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Objective. Intrahepatic cholestasis of pregnancy (ICP) significantly impacts the maternal and fetal safety. Research on the role of clinical pharmacists in guiding drug therapy for this condition remains limited. This study aimed to evaluate the effectiveness of graded pharmaceutical care for women with intrahepatic cholestasis of pregnancy and to provide a theoretical foundation for clinical pharmacist services. Study Design. This study comprises a pre‐and‐post analysis of women with intrahepatic cholestasis of pregnancy (ICP) treated between December 2019 and June 2023 at a tertiary hospital in Jiangsu province. Each group consisted of 102 participants. The control group received standard treatment, while the guardianship group received graded pharmacological care provided by a clinical pharmacist. The effectiveness of pharmacological monitoring by clinical pharmacists was assessed by comparing and analyzing clinical outcome indicators, quality management indicators, safety indicators, and economic factors. Results. The guardianship group exhibited a noteworthy 12.8% reduction in combined adverse pregnancy outcome and more effective management of total prenatal bile acids compared to the control group (16.05 µmol/L vs. 22.85 µmol/L, P < 0.05). The guardianship group displayed superior rationalization of therapeutic drugs and medication duration (P < 0.05). The cost‐benefit analysis revealed a favorable economic impact concerning medication costs but did not indicate economic significance regarding total inpatient costs. Conclusion. The implementation of a graded pharmaceutical care model by a clinical pharmacist holds the potential to enhance outcomes for women experiencing intrahepatic cholestasis during pregnancy, mitigate adverse pregnancy results, optimize the rational utilization of therapeutic medications, and yield positive economic results. [ABSTRACT FROM AUTHOR]

What is known and objective: Unintentional medication discrepancies (UMDs) are common in geriatric patients during care transitions, resulting in frequent undesirable consequences. Medication reconciliation could be a useful practice to prevent or ameliorate UMD. However, this practice in Vietnamese hospitals has not been well established or standardized. This study aims to determine the effect of pharmacist‐initiated educational interventions on improving medication reconciliation practice. Methods: This prospective 6‐month pre‐and post‐study was conducted in two internal medicine wards in a Vietnamese 800‐bed public hospital. Pharmacists provided training and short‐term support to physicians on medication reconciliation. Primary outcome measures were the proportions of patients with at least one UMD at admission. Secondary outcome measures were the proportions of patients with preventable adverse drug events (pADEs) score ≥0.1 due to these UMDs. Odds ratio and 95% confidence intervals were assessed based on a multivariate logistic regression model. Results and discussion: One hundred fifty‐two patients were recruited in the pre‐intervention phase, and 146 in the post‐intervention phase. Following the intervention, the proportion of geriatric patients with ≥1 UMD at admission significantly decreased from 55.3 to 25.3 % (ORadj 0.255, 95% CI: 0.151–0.431). Similarly, the proportion of patients with a pADE ≥0.1 at admission reduced from 44.1 to 11.6% [ORadj 0.188, 95% CI: 0.105–0.340] post‐intervention. What is new and conclusion: Our pharmacist‐initiated educational interventions have demonstrated the ability to produce substantial improvement in medication reconciliation practice, reducing UMDs and potential harm. Our approach may provide an alternate option to implement medication reconciliation for jurisdictions with limited healthcare resources. [ABSTRACT FROM AUTHOR]

What Is Known and Objective: Immune‐mediated inflammatory diseases (IMIDs) are a group of chronic and highly disabling diseases. The objective is to evaluate the satisfaction with the health care received by patients with the most prevalent IMIDs in Spain: inflammatory bowel disease (IBD), psoriasis (Ps) psoriatic arthritis (PsA), rheumatoid arthritis (RA) and spondyloarthropathies (SpAs), and to determine the factors that influence patient satisfaction. Methods: This was an observational, cross‐sectional, multicentre study in a real‐world evidence context conducted in the Pharmacy Service in four hospital centres of the Community of Madrid that belong to the National Health System. The study included adult patients diagnosed with an IMID who had attended the Pharmacy Service at least three times. The patients were grouped according to the main IMID. Health care satisfaction was evaluated using the chronic patient experience assessment (IEXPAC) questionnaire. The responses to IEXPAC are grouped into three factors: productive interactions, new relational model and patient self‐management, with a total score from 0 (worst) to 10 (best experience). Health‐related quality of life (HRQoL) was also evaluated using the EQ‐5D‐5L questionnaire, and pharmacological adherence was evaluated through the Morisky‐Green test. Results and Discussion: A total of 578 patients were analysed (IBD = 25.3%; Ps = 19.7%; SpAs = 18.7%; RA = 18.5%; PsA = 17.8%). The mean age (SD) was 49.8 (12.3) years and 50.7% were male. The average score (SD) for the total IEXPAC sample was 6.6 (1.9). RA was the IMID with the lowest score, at 5.83 (2.0), significantly lower than the scores of Ps (SD) [7.01 (1.7); p = 0.003], IBD [6.83 (1, 9); p = 0.012] and SpAs [6.80 (1.6); p = 0.001]. Productive interactions (SD) [8.5 (1.8)] and patient self‐management (SD) [7.3 (2.3)] were the factors with the highest scores, and the new relational model had the lowest score (SD) [3.2 (2.7)]. Male gender, a longer time interval between medication administrations and a higher HRQoL were correlated with better patient satisfaction. Current biological therapy (according to the Anatomical Chemical classification system) also had a significant influence; patients treated with tumour necrosis factor inhibitors and interleukin inhibitors showed greater satisfaction than those treated with selective immunosuppressants. What Is New and Conclusion: The IEXPAC results show high general satisfaction with care quality reported by patients with IMIDs treated in the Pharmacy Service. However, there are areas of improvement in care quality specially health professional–patient communication, such as increasing access to information, and promoting and facilitating relationships with patients in similar conditions. [ABSTRACT FROM AUTHOR]

What is Known and Objective: The scope of clinical pharmacy services has changed during COVID‐19 pandemic with the view to mitigating both exposure and spread of the virus. The performance of novel pandemic‐driven services such as tele‐pharmacy has remained unexplored, until now. The aim of this study is to investigate the perceptions of healthcare providers of the impact of tele‐pharmacy services provided in critical care units during COVID‐19. Methods: A qualitative study of semi‐structured interviews conducted with healthcare practitioners who worked in COVID‐19 intensive care units and remotely interacted with clinical pharmacists at the Weill Cornell‐affiliated Hamad Medical Corporation, Doha, Qatar. Random sampling technique was employed to recruit participants, with the resultant interview guide piloted before commencement of data collection process. Results and Discussion: From a total 129 and 200 physicians and nurses, respectively, 20 interviews were conducted with physicians (n = 15), and nurses (n = 5). From these interactions, a number of major themes emerged including: satisfactory understanding across clinical environment and personnel (physician and nurses) about remote clinical pharmacists' roles; additional robust feedback on the perception of the remote clinical pharmacy service; an understanding by 'frontline' health personnel on the discernible differences between remote and in‐person coverage of clinical pharmacists; a reflection by both physicians and nurses on the novel challenges involved in the implementation of such pandemic‐driven service; and solutions to overcome these challenges. What is New and Conclusion: In this novel qualitative study of pandemic‐driven tele‐pharmacy service, we found a positive perception amongst healthcare practitioners towards this service; with residual challenges that will need further evaluation by large sampled sized surveys or mixed methods research. [ABSTRACT FROM AUTHOR]

What is known and objective: New pharmacy curricula include content that equip students with a bundle of professional and interpersonal skills that allows the provision of evidence‐based patient‐centred pharmaceutical care (PC). PC has been adopted as a practise model underpinning these new roles for pharmacists in developed countries. However, anecdotal evidence suggests that countries in the Middle East/North Africa (MENA) region have been relatively slow in including PC in pharmacy education. There seems to be a need to more accurately describe the extent to which PC is included in pharmacy education in the MENA region. The objective of this systematic review was (a) to determine the status of PC education in schools and colleges of pharmacy in the MENA region and (b) to identify pharmacy students' and/or educators' perceptions and attitudes towards PC, preparedness level to PC provision and perceived barriers to implement this practise model in countries of the MENA region. Methods: A comprehensive literature search was conducted using MEDLINE, EMBASE, SCOPUS, International Pharmaceutical Abstract and ProQuest databases to identify articles published from 2000 to 2021. Selection of studies for inclusion in the review was based on a pre‐determined eligibility criterion to retrieve original research articles addressing the review objectives. Results: Nine articles were eligible for inclusion in the review. The majority of the studies (n = 8) employed a survey‐based research method. The studies were conducted in Jordan (n = 4), Kuwait (n = 2), Qatar (n = 2), Saudi Arabia (n = 1) and United Arab Emirates (n = 1). The findings suggest that pharmacy students had overall positive attitude and perception towards PC and some studies reported that students expressed good preparedness levels to implement most of the PC aspects. Several barriers to the implementation of PC were reported such as the slow educational reforms in pharmacy programs and a number of organizational and professional barriers. The studies provided recommendations for improvements in the pharmacy curricula to support pharmacy students' preparation to become competent PC practitioners. What is new and conclusion: The literature describing PC education in the MENA region is limited. Joint efforts among educational institutions and health authorities are needed to support PC implementation. There is a need to conduct further research to explore the status of PC education and practise in the different countries within the MENA region. This can drive future directions of pharmacy education to meet the needs of the pharmacy profession and healthcare systems in these countries. [ABSTRACT FROM AUTHOR]

