daily dose post congress edition

Dr Roberto Frontini reflects on 6 years as EAHP President and looks to the future

April 2015The EAHP

Daily dose

An EAHP Congress never really leaves you – the learning and ideas transmitted remain with attendees as they take forward their daily practice across Europe and the world. To help provide attendees

with a summary recap of some of the sessions presented we present the final post-Congress Daily Dose edition for your reading pleasure!

Post Congress

Edition©

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Welcoming attendees to the 20th EAHP Congress in Hamburg, EAHP President Dr Roberto Frontini couldn’t help but share some personal memories of his time studying in the city, and meeting his future wife. But it was also an occasion to reflect on his 6 years serving as EAHP President, and share some thoughts with the profession for the future.

Achieving one’s aspirations, both in the personal and professional sense, is never an easy task, with frustrations, financial limits and other obstacles getting in the way, and sometimes appearing insurmountable. However, the lesson of history is to shape one’s own reality and view obstacles as a motivating challenge to overcome.

It was with this in mind that Dr Frontini described how he found himself in the role as a lobbyist for hospital pharmacists, but more in particularly for patients, their needs, and their outcomes. This means most of all, healthcare professionals working together to achieve shared goals and objectives for better patient care. This approach to advocacy was underlined in the creation of

the 44 European Statements of Hospital Pharmacy which were developed in a partnership project with numerous other healthcare professional organisations and patient organisations. In this sense, they represent a shared vision for the future of hospital pharmacy.

Following the statements, Dr Frontini likes to keep in his mind every day in his daily work, the first statement of the forty four: “The overarching goal of the hospital pharmacy service is to optimize patient outcomes through working collaboratively within multidisciplinary teams in order to achieve the responsible use of medicines across all settings”.

He closed with a quote from Seneca: “If a man does not know to what port he is steering, no wind is favourable to him.” The Statements give us the destination to head for.

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2 | 20th Congress of the EAHP

By: Brendan Murray, hospital pharmacist, UK

http://theenthusiasticpharmacist.com/blog/Twitter: @TEPharmacist

Cam Battley, who is a health sector management consultant from Canada, presented the session. The session was designed to help hospital pharmacists act as voices for their patients, tackle team challenges, engage effectively with management, and progress personal career development.

The 90 minute session highlighted to attendees different examples of leadership styles such as the hesitant leader, the aggressive leader, and the learning leader. The session also explored key leadership tools such as “legitimate persuasion”, how to structure effective communication, advocating your point of view and “assertive engagement”.

Among the motivational statements that were emphasised were:

- “One must be trooper before one can be a general”

- “Be an enthusiastic leader”

- “We are better communicators when we are getting blood to the brain”

- “There is always time for the things that matter “. EAHP warmly thanks our industry partners for their continued commitment to supporting the goals of

hospital pharmacists.

Platinum Partner Platinum Partner

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Pfizer WorkshopMake your voice heard

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Budgetary constraints and patient care

Professor Constantino Sakellarides described the health statistics of Portugal, highlighting a strong public health tradition. He presented the recently published report from the WHO and EU Observatory titled, “The impact of the financial crisis on the health system and health in Portugal”. In his opinion Portugal was in a perfect storm of low economic growth and large amounts of external borrowing.

“If this was a clinical trial then it would have been stopped long ago”

He highlighted that following 2007 the countries with the highest interest rates were also the ones who, by the WHO criteria, were not providing the best healthcare to their citizens. He continued that in 2011 an Economic Adjustment Programme was launched in Portugal. By the end of 2012 this programme had failed to achieve all financial targets and increased the tax burden of citizens and dramatically cut the public expenditure.

He explained that the EU has an obligation to analyse the health impact of other policies which Professor Sakellarides claims did not happen. There was no anticipation of the consequences, he said. The consequences were cuts in the health service, salary reductions, increased workload, worsening conditions and higher user charges. Patients therefore were refraining from visiting healthcare professionals and consequently presenting with worse conditions later on.

Dr Melo Gouveia expressed his frustration as a pharmacist running the pharmacy department in a hospital in Lisbon. He said that due to the financial crisis in 2011, 23 Portuguese hospitals were not supplied with medicines, staff were not replaced, equipment was not maintained, salarys were reduced and staff morale was very low. The workload providing data to the government and other bureaucracy did increase though – so not everything reduced, he joked.

Regarding procurement he commented that he had to reduce the amount of stock contained within the department and keep tighter controls. On average he said there is 15 days’ worth of stock in a Portuguese hospital.

He has decisions to make including how to supply the patient in the hospital; should he continue with the standard unit dose delivery, when it is staff intensive and he needs them doing other things. What would the impact be on nurses if he did?

He discussed other considerations he needed to make including cyto-toxic preparation, compounding, outpatient services and clinical pharmacy services. He had to stop an innovative project on medicine reconciliation due to lack of fund-ing. He said that in every decision he needed to think of what is best for the patient and described how he managed the department in the circumstances.

Seminar C2Seminar C3Methodologies underlying patient safetyProfessor Bryony Franklin, of Imperial College Healthcare NHS Trust and UCL School of Pharmacy, introduced Congress attendees to the different approaches (retrospective and prospective) to improving patient safety and strategies to bring them both together.

