Author(s)

D. PROTZENKO (1) (2), Y. GONZALEZ (2), M. TASHAN (2), J. CARDI (2), A. PLAN (1) (2).

(1) CHICAS, CLINICAL PHARMACY, GAP, FRANCE.
(2) CHICAS, HOME-HOSPITALIZATION, GAP, FRANCE.

Why was it done?

Our service area spans four departments in France, encompassing numerous mountain valleys with weather-dependent access, making deployment challenging. Additionally, some patients are over two hours’ drive from our hospital.

What was done?

We developed a territorial network by integrating hospital and extra-hospital structures into our home-hospitalization logistics circuit. This integration allowed us to strategically place equipment storage points across our region, enhancing the speed of care in emergencies.

How was it done?

We utilized a computerized tool to map areas accessible within 30 minutes by car and identified strategic points (both hospital and extra-hospital) to maximize coverage with minimal investment.

To optimize operations and improve response times, we established equipment storage points with ready-to-use kits. These kits, created through multi-disciplinary meetings to address key emergency scenarios, are designed to address a range of situations, including post-operative treatments, pressure sores, and end-of-life care, which are particularly prevalent in our population. The variability of care settings—such as patients’ homes, short-term rehabilitation facilities, and long-term care facilities— is also considered. This approach ensures that nurses and doctors can access the necessary equipment at all time, regardless of their location or the specific care requirements. We formalized partnerships to ensure the presence of these kits at designated sites, which are now referenced on a map accessible to our team. Quality processes were implemented to maintain kit quality and prevent expiry.

What has been achieved?

Immediate deployment of equipment for home hospitalization is now possible, regardless of patient location or weather conditions.

What next?

We are expanding our network by recruiting additional partners to enhance our local coverage. This strategy will also apply to areas with shared medical and paramedical skills, improving our responsiveness, particularly in end-of-life care situations. We will also forge new partnerships to broaden our capabilities, enabling other hospitals to prepare patient materials or medications, or to be used as parcel delivery service.

Author(s)

A. Car, E. Fortina, E. Lanzone, C. Rossi

Why was it done?

Pharmaceutical logistics is a complex process aimed at ensuring patient health. Key tasks include procurement, storage of drugs, as well as medical devices (MD), and economic materials (EM) distribution. The first outsourcing model warehouse, called MUS, was established to minimize inventories, reduce logistics costs, optimize management, improve product tracking and traceability, digitize logistics processes, and expedite administrative tasks.

What was done?

In March 2023, the first centralized warehouse project was launched in a region of northern Italy. MUS is managed by Local Health Authorities (LHA) Leader’s Hospital Pharmacists (HP) in collaboration with administrative staff and an external logistics operator.

How was it done?

The MUS was initiated with the entry of LHA Leader (LHA1). In September 2023, LHA2 and LHA3 joined the project, followed by LHA4 in February 2024. The participating LHAs serve 900,000 inhabitants and cover an area of 6,600 km². Medicines management and movement are entrusted to a logistics operator. LHA1 is responsible for the supply phase of medicines, medical devices (MD), economic materials (EM), and for processing departmental requests.

What has been achieved?

To date, MUS is 18 months old, has an area of 8,000m2 and manages 7 hospitals, 1556 delivery centers (DC), 4781 products: 2639 drugs, 1633 MD, 509 EM. On average, there are 5184 requests and 50300 product lines requested, monthly. MUS’s economic value stocks is 11.9million euros, of which 10.8million euros are drugs. Innovations have been introduced: instrumentation suitable for optical reading, acquisition of license plates, AIC verification. Deliveries to DCs are tracked, the installation of AUTOSTORE, an automated storage and recovery system, is still in the experimental phase. Digitalisation and dematerialisation are replacing old paper systems. The databases of pharmaceutical and MD products have been standardized to satisfy the requests of all LHAs participating in MUS, speeding up the purchasing procedures.

What next?