What is known and objective: The Diabetes MedsCheck (DMC) pharmacist service improves patient medication use and provides education on diabetes self‐management. The original 2012 program evaluation identified barriers and facilitators in implementation. There are no recent studies exploring pharmacists' experiences with the DMC service. This pilot study may contribute to achieving an optimal diabetes management service in Australia. To explore the experiences of community pharmacists in providing the DMC service. Methods: A purposive sampling approach was used to recruit practising Australian community pharmacists from July to December 2019. Inclusion criteria included provision of DMC service for more than 1 year and having delivered the service within 3 months of recruitment. Semi‐structured interviews elicited pharmacists' experience with the DMC service. Results and discussion: Twelve interviews of community pharmacist owners, managers and employees (including three who had additional medication review and diabetes qualifications), resulted in four primary themes: benefit of and need for training in diabetes management, challenges of service delivery and implementation, the challenge of patients' diabetes management and the positive effect of DMC on pharmacists' professional satisfaction from the positive impact on patient interactions and diabetes management. Pharmacists highlighted the need for continuous training on diabetes management and patient communication, and a dedicated time and space for service provision for optimal implementation and delivery of DMC. DMC helped to fulfil pharmacists' desires to provide health care. Pharmacists perceived through patient engagement and patient feedback that DMC benefits patient health care. What is new and conclusion: Positively, the implementation of the DMC service has promoted engagement with other health professionals while also contributing to pharmacists' professional satisfaction. Patient satisfaction and awareness of the health knowledge that pharmacists provide promotes pharmacist capabilities to the public. To ensure that accessible diabetes care in community pharmacy is optimized for greatest patient care, pharmacists delivering DMC should be supported by provision of contemporary diabetes management training and communication skills. Additional investment in community pharmacy operational set‐up, such as dedicated pharmacist time, dedicated consulting space, upskilling of staff and investment in technology is also required to support optimal delivery of DMC. [ABSTRACT FROM AUTHOR]

What is known and objective: Pharmacotherapy is an essential strategy for the treatment of many medical conditions especially chronic disease and often involves multiple medications being used simultaneously. Increasing the use of medications may pose some challenges to safe and effective drug therapy and if not identified and prevented by the pharmacists eventually can lead to drug‐related problems (DRPs). The present study aimed to examine the incidence of DRPs in Iranian patients and to evaluate patients' adherence to the clinical pharmacist interventions as well as the physicians' acceptance of these recommendations. Methods: This study was conducted in a university‐affiliated outpatient pharmacotherapy clinic over a 22‐month period. Patients aged 18 years and older with at least one chronic disease receiving at least four medications were included in the study. The patients were interviewed by a clinical pharmacist for comprehensive medication review. DRPs were identified using the DOCUMENT classification system. Recommendations were provided by the clinical pharmacist including interventions involving patient and/or physician to resolve DRPs. The patients were followed up after 2 weeks to evaluate their compliance and physician acceptance of clinical pharmacist recommendations. Results and discussion: Two hundred patients were included in this study. Overall, 875 DRPs were identified with an average of 4.37 per patient. The most prevalent DRPs were related to patient education or information (22.8%), undertreated indications (17.4%) and patient compliance (17.2%). The most common drugs associated with DRPs were alimentary and metabolism (22.2% of DRPs) followed by the cardiovascular system (19.2%) and nervous system (9.6%) medications. The DRP incidence correlated with gender only and was higher in females (p = 0.019). The clinical pharmacist provided 912 interventions with an average of 4.56 and 1.04 interventions per patient and per DRPs respectively. Patient education (41.3%), medication initiation or discontinuation (24.5%), and non‐pharmacological interventions (12.9%) were the most common clinical pharmacist interventions. Out of 912 interventions, 665 were followed up, out of which 427 were patient dependent and 228 involved physicians. The patient's compliance with clinical pharmacist recommendations was 81.2%. The physician acceptance rate of the recommendations was 44.1%. What is new and conclusion: The study shows that especially designed services such as pharmacotherapy clinics running by clinical pharmacists are necessary to detect and resolve DRPs in an effective way. The high compliance rate of the patients indicates patients' confidence in the clinical pharmacist services provided in the pharmacotherapy clinic. The low acceptance rate of the physicians highlights the need to improve interprofessional collaboration between clinical pharmacists and physicians in an outpatient setting. [ABSTRACT FROM AUTHOR]

What is known and objective: The pharmacist's role has evolved dramatically over the last few decades and shows considerable impact globally. The aim of this systematic review was to describe the nature and extent of studies evaluating the impact of pharmacist‐provided services on clinical, humanistic and economic outcomes in different healthcare settings across the Arab world. Methods: A systematic literature search was conducted using the following databases from their inception until June 2020: Cochrane, Embase, MEDLINE, PubMed, ScienceDirect and Scopus. Reporting was done according to PRISMA guidelines, and the quality assessment utilized the Mixed Methods Appraisal Tool. Results and discussion: Thirty‐five eligible studies were included in this review, the majority of which were randomized controlled trials (RCT) (n = 26) conducted in hospital settings (n = 26). Most of the studies involved patients with specific medical conditions (n = 29) and pharmacist's interventions involved mainly medication therapy management (n = 32), counselling and education (n = 29), and medication therapy recommendations (n = 12). Several studies showed a positive impact (i.e., a statistically and/or clinically significant difference in favour of pharmacist‐provided care or intervention) of pharmacist‐provided services on clinical (n = 28), humanistic (n = 6) and economic (n = 5) outcomes. Conversely, five studies showed neutral or mixed effect of pharmacist interventions on clinical and humanistic outcomes. What is new and conclusion: The findings of this systematic review demonstrate a positive impact of pharmacist‐provided services on clinical, humanistic and economic outcomes across diverse settings in the Arab world. Most of the included studies evaluated clinical outcomes and were from hospital setting. Directed approaches are needed to advance pharmacy practice across various healthcare settings in the Arab world. [ABSTRACT FROM AUTHOR]

What is known and objective: The orthogeriatric path (hip‐fractured elderly patients) is composed of several transition points (emergency surgery, orthopaedic, geriatric and rehabilitation units). The intervention of clinical pharmacists can ensure the continuity of patients' drug management during their hospital stay. The aim of the study was to assess the implementation of clinical pharmacy activities in an orthogeriatric pathway, regarding its impact on medication error prevention, the healthcare professionals' and patients' satisfaction, and the estimated associated pharmaceutical workload. Methods: Participants were aged 75 or older and managed for proximal femoral fracture. Their admission prescription was reviewed. If they were evaluated at high risk of adverse event (AE), medication reconciliation (MedRec) and pharmaceutical interviews (admission, discharge, and targeted on oral anticoagulant) were added at different steps of their care pathway. The achievement and duration of each clinical pharmacy activity were recorded. The number of pharmaceutical interventions (PI) made during prescription review, and unintentional discrepancies (UID) identified during MedRec were collected. A satisfaction questionnaire was sent to patients and healthcare professionals. Results and discussion: Among 455 included patients, 284 patients were considered at high risk of AE. Clinical pharmacy activity achievement rates varied between 12% and 98%. A total of 622 PI and 333 UID were identified. The overall patients' and healthcare professionals' satisfaction was rated from 63% to 100%. The total workload was estimated at 376 h: on average 16 min per prescription review, 43 min per admission MedRec, 26 min per discharge MedRec and 17 to 25 minutes per interview. Conclusion: The implementation of the programme showed a high potential of drug management securing. To sustain it, additional pharmaceutical human resources and high‐performance computing tools are needed. [ABSTRACT FROM AUTHOR]

What is known and Objective: Clinical pharmacists' involvement in the care of solid organ transplant recipients has been discussed worldwide given its potential to improve clinical outcomes. As thoracic transplant activity grows in Brazil, it is important to understand how pharmacists are inserted in transplant programmes nationwide. We conducted a survey to explore clinical pharmacy activities in thoracic transplant centres in Brazil and compared them with accredited programmes in the United States. Methods: An electronic questionnaire was distributed to all 40 heart and lung transplant centres registered in the Brazilian Organ Transplantation Agency (ABTO) in May 2019. Survey findings were compared to previously published data from accredited U.S. centres. Results and Discussion: From 22 centre respondents, ten (45.5%) declared not to have a pharmacist at any part of the transplantation process, which translated into 158 (37.6%) transplant recipients without any direct pharmaceutical care. In centres with pharmacists (n = 12), none had a full‐time professional dedicated to their heart and/or lung programmes. When compared to U.S. centres, there was a significantly lower insertion of clinical pharmacist activities among Brazilian centres. What is new and Conclusion: Our findings point to an unmet need related to clinical pharmacy activity within thoracic transplant programmes, especially in a developing country, and highlight a call for action in order to reach higher accredited regulatory standards regarding pharmacist‐driven workforce in transplant care worldwide. [ABSTRACT FROM AUTHOR]

What is known and objective: Paediatric intensive care patients are at high risk for prescription errors due to the more complex process of medication prescribing. Clinical decision support systems (CDSS) have shown good results in effectively reducing prescription errors. A specific dosing CDSS was developed that can check and suggest normal dose, dose limits and administration frequencies. This study aimed to assess the effect of this CDSS on protocol deviation (as measure of prescription error) types and frequency in a paediatric intensive care unit (PICU). Methods: A retrospective observational study was conducted evaluating 9342 prescriptions in a 4‐month period before and after the implementation of a CDSS in the PICU of the University Medical Center Utrecht. Medication forms were reviewed to identify protocol deviations (and therefore possible prescription errors). The incidence and nature of deviations from evidence‐based protocols that were unintended and needed to be adjusted, were determined. Results and discussion: In the period before the dosing CDSS, we identified 45 protocol deviations in 5034 prescriptions (0.89%), 28 of which could not be justified (0.56%) and 11 needed to be adjusted (0.22%). In the period after the implementation of the CDSS, there were 21 protocol deviations in 4308 prescriptions (0.49%) of which ten without a valid reason (0.23%) of which two were adjusted (0.05%). What is new and conclusion: The specific dosing CDSS was able to significantly reduce unintentional prescription dose deviations and the number of prescriptions that needed to be adjusted, in an existing low incidence situation. [ABSTRACT FROM AUTHOR]