“Errors need to be reported”, she said describing the incident reporting systems at local, national and international levels and their purposes and importance. She gave details about the National Reporting and Learning Systems (NRLS) in the UK and explained that since 2003 it has received 11 million reports. In Sweden and Switzerland there are similar initiatives.

When an error occurs often a “root cause analysis” is conducted and this requires a structured and systematic approach she described. Asking the questions ‘what?’, ‘how?, ‘why?’ helps to get to the bottom of an issue. Within this however, it is important to avoid blame, and rather learn how to prevent the incident from occurring in the future. Using techniques such as the fish bone diagram, the Swiss cheese model and the London protocol she gave the audience hints and tips to conduct root cause analysis in their own hospital. Collective analysis can be done nationally and upon the reports received the NRLS may issue warnings, including a Stage 3 Alert. This kind of directive mandates organisations to confirm

that specific actions have been implemented. Collective analysis can also be used to review protocol compliance for near misses or events such as intrathecal administration of vinca alkaloids, as her research shows.

The barriers to incident reporting are given attention in the seminar, with about 99% of errors estimated to be not reported. Contributing factors to the failure to report errors include the lack of knowledge that an error has occurred, unfamiliarity with how to report, a lack of time or fear of blame. Professor Franklin provided guidance and potential solutions to increase error reports, and referred the audience to relevant World Health Organisation guidelines.

Dr Julien Duquesne of CHU Nice described prospective approaches to improve medication safety. A risk reduction plan should be initiated with the purpose of avoiding errors from occurring. There will always be a level of risk present but the key is to achieve an acceptable level of risk. He recommended a review of processes including how often an error is occurring, what is the significance to the patient and how is it detected. This will enable practitioners to attribute a risk to each activity. He concluded with an introduction into the various methods including HACCP, FMECA and FRAM.

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Leadership, advocacy and communication skills: helping today’s hospital pharmacist shape tomorrow’s professional landscape

photo courtesy: Brendan Murray

20th Congress of the EAHP | 3

Synergy SatelliteTargeted drugs - scattered goals Advances in molecular biology and genetic research have expedited cancer drug development tremendously. The goal is still to develop ‘personalized and tailored drugs’ that precisely target the specific molecular defects of a cancer patient. For over one hundred years since Paul Ehrlich imagined ‘magic bullets’ for use in the fight against human diseases, generations of scientists have been inspired to devise powerful molecular cancer strategies.

This symposium showed where the cutting edge of targeted treatment lies today. It attracted a large audience, demonstrating again the popularity of the synergy satellite programme. These accredited teaching sessions have become an important part of the EAHP Congress in recent years – a Congress that this year drew 3551 people to attend.

Standard or tailored chemotherapy?

Overall long-term survival of children with cancer at primary diagnosis is about 75-80%. Response rates for many adult cancers have also improved dramatically, with the exception of some difficult-to-treat cancers such as brain and pancreatic tumours and non-small cell lung cancer. So established chemotherapy is the choice for most patients. For difficult cancers and for relapses of cancer in young patients, attention turns towards new treatments. In relapsed younger patients, survival drops down to 10-20% at 2 years in high-risk cancers.

Inclusion criterion for most clinical trials is the histomorphological diagnosis; molecular markers are rarely addressed. The mechanism of action of many drugs used in oncology is not really understood (including

chemotherapy and most targeted drugs). Nevertheless tumour characterization can now be performed, giving information about gene expression, genetics and epigenetics. The overall frequency of mutations per genome is significantly lower in paediatric tumours so the search can start for individualized treatment. In contrast, pancreatic cancer could be the results of any, or some, of 2.500 mutated genes.

The target for so-called “checkpoint inhibitors” is the patient’s immune system. The challenge is to activate it sufficiently that it will destroy tumour cells, without causing auto-immune disease. The chief mediators of anti-tumour activity are T cells. Response rates are encouraging and the new drugs have a significant effect on overall survival.

The challenges facing hospital pharmacists

The challenges include: − Access to new treatments − Off-label use and reimbursement − Finding suitable formulations for administration − Pharmaceutical care (including information to patients and healthcare professionals):

• Generally high risk of interactions, especially oral therapies

• Very different recommendations for administration schedules depending on food intake

• Patient self-management (adherence, toxicities, supportive care measures) necessary

• Dose splits and applicable formulations in childhood cancer treatment

The reader is encouraged to look at the lecture material on the EAHP website to find out more about targeted treatment, a case study and a suggested patient information leaflet. The pharmacist faces multiple challenges in handling targeted therapies. Traditional responsibilities (e.g. logistics) are added to by financial and clinical pressures as well as patient safety considerations. Clinical studies will increasingly demand pharmaceutical expertise and demand intensive co-operation between healthcare professionals.

Detailed information is also given about the INFORM Consortium (Individualised therapy For Malignancies in children). This German initiative is currently in a pilot phase. Of 52 patients screened, 21 can be offered individualised treatment (study awaiting publication).

