About the Hospital Pharmacy

1. Hospital Pharmacy

 The activities of the Hospital Pharmacy include the improvement of the quality of drug prescribing, the outcomes of pharmacotherapeutic treatment, and the precention and management of medication errors, drug-drug interactions, and side effects. The activities and services of clinical pharmacy specialists focus on ensuring, developing, and promoting the rational, appropriate, and safe use of medications (European Society of Clinical Pharmacy, ESCP).
Hospital Pharmacy was established in 1996 at the Dubrava University Hospital, under the leadership of Professor Vesna Bačić Vrca, clinical pharmacy specialist, when a pilot project called the Unit Dose Drug Distribution System was launched in the Department of Cardiac and Transplant Surgery in cooperation with the American Texas Heart Institute.

 A clinical pharmacist, as part of a multidisciplinary team, monitors the patient´s course of treatment on a daily basis, monitors the prescribed pharmacotherapy, and recommends pharmaceutical interventions to the prescriber or expert panel, e.g. the application of the appropriate drug dose, dosing interval, and pharmaceutical form. Monitoring of prescribed pharmacotherapy reduces the possibility of clinically significant drug-drug interactions, side effects, and other medication errors. The clinical pharmacist provides professional information about pharmacotherapy to members of the healthcare team. They also educate and advise patients on the importance of prescribed pharmacotherapy and the correct use of medicines.

 Clinical pharmacists participate in the Hospital Drug and Therapeutics Committee

The Hospital Drug and Therapeutics Committee assesses the justification for the use of medicines in accordance with the current List of Medications of the Croatian Health Insurance Fund. The Committee also submits documentation on the treatment outcomes and the reasons for the discontinuation of pharmacotherapeutic treatment. It also actively contributes to reducing the cost of pharmacotherapy in accordace with the national drug policy, while ensuring the best choice of pharmacotherapy for most patients.

Clinical pharmacist as part of the antimicrobial stewardship

Antimicrobial Stewardship (AMS) is a coherent set of actions that measures, optimizes, and improves the use of antimicrobial drugs. The goals of AMS are to change the inappropriate prescribing and excessive use of antimicrobial drugs in order to maintain the effectiveness of antibiotics and limit the further spread of antimicrobial resistance. AMS actions include review and evaluation of antimicrobial therapy prescriptions, implementation of guidelines, and comprehensive education. AMS is conducted by the hospital’s designated antimicrobial therapy management team (A-Team). It is important to emphasize that the A-Team requires a multidisciplinary approach. The A-Team includes infectious disease specialists, clinical pharmacists, clinical microbiologists, and other clinicians.

Clinical pharmacists at the hospital wards

Clinical pharmacists participate in expert panel meetings and visits. Clinical pharmacists provide pharmacotherapy reviews, determine pharmacotherapy problems, and recommend pharmacotherapeutic interventions. The work of clinical pharmacists in the department contributes to the solution and prevention of pharmacotherapy problems.

Clinical pharmacist conducts the process of medication reconciliation

Medication reconciliation is a process of identifying the most accurate list of a patient’s current medicines, including the name, dosage, frequency, and method of administration, and comparing them to the list currently in use, identifying any discrepancies and documenting changes, resulting in a complete, accurately communicated medication list.
The clinical pharmacist obtains the best possible medication history (BPMH) and compares it with the prescribed pharmacotherapy in the hospital, including the necessary interventions of the clinical pharmacist.
The process of medication reconciliation has been advocated by many patient safety organizations and agencies seeking to implement it. The transfer of care is a critical point during which unintentional discrepancies can occur. Unintentional discrepancies can lead to negative treatment outcomes, generate new hospitalizations, and cause significant financial costs to the healthcare system. As significant healthcare resources are spent on optimizing hospital care, it is important to establish a model for handover of care between hospitals and primary healthcare.
Medication reconciliation is part of the optimized transfer care model. An optimal transfer care model reduces unintentionded discrepancies, improves treatment outcomes, and increases patient safety.

Before discharge from hospital, the clinical pharmacist, in collaboration with the hospital doctor, draws up the best possible medication discharge plan (BPMDP), which includes information on:

• Medications that will remain after discharge from the hospital,
• Changes in pharmacotherapy made during the hospital stay,
• -Medicines that are to be newly introduced or whose administration is to be discontinued upon discharge from hospital.

Teaching activities and education

 The Hospital Pharmacy at Dubrava University Hospital is a teaching and educational base of the Faculty of Pharmacy and Biochemistry, University of Zagreb. Professor Vesna Bačić Vrca has been leading post-graduate specialist study Clinical Pharmacy and the main mentor for more than 30 clinical pharmacy trainees.

Different teaching and educational activities are carried out in Dubrava University Hospital:

• for the integrated graduate study course Clinical Pharmacy with Pharmacotherapy,
• for the courses of the post-graduate specialist study Clinical Pharmacy,
• for the courses of the post-graduate doctoral study Clinical Pharmacy,
• for professional training of students of the Faculty of Pharmacy and Biochemistry,
• for education for the postgraduate specialist study of Clinical Pharmacy,
• for the specialization in Clinical Pharmacy
• for the ERASMUS program for pharmacy students from other EU countries.

Clinical pharmacists of the Dubrava University Hospital are delegated by the Croatian Pharmacy Chamber as the main mentors for the specialist training.

 Scientific research work

Clinical pharmacy specialists in Dubrava University Hospital promote the rational and safe use of medicines through active participation in national and international congresses and other scientific meetings and by publishing professional and scientific papers in the field of clinical pharmacy. In the past twenty years, we have published more than 50 scientific and professional papers in which we presented the results of our activities in the field of hospital and clinical pharmacy. We have actively participated in national and international scientific and professional meetings and have also organized scientific and professional conferences.
Clinical pharmacists of the Dubrava University Hospital Dubrava are mentors for graduate, specialist theses and doctoral dissertations in the field of clinical pharmacy.
Also, the Hospital Pharmacy cooperates with external institutions in projects that increase the safety of pharmacotherapy. The projects are related to the medication reconciliation, care transfer, drug-drug interactions, dose adjustment, antimicrobial stewardship, deprescription, and the unit dose drug distribution system.

PASQ project

The implementation of medication reconciliation in Croatia was initiated as part of the Work Package 5 of the European Union Network for Patient Safety and Quality of Care (PaSQ) project. Since 2014, Dubrava University Hospital has been involved in the implementation of medication reconciliation project activities. The medication reconciliation process was led by a clinical pharmacist at the hospital. The results indicate that clinical pharmacists play an important role in the detection of unintentional discrepancies and contribute to the prevention of negative effects on patients.

Project – The effect of implementing an integrated pharmacotherapy coordination model on the frequency of unintentional discrepancies and patient safety

The integrated model represents a structured process for medication reconciliation, along with other pharmaceutical interventions, in the hospital and primary health care. The model is led by a hospital clinical pharmacist. It also involves hospital physicians, primary care physicians, community pharmacists and patients. The integrated medication reconciliation model used in this project was designed and developed in collaboration with the following partners:

• Dubrava University Hospital,
• the Agency for Quality and Accreditation in Health Care and Social Welfare,
• the Clinical Pharmacy Section of the Croatian Pharmaceutical Society,
• the Croatian Society for Quality Improvement of Health Care of the Croatian Medical Association,
• the Community Health Centre Zagreb—East and
• Zagreb City Pharmacies
• By implementing this integrated model, which includes a comprehensive professional approach at all levels of the healthcare system, optimal control over the transfer of healthcare in terms of pharmacotherapy would be achieved.

Work in professional societies

Clinical pharmacists actively participate in the work of:

• Section for Clinical Pharmacy of the Croatian Pharmaceutical Society,
• Section for Hospital Pharmacy of the Croatian Pharmaceutical Society,
• Committee for Hospital Pharmacy of the Croatian Chamber of Pharmacy.

They also actively participate in the work of international societies:

• European Association of Hospital Pharmacists, EAHP,
• European Society of Clinical Pharmacy, ESCP. 

2. The laboratory for galenic and magistralpreparations

In the laboratory of the