education and reassurance, the team prevented unnecessary changes in therapy, maintained clinical stability and reduced the risk of confusion or treatment disruption. This finding highlights the critical role of patient support in achieving sustainable biosimilar integration within complex clinical settings.

Beyond maintaining high switch rates, the initiative achieved significant qualitative outcomes in terms of patient trust and clinical collaboration. The presence of a dedicated pharmacist, pharmacy technician and nurse team enhanced communication among healthcare professionals, fostered consistency in decision making and provided a reliable mechanism for resolving patient concerns. This interdisciplinary structure has proven to be a cost effective and patient centred approach that strengthens confidence in biosimilars, setting a precedent for similar models in other therapeutic areas.

What next?

The success of the Biosimilar Switch Team provides a compelling model for future biosimilar transitions. Moving forward, the Biosimilar Switch Team could be replicated and scaled to support switches to other biosimilars or new biologic therapies across different clinical departments. Hospitals and healthcare organisations could adopt similar multidisciplinary teams to manage transitions more systematically, thereby achieving consistency in patient outcomes and maximising healthcare cost savings at a larger scale.

Further development of the Biosimilar Switch Team could include the integration of digital health tools to streamline patient monitoring and communication. For instance, electronic dashboards could track disease activity scores, patient reported outcomes and adherence data in real time, allowing for early identification of patients at risk of poor compliance or treatment dissatisfaction. Virtual consultations and e-learning resources could extend the reach of patient education, reducing the burden on staff while maintaining high quality support and reassurance.

Finally, future work should focus on long term outcome evaluation and standardisation. This includes collecting longitudinal data on clinical effectiveness, patient satisfaction and cost efficiency to demonstrate the sustained benefits of biosimilar adoption. The development of standardised training materials, institutional guidelines and performance metrics will further embed this practice into clinical governance structures. By continuing to evolve and share best practices, the Biosimilar Switch Team team can contribute to a national and international blueprint for successful, patient centred biosimilar integration in healthcare systems.

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.