What is known and Objective: Donor agencies provide most of the funds for HIV services in developing countries. Due to the global economic downturn, there has been a reduction in funding for HIV‐related services in Nigeria. This study compared the willingness to pay (WTP)‐willingness to accept (WTA) ratios for prevention of mother‐to‐child transmission (PMTCT) services to specialized clinical pharmacy services among patients of two Nigerian hospitals. Methods: This was a cross‐sectional survey using contingent valuation method at Ahmadu Bello University Teaching Hospital (ABUTH) and University of Nigeria Teaching Hospital (UNTH). WTP and WTA were elicited using an interviewer‐administered questionnaire and a payment card. The responses to the WTP and WTA questions were reported as frequencies and percentages, while the amounts were determined as mean. All costs were obtained in Nigerian Naira (N360 = $1). Results and Discussion: Of the 219 mothers who participated in the study, 172 (78.5%) had no health insurance. Primary prevention of HIV (PPV) had the highest "yes" WTP response of 152 (69.4%) and the highest mean WTP amount of N6067.20. It also had the least "no" WTA response of 162 (74.0%) and the least WTA amount of N232.09. Specialized clinical pharmacy service (SCPS) had the highest WTA/WTP ratio of 4.0826 in ABUTH and 9.3750 at UNTH. Its income effect was −3.0826. A 1% increase in income led to 0.0550 (95% CI: −0.3068 to 0.1968) decreased odds to pay for PPV. What is new and Conclusion: Most patients assessed in this study were willing to pay for PPV than other services. Majority of them were also willing to forgo PMTCT Drugs Only. SCPS had the highest value for the patients, but they did not want to pay a high amount for it. Employment status, health insurance status, educational level and age were predictors of patients' WTP and WTA. [ABSTRACT FROM AUTHOR]

What is known and Objective: There is no optimal standardized model in the transfer of care between hospitals and primary healthcare facilities. Transfer of care is a critical point during which unintentional discrepancies, that can jeopardize pharmacotherapy outcomes, can occur. The objective was to determine the effect that an integrated medication reconciliation model has on the reduction of the number of post‐discharge unintentional discrepancies. Methods: A randomized controlled study was conducted on an elderly patient population. The intervention group of patients received a medication reconciliation model, led entirely by a hospital clinical pharmacist (medication reconciliation at admission, review and optimization of pharmacotherapy during hospitalization, patient education and counselling, medication reconciliation at discharge, medication reconciliation as part of primary health care in collaboration with a primary care physician and a community pharmacist). Unintentional discrepancies were identified by comparing the medications listed on the discharge summary with the first list of medications prescribed and issued at primary care level, immediately after discharge. The main outcome measures were incidence, type and potential severity of post‐discharge unintentional discrepancies. Results and discussion: A total of 353 patients were analysed (182 in the intervention and 171 in the control group). The medication reconciliation model, led by a hospital clinical pharmacist, significantly reduced the number of patients with unintentional discrepancies by 57.1% (p < 0.001). The intervention reduced the number of patients with unintentional discrepancies associated with a potential moderate harm by 58.6% (p < 0.001) and those associated with a potential severe harm by 68.6% (p = 0.039). The most common discrepancies were incorrect dosage, drug omission and drug commission. Cardiovascular medications were most commonly involved in unintentional discrepancies. What is new and Conclusion: The integrated medication reconciliation model, led by a hospital clinical pharmacist in collaboration with all health professionals involved in the patient's pharmacotherapy and treatment, significantly reduced unintentional discrepancies in the transfer of care. [ABSTRACT FROM AUTHOR]

What is known and objective: Even if total joint arthroplasty (TJA) patients have received conventional antithrombotic therapy, the incidence of thrombosis remains high. Clinical pharmacists have been involved in the multidisciplinary team of orthopaedics, but their roles and functions are not yet defined. The objective of this study was to assess the impact of clinical pharmacist services on the use of anticoagulant drugs, the rationality of medication and the incidence of thrombosis in patients with TJA. Methods: This retrospective, observational cohort study was conducted for patients undergoing TJA procedures. Study variables were collected for a baseline period of 1 January 2016 to 30 June 2017 and an intervention period of 1 January 2018 to 30 June 2019, allowing for a 6‐month run‐in period. For demographic characteristics, the use of anticoagulant drugs and the incidence of thrombosis between the baseline and intervention periods, the data were statistically analysed. Results and discussion: During the 36‐month study timeframe, a total of 591 TJA procedures were performed. A total of 577 participants were included in the study (240 in the baseline group and 377 in the intervention group). After clinical pharmacist participation, the prevention rate of anticoagulant drugs (p < 0.05), the proportion of oral anticoagulants (p = 0.000) and the course of preventive treatment (p = 0.004) increased significantly. The time of administration was shortened from after 24 h to within 24 h post‐surgery (p = 0.000). Although the incidence of symptomatic DVT reduced in the intervention period, there was no statistical difference in either the hospital, 1‐month follow‐up, or 3‐month follow‐up after surgery (all p > 0.05). What is new and conclusion: Within the limitations of a retrospective study, clinical pharmacist intervention was associated with improvements in anticoagulation management of TJA procedures, likely conferring beneficial effects. [ABSTRACT FROM AUTHOR]

What is known and objective: Renal impairment (RI) and renal drug‐related problems (rDRP) often remain unrecognized in the community setting. A "renal pharmacist consultant service" (RPCS) at hospital admission can support patient safety by detecting rDRP. However, the efficient information sharing from pharmacists to physicians is still discussed. The aim of the study was to test the implementation of a RPCS and its effectiveness on prescription changes and to evaluate two ways of written information sharing with physicians. Methods: Urological patients with eGFRnon‐indexed of 15‐59 ml/min and ≥1 drug were reviewed for manifest and potential rDRP at admission by a pharmacist. Written recommendations for dose or drug adaptation were forwarded to physicians comparing two routes: July‐September 2017 paper form in handwritten chart; November 2017‐January 2018 digital PDF document in the electronic patient information system and e‐mail alert. Prescription changes regarding manifest rDRP were evaluated and compared with a previous retrospective study without RPCS. Results and discussion: The RPCS detected rDRP in 63 of 234 (26.9%) patients and prepared written recommendations (median 1 rDRP (1‐5) per patient) concerning 110 of 538 (20.5%) drugs at admission. For manifest rDRP, acceptance rates of recommendations were 62.5% (paper) vs 42.9% (digital) (P = 0.16). Compared with the retrospective study without RPCS (prescription changes in 21/76 rDRP; 27.6%), correct prescribing concerning manifest rDRP significantly increased by 27.1%. What is new and conclusion: A RPCS identifies patients at risk for rDRP and significantly increases appropriate prescribing by physicians. In our hospital (no electronic order entry, electronic chart or ward pharmacists), consultations in paper form seem to be superior to a digital PDF document. [ABSTRACT FROM AUTHOR]

What is known and objective: Pharmacogenomics (PGx) testing can be effective for supporting precision medicine. The purpose of this study was to assess the knowledge, attitude and practice behaviours of pharmacists in relation to such testing through a survey. We also aimed to identify potential obstacles to implementation of PGx testing by pharmacists and the characteristics of hospital pharmacists involved. Methods: We performed a web‐based survey regarding PGx in Japan. The survey contained a questionnaire related to PGx, which consisted of 30 items and was made accessible via the official Japanese Society of Pharmaceutical Health Care and Sciences (JSPHCS) website. The characteristics of hospital pharmacists associated with involvement in PGx testing were evaluated using univariate and multivariate analyses. Results and discussion: One thousand three‐hundred and thirteen pharmacists responded to the survey. The results revealed that the majority of respondents recognized the role that germline PGx testing can play in determining individual drug responses and that pharmacists have embraced the potential of PGx testing to improve patient care. However, only 26% of pharmacists were involved in PGx testing. We also found that most respondents (81.0%) believed that the lack of insurance coverage for PGx testing was a major barrier to its clinical implementation. Hospital pharmacists involved in PGx testing included certified pharmacists in JSPHCS and pharmacists who had studied PGx in university; however, only 12.4% of pharmacists had received specific PGx‐related education. What is new and conclusion: The findings of this survey highlight the necessity to increase the number of PGx tests covered by insurance, and the importance of effective education to inform and facilitate clinical implementation of PGx testing. [ABSTRACT FROM AUTHOR]

What is known and objective: Prescribing errors are the leading cause of adverse drug events in hospitalized patients. Pharmaceutical validation, defined as the review of drug orders by a pharmacist, associated with clinical decision support (CDS) systems, significantly reduces these errors and adverse drug events. In Belgium, because clinical pharmacy services have limited public financial support, most pharmaceutical validations are performed at the central pharmacy instead of on‐ward, by hospital pharmacists doing dispensing activities. In that context, we aimed at evaluating whether the strategy of CDS‐guided central validation was the most appropriate method to improve the quality and safety of medicines' use compared to an on‐ward pharmaceutical validation. Methods: Our retrospective observational study was conducted in a Belgian tertiary care hospital, in 2018–2019. Data were extracted from our validation software and pharmacists' charts. The outcomes of the study were the number of pharmaceutical interventions due to the detection of prescribing errors, reasons for interventions, their acceptance rate and their potential clinical impact (according to two blinded experts) in the central pharmacy and on‐ward validation groups. Results and discussion: Despite the use of the same CDS, a pharmaceutical intervention following the detection of a prescribing error was made for 2.9% (20/698) of central group patients and 13.3% (93/701) of on‐ward patients (χ2 = 49.97, p < 0.001). Interventions made at the central pharmacy (n = 20) mostly relied on CDS‐alerts (i.e. drug‐drug interaction [25%] or overdosing [20%]) while interventions made on‐ward (n = 93) were also for pharmacotherapy optimization (i.e. no valid indication [25%] or inappropriate drug's choice [11%]). The on‐ward validation group showed a higher acceptance rate compared to the central group (84% and 65%, respectively [Fisher's test, p = 0.053]). Proportions of interventions with significant or very significant clinical impact were similar between the two groups but as fewer interventions were made centrally, a significant proportion of errors were probably not detected by the central validation. What is new and conclusion: On‐ward pharmaceutical validation leads to a higher rate of prescribing error detection. Pharmaceutical interventions made by on‐ward pharmacists are also better accepted and more relevant, going further than CDS‐alerts. [ABSTRACT FROM AUTHOR]