MUS’s growth must be monitored, in terms of quality of performance and spending optimization. The project is being expanded and the entrance to a hospital is needed to become fully operational. HP’s most challenging task is to orchestrate logistical activities, collaborate with logistics operator, ensuring quality, safety and timeliness of the service and keep the patient’s health as the main objective.

Author(s)

H. RIBES-ARTERO, MJ RUIZ-CALDES, E. MONTEAGUDO-SANTOLAYA, J. GARCIA-PELLICER, J.L. POVEDA-ANDRES

Why was it done?

We have implemented a quality management system (QMS) in the Pharmacy Advanced Therapies Unit for the management of advanced therapy medicinal products (acquisition, receipt, storage and dispensation) in accordance with ISO 9001:2015 standards.

What was done?

In the healthcare field, improving the quality of care is a fundamental objective. This involves a continuous and self-critical process of evaluation to identify problems and opportunities for improvement in care. The Spanish National Health System’s Quality Plan includes strategies such as external and periodic evaluation of the quality and safety of healthcare centres and services through audits, with the aim of achieving clinical excellence and improving patient safety and care. The rise of advanced therapies led to a change in the processes of acquisition, storage, and dispensing of medications, as these are cryopreserved therapies that require specific facilities. In our hospital, the Pharmacy Service was designated to carry out these processes.

How was it done?

The project was developed over 12 months in three phases: phase 1 (analysis of the current situation, establishment of a pharmacist working group and training of pharmacists), phase 2 (design documentation, and implementation of the QMS and certification), and phase 3 (analysis of the indicators after the implementation of the QMS, continuous evaluation of them and application of corrective measures).

What has been achieved?

To develop the QMS, we had to create 1 management manual, 8 work protocols, 25 records, 2 work instructions and 2 annexed documents. Once created, we obtained the ISO 9001:2015 certification for our QMS through an external auditing company. As quality indicators (after the certification) we have obtained favourable outcomes in 2 external audits from the pharmaceutical industry and recorded a total of 4 minor non-conformities. Regarding activity indicators, we have dispensed 18 therapies and 4 new work protocols have been created.

What next?

The pharmacist must be the healthcare professional responsible for managing advanced therapies, and implementing, certifying and recertifying a QMS in accordance with ISO 9001:2015 standards is a guarantee of the quality of our healthcare work at the hospital, recognized by other healthcare professionals, patients and the pharmaceutical industry.

Author(s)

Michelle Ann Matzen, Linda Jeffery, Mette Juul-Gregersen, Bente Jonassen, Lene Juhl Biltsted

Why was it done?

At the regional hospitals in Horsens and Randers, the pharmacy helps mix selected intravenous (IV) antibiotics for patients admitted to inpatient wards (piperacillin/tazobactam, cefuroxime, and cloxacillin).
The mixing takes place centrally and is then distributed to the relevant wards.
Our electronic prescribing system does not help us to identify which/how many patients require these antibiotics so the number of prescriptions for each ward was manually counted before the mixing process.
To reduce medication waste, the manual counting was done every morning and noon, with an estimated time consumption of about 1 hour per day per location.
The goal was to move away from manual counting and towards an automated solution.

What was done?

The pharmacy assists wards in mixing IV antibiotics. There was a desire to digitize and streamline the workflow through development of a software robot.

How was it done?

The pharmacy assembled a team from two locations and reached out to the region’s robotic process automation (RPA) developers.
The pharmacy set requirements and expectations for the RPA solution with the developers.
Throughout the development, the programming was revised and adjusted several times to obtain the most accurate prescription data.
To verify the robot’s counting, manual counts were conducted multiple times during the process, leading to adjustments in the robot’s programming.

The development of the RPA solution spanned 9 months.

What has been achieved?

The fully developed RPA solution is now used at both locations. A report is emailed twice a day, after which antibiotics are mixed and distributed to the relevant wards.
Benefits:
• Frees up time for other tasks
• Data is more up-to-date regarding changes in patients’ medications
• Medication waste is minimized

What next?