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The Congress is a great opportunity for convening leaders of hospital pharmacy. An EAHP Members’ Meeting on Tuesday 24 March updated representatives from national hospital pharmacy associations with the latest news on EAHP activities and European matters that affect hospital pharmacy.

EAHP’s 2015 Baseline Survey

Petr Horák and Jonathan Underhill presented the first results of EAHP’s 2015 baseline survey of hospital pharmacy practice across Europe. The survey is a tool for EAHP members to benchmark the current state of hospital pharmacy in their country against neighbours and the European whole, and serves as primary reference for understanding the extent to which the European Statements of Hospital Pharmacy are being delivered.

The questionnaire was translated into 15 languages and investigated each EAHP country’s current position in relation to each of the 44 Statements. It also looked at matters such as capacity (number of hospital pharmacists) and capability (level of training and experience of the hospital pharmacists). Finally, it probed general issues about implementation of the statements, such as readiness and any barriers to implementation.

The biggest barriers to implementation observed in the preliminary analysis of answers were difficulties with the statements highlighted in the panel opposite. Other replies and comments suggested that some hospitals surveyed did not undertake or publish practice research.

The authors hope to publish their findings in June 2015.

Implementation of the Falsified Medicines Directive

A new Regulation is being finalised by the European Commission which will mandate hospital pharmacists in every EU country to conduct a ‘final check’ of every package of medicine in the hospital by scanning a ‘unique identifier’ (a 2D barcode). This will verify that the medicine is from the legitimate supply chain. John Chave, President of the European Medicines Verification Organisation (EMVO), kindly addressed the meeting, explaining some of the serious impacts that the Regulation could have for both community pharmacy and hospital pharmacy practice. Over 99% of drugs used in hospitals will be covered.

The Directive requires a verification of the medicine package at ‘the point of dispensing’. However it is problematic to define at exactly what point a medicine is dispensed in a hospital. It seems sensible to verify the unique identity of medicines by a barcode check when they are received in the hospital, preferably at bulk level. However there is a serious threat the opportunity to ‘check out’ medicines at a bulk level will not exist in the new Regulation, with potential major impacts for hospital pharmacy practice, staffing and resourcing.

Once published the Regulation will not be open to national interpretation, but will be binding on all EU member countries, and take effect in 2018.

EAHP members determined a need for national representations to be made to EU Governments highlighting serious concerns.

Report of EAHP members’ meeting

The 5 Statements that appear to have the biggest barriers to implementation

Statement

S44 The pharmacists in our hospital enter all medicines used onto the patient’s medical record on admission.

S45The pharmacists in our hospital contribute to the transfer of information about medicines when patients move between and within healthcare settings.

S64 The pharmacists in our hospital routinely publish hospital pharmacy practice research.

S53 Our hospital uses an external quality assessment accreditation programme to assure our medicines use processes

S11 The pharmacists in our hospital work routinely as part of multidisciplinary team.


Scanning barcodes to achieve a revolution in patient safety

It was “Breakfast and Barcoding” for an early morning start to the Thursday congress programme for a Synergy Satellite: barcoding the single dose of drugs to improve patient safety.

The UZ Leuven experience: bedside scanning and CPOE prevent errors

Thomas De Rijdt, Assistant Director at UZ Leuven’s Department of Pharmacy (Belgium) introduced the achievements his hospital had made in integrating Computerised Prescription Order Entry (CPOE) with bedside scanning to create an holistic approach to prevent medication error: especially prescribing and administration error.

The CPOE system can be deployed to help ensure accurate prescribing and include a variety of prompts in relation to potential interactions, high doses or other forms of support. Bedside scanning provides the safeguard of a final check by the nurse that the medicine about to be administered is indeed the right medicine, for the right patient, being given at the right time, in the right dose, and by the right route of administration. In this sense, the whole system represented an important collaboration between doctors, nurses and pharmacists as all are intimately involved in both the design and implementation. A recently made video by UZ Leuven gave an impression of the overall

result, with all health professionals involved speaking of its value to the safety of the hospital’s operations.

Thomas ended his presentation with a small note of caution. No system is perfect or provides a magic bullet for all patient safety risks. Furthermore, new risks can emerge, unforeseen at the initial design phase. Therefore continuing vigilance is required, including adaptability and evolution of the system in response to novel identified events.

GS1’s contributions, including a global standard for the single unit

Ulrike Kreysa, Vice-President of Healthcare at GS1’s Global office

in Brussels, described the role her organization is playing in helping to spread the bedside scanning achievements made by UZ Leuven to other parts of Europe and the world.

GS1 is a non-profit international organization focused on improving the use of global standards to make industries and sectors, such as the health sector, safer and more efficient. Indeed, the lack of global standards in many aspects of healthcare can be seen to add risk and increase inefficiency. An example includes the frequent experience of containers displaying multiple bar coding in many different forms. This leads to confusion, uncertainty and waste. GS1 is trying to resolve these issues by agreeing global bar code standards.

Such agreements are not always simple and straight forward as the barcoding of medicinal products can be complicated. The issue of space is often problematic for example, though the 2D datamatrix barcode is proving critical in overcoming such obstacles. The small barcode can contain a large datastream with many information fields about the product such as: GTIN, expiry date, serial and batch number.