What is known and objective: The drug therapy of critically ill patients requires intensive evaluation and management due to their severity of illness. These patients often require complex medication regimens. This study analysed the pharmaceutical care provided by clinical pharmacists (CPs) in a single medical centre in Taiwan. In addition, we explored the drug‐related problems (DRPs) experienced by patients in intensive care units (ICUs) to determine how to improve the quality and safety of drug therapy. Methods: This retrospective study was conducted from February 2019 to January 2020. The CPs implemented Taiwan's National Health Insurance (NHI) Scheme for Improving Hospital Drug Safety and Quality programme to improve the safety and quality of drug therapy. The CPs included in the study had at least 2 years' clinical experience and had participated in an ICU team for at least 6 consecutive months. They provided individualized drug treatment evaluation and intervention. Content of care was documented in the Clinical Pharmacy Service Record. Results and discussion: A total of 4374 pharmacy care records were evaluated by 12 CPs. The major category of ICU pharmaceutical care was medication reconciliation (n = 2938; 67.2%). Most of the medication interventions were for errors in dosing or dosing frequency (n = 218; 55.8%). Patients with renal dysfunction required more pharmaceutical interventions than did patients with normal renal function (odds ratio = 1.63; 95% confidence interval 1.31‐2.01). The main interventions were related to antimicrobial agents (n = 386; 81.3%). During the study period, 99.2% of interventions were accepted and 90.8% were changed within 24 hours. What is new and conclusion: Increased pharmaceutical interventions for patients with renal dysfunction compared with patients with normal renal function were observed. Most cases of inappropriate frequency of dosing or dosing of antimicrobial agents required intervention. [ABSTRACT FROM AUTHOR]

What is known and objective: Drug consultation is an important part of pharmaceutical care offered by clinical pharmacists. We explored the characteristics of telephone drug consultations in an obstetrics and gynaecology speciality hospital to provide a reference as to how to improve drug consultation and pharmaceutical care. Methods: We retrospectively analysed records of telephone consultations regarding medication use between 2014 and 2019 in our hospital. Any consultation cases with incomplete records were excluded from our analysis. Of the 1353 consultation cases included in our study, we further classified them into different categories based on the content of the consultations, the type of medications being inquired about, and the groups of people who sought medication guidance. Pareto analysis was performed to separate the main issues the callers were concerned about from the more minor concerns. Results and discussion: The medication issues that prompted the caller to consult with our clinical pharmacists could be divided into 12 categories, among which the main issues concerned usage and dosage, choice of drug variety, drug incompatibility (drug mixture in infusion bag or tube), adjustment of the treatment plan, and skin tests (cumulative percentage 76.3%). The minor issues involved medication use during pregnancy and lactation and adverse reactions. The top three types of drugs that callers asked about were antimicrobials (600 cases, 44.4%), anti‐tumour drugs (151 cases, 11.2%) and reproductive system drugs (111 cases, 8.2%). The callers could be divided into four groups as follows: doctors (865 cases, 63.9%), nurses (280 cases, 20.7%), patients (116 cases, 8.6%) and other medical professionals (92 cases, 6.8%). What is new and conclusion: Usage and dosage, choice of drug variety, drug incompatibility, adjustment of treatment plan and skin tests represented the main issues for telephone drug consultations in our hospital. Doctors and nurses were most likely to consult clinical pharmacists regarding these issues. Improved drug consultation services are needed to allow more patients to have access to advice from pharmacists. Such access would better enable pharmacists to fulfil their roles in advising the appropriate use of drugs to ensure better patient care and medication compliance. [ABSTRACT FROM AUTHOR]

What is known and objective: In China, with the increased number of oncology patients and use of novel antitumour drugs, the demand of oncology clinical pharmacy services is also growing. However, the current status of oncology clinical pharmacy services in China was seldom reported. The purpose of the study was to investigate the contents and features of oncology clinical pharmacy services and self‐evaluations of the oncology pharmacists in China, and to identify related problems for further development. Methods: A 55‐item online questionnaire was distributed to oncology‐related clinical pharmacists in Chinese hospitals in January 2019. Pharmacists answered the questions on the WeChat platform. Data were analysed using descriptive statistics. Results and discussion: The respondents of the 166 valid questionnaires were from 29 provinces (or autonomous regions or municipalities). Their average working experience for clinical pharmacy was 4.86 years. The average duration of their clinical services was 3.27 h/d. The clinical pharmacy services consist of 15 types, and their workload on each service type was summarized. Pharmacists are not frequently participating in establishing pharmacotherapy protocols, therapeutic drug monitoring and pharmacogenetic/pharmacogenomic services. About 80% (81.33%) of the pharmacists thought that other healthcare professionals knew the nature of their work. The biggest barrier for career development of the pharmacists was insufficiency of professional skills. In most cases, the clinical service accounted for <30% of the overall performance evaluation of the pharmacists. Most of the participating pharmacists were not satisfied with their current salary. The overall evaluation score for their career happiness was 6.27 out of 10. What is new and conclusion: The value of oncology clinical pharmacists is being increasingly recognized, but advanced services need further expansion. Increasing the time serving in patient care, optimizing performance evaluation mechanisms and strengthening their skills are possible ways for pharmacists to provide superior services. This study showed the current service of oncology clinical pharmacists in most parts of China, which may provide reference for policymakers, promote international communications and shed light on future development of oncology clinical pharmacy. [ABSTRACT FROM AUTHOR]

What is known and objective: In the mid‐1960s, clinical pharmacy developed in the USA, and as the demand for pharmaceutical services continued to grow, their impact began to be taken seriously. However, the participation of clinical pharmacists as members of the multidisciplinary team in the orthopaedic department is still in its infancy, although its role in orthopaedics has not been defined. The object of this study was to identify and discuss the impact of pharmaceutical care in the orthopaedic department. Methods: A literature search was conducted on MEDLINE, PubMed, Web of Science, the Cochrane Library and CNKI (China National Knowledge Infrastructure) for papers published between 1998 and 2019, using the keywords pharmacy, pharmacist, and medication or drug combined with orthopaedic. Other available resources were also used to identify relevant articles. Results and discussion: Based on the available evidence in 74 articles, it was found that clinical pharmacists play an important role in all aspects of rational use of medications, medication review and reconciliation, monitoring adverse drug events, risk assessment, and medication education and counselling. In addition, clinical pharmacy services were developed to minimize medication errors, adverse drug events and medical costs, but clinical pharmacy is still in its early stages in orthopaedics. What is new and conclusion: A multidisciplinary approach should be adopted in the orthopaedic department, as pharmacist interventions can be vital for promoting the safety, effectiveness and cost‐effectiveness of pharmacotherapy. Although pharmacists' contributions to orthopaedics are not yet fully recognized, pharmaceutical services can undoubtedly contribute to both clinical and societal outcomes. [ABSTRACT FROM AUTHOR]

What is known and objective: As the global adoption of ENFit‐compatible syringes becomes more widespread, it is important for syringe users to understand the risk of dosing inaccuracy for both the oral and enteral routes of use. Describing the risk of dosing inaccuracy specifically related to route of use is important to the end users' understanding of the clinical impact of device changes. The objective of this study was to compare the performance of female design ENFit low dose tip (LDT) syringes when used for enteral medication administration to the syringe performance during oral administration conditions. Methods: This study was a secondary analysis of a prospective study conducted at the University of Florida Health Shands Hospital in conjunction with the University of Florida College of Pharmacy. Dosing variance (DV) up to 10% for low‐risk medications and DV up to 5% is the target for high‐risk medication administration is considered acceptable. The primary outcome was the frequency of administration volumes exceeding 10% of the expected amount when using the ENFit LDT syringe for both oral and enteral medication administration. Secondarily, the performance of standard ENFit syringes and the frequencies of DV exceeding 5 and 10% were also evaluated in the same conditions. Results and discussion: A total of 264 tests were evaluated (ENFit LDT, n = 210; ENFit standard tip, n = 54). Using the LDT syringe for the enteral route resulted in statistically significant higher rates of unacceptable dosing variance >10% when compared to the oral application (26.9% vs 12.9%, P =.01). The frequency of LDT syringe DV >5% was significantly greater than >10% variance, regardless of oral or enteral use. Standard ENFit syringes had overall fewer tests with unacceptable dosing variance and showed no difference in performance between applications. What is new and conclusions: This study raises additional clinical concerns specifically related to the enteral use of ENFit LDT syringes within commonly accepted dosing variance ranges. Enteral and oral application of LDT syringes yield unacceptably high rates of dosing variance for high risk medications with narrow therapeutic index. [ABSTRACT FROM AUTHOR]

What is known and objective: While many countries have central agencies responsible for formulary development, within the United States, each hospital, health care system, or insurance provider has their own pharmacy and therapeutic committee, leading to both inefficiencies and inequalities across formularies. The number and variety of processes within pharmacy and therapeutic committees also increases the likelihood that conflicts of interest will influence the development of formularies. We sought to determine how such influences could be reduced by reviewing international evidence related to the presence and harms of conflicts of interest in formulary development. Methods: Several approaches have been taken to reduce the influence of conflicts of interest in pharmacy and therapeutics committee processes, including include disclosure, recusal, exclusion, universal consideration and dual committees. The feasibility of each of these approaches is considered in the context of the United States. Results and Discussion: A proposal is drawn from the discussion of various approaches to conflicts of interest in pharmacy and therapeutics committees: multicenter formulary development. What is new and conclusion: Multicentre formulary development, where resources are pooled across institutions, may lead to a reduction in the influence of conflicts of interest in pharmacy and therapeutics committee processes in the United States, increasing the chances of including the most safe, efficacious and cost‐effective drugs on formularies. [ABSTRACT FROM AUTHOR]