There are plans to create a similar setup for a central mixing unit at Aarhus University Hospital, where the RPA solution can be implemented from the start.
There is potential for the RPA solution to be used at other locations/departments, with different medications. For example, monitoring of inhalation preparations or anticoagulant medications.

Author(s)

(NFR) Nathalie Fogh Rasmussen
(MS) Maja Schlünsen
(JHPR) Joo Hanne Poulsen Revell
(LJK) Lene Juel Kjeldsen

Why was it done?

Exchanging medication stocks between hospital wards is a common method for reducing pharmaceutical waste at hospitals. However, the impact of such systems is unclear. Therefore, we aimed to calculate the annual economic cost savings after the establishment of a medication exchange system at the University Hospital of Southern Denmark in Aabenraa.

What was done?

A medication exchange system at a Danish hospital was evaluated according to avoidance of medication waste and potential economic impact.

How was it done?

For two weeks in February 2024, pharmaconomists registered all medications that were exchanged between six hospital wards representing 147 of 302 hospital beds. The quantity of the excess medications when returned was registered and the amount of pharmaceutical waste was calculated. This was compared to the amount of waste incurred by ordering a whole package for the ward. Moreover, the economic cost was calculated based on the value per package and compared to the economic costs of purchasing whole packages.

What has been achieved?

In total, 244 exchanges were registered. The pharmaceutical waste was estimated to 13-26%. The Department of Pulmonary Diseases, followed by the Department of Gastrointestinal Diseases, caused the greatest waste. The exchanged medicine had an economic cost of 3,566 DKK (478 euro). In comparison, the cost of purchasing whole packages was estimated to 21,042 DKK (2,822 euro). Thus, the total cost saving was ((21,042-3,566 DKK)x(52/2 weeks)=454,376 DKK (60,935 euro), corresponding to ((454,376/147) x 302)= 933,480 DKK (125,146 euro) for the entire hospital. The results led to establishment of a physical medication room to store the excess medication available for other clinical wards. All medications are registered electronically to support optimal use of excess medication throughout the hospital.

What next?

The economic evaluation may be replicated for comparable medication exchange systems at other hospitals, and thus, generate evidence for the economic and environmental impact of the system.

Author(s)

Palacio-Lacambra, ME
Cabañas-Poy, MJ
Lalueza-Broto, MP
Florensa-Royo, E
Fernández-Polo, Aurora
Marrero-Álvarez, P
Juárez-Giménez, JC
Gabarro-Portella, G
Gorgas-Torner, MQ

Why was it done?

The problems caused by medication shortages are significant, pose a risk to patient care, and require good coordination between different levels of the healthcare system (primary care and hospital pharmacy services (PS)). Drug shortages can adversely affect drug therapy, compromise or delay medical procedures, and result in medication errors.

The objectives of the working group are to define the internal processes of the PS regarding the management of and communication between professionals about medication supply shortages and to coordinate the referral of primary care community patients for dispensing at the hospital.

What was done?

A multidisciplinary working group was established, including representatives from various pharmacy areas (management, outpatient dispensing, drug information center, pediatrics) and representatives from the Primary Care Medication Management Area in our Health Region, where our center serves as the reference hospital.

The “Supplier Shortage Working Instruction” has been updated, and a pathway has been established for referring patients from primary care to the outpatient pharmacies (adult and pediatric) of our hospital.

How was it done?

Internal meetings of the PS were held to update the “Supplier Shortage Working Instruction,” considering the different situations of medications in shortage (exclusive and/or non-substitutable, substitutable, and community pharmacy medications in shortage).

A meeting with Primary Care representatives was conducted to define the pathway for referring community patients with medications in shortage imported from abroad through the Spanish Agency of Medicines and Medical Devices.

What has been achieved?

The internal working instruction has been redefined, and a shared resource for the entire PS has been created to centralize relevant information for the management of medications in shortage, which is kept up-to-date.

A referral pathway has been established for Primary Care patients to the outpatient pharmacies of our hospital. Two pharmacists from the PS coordinate shortage information with Primary Care. Primary Care reports the number of patients with active prescriptions requiring medication, which ensures adequate stock levels and enables patient scheduling to enhance their experience.