In view of the growing prevalence and necessity of 2D barcodes, Ms Kreysa emphasised strongly that IT purchasers must concentrate on camera-based scanners (as opposed to other versions, such as laser scanners).

Congratulating UZ Leuven on its bedside scanning

success, Ulrike gave an overview of the progress being made elsewhere across the globe to make barcodes on the single unit packaging of medicines a powerful tool in protecting patient safety. In Denmark the group purchasing organization Amgros has secured agreements from many suppliers to barcode their products to the single unit in order to deliver safety improvements. In the USA and Taiwan Government regulations have been achieved in this area. In Brazil and Argentina many hospitals are now following the UZ Leuven bedside scanning example.

Pfizer: Barcoding medicines to the single unit is responding to an important customer need

Chris Dierickx, Business Development Manager in Pfizer Global Supply, outlined how his company had responded to the needs hospital pharmacies had described in terms of the desire for identifying 2D datamatrix barcodes to be included on the single unit of the primary package of medicines. The worldwide standard for such barcodes that has now been created by GS1 (‘The level below the each’) has been highly beneficial in this regard.

A Pfizer pilot project in Belgium has now given further demonstration of how single unit barcoding at the manufacturing stage can be achieved, albeit without variable data (e.g. batch number and expiry date). The practical reasons for not being able to achieve variable data in the barcode at the current time were explained. Static data (e.g. medicine name, manufacturer etc) can be included in the over-arching ‘artwork’ for the product packaging. The inclusion of variable data however requires repeated changes to packaging lines which presents additional logistical complications.

Synergy SatelliteBarcoding the single dose of drugs to improve patient safety

The transition of care is an important area where pharmacists can play a key role. The patient may move from one ward to another, from one healthcare facility to another or be discharged from home potentially with errors in their medication unless an intervention is made, usually by the pharmacist.

Professor Marilyn Stebbins presented an overview, including from her own work at the University of California, San Francisco. She explained the effect that

the new health reimbursement system, “Obamacare” was having on healthcare, describing that hospitals were now paid for reduced re-admissions. She described that there were financial incentives to encourage hospital based institutions to partner with community based organisations to improve transitional care processes. In another step to try to encourage improved patient care the readmission rates of each hospital participating will be publicly available online and as such, readmission in the first 30 days after discharge is a key quality indicator.

Presenting a recent systematic review she highlighted that out of the 48 studies of hospital initiated transitional care interventions only 3 were statistically significant at reducing adverse event rates, all led by pharmacists. Interventions can range from admission reconciliation and counselling, pharmacist as part of the medical team, discharge reconciliation and counselling, discharge letter and post discharge follow up. Pharmacists cannot make improvements alone and must work with other healthcare professionals to increase the effectiveness of any pharmacist intervention.

Her final message was that, although not perfect, the changes being made in the USA’s health system are a step in the right direction in terms of improving processes in the transfer of patient care.

Dr Tamasine Grimes outlined in her presentation the medication safety risks for drug related harm at transitions of care, described evidence based strategies to promote patient safety and to assess suitability within a given hospital setting.

She described that 20% of readmissions with the 1st year of hospital treatment were drug related, more than 8% of emergency admissions were drug related (Ahern et al) and 6% of discharges have a potentially severe drug error.

Dr Grimes mentioned that transitions also occur not only when the patient moves but also when medical teams change or staff changes at the end of shifts. She highlighted the work that has been conducted on this issue, including an initiative she had been involved in called “Collaborative Pharmaceutical Care at Tallaght Hospital (PACT)” . Interventions included pharmacists working within the medical team, increased numbers of clinical pharmacists, leading medicines reconciliation, major changes to the drug chart (co-signed) and conducting discharge medication reconciliation. As a result PACT patients had a lower prevalence of error at admission and discharge. To prevent one potentially severe error 20 patients needed to be screened.

Seminar CL1Medication safety in transitions of care

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Dr Lene Juel Kjeldsen (Denmark) and Dr Torsten Hoppe-Tichy (Germany) from the EAHP Scientific Committee provided the audience with the hints and tips for writing a good abstract, that could be accepted for EAHP poster exhibition in the future.

They described that the abstract starts with a good study. Therefore, the importance of a clear research question, SMART objectives, clear and valid methods and a well established protocol was stressed.

After a short introduction in which the differences between quantitative and qualitative data was explained, participants were challenged to improve on two abstracts, which were received by the Scientific Committee. This exercise helped participants reflect on common mistakes that authors make.

Take home messages included:

1. Check the guidelines prior submitting your abstract! Every journal and

every congress have their own requirements, even though the basic structure is the same.

2. Try to summarise every paragraph in one sentence in order to check if your message is clear!

3. Keep the line of thought through the abstract! The same idea should be reflect in title, purpose and conclusion.

4. Ask your colleagues for feedback!

They concluded that in the end, it is important to keep in mind that an abstract should be written with the aim to provide the audience with new information and present your research.

