Adverse drug events contribute to rising health care costs. Clinical pharmacists can reduce their risks by identifying and solving drug-related problems (DRPs) through medication review. To develop an economic model to determine whether medication reviews performed by clinical pharmacists could lead to a reduction in health care costs associated with the prevention of potential adverse drug events. Two pharmacists performed medication reviews during ward rounds in an internal medicine setting over one year. Avoided costs were estimated by monetizing five categories of DRPs (improper drug selection, drug interactions, untreated indications, inadequate dosages, and drug use without an indication). An expert panel assessed potential adverse drug events and their probabilities of occurrence for 20 randomly selected DRPs in each category. The costs of adverse drug events were extracted from internal hospital financial data. A partial economic study from a hospital perspective then estimated the annual costs avoided by resolving DRPs identified by 3 part-time clinical pharmacists (0.9 full-time equivalent) from 2019 to 2020. The return on investment (ROI) of medication review was calculated. The estimated annual avoided costs associated with the potential adverse drug events induced by 676 DRPs detected was € 304,170. The cost of a 0.9 full-time equivalent clinical pharmacist was € 112,408. Extrapolated to 1 full-time equivalent, the annual net savings was € 213,069 or an ROI of 1–1.71. Sensitivity analyses showed that the economic model was robust. This economic model revealed the positive financial impact and favorable return on investment of a medication review intervention performed by clinical pharmacists. These findings should encourage the future deployment of a pharmacist-led adverse drug events prevention program.

Background Adverse drug events (ADEs) can be prevented by deploying clinical decision support systems (CDSS) that directly assist physicians, via computerized order entry systems, and clinical pharmacists performing medication reviews as part of medical rounds. However, physicians using CDSS are known to be exposed to the alert-fatigue phenomenon. Our study aimed to assess the performance of PharmaCheck—a CDSS to help clinical pharmacists detect high-risk situations with the potential to lead to ADEs—and its impact on clinical pharmacists’ activities. Methods Twenty clinical rules, divided into four risk classes, were set for the daily screening of high-risk situations in the electronic health records of patients admitted to our General Internal Medicine Department. Alerts to clinical pharmacists encouraged them to telephone prescribers and suggest any necessary treatment adjustments. PharmaCheck’s performance was assessed using the intervention’s positive predictive value (PPV), which characterizes the proportion of interventions for each alert triggered. PharmaCheck’s impact was assessed by considering clinical pharmacists as a filter for ruling out futile alerts and by comparing the final clinical PPV with a pharmacist (the proportion of interventions that led to a change in the medical regimen) to the final clinical PPV without a pharmacist. Results Over 132 days, 447 alerts were triggered for 383 patients, leading to 90 interventions (overall intervention PPV = 20.1%). By risk class, intervention PPVs made up 26.9% (n = 65/242) of abnormal laboratory value alerts, 3.1% (4/127) of alerts for contraindicated medications or medications to be used with caution, 28.2% (20/71) of drug–drug interaction alerts, and 14.3% (1/7) of inadequate mode of administration alerts. Clinical PPVs reached 71.0% (64/90) when pharmacists filtered alerts and 14% (64/242) if they were not doing it. Conclusion PharmaCheck enabled clinical pharmacists to improve their traditional processes and broaden their coverage by focusing on 20 high-risk situations. Alert management by pharmacists seemed to be a more effective way of preventing risky situations and alert-fatigue than a model addressing alerts to physicians exclusively. Some fine-tuning could enhance PharmaCheck's performance by considering the information quality of triggers, the variability of clinical settings, and the fact that some prescription processes are already highly secured.

Background and importance In the internal medicine department of our hospital, medication review provided by pharmacists during medical rounds is offered to only a fraction of the 200 inpatients, due to limited resources. In order to detect high risk situations potentially leading to adverse drug events, we developed PharmaCheck, an electronic tool that screens all patient electronic health records (EHR) in real time, by aggregating drug prescriptions, laboratory values, vital signs and medical problems. Aim and objectives To determine the impact of PharmaCheck in the identification of high risk situations and on the clinical pharmacist's interventions. Material and methods PharmaCheck was set to screen 20 situations distributed into four risk classes: a drug prescription with an abnormal laboratory value, a contraindication, a drug–drug interaction (DDI) and an inadequate administration mode. For 150 days (February to August 2020), PharmaCheck performed a daily screen of patients' EHR, admitted to the internal medicine department. As soon as an alert was triggered, the clinical pharmacist analysed the patient's clinical context to suggest a treatment adjustment when needed. An observational prospective study was performed to assess the distribution of each risk class, the predictive positive value of each alert (PPV: proportion of situations associated with an intervention) as well as the acceptance rate by the prescribers. Results 430 alerts were triggered for 387 patients (3.3±1.9 alerts/day) with a global PPVof 19.3% (n=83/430). Regarding risk classes, PPVs were 25.6% (n=58/226) for abnormal laboratory value, 3.10% (4/127) for contraindications, 28.2% (20/71) for DDIs and 16.7% (1/6) for inadequate administration mode. The approval rate of treatment adjustment suggestions was 71.1% (n=59/83); rejections were related to an acceptable risk–benefit balance (n=20) or an unknown cause (n=4). Conclusion and relevance PharmaCheck identified a significant number of high risk situations. By contextualising these alerts the clinical pharmacist selected the most relevant ones to suggest treatment adjustment, mostly accepted by physicians. Beyond the clinical context, the relevance of alerts depends on the informative quality of the triggering elements, explaining a low PPV for some risk classes (eg, contraindication, depending on unstructured textual medical problems). PharmaCheck expands the coverage of the clinical pharmacist for selected situations and we plan to transpose this strategy to other, more fragile, patient populations (eg, geriatrics, paediatrics, oncology). References and/or acknowledgements Conflict of interest No conflict of interest

Complementary medicine (CM) is used by one third to one half of cancer patients throughout the world. The objective of this study was to describe the prevalence of CM use and the potential for interactions with cancer treatments in an academic oncology centre. A cross-sectional study was conducted among patients undergoing current cancer treatment. Among 132 included patients, 56% had used CM since their cancer diagnosis and 45% were using CM during cancer treatment at the time of the survey. The main CM used were green tea (35%), herbal tea (35%), homeopathy (27%), dietary supplements (27%), and herbal medicines (27%). A small majority of patients (58%) spontaneously mentioned the use of CM to their oncologist. Of 42 identified combinations of concomitant use of biologically based CM and anticancer agents among the study patients, the potential for pharmacokinetic interactions of clinical relevance was not expected in 17 combinations (40%), hypothetical and deemed unlikely in 23 (55%), and of probable low clinical relevance in 2 (5%). Considering the high prevalence of CM use, active enquiries should be made by healthcare professionals to detect symptoms that may relate to CM tolerance and effects or that suggest interactions between CM and cancer treatments.

Background Our chemotherapy production unit decided to rethink its organisational strategy and to revise its production processes through lean methodology to meet growing activity, in the context budget constraints that limit the increase in staff. Purpose To evaluate the impact of a lean management approach on the efficiency of a chemotherapy unit. Material and methods A five-step lean methodology approach was applied with a team of 12 technicians and five pharmacists supported by a lean expert, from January 2015 to July 2016: DEFINE: objectives, value stream mapping, process flows. MEASURE: steps, process duration, use of stock. ANALYSE: added-value steps, waste, waiting time and causes. IMPLEMENT: imagine and implement solutions. CONTROL: efficiency, performance, satisfaction. Results The team identified 73 items impacting the efficiency of the process during the 'Measure' phase. During the 'Analyse' step, 18 opportunities divided into four main themes were proposed to improve the organisation: Flow: smoothing the activity and reducing the early morning peak (–12% between 7 and 9 am), producing continuously according to demand of the day ('Just in time' eight maximum ongoing preparations), improving occupancy rates of isolators (+25% between 10 and 12 am, and +20% between 1 and 4 pm), revising the steps of double–control and using mistake–proofing resulted in a decrease in crossing time of manufacturing from 9 hour 45 min to 1 hour 45 min. bull; Space: reorganisation with a reduction of unnecessary movements. bull; Management: creation of a position of 'coordinator of the day', and daily meetings ('Obeya') to reassign tasks. bull; Stock and control: rationalisation of storage and orders. A net gain of 40% full-time equivalent was reached. The satisfaction survey showed a positive acceptance of the project and its conduct. Conclusion The application of a lean methodology allowed the optimisation of the management of our chemotherapy production unit and saved human resources. The main actions were to eliminate waiting time, to smooth daily activity, and to reorganise roles, spatial organisation and storage. The positive impact on the efficiency of our facility and the satisfaction of the team proved that lean methodology is a relevant tool in the hospital pharmacy. No conflict of interest

L’unité de production des chimiothérapies a décidé de repenser sa stratégie organisationnelle et de revoir son processus de production par la méthodologie lean pour répondre à une activité croissante, malgré des ressources stables. Les objectifs de ce projet sont d’augmenter la productivité et la qualité, tout en diminuant les délais et coûts de production, puis d’améliorer la qualité de vie au travail. Le projet a été mené par l’équipe de production, sous la supervision d’un pharmacien accompagné d’un expert lean, de janvier 2015 à juillet 2016. L’application de la méthodologie lean s’est faite selon une démarche classique en 5 étapes : – définir : objectifs, cartographie, familles de processus et flux ; – mesurer : étapes, durée du processus, tracé des déplacements, utilisation du stock ; – analyser : valeurs ajoutées des étapes, gaspillages, temps d’attente et causes ; – implémenter : imaginer et mettre en œuvre des solutions ; – contrôler : efficience, performance, satisfaction. Sur 73 éléments impactant l’efficience du processus, l’équipe a proposé 18 points d’amélioration classés en 4 thèmes dont les principaux sont : – flux : lissage de l’activité et du pic de production matinal (−12 % entre 7 et 9 h) en produisant en continu selon la demande du jour (« just in time », 8 préparations max. en cours), en révisant les étapes de double insu et en utilisant des détrompeurs. Un meilleur taux d’occupation des isolateurs (+24,8 % entre 10 et 12 h et +19,6 % entre 13 et 16 h) et une diminution du temps moyen de parcours d’une production de 9 h 45 à 1 h 43 ont pu être mis en évidence ; – espace : réorganisation des locaux (diminution des déplacements) ; – management : création d’un poste de « coordinateur du jour » et réunions quotidiennes pour réattribuer les tâches ; – stock et commande : rationalisation du stock et des commandes. Le nombre moyen de personnes dans l’unité est passé de 4,7 à 4,3 personnes (un gain de 40 % d’équivalent temps-plein). L’enquête de satisfaction montre une acceptation positive du projet et de sa conduite. L’application du lean a permis d’optimiser le processus de production des chimiothérapies et de gagner en temps humain. Les principales actions ont été d’éliminer les pics de production et lisser l’activité journalière, de réorganiser les rôles, les locaux et le stock. L’impact positif sur la durée du processus, la performance de production et la satisfaction de l’équipe de production démontrent que le lean est un outil à promouvoir en pharmacie hospitalière.