What next?

Having an internal pathway has improved the management of medication shortages in the PS, as well as enabled the coordinated referral of community patients.

It is applicable to all PS involved in dispensing foreign medications due to shortages.

Author(s)

Minke Jongsma, hospital pharmacist, Tjongerschans Hospital, Heerenveen, The Netherlands
Marja Bogaards, hospital pharmacist, Haaglanden Medisch Centrum, Den Haag, The Netherlands
Annemiek Zwetsloot, ICT consultant, Panacea Informatics, Oosterbeek, The Netherlands
Folkert Botma, ICT consultant, Panacea Informatics, Oosterbeek, The Netherlands

Why was it done?

A significant proportion of valuable medications, often produced far from where they are used, ends up discarded without ever being administered. Due to limited visibility into actual medication use, hospitals face challenges in understanding which drugs contribute to waste.
Analyzing internal data allowed us to gain insight into different aspects of medication waste. Addressing these aspects successfully improved sustainable use of medication.

What was done?

We developed a medication waste dashboard to promote sustainable decision-making across medication policies, purchasing, prescribing, distribution, administration, and waste management.

How was it done?

Daily, hospital pharmacies register all medication orders and dispensations (to patients or for stock), while nursing staff document actual administrations. The discrepancy between dispensed and administered drugs provides useful insight into unnecessary medication waste.

What has been achieved?

We integrated dispensing and administration data into a dashboard, offering real-time visibility at the organizational, departmental, ward, and drug group levels. This tool allows our multidisciplinary team to conduct trend analyses and implement greener practices. Key outcomes include: 1) reduction of medication waste, 2) preventing excessive stock accumulation, 3) optimizing internal processes, and 4) maximizing reuse. Additionally, these data supports effective management during drug shortages and provides critical insights into missing opioids.

What next?

Utilizing data allows us to retrospectively analyze trends and project future scenarios, unlike traditional waste-bin audits. This data-driven approach empowers us to make proactive adjustments, guiding hospitals toward long-term medication waste reduction and facilitating benchmarking across healthcare institutions.

Author(s)

C.ALINOVI, J.ZAMPA, D.PECANI
Toulouse University Hospital, FRANCE, Toulouse

Why was it done?

To set up tools to better manage medical device (MD) supply shortages, given the significant increase in the number of shortages in recent years.

What was done?

To better manage MD supply shortages in hospitals, a score has been developed to classify devices by their criticality during supply disruptions. This score considers various factors, such as : number of hospital departments using the product, average daily consumption rate, single-use vs. reusable nature of the product or Availability of alternatives.

How was it done?

A set of criteria and their interrelations were tested to establish a criticality score that categorizes MD into three levels : ‘supercritical’, ‘critical’, and ‘non-critical’. These categories reflect the potential impact on patient care in the event of a shortage. Thresholds, such as the daily consumption rate, were particularly important in defining this score.

What has been achieved?

To validate the scoring method, 33 combinations of criteria and 1,257 threshold variations were tested on a sample of 66 products. These products had previously been rated by expert pharmacists for criticality. Sensitivity and specificity calculations were used to compare the test results with expert evaluations. After testing, three combinations achieved the desired accuracy, and one of these was selected.
The final scoring method was applied to 764 MD in stock at the hospital, identifying 44 as ‘supercritical’. The security storage thresholds were increased for these 44 MD so that they would be less affected in the event of a shortage, and are MD targeted during order delays, so that they can be relaunched as a priority.

What next?

A similar scoring system will be developed for MD managed in non-stock mode to classify the most critical items in the event of a supply shortage.

Author(s)

SS Suvi Sivula, JN Jonna Niemi, KM Konsta Malmi, EA Elina Ahomäki

Why was it done?

In 2021, over 110,000 kilograms of pharmaceutical waste was produced at HUS Helsinki University Hospital, Finland (HUS). That was almost 2.5 million euros when the value of the medicines and the pharmaceutical waste management costs were considered. In 2022, HUS Pharmacy launched a project to reduce pharmaceutical waste, both for economic and environmental reasons.