Workshop 8

The EAHP Congress was pleased to welcome Dr. Jean Francois Roche from the European Commission to explain in person the pan-European legal framework for medical device safety, including market surveillance, pre market authorization and post market vigilance.

Under current EU law medical devices do not usually require pre market authorization in the way that pharmaceutical products do, with the safety of the device placed on the market largely considered to be the manufacturer’s responsibility. However, some classes of devices do require involvement and oversight by national ‘notified bodies’. Even in these instances, the notified body’s role can more around checking the quality of processes rather than clinical testing.

In all, the European model of device regulation is considered to be one of ‘light regulation’, which presents both advantages and disadvantages. Overall, it is seen to help foster innovation and enable products to be brought to market in reasonably fast time periods.

In respect of vigilance, the responsibilities in this area lie primarily with manufacturers who are expected to report all incidents. Interpretation issues have arisen as to what classifies as an incident

that should be reported however. Many European countries have added reporting opportunities and responsibilities for healthcare professionals, but the picture is varied as to whether this is a mandatory obligation or voluntary.

Reports at a national level are passed up to a European database. In addition, the European Commission supports a European Vigilance Working Group which aims to find opportunities for improved harmonization of reporting, definitions and forms of implementation, for example standardized reporting forms. The current use of non-standard nomenclature across Europe hampers aggregation and analysis of vigilance data at the European level.

With all this in mind, the European Commission has put forward proposals to overhaul the existing EU medical device directive and replace it with an updated EU Regulation. This will enhance the role of the EU vigilance database, bring about standardized reporting and make a step change in public accessibility to the information held in the database. The intention is enhance early signal detection via the new database, with the working name of Eudamed III.

The art of writing an abstract

Student Programme

The future of medical device vigilance in Europe

Patient safety and healthcare improvements - the hospital pharmacist’s contribution

This session was an introduction to evidence based clinical pharmacy. Citing the definition from “Sackett et al (1996)” Professor Wiffen described that using both systematic reviewed research and clinical expertise can provide the optimal patient care. Nevertheless, he emphasised that patient preference was a key factor in evidence practice, even giving his own example about how a recommended medication was not his preference!

He recommended the CINAHL database as a trustworthy resource for clinical pharmacy literature and described the GRADE system of critical appraisal of journal articles. Throughout the workshop, he gave real life examples reviewing the best available evidence for a number of medicines commonly used. The process for creating a research question using the PICO method was discussed and the technical terms of NNT, validity,

L’Abbé plots were shown to the delegates. He also presented forest plots as a way to illustrate results of individual studies and meta-analyses.

To test the newly acquired knowledge delegates were encouraged to conduct a critical review of a paper published in a reputable journal. The delegates were able to use their experience and developed critical analysis skills to highlight that this paper should possibly not be used when making future clinical decisions. In the interest of patient safety, participants can now use the evidence in their own practice.

Evidence based clinical pharmacy

The EAHP would like to thank the following sponsors for their contributions to the 20th

Congress of the EAHP

Workshop 5

Congress bagsbrought to you by

Mini Programme bookbrought to you by

Cyber Cafébrought to you by

Seminar CL2 - Medical device vigilance

The EAHP continues to welcome undergraduate students at the EAHP annual congress and help them develop their careers as hospital pharmacists of tomorow. On Wednesday afternoon, students from over 15 European and non-European countries came together to discuss the hospital pharmacist’s contribution for patient safety. This was facilitated by university lecturers from Robert Gordon University Aberdeen and members of the European Pharmaceutical Students’ Association Executive.

The beginning of the session focused on understanding the

required terminology associated with patient safety and aimed to develop an awareness of facilitators and barriers to patient safety. Don Berwick’s ideas were emphasised: (1) Put the patient experience first;(2) Hear and empower patients;(3) Invest in staff to grow and develop their own abilities and working together and (4) Organisational transparency.

After the coffee break, the focus of the session was quality improvement methodology, in particular Plan-Do-Study-Act (PDSA) health improvement methodology. The students

were confronted with three challenging pharmaceutical care cases. They discussed the application of the PDSA tools and shared their solutions with the facilitators.

The student symposium equipped students with new knowledge and probably even more importantly with new inspirations. They had an opportunity to network with their peers and learn valuable aspects of patient safety which are important for their future careers.

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Seminar C1Improving patient safety through multidisciplinary teamwork“If everyone is moving forward together, then success takes care of itself”, is an oft-applied quote attributed to famed American industrialist Henry Ford. This aphorism may well be used to describe the model of multi-disciplinary error reporting and incident investigation described by Jeff Martin of Birmingham Children’s Hospital at the Seminar on “Improving patient safety through multidisciplinary teamwork”.

A potted history of conceptual thinking on adverse events

Jeff described to Congress attendees the historical progress in safety culture: from a pre-enlightenment dominating view that tragic events were the will of God, to a post enlightenment understanding that such incidents could be the result of accident or random incident. In more modern times, from the 1970s onwards, media attention and political scrutiny on fatal accidents, combined with management study focus, had highlighted where risks were being inappropriately managed and improvement opportunities could be identified.

The need for a ‘fair accountability’ culture

In the UK, the 1990s and 2000s had revealed an additional need to find ways to help professionals within large organisations, such as the NHS, to overcome fears of attracting blame when reporting safety incidents. This included blame not just from internal management, but also potentially from the media and legal authorities in the case of more serious adverse events. Consequently, efforts are being made across the health system to establish a “fair accountability culture”. This is now supported by guidance and good practice from health professional regulators, as well as employer initiatives, and includes a strong onus on detecting system and process issues that can make human error more likely.

More than one victim from an incident

Jeff went on to describe the need for understanding that often, when an adverse incident does occur, there is more than one victim. As well as the patient, it should be acknowledged that close family and carers must also be understood as affected parties. Finally, healthcare professionals themselves can often be discovered to suffer symptoms of deep shock about an incident they may have been involved in, reliving the event repeatedly. The needs of all impacted persons from an incident should be appreciated and met.

Categorising reported incidents by risk and harm

For any incident reporting system to work effectively, the target group of individuals expected to report must receive feedback from their reports and evidence that the reports are making a positive difference. Without this, levels of reporting can be seen to consistently fall over time. Jeff therefore described what happens to reports of incidents in the context of Birmingham Childrens’ Hospital (BCH). Reports are categorized according to the level of harm, and the risk level associated with the incident, which enables a matrix scoring system to be used in order to rank the incident. Most reports of incidents are of low risk/low harm, but those that fall into the category of high risk and/or high harm can be prioritized accordingly.

Incident investigation and reporting BCH uses an incident investigation flowchart to direct how each incident reported should be treated, and by whom, and what forms of feedback are provided. The system makes use of a classification system developed in the USA by the National Coordinating Council for Medication Error Reporting that seeks to overcome some the subjective interpretation barriers that can arise when considering what constitutes ‘harm’ and ‘error’.

The experience of data collection on incidents that BCH has now accumulated enables analysis of where incidents are originating from, with administration and prescribing error the most common forms. Looking further into this latter area, it can be seen that incomplete information on the prescription and overdosing are the most common types of prescription error.

The multi-disciplinary aspect

BCH takes particular care to employ multi-disciplinary teams in the investigation of incidents, which improves their effectiveness from an enhanced understanding of all aspects of the medication process, from prescription through to dispensing, to administration. The implementation of changes related to incident reports and feedback is conducted using a ‘post heroic’ model of leadership, or in other words, the concept of leadership at many levels (e.g. within the nursing team, pharmacy team, prescribing team etc.).

For the closing keynote speech, EAHP was delighted to welcome nuclear safety expert Howard Bergendahl to expand on the lessons in improving safety in the nuclear industry that might be transferred to the healthcare sector.

A review of safety incidents in the airline industry in the 1970s had starkly revealed the level to which miscommunication could be a serious source of adverse incidents and events. However, with proper foresight and planning, most error situations can be seen to

be predictable, manageable and preventable.Error hazard is human in nature. With an understanding of how humans make errors, error precursors can be identified. These include stress, time pressure, multi-tasking and imprecise communication.

Certain adaptions in behavior can help prevent error such as taking a questioning attitude to tasks, and stopping when uncertain or unsure. Pre task briefings and timeouts are other helpful behaviors in preventing error.

Another important factor in safety is organizational attitudes. The space shuttle Columbia disaster could be highlighted as a case study of when becoming comfortable with a commonly presented risk could be a very damaging mindset to enter into. A leadership commitment to safety culture is vital, and that commitment should ideally be to zero incidents.

Demonstration that a safety culture may be in place within an organization includes evidence of a questioning attitude by employees. “Are you sure?”, “What do you think?”

Practical Pharmaceuticstextbook

Keynote 3 - Howard W. Bergendahl

The Practical Pharmaceutics textbook contains essential knowledge on the preparation, control, logistics, dispensing, and use of medicines. It features chapters written by experienced pharmacists working in hospitals and academia throughout Europe, complete with practical examples as well as information on current EU-legislation.

This book is an essential reference for any pharmacy engaged in preparation activities and for any student attempting to study the practicalities and legality behind this essential function of pharmacies.

For more information visit: www.eahp.eu/publications/textbookPractPharm

This project is financed by the EAHP and the Dutch

1Bouwm

an-Boer · Fenton-May · Le Brun Eds.

Yvonne Bouwman-Boer · V‘Iain Fenton-May · Paul Le Brun Editors

Practical PharmaceuticsAn international guideline for the preparation, care and use of medicinal products

Practical Pharmaceutics

Yvonne Bouwman-BoerV‘Iain Fenton-MayPaul Le Brun Editors

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Practical Pharmaceutics

This book contains essential knowledge on the preparation, control, logistics, dispensing, and use of medicines. It features chapters written by experienced pharmacists working in hospitals and academia throughout Europe, complete with practical examples as well as information on current EU-legislation.From prescription to production, from usage instructions to procurement and the impact of medicines on the environment, the book provides step-by-step coverage that will help a wide range of readers. It offers product knowledge for all pharmacists working directly with patients, and it will enable them to make the appropriate medicine available, to store medicines properly, to adapt medicines if nec-essary, and to dispense medicines with the appropriate information to inform patients and caregivers about product care and how to maintain their quality. This basic knowledge will also be of help to industrial pharmacists to remind and focus them on the application of the medicines manufactured.The basic and practical knowledge on the design, preparation and quality management of medicines can directly be applied by the pharmacists whose main duty is production in community and hospital pharmacies and industries. Undergraduate as well as graduate pharmacy students will fi nd knowledge and backgrounds in a fully coherent way and fully supported with examples.

ISBN 978-0-000-00000-2

An international guideline for the preparation,care and use of medicinal products

Safety in high reliability industries - What healthcare professionals can learn

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European Journal ofHospital Pharmacy

ejhp.bmj.com

The European Journal of Hospital Pharmacy (EJHP) continues to evolve,offering quality content to help your daily practice, improve your generaland specific knowledge of evidence-based practice, and give you sometools to support your activities.

By concentrating on evidence-based content, EJHP now carries crucialresearch on what hospital pharmacists discover in the daily care ofpatients, highlighting how to translate the evidence to individualpatients and therefore be of great use to the hospital pharmacist.

Read EJHP for thought-provoking editorials, catch up on new research,understand the evidence, and to find out how it can improve your clinical practice.

WHAT’S NEW IN EJHP?We have added a whole host of features to the journal in line with thecontinuing development of this essential resource:

• New medicines information section

• Each issue contains a special report on evidence based pharmacy

• Themed issues focus on topics that are important to the hospital pharmacist

• Key research addressing the needs of clinical pharmacists

THE ONLY OFFICIAL JOURNAL OF EAHP

HELPING HOSPITALPHARMACISTS PROVIDE BETTERPATIENT CARE

INVITATION TO CONTRIBUTEWhy submit your work to EJHP?

• Quality: The journal concentrates on evidence-based research and therefore publishes practical and innovative content to directly help pharmacists

• Reach: the journal is distributed to over 15,000 pharmacists in 32 countries

• Speed: Time from acceptance to online publication is 19 days

• Prestige: EJHP is the only official journal of European Association of Hospital Pharmacists

HELP SHAPE THE PRACTICE OF HOSPITAL PHARMACYAND SUBMIT YOUR ARTICLE TO THE PREMIER JOURNALIN HOSPITAL PHARMACY.To find out more, take a look at what type of articles we are looking for and submit online.

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The current strategic plan of the German Association of Hospital Pharmacists (ADKA) pays particular attention to safety and quality of drug treatment, drug information, educational matters, preparation of medicinal products, pharmaceutical logistics and finance. The German approach combines the traditional tasks of pharmaceutical logistics and drug preparation with patient-oriented clinical services including pharmacoeconomic aspects.

Drug information service, KAMPI

Since 2004 ADKA has hosted and developed an internet-based documentation tool, the ADKA Drug Information database, which encourages systematic documentation of enquiries, search strategies and answers to reduce cost and personal resources while intensifying interdisciplinary team work within the hospital. Since 2011 a sharing platform has been built to actively share information. In 2014 KAMPI was established to train and support ADKA members, especially small hospital pharmacies, in their drug information activities by counselling on research strategies, answering complex enquiries and adding them to the sharing platform.

Antibiotic stewardship (ABS)

German hospital pharmacists are engaged in ABS firstly because there are unmet needs, lack of innovation and suboptimal use of antimicrobial drugs. Secondly, there is good evidence that ABS programmes have positive

outcomes in quality of treatment and costs, and thirdly some of their duties are legal obligations. The main activities undertaken by members of the ADKA have been educational, teaching physicians and pharmacists antimicrobial stewardship and infectiology. They were also represented in a German/Austrian working group that published the ABS Guideline in 2013. Furthermore there is the nationwide ADKA-if-RKI project that documents antibiotic consumption.

Closed loop of medicines administration (CLMA), seamless care

Essential requirements for CLMA are physician order entry, pharmacy validation, unit-dose supply and electronic documentation of drug administration. However, the average level of electronic medical record capabilities in Germany is comparatively low and fewer than 2% of German hospitals have introduced unit doses. ADKA is committed to creating the conditions for CLMA. An example of the successful implementation is the UKE (with 1,400 patients being treated in a paperless process with over 10,000 units daily). Clinical pharmacists visit 70 wards daily and check all new prescriptions. A huge number of seamless care projects all over Germany show that the involvement of clinical pharmacists can increase medication safety at the interfaces of in- and outpatient treatment.

Clinical pharmacist interventions for patient safety

With ADKA-DokuPIK (www.adka-dokupik.de) German hospital pharmacists established a self-reported, internet-based documentation system for pharmacists’ interventions (PIs) as well as medication errors (ME). About one quarter of interventions are due to inappropriate use of drugs, followed by wrong dose or administration interval. The vast majority of suggested PIs are implemented resulting in optimised drug treatment. With DokuPIK, we have a valuable instrument adding value to clinical pharmacists’ services - recently translated into English.

Education/teacher practitioner

German hospital pharmacists are involved in undergraduate teaching, bedside teaching and problem-based learning. Objective structured clinical examination has become more important to assess the students’ competencies and teacher practitioner posts have been created for clinical pharmacy.

Postgraduate studies include a three-year course that now includes the ongoing documentation of practical skills in relevant areas of clinical pharmacy. Moreover, the number of PhD students in hospital pharmacy has increased; there is now an annual meeting including short communications to enhance mutual exchange.

Highlights of German Hospital Pharmacy

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One of the most exciting parts of the EAHP congress every year is the recognition of outstanding scientific research in the hospital pharmacy field. This year was no exception and the posters accepted represented the best research in topics such as medicines production, pharmacokinetics, clinical pharmacy, patient safety and drug information. This year 535 posters were presented

at the congress and the winner’s are described below.

3rd Prize was awarded to Carlota Salazar (Spain) with the poster titled, “Parenteral Nutrition (PN) in premature infants: risk analysis after redesigning a production process.” In an attempt to reduce the risk associated with this pharmacy service a process redesign took place and the reduction in risk was quantified using the FMECA analysis technique. The incorporation of electronic prescribing, biochemical controls and a second check at various points allowed for a 65.5% risk reduction in this critical hospital pharmacy process.

Salazar, C., et al., PS-042 Parenteral nutrition (PN) in premature infants: risk analysis after redesigning a production process. European Journal of Hospital Pharmacy, 2015. 22(Suppl 1): p. A158-A159

2nd Prize was awarded to Rianne Zaal (the Netherlands) with the poster titled, “Evaluation of a systematic tool to reduce inappropriate prescribing (STRIP) in adults with intellectual disability: a pilot”. The systematic tool was piloted in an attempt to reduce polypharmacy in the intellectually disabled patient population. Following 27 medication reviews the involvement of

legal representatives, caregivers was high, drug related problems were identified and costs were reduced. Unfortunately a low proportion of interventions were accepted within 6 months after the review.

Zaal, R., et al., PS-046 - Evaluation of a systematic tool to reduce inappropriate prescribing (STRIP) in adults with intellectual disability: a pilot study. European Journal of Hospital Pharmacy, 2015. 22(Suppl 1): p. A160.

1st Prize was awarded to Natalia Navas Iglesias with the poster titled, “Long term stability of diluted solutions of the monoclonal antibody infliximab.” This stability of this TNF alpha inhibitor used to treat a number of conditions including rheumatoid arthritis, crohn’s disease and ulcerative colitis was assessed in preparations of sodium chloride 0.9% solution at 4°C and -20° C. A notable loss (50%) of biological activity was seen after the second day of reconstitution.

Suárez González, I., et al., PP-028 - Long-term stability of diluted solutions of the monoclonal antibody infliximab. European Journal of Hospital Pharmacy, 2015. 22 (Suppl 1): p. A131-A132.

The 1st prize for the Good Practice Initiatives (GPIs) was awarded to Patricia Ging (Ireland) for the GPI titled, “Innovating and collaborating synergy between the hospital pharmacy and the University. In Section 6: Education and Research this GPI was selected because of the good model partnership encouraging students to consider hospital pharmacy as a career and improve the professional identity of the hospital pharmacist. Positive student feedback was received and no

additional costs were required. Now it is being shared with other hospitals/universities in the country – that is what we call a Good Practice Initiative!

The EAHP-EPSA student science award was presented to Claudine Aziz (Ireland) with the title, “Compliance with the health information and quality authority of Ireland national standard for patient discharge summary information: a retrospective study in Secondary Care.” In an attempt to reduce the discrepancies of patient discharge and following the national guidance on the issue an audit was conducted to compare against the national standard. A high number of discharge summaries contained inconsistencies (73.7%), only 2% had clear allergy information documented and overall a compliance with the standard was 79.5%. The student researcher concluded that the quality of discharge summaries was inadequate and increased compliance with the national standard will improve communication across the interface of patient care.

Poster & GPI prize winners

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“Hospital pharmacists taking the lead - partnerships and technologies”

16 -18 March 2016, Vienna, Austria

OFFICIAL CONGRESS LANGUAGE : ENGLISH

Registration opens 1st August 2015Abstract submission deadline: 15th October 2015

#EAHP16

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EAHP appreciates the continued support of : Bayer HealthCare and Roche, Platinum Partners - Amgen and Novartis Oncology, Gold Partners - Pfizer and Baxter, Corporate PartnersTHE EUROPEAN ASSOCIATION OF HOSPITAL PHARMACISTS REPRESENTS MORE THAN 16,000 HOSPITAL PHARMACISTS IN 34 EUROPEAN COUNTRIES AND IS THE ONLY EUROPEAN ASSOCIATION OF NATIONAL ORGANISATIONS REPRESENTING HOSPITAL PHARMACISTS AT EUROPEAN AND INTERNATIONAL LEVELS.

The European Association of Hospital Pharmacists (EAHP) is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education

INFORMATION: CONGRESS SECRETARIAT

TEL: +32 (0)2/741.68.22 +32 (0)2/741.68.21 FAX: +32 (0)2/734.79.10EMAIL: [email protected]: WWW.EAHP.EU

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