What is known and objective: Medication reconciliation is recommended to be performed at every transition of medical care to prevent medication errors or adverse drug events. This study investigated the impact of pharmacy‐led medication reconciliation on medication discrepancies and potential adverse drug events in the ED to assess the benefits of pharmacy services. Methods: The systematic review and meta‐analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. The PubMed, Ovid Embase and Cochrane library databases were searched up from inception to 1 July 2018. Studies comparing the effectiveness of the medication reconciliation service performed by pharmacy personnel to usual care (nurses or physicians) in the ED were included. Duplicated studies, non‐clinical studies, studies with ineligible comparators or study designs were excluded. Results and discussion: Eleven studies were eligible for qualitative analysis, and 8 studies were included in meta‐analysis. Pharmacy‐led medication reconciliation substantially reduced medication discrepancies in the ED. The most common medication discrepancies included medication omission and incorrect/omitted dose or frequency. Unlike usual care, pharmacy‐led medication reconciliation significantly reduced the proportion of patients with medication discrepancies by 68% (response rate 0.32; 95% confidence interval (CI): 0.19‐0.53, P < .0001) and the number of medication discrepancy events by 88% (response rate 0.12; 95% CI 0.06‐0.26, P < .00001). Intervention decreased the number of discrepancies per patient by 3.08 (mean difference −3.08; 95% CI: −4.76 to −1.39, P = .0003). Subgroup analysis revealed no differences between pharmacists and pharmacy technicians in medication reconciliation performance pertaining to medication discrepancies. The patients with several comorbidities or those administered numerous medications received marked benefits related to reduced medication discrepancies from pharmacy‐led medication reconciliation. Moreover, a randomized controlled trial revealed decreased risk of potential adverse drug events by pharmacy‐led medication reconciliation in patients receiving care in the ED. What is new and conclusion: Pharmacy‐led medication reconciliation significantly decreased the number of medication discrepancies. However, only one study investigated potential adverse drug events in patients receiving care in the ED. Therefore, further studies investigating the direct clinical impact of decreased medication discrepancies are required. [ABSTRACT FROM AUTHOR]

What is known and objective: The evaluation of clinical pharmacy services is essential for their further development and establishment. We analysed drug‐related problems (DRPs) and subsequent clinical pharmacists' interventions (PIs) at a Swiss university hospital. Method: We conducted a retrospective analysis of DRPs and subsequent PIs that were identified and implemented during interdisciplinary ward rounds in internal medicine at the University Hospital Basel, Switzerland, between 2015 and 2017. We estimated the potential clinical and economic impact of PIs using a validated evaluation tool (CLEOde). Results and discussion: Based on medication reviews of 5441 patients, clinical pharmacists identified 5024 DRPs, of which 2892 DRPs (57.6%) were followed by a PI that was directly accepted and implemented by the physician in charge and included in the present analysis. The leading cause and type of PIs were inappropriate dose and dose adjustment, respectively. Overall, 97.8% of DRPs were followed by PIs with an expected clinical benefit for the patients (major: 11.1%; moderate: 27.6%; minor: 59.1%). The drugs most often involved in PIs of major clinical impact were antithrombotics, acid blockers and cardiovascular drugs. With regard to the economic impact, 40.7% of DRPs implied PIs resulting in an increase of immediate therapy costs, whereas 39.3% implied PIs resulting in a decrease of immediate therapy costs. The remaining PIs were cost‐neutral. What is new and conclusion: This study emphasizes that clinical pharmacists may help improve the effectiveness and safety of pharmacotherapy on acute care medical wards. [ABSTRACT FROM AUTHOR]

What is known and objective: Pharmacists play vital roles in medicines optimization in different care settings. Studies have shown that optimizing patient's pre‐existing co‐morbidities prior to the surgery leads to better post‐operative outcomes. The Enhanced Surgical medicines optimization service (ESMOS) is an innovative surgical pharmacy service introduced at a large teaching hospital in the UK in September 2017 which aimed to reduce the length of stay and post‐operative complications in general surgical patients. This purpose of this study is to evaluate the implementation and outcomes of this service at 12 months after it was rolled out. Methods: This cohort study was undertaken between September 2017 and September 2018. Adult patients undergoing elective major general surgical procedures were included and stratified into four sub‐specialties, including hepato‐pancreato‐biliary (HPB), upper gastrointestinal (GI), lower GI and vascular surgery. Patients undergoing emergency and day case procedures or with missing outcome data were excluded from this study. Patients' demographics, baseline co‐morbidities, high‐risk medications, American Society of Anaesthesiologists (ASA) physical status classification, surgical procedure, post‐operative complications, length of stay and nature of pharmacist interventions were collected and reported by descriptive statistics. Length of stay was compared with the corresponding expected length of stay by the national standard. Results and discussion: A total of 246 patients were included in the four general sub‐specialties: HPB (n = 82), upper GI (n = 17), lower GI (n = 87) and vascular (n = 60). There was a significant reduction in the median length of stay in three surgical specialties, compared with the national standard: lower GI (median reduction: −2; IQR: −4, 1.8; P = .038), HPB (median reduction: −4.5; IQR: −7, −1; P = .001) and vascular (median reduction: −2; IQR: −4, 0; P = .043). What is new and conclusion: The ESMOS model is a novel care pathway that allows both early identification of medicines optimization and peri‐operative drug management issues in surgical patients, and potentially reduces the overall length of stay. [ABSTRACT FROM AUTHOR]

Summary: What is known and objective: The literature has reported suboptimal real‐world use of oral anticoagulants in patients with atrial fibrillation (AF). Anticoagulation management services (AMSs) in community pharmacy have rarely been evaluated, and no formal process is available to enable pharmacists to evaluate and improve their clinical practices. Our objective was to assess the feasibility of implementing, through a practice‐based research network (PBRN), a quality improvement programme on AMSs by community pharmacists for AF patients and explore its impact on the quality of clinical practices and pharmacists' knowledge. Methods: An uncontrolled pre/post‐pilot study was conducted through a PBRN. Pharmacists identified 5‐20 AF patients on oral anticoagulants per pharmacy and completed questionnaires at baseline (T0) and after 6 months (T6). Clinical practices were evaluated using a set of quality indicators (QIs). QI scores ranged from 0% (no QI achieved) to 100% (all QIs achieved). The programme included an audit and feedback based on QIs and a personalized training programme (including online videos). Participation rates and satisfaction were documented. Mean changes (T6‐T0), with 95% confidence interval (CI), in QIs and knowledge scores were computed. Results and discussion: A total of 37 pharmacies (50 pharmacists) identified 222 patients who had received either vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), or both. All pharmacies received their baseline quality report (audit), and facilitators contacted by phone 97% of pharmacies (feedback). Each of the six online videos was completed by at least 48% of pharmacists. Baseline mean global QI scores for VKAs and DOACs were 39.1% (95% CI: 35.7%‐42.4%) and 12.3% (7.8%‐16.8%), respectively. Over a 6‐month period, they increased by 12.5% points (7.5%‐17.5%) and 9.9% points (3.8%‐16.1%), respectively. Baseline mean global knowledge score was 68.7% (65.4%‐72.0%) and increased by 4.3% points (1.2%‐7.4%). What is new and conclusion: Implementing a quality improvement programme for AMS in community pharmacy is relevant and feasible and may improve pharmacists' practices and knowledge. Anticoagulation management services (AMSs) in community pharmacy have rarely been evaluated. This study assessed the feasibility of implementing, through a practice‐based research network, a quality improvement programme on AMSs for atrial fibrillation patients. Results show the programme is relevant and feasible and may improve pharmacists' practices and knowledge. [ABSTRACT FROM AUTHOR]

Summary: What is known and objective: In this study, the effectiveness of pharmaceutical care on treatment outcomes for patients with first‐time pulmonary tuberculosis in China was assessed. Methods: In this study, patients were randomized either to the usual care (UC) group (n = 72) where patients received routine medical and nursing care or to the pharmaceutical care (PC) group (n = 59) where patients were simultaneously provided with pharmaceutical care. The primary objectives were to evaluate whether treatment outcomes and patient adherence improved more in the PC group than in the UC group. In addition, in PC group, outcomes included the number of patient‐reported pharmaceutical care issues and pharmacists' interventions. Results and discussion: As compared to the UC group, treatment success rate was improved in the PC group, but the difference was not statistically significant (71% vs 54%; P = 0.137). However, as compared to the UC group, the number of patients who attended all of the scheduled visits was higher in the PC group; the difference was statistically significant (81% vs 60%, P = 0.018). Furthermore, the number of patients who had positive test results for all of the isoniazid tests was higher in the PC group than in the UC group; the difference was also statistically significant (80% vs 50%, P = 0.002). The consumed medication rate was improved in the PC group, but no significant difference was found between the two groups. The patient‐reported pharmaceutical care issues mainly included dermatological, gastrointestinal, hepatic, metabolic, sensory, central nervous system and haematological problems. On the basis of clinical examination, laboratory parameters and drug information database, the pharmacists addressed most of these pharmaceutical care issues. What is new and conclusion: Pharmaceutical care might improve patient adherence for patients with first‐time pulmonary tuberculosis in China, and further, rigorously controlled trials are required. Pharmaceutical care service might improve patient adherence for patients with first‐time pulmonary tuberculosis in China. [ABSTRACT FROM AUTHOR]

Summary: What is known and objective: Due to advances in healthcare and treatment options, there is a need for pharmacists with additional post‐graduate residency training. With the growing need for residency‐trained pharmacists, obtaining a post‐graduate pharmacy residency has become more competitive. The objective of this study was to capture the perspectives of post‐graduate year 1 residency programme directors (RPDs) in the United States (US) regarding aspects of a candidate's application and interview they found most important when selecting future residents. Methods: A cross‐sectional, electronic survey was distributed via e‐mail to PGY‐1 pharmacy RPDs in the USA. RPDs were identified via the American Society of Health‐System Pharmacists' pharmacy residency directory. Data related to programme demographics, candidate applications and interview evaluations were collected. RPDs' perceptions were captured via a 5‐point Likert scale (1 = strongly disagree; 5 = strongly agree). Results and Discussion: A total of 327 (26.6%) RPDs completed the survey. RPDs highly considered overall compatibility (mean Likert score: 4.9), letters of recommendation (4.6) and letter of interest (4.5) when inviting candidates for on‐site interviews. Residency programmes focusing in acute care valued hospital pharmacy work experience more compared to non‐acute care‐focused residency programmes (4.2 vs 2.9). During the interview, critical thinking ability (4.8), verbal communication (4.8) and overall compatibility (4.9) were viewed as highly important when considering ranking of candidates. What is new and conclusion: Due to the competitive nature of obtaining a residency programme, insight from RPDs on factors they consider significant when assessing prospective residents is valuable. The results from this study show that a strong letter of intent, letters of recommendations and overall compatibility are considered important by RPDs and should be used by candidates to better prepare themselves for residency applications. Additionally, the candidate should remain knowledgeable about the residency programme and be able to respond to questions asked during the residency interview process. Due to the competitive nature of obtaining a residency program, insight from residency program directors on factors they consider significant when assessing prospective residents is valuable. A strong letter of intent, letters of recommendations, and overall compatibility are considered important by residency program directors and should be used by candidates to better prepare themselves for residency applications. Additionally, the candidate should remain knowledgeable about the residency program, and be able to respond to questions asked during the residency interview process. [ABSTRACT FROM AUTHOR]

Summary: What is known and objectives: Most of the clotting factor (CF) dispensations to haemophiliac patients are centralized in a few haemophilia treatment centres, necessitating frequent visits and long travel distances. The aim was to evaluate the home delivery programme developed by the Outpatient Pharmaceutical Care Unit (OPCU) through the association of patients (ASHECOVA). Methods: A specific software programme was designed to communicate the individual CF requirements. Dispensations were prepared in advance, and an ASHECOVA member collected and delivered to patients' homes in optimal conditions. Data regarding the programme were analysed from December 2011 to December 2017. An electronic satisfaction survey with 34 questions was conducted, asking about organizational aspects, education and communication, use of apps and satisfaction level. Results and discussion: Forty‐nine patients were included and 2464 home deliveries were made, without any reported incident related to dispensation errors, drug preservation, communication or confidentiality problems. This system avoids 11.4 annual dispensation visits per patient to OCPU, and a mean travel distance, time and cost of 1189.1 km, 945.3 minutes and 373.5 euros, respectively. Overall satisfaction with home delivery was 9.7, without any change suggested in the current system. Ninety‐five per cent of individuals believed that the programme improves adherence and all patients would recommend it to other patients. The most common benefits reported were less frequent visits to hospital, reducing time and cost spent on transportation. What is new and conclusion: The home delivery programme guarantees a proper follow‐up of treatments with full patient satisfaction. This programme allows OPCU to achieve better pharmaceutical care, traceability of the process and optimization of working times and CF stock management. The home delivery process include: 1) Patient authorizes individually a delegated dispensation; 2) On‐line communication Pharmacy and Patients' Association; 3) Pharmaceutical validation and dispensation is prepared in advance; 4) Patients' Association collects the medication and delivers it to patient´s home in optimal conditions. [ABSTRACT FROM AUTHOR]

Summary: What is known and objective: Polypharmacy, medication errors and adverse events are common in older people receiving home nursing medication management support. Access to clinical pharmacists is limited. In Australia, few home nursing clients receive a general practitioner (GP)‐initiated pharmacist‐led Home Medicines Review, despite their eligibility and community nurses' (CN) efforts to facilitate this. An integrated home nursing clinical pharmacy service, in which CNs directly referred clients to a pharmacist, was therefore developed and piloted. The aim was to explore the number and type of medication‐related problems (MRPs) and medication treatment authorization (medication order) discrepancies identified and addressed by clinical pharmacists. Methods: Two part‐time clinical pharmacists were employed. They reviewed and reconciled clients' medications, educated clients/carers about their medicines, provided advice and support to CNs and worked with clients' GPs and other prescribers to optimize medication regimens and revise/update nurses' medication treatment authorizations. Evaluation involved review of clients' medicines data, including treatment authorizations and pharmacist medication review reports. Results and discussion: Eighty‐four clients (median 86 years, 6 health conditions, 13 medications) were reviewed. The pharmacists identified 334 MRPs (median 4 per client) and 307 medication discrepancies in treatment authorizations (median 2 per client). The pharmacists made 282 recommendations to prescribers to address MRPs; 148 (52.5%) recommendations were acted on, resulting in 190 medication changes for 60 (71.4%) clients (median 2 per client). The pharmacists prepared, or assisted GPs to update, treatment authorizations for 68 (81%) clients. What is new and conclusion: Integrating pharmacists into a home nursing service identified and addressed MRPs and medication treatment authorization discrepancies, hence contributing to enhanced medication safety. In this study, clinical pharmacists working within a home nursing service identified and addressed medication order discrepancies and other medication‐related problems (most commonly inappropriate and unnecessary medicines, non‐adherence and adverse drug reactions) by working with clients, community nurses, medical practitioners and community pharmacists. [ABSTRACT FROM AUTHOR]

Summary: What is known and objective: Drug therapies are critical for preventing secondary complications in acute coronary syndrome (ACS). The purpose of this study was to develop and apply a pharmaceutical care service (PCS) algorithm for ACS and confirm that it is applicable through a prospective clinical trial. Methods: The ACS‐PCS algorithm was developed according to extant evidence‐based treatment and pharmaceutical care guidelines. Quality assurance was conducted through two methods: literature comparison and expert panel evaluation. The literature comparison was used to compare the content of the algorithm with the referenced guidelines. Expert evaluations were conducted by nine experts for 75 questionnaire items. A trial was conducted to confirm its effectiveness. Seventy‐nine patients were assigned to either the pharmacist‐included multidisciplinary team care (MTC) group or the usual care (UC) group. The endpoints of the trial were the prescription rate of two important drugs, readmission, emergency room (ER) visit and mortality. Results and discussion: The main frame of the algorithm was structured with three tasks: medication reconciliation, medication optimization and transition of care. The contents and context of the algorithm were compliant with class I recommendations and the main service items from the evidence‐based guidelines. Opinions from the expert panel were mostly positive. There were significant differences in beta‐blocker prescription rates in the overall period (P = .013) and ER visits (four cases, 9.76%, P = .016) in the MTC group compared to the UC group, respectively. What is new and conclusion: We developed a PCS algorithm for ACS based on the contents of evidence‐based drug therapy and the core concept of pharmacist services. [ABSTRACT FROM AUTHOR]

Summary: What is known and objective: To facilitate the identification of drug‐related problems (DRPs) during medication review, several tools have been developed. Explicit criteria, like Beers criteria or STOPP (Screening Tool of Older Peoples’ Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria, can easily be integrated into a clinical decision support system (CDSS). The aim of this study was to investigate the effect of adding a CDSS to medication review software on identifying and solving DRPs in daily pharmacy practice. Methods: Pre‐ to post‐analysis of clinical medication reviews (CMRs) performed by 121 pharmacies in 2012 and 2013, before and after the introduction of CDSS into medication review software. Mean number of DRPs per patient, type of DRPs and their resolution rates were compared in the pharmacies pre‐ and post‐CDSS using paired t tests. Results and discussion: In total, 9151 DRPs were identified in 3100 patients pre‐CDSS and 15 268 DRPs were identified in 4303 patients post‐CDSS. The mean number of identified DRPs per patient (aggregated per pharmacy) was higher after the introduction of CDSS (3.2 vs 3.6 P < .01). The resolution rate was lower post‐CDSS (50% vs 44%; P < .01), which overall resulted in 1.6 resolved DRPs per patient in both groups (P = .93). After the introduction of CDSS, 41% of DRPs were detected by the CDSS. The resolution rate of DRPs generated by CDSS was lower than of DRPs identified without the help of CDSS (29% vs 55%; P < .01). The two most prevalent DRP types were “Overtreatment” and “Suboptimal therapy” in both groups. The prevalence of “Overtreatment” was equal in both groups (mean DRPs per patient: 0.84 vs 0.77; P = .22), and “Suboptimal therapy” was more frequently identified post‐CDSS (mean DRPs per patient: 0.54 vs 1.1; P < .01). What is new and conclusion: The introduction of CDSS to medication review software generated additional DRPs with a lower resolution rate. Structural assessment including a patient interview elicited the most relevant DRPs. Further development of CDSS with more specific alerts is needed to be clinical relevant. [ABSTRACT FROM AUTHOR]

What is known Penicillin allergy limits therapeutic options for patients but often disappears over time, leaving patients erroneously labelled allergic and leading to the utilization of broad-spectrum and more expensive antibiotics. Penicillin allergy can be effectively assessed via skin testing. Objective To improve patient access to penicillin allergy testing by implementing a pharmacist-provided service in a hospital setting. Comment Beta-lactams remain a mainstream therapy for many infections due to their effectiveness, low side effects and affordability. Typically, patient access to penicillin allergy testing is limited by the availability of allergy specialists, who traditionally perform such testing. A pharmacist-provided penicillin allergy testing service was implemented at our hospital in 2015 and became a powerful antibiotic stewardship tool. Removing penicillin allergy from patient profiles significantly expanded therapeutic options, expedited discharges and reduced costs of care. What is new Pharmacists can expand patient access to penicillin allergy testing. Conclusion Pharmacist-provided penicillin allergy testing permitted optimized antibiotic treatment and expedited discharges. [ABSTRACT FROM AUTHOR]

What is known and objective Medication errors are a significant cause of morbidity and mortality especially with antineoplastic drugs, owing to their narrow therapeutic index. Gravimetric workflow software systems have the potential to reduce volumetric errors during intravenous antineoplastic drug preparation which may occur when verification is reliant on visual inspection. Our aim was to detect medication errors with possible critical therapeutic impact as determined by the rate of prevented medication errors in chemotherapy compounding after implementation of gravimetric measurement. Design A large-scale, retrospective analysis of data was carried out, related to medication errors identified during preparation of antineoplastic drugs in 10 pharmacy services ('centres') in five European countries following the introduction of an intravenous workflow software gravimetric system. Errors were defined as errors in dose volumes outside tolerance levels, identified during weighing stages of preparation of chemotherapy solutions which would not otherwise have been detected by conventional visual inspection. Key results The gravimetric system detected that 7.89% of the 759 060 doses of antineoplastic drugs prepared at participating centres between July 2011 and October 2015 had error levels outside the accepted tolerance range set by individual centres, and prevented these doses from reaching patients. The proportion of antineoplastic preparations with deviations >10% ranged from 0.49% to 5.04% across sites, with a mean of 2.25%. The proportion of preparations with deviations >20% ranged from 0.21% to 1.27% across sites, with a mean of 0.71%. There was considerable variation in error levels for different antineoplastic agents. What is new and conclusion Introduction of a gravimetric preparation system for antineoplastic agents detected and prevented dosing errors which would not have been recognized with traditional methods and could have resulted in toxicity or suboptimal therapeutic outcomes for patients undergoing anticancer treatment. [ABSTRACT FROM AUTHOR]

What is known and Objective Biopharmaceuticals are an important class of drugs for the treatment of autoimmune/inflammatory and oncologic diseases. With patent expiries, biotechnological manufacturers can now develop biosimilar drugs. Due to timeliness of introducing new and more complex biosimilars, the Portuguese Association of Hospital Pharmacists gathered to develop a common positioning on the use of biosimilar monoclonal antibodies. Main issues The European pathway to biosimilar approval was developed to improve affordability and access to biological therapies, but it remains a work in progress because unresolved issues remain. Due to the present reality of biosimilar monoclonal antibodies, hospital pharmacists must play an important role in ensuring the safe, effective and cost-effective use of biosimilars in health systems; and educating healthcare administrators, providers, legislators, policymakers, payors and patients about these products. What is new and conclusion The conclusions presented in this work focused on the proposal for optimal biosimilar prescription criteria, the preparation of original biologics and biosimilars in the pharmacy, the management and selection of suppliers, extrapolation issues, the specific role of pharmacovigilance and risk management for the optimal use of biosimilar monoclonal antibodies. [ABSTRACT FROM AUTHOR]

What is known and objective Because of the impact of drug-related problems ( DRPs) on morbidity and mortality, there is a need for computerized strategies to increase drug safety. The detection and identification of the causes of potential DRPs can be facilitated by the incorporation of a pharmacy warning system ( PWS) in the computerized prescriber order entry ( CPOE) and its application in the routine validation of inpatient drug therapy. A limited number of studies have evaluated a clinical decision support system to monitor drug treatment. Most of these applications have utilized a small range of drugs with alerts and/or types of alert. The objective of this study was to describe the implementation of a PWS integrated in the electronic medical record ( EMR). Methods The PWS was developed in 2003-2004. Pharmacological information to generate drug alerts was entered on demographic data, drug dosage, laboratory tests related to the prescribed drug and drug combinations (interactions, duplications and necessary combinations). The PWS was applied in the prescription reviews conducted in patients admitted to the hospital in 2012. Results and discussion Information on 83% of the drugs included in the pharmacopeia was introduced into the PWS, allowing detection of 2808 potential DRPs, representing 79·1% of all potential DRPs detected during the study period. Twenty per cent of PWS DRPs were clinically relevant, requiring pharmacist intervention. What is new and conclusion The PWS detected most potential DRPs, thus increasing inpatient safety. The detection ability of the PWS was higher than that reported for other tools described in the literature. [ABSTRACT FROM AUTHOR]

What is known Documentation is a process indicator utilized to evaluate quality clinical pharmacist services. In this framework, documentation of dispensing, besides supporting patient care, allows evaluation of the impact of counselling. Objective To identify and assess studies of documentation by pharmacists in the dispensing process. Method A systematic review was carried out according to the following steps: (i) identification of studies in the following databases: PubMed/Medline, Web of Science, Scopus and Lilacs, using the descriptors 'counselling', 'dispensing', 'community pharmacy services', 'pharmacies' and 'pharmacists' in different combinations; (ii) evaluation of studies, in which the title, abstract and full text of the studies, and the evaluation of the methodological quality of the selected studies were analysed. Results In total, 26 articles met the specific criteria. Few studies addressed documentation as part of the dispensing working process (3), and 16 articles reported documentation using non-electronic systems. The main variables documented were patient information, drug therapy problems and clinical interventions. Furthermore, 20 studies showed the effects of documentation in the dispensing process and 23 studies included statistical evidence. Eight articles met between 42% and 75% of the 28 items recommended by the STROBE initiative, and two articles met approximately 60% of the 36 items recommended by the CONSORT initiative. What is new and conclusion Few studies address documentation as part of the dispensing working process. Thus, researchers should be concerned with standardizing documentation and implementing more robust designs and multicenter studies. [ABSTRACT FROM AUTHOR]

What is known and objective: Medication reconciliation is recognized as an important tool for the prevention of medication discrepancies and subsequent patient harm at care transitions. However, there is inconclusive evidence as to the impact of medication reconciliation at hospital transitions overall, as well as pharmacy-led medication reconciliation services. This review sought to evaluate the impact of pharmacy-led medication reconciliation interventions on medication discrepancies at hospital transitions and to categorize these interventions as single transition interventions or multiple transitions interventions. Methods: PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO databases, inclusive from inception to December 2014, were searched. Included studies were published studies in English that compared the effectiveness of pharmacy-led medication reconciliation interventions to usual care and that aimed to assess medication discrepancies at hospital transitions. 'Usual care' was defined as any care where targeted medication reconciliation was not undertaken as an intervention, or if an intervention was conducted, it was not provided by a pharmacist/ pharmacy technician. Results and discussion: Nineteen studies which involved a total of 15 525 adult patients were included. Eleven studies were randomized controlled trials. Overall, pharmacy-led medication reconciliation intervention usually revealed a trend towards reduction in medication discrepancies, compared with usual care. Seventeen studies involving 18 medication reconciliation interventions targeting the various transitions (admission, 9; discharge, 4; and multiple transitions, 5) were included in the meta-analysis. Compared with usual care, single medication reconciliation interventions at transitions in care (either admission or discharge) showed a significant reduction of 66% in patients with medication discrepancies (RR 0.34; 95% CI: 0.23-0.50) in favour of the intervention. There was no difference between groups for interventions targeting multiple transitions (RR 0.88; 95% CI: 0.77-1.02). Subgroup analyses confined to RCTs showed that there were no differences for target of transition (admission vs. discharge), type of intervention (multifaceted intervention vs. medication reconciliation) and setting (single centre vs. multicentre), nor pharmacists vs. pharmacy technicians (non-RCTs only). Importantly, medication discrepancies of higher clinical impact were more easily identified through pharmacy-led interventions than with usual care. What is new and conclusion: Pharmacy-led medication reconciliation interventions were found to be an effective strategy to reduce medication discrepancies, and had a greater impact when conducted at either admission or discharge but were less effective during multiple transitions in care. Further studies that are designed to assess the impact of the involvement of pharmacy technicians in medication reconciliation are also needed. [ABSTRACT FROM AUTHOR]

What is known and objective Generic manufacturers help decrease the cost of antiretroviral ( ARV) and antimicrobial medications which are used to treat opportunistic infections ( OIs) in developing countries. Concerns have been expressed about potential quality issues with such medications as a result of the identification of numerous counterfeit medications in developing countries. However, few studies have assessed the quality of these medications using the United States Pharmacopeia ( USP) compendial standards. The goal of this study was to assess the quality of ARV and OI medications obtained from various sources, including South Africa, United States, China, Ethiopia, Thailand, Laos, Mexico, Nigeria and five Internet pharmacies. Methods Zidovudine, lamivudine, efavirenz, nevirapine, isoniazid and sulfamethoxazole/trimethoprim tablets/capsules were obtained from eight countries and five Internet pharmacies. The tablets/capsules were separated into distinct samples, based on the drug's active ingredient, manufacturer and drug control number. Each distinct sample was analysed for drug content, dissolution, content uniformity and breaking force using USP 32-National Formulary 27 ( USP 32- NF 27) compendial methods and compared to the USP standards. Results and discussion A total of 2027 tablets/capsules were obtained with 88 distinct samples identified. All samples met the USP 32- NF 27 standards for drug content with a range of 92·7-108·6%. Six of the 88 samples failed the dissolution test by 1·5-8·3% below the standard range. Ninety-eight per cent of all 88 samples met the USP criteria for content uniformity based on weight variation. One sample of isoniazid was found to have a low breaking force of 2·8 kiloponds. The results of this study show that there were no problems with the samples of ARV and OI medications tested for drug quality from the specified locations. As there are many studies and reports that discuss the poor quality of generic medications with only a few assessing drug quality, the implications of this study's results are to: (i) help better understand patient outcomes; (ii) help patients gain access to beneficial medications for HIV and OIs; and (iii) ensure an overall increase in access to medications where needed. What is new and conclusion This study is one of the largest to date concerning medication type and sample size for the assessment of ARV and OI medications using drug content as a measure of quality. The samples were obtained from more diverse geographical locations compared to previous studies and, for the first time, included Internet pharmacies. In addition to drug content, this study evaluated a more complete quality profile including dissolution, content uniformity and breaking force. This study showed that drug quality should be assessed consistently in order to better identify counterfeit medications compared to current assessments and that there should be uniform guidelines for how to assess quality. [ABSTRACT FROM AUTHOR]

What is known and objective Since 2007, pharmacists in Alberta have had authority to adapt existing prescriptions and independently prescribe medications after a peer review process. This study aimed to explore and characterize how pharmacists incorporated prescribing into practice 3 years after this legislation was approved. Methods We invited pharmacists to participate in semi-structured telephone interviews to discuss their prescribing practices. Pharmacists working in community, primary care network, hospital or other settings were selected using a mix of purposive and random sampling. Two investigators independently analysed each transcript using an Interpretive Description approach and thematically categorized prescribing practices according to the level of adoption. Results and discussion Thirty-eight pharmacists ( n = 13 independent prescribers) participated. Eighteen (47%) had a primary practice site from community practice, eight (21%) primary care, five (13%) hospital practice and seven (18%) from other settings including specialty clinics and long-term care. Twenty-eight participants were categorized as adopters and ten as non-adopters in their primary practice setting. Prescribing practices adopted were characterized as product focused, disease focused or patient focused. Sixteen (42%) described product-focused prescribing where they continued an existing therapy or substituted medications based on formulary guidelines. Seven (18%) described disease-focused prescribing where current therapies were adapted or initiated based on a protocol in a specific therapeutic area. Five (13%) described patient-focused prescribing where they initiated therapy based on patient needs and values, their assessment of the patient and best evidence. Non-adopters were not prescribing, but many described provision of disease or patient-focused care where they influenced prescribing by interacting with other members of the healthcare team. Most commonly, community pharmacists participated in product-focused prescribing, whereas hospital and primary care pharmacists practised disease-focused prescribing. What is new and conclusion Our data suggest that there have been context-related differences in uptake across practice settings. Despite this, pharmacists in all studied settings engaged in prescribing activities using three approaches and many pharmacists who were not directly prescribing medications reported having involvement in drug therapy decision-making. [ABSTRACT FROM AUTHOR]

What is known and objective: Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug-related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post-discharge hospital revisits or death. Methods: This prospective, controlled study included all patients hospitalized in three internal medicine wards in a university hospital, between 1 January 2006 and 31 May 2008. Medication reconciliation on admission and inpatient medication review, conducted by clinical pharmacists in a multiprofessional team, were implemented in these wards at different times during 2007 and 2008 (intervention periods). A discharge medication reconciliation was undertaken in all the study wards, during both control and intervention periods. Patients were included in the intervention group ( n = 1216) if they attended a ward with medication reconciliation and review, whether they had received the intervention or not. Control patients ( n = 2758) attended the wards before implementation of the intervention. Results and Discussion: No impact of medication reconciliation and reviews on ED revisits [hazard ratio (HR), 0·95; 95% confidence interval (CI), 0·86-1·04]or event-free survival (HR, 0·96; 95% CI, 0·88-1·04) was demonstrated. In the intervention group, 594 patients (48·8%) visited the ED, compared with 1416 (51·3%) control patients. In total, 716 intervention (58·9%) and 1688 (61·2%) control patients experienced any event (ED visit, hospitalization or death). Because the time to a subsequent ED visit was longer for the control as well as the intervention groups in 2007 than in 2006 ( P < 0·05), we re-examined this cohort of patients; the proportion of patients revisiting the ED was similar in both groups in 2007 ( P = 0·608). What is new and conclusion: Routine implementation of medication reconciliation and reviews on admission and during the hospital stay did not appear to have any impact on ED revisits, re-hospitalizations or mortality over 6-month follow-up. [ABSTRACT FROM AUTHOR]

What is known and Objective: To determine to what extent patient interviews contribute to the identification of drug-related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance. Methods: We performed a cross-sectional study within the intervention arm of a randomized controlled trial. Patients were recruited from 10 Dutch community pharmacies. Patients were eligible if they were home-dwelling, aged 65 years and over and used five or more different drugs, including at least one cardiovascular or antidiabetic drug. The community pharmacist interviewed the patient at home about the medicines and identified potential DRPs in combination with medication and clinical records. This medication review was assessed and modified by an independent pharmacist reviewers' panel. Outcomes were the number and type of DRPs and recommendations and percentage of clinical relevant DRPs. Clinical relevance of DRPs was assessed by DRPs assigned a high priority, DRPs followed by recommendations for drug change and DRPs followed by implemented recommendations for drug change. Results: A total of 1565 potential DRPs and recommendations (10 per patient).were identified for 155 patients (median age, 76 years; 54% women). Fifty-eight per cent of all recommendations involved a drug change; 27% of all DRPs were identified during patient interviews and 74% from medication and clinical records. Compared to DRPs identified from patient medication and clinical records, DRPs identified during patient interviews were more frequently assigned a high priority (OR = 1·8 [1·4-2·2]), were more frequently associated with recommendations for drug change (OR = 2·4 [1·9-3·1]) and were implemented recommendations for drug change (OR = 2·8 [2·1-3·7]). What is new and Conclusion: This study shows that more than a quarter of all DRPs were identified during patient interviews. DRPs identified during patient interviews were more frequently assigned a higher clinical relevance. [ABSTRACT FROM AUTHOR]

What is known and Objective: The sensible dosing of medicines can ensure that patients receive neither excessive doses leading to toxicity nor inappropriately low doses leading to undertreatment. Computerized prescribing systems with embedded decision support can check doses during prescription order entry and display alerts when the prescribed doses are out of range. We have been unable to identify any scheme for the systematic addition of dosing information to CPOE systems. We used pharmacological data to design an algorithm for dose range checking that we tested on a subset of medicines in an electronic prescribing system to ensure that the rules could be implemented in practice. Methods: We drafted an initial algorithm based on pharmacological principles, tested it on a subset of frequently prescribed drugs in an electronic prescribing system and then refined it. We considered which clinical decision support functions systems would require to be maximally effective. Results and Discussion: The final algorithm contained eleven broad factors. We tested it on 30 drug-route-form combinations, and it accommodated the information for all of these combinations. We also identified a variety of system functions that would be required for comprehensive dosing decision support. What is new and Conclusion: The dose range checking algorithm that we have derived from first principles will allow the clinical workflow and warnings to be constructed more effectively within systems to enhance patient safety. This will form a basis for the development of optimal schemes for adding decision support to prescribing systems. [ABSTRACT FROM AUTHOR]

Summary What is known and Objective: Anticoagulation consultations provided by a pharmacist-staffed inpatient service, similar to the experience reported in outpatient anticoagulation clinics, can potentially improve anticoagulation control and outcomes. At Tan Tock Seng Hospital, a 1200-bed acute care teaching hospital in Singapore, pharmacist-managed anticoagulation clinics have been in place since 1997. Pharmacist-managed services were extended to inpatient consultations in anticoagulation management from April 2006. Our objective was to assess the effect of implementing a pharmacist-managed inpatient anticoagulation service. Methods: This was a single-centre cohort study. Baseline data from 1 January 2006 to 31 March 2006 were collected and compared with post-implementation data from 1 April 2006 to 31 March 2007. Patients newly started on warfarin for deep vein thrombosis, pulmonary embolism or atrial fibrillation in general medicine and surgery departments were included. The three endpoints were as follows: (i) percentage of international normalized ratios (INRs) achieving therapeutic range within 5 days, (ii) INRs more than 4 during titration and (iii) subtherapeutic INRs on discharge. Results and Discussion: A total of 26 patients in the control period were compared with 144 patients who had received dosing consultations by a pharmacist during the initiation of warfarin. The provision of pharmacist consult resulted in 88% compared to 38% ( P < 0·001) of INR values achieving therapeutic range within 5 days. There was a reduction in INR values of more than 4 during titration from 27% to 2% ( P < 0·001), and subtherapeutic INR values on discharge without low molecular weight heparin from 15% to 0% ( P < 0·001). The mean time to therapeutic INR was reduced from 6·5 to 3·9 days ( P < 0·001) and mean length of stay after initiation of warfarin from 11 to 7·7 days ( P = 0·004). What is new and Conclusion: Inpatient anticoagulation care and outcomes were significantly improved by a pharmacist-managed anticoagulation service. The time to therapeutic INR was achieved appropriately and efficiently without compromising patient's safety. [ABSTRACT FROM AUTHOR]

Summary [ABSTRACT FROM AUTHOR]

Despite the proven effectiveness of antithrombotic therapy for atrial fibrillation (AF), the treatment remains suboptimal. The aim of this study was to implement and evaluate a system to improve the appropriate use of antithrombotics for stroke prevention in AF utilizing a clinical pharmacist as a stroke risk assessor. Hospital in-patients with AF were prospectively identified and they received a formal stroke risk assessment from a pharmacist. The patients' risk of stroke was assessed and documented according to Australian guidelines and a recommendation regarding antithrombotic therapy was made to the medical team on a specially designed stroke risk assessment form. One hundred and thirty-four stroke risk assessments were performed during the intervention period. For those patients at high risk of stroke and with no contraindication present (warfarin-eligible patients), 98% were receiving warfarin on discharge from hospital compared to 74% on admission ( P < 0·001). Of the 50 (37%) assessments that recommended a change of therapy, 44 (88%) resulted in a change in the patient's current antithrombotic therapy compared to their admission therapy. Thirty (68%) of the assessments resulted in an 'upgrade' to more-effective treatment options for example from no therapy to any agent or from aspirin to warfarin. The pharmacist-led stroke risk assessment program resulted in a significant increase in the proportion of patients receiving appropriate thromboprophylaxis for stroke prevention in AF. The methods used in this study should be evaluated in a larger trial, in multiple hospitals, with different pharmacists performing the intervention. [ABSTRACT FROM AUTHOR]

Background: There is a need to develop capacity measures for pharmacy services for strategic purposes, to provide guidance on safe working limits and to contribute to the target 40% reduction in serious medication errors by 2005. Attempts have been made to quantify workloads in the form of items/person/hour (i/p/h). However, much of these data are anecdotal, small scale or associated with vague methodology. Objective: We estimate national average dispensing rates by collecting accurate data from secondary care dispensaries across Wales. Method: Seventeen sites collected hourly data relating to staff time and items dispensed over a 3-day period. The result showed a Welsh national average for non-specialist hospital pharmacy dispensing rates of 9·9 items/person/h (95% CI = 0·9, n = 17). There was a significant positive association between hospital size and telephone interruptions ( rs = 0·83, P < 0·001) but no correlation between hospital size and dispensing rates ( rs = 0·06, P = 0·822). [ABSTRACT FROM AUTHOR]

Aim: To identify the services that hospital pharmacies were providing in 1999 to facilitate seamless care upon patient discharge. Design: Postal questionnaire containing closed and open questions. Subjects and setting: U.K. Trust hospitals. Questionnaire addressed to Chief Pharmacists to be completed by themselves or most appropriate deputy, then returned anonymously in prepaid envelope. Results: The response rate was 73·4% (163/222). 71·2% of responses came from general hospitals and 23·3% from teaching hospitals. Junior medical staff members were responsible for preparing virtually all discharge prescriptions, which were checked against the ward prescription chart by pharmacists in three-quarters of U.K. Trusts. Hospitals used a wide variety of methods to communicate information about medicine regimens to GPs. There was also wide variation in the provision of discharge counselling, telephone ‘help-lines’ and clear medication records to patients. Few hospitals involved community pharmacies routinely in the discharge process. Conclusion: There is still wide variation within hospital pharmacy practice in meeting the medicines-related needs of patients at discharge. [ABSTRACT FROM AUTHOR]

The article presents the discussion on 47th year of publication of the Journal of Clinical Pharmacy and Therapeutics (JCPT) becoming a monthly from a bimonthly. Topics include pharmacy profession having better clinical training for serving patients better and having greater opportunity delivering the clinical service; and containing editing and management much of the activities conducting online remotely before COVID-19 lockdowns.