What was done?

The goal was to reduce the annual pharmaceutical waste in euros and in kilograms at HUS, primarily at the Pharmacy. We also aimed to help departments to reduce their pharmaceutical waste.

How was it done?

The project group was formed of about 15 pharmacists and pharmacy technicians from different units of HUS Pharmacy, located in different areas in Southern Finland. The project team met monthly to review the costs and causes of pharmaceutical waste at the Pharmacy. The team discussed challenges, shared good practices and came up with ideas. In addition, departments were supported in reducing pharmaceutical waste with lectures, materials, videos etc.

During the project we found three main reasons for producing pharmaceutical waste: expired products, residues of cytotoxic drugs and compounding errors. To avoid these, we created a better overview on the whole stock of the Pharmacy, internal communication was increased, and products were moved more actively between units. Unit-specific procedures were also developed, collaboration with departments was increased, and published studies were used especially to reduce cytotoxic waste.

What has been achieved?

During the project, the annual value of wasted pharmaceuticals at the Pharmacy decreased from 928,000 euros (year 2021) to 507,000 euros (year 2023). In addition, the annual amount of pharmaceutical waste at HUS reduced from 112 000 kilograms to 101 000 kilograms. Also, the total cost of pharmaceutical waste at HUS, including the value of wasted pharmaceuticals, decreased.

What next?

The project team’s work has become a permanent part of our work instead of a project.
Collaboration between all healthcare workers is in a key role for reducing pharmaceutical waste. Waste cannot be completely avoided, but it can be reduced significantly, as our project has revealed.
Procedures must be developed further, for example early notifications from departments to the Pharmacy about changes in medical practices are critical for managing our stock.

Author(s)

Gutiérrez Palomo, S; Guillén Martínez, O; Miralles Andreu, G; Jiménez Pulido, IP; Soriano Irigaray, L; Murcia López, AC.

Why was it done?

Pharmacy Service(PS)initiates the evaluation, management and procurement of medicines in exceptional circumstances(MEC), a complex process in terms of each treatment requeriment, the regulatory agencies/professionals involved and the phases/timescales of the evaluation process, which can be improved by the implementation of technology.

What was done?

The objective is to describe the implementation of a specific informatic platform(IP)for the use of MEC in a PS.
The IP was implemented in September 2023 to centralize the request MEC process by the optimization of their monitoring and evaluation and to promote specific management knowledge for each treatment.

How was it done?

1. The responsible physician contacts the PS to initiate a treatment considered as MEC, submitting an individualised prescription per patient.

2. The PS determines the specific treatment procedure and the authorizations needed to make the request to the responsible agency.

3. The PS introduces the request into the IP and attaches the corresponding individualised treatment document.

4. With the agreement and signature of the PS head, the request is sent to the Hospital Director for evaluation and conformity, recording the date of processing in the IP.

5. After having the hospital approvals, PS sends the request to the corresponding agency, attaching the document in the IP.

6. Once the request has been assessed by the apropriate health agency, the resolution document is attached in the IP, recording the resolution date and updating its status.

7. The IP is connected to the electronic medical record program , generating an automatic report with the request resolution in the patient’s medical record.

What has been achieved?

Since September 2023, 217 MEC requests have been received. As for their resolution, 190(88%) were authorised, 14(6%)pending resolution, 9(4%) refused and 4(2%)cancelled. By medical services, the most requests were distributed as follows: 69(32%) oncology, 27(12%) haematology, 18(8%) neurology, 16(7%) anaesthesiology, 14 (6%) cardiology. The drugs with the most requests were: glycopyrronium(16), atezolizumab(9), cysplatine(8), pembrolizumab(7), bevacizumab(6), mavacamten(6), nadolol(6), labetalol(6).

What next?

A simple, user-friendly and highly useful platform that can be implemented in any PS with a pharmacist specialised in the management of MEC and included in multidisciplinary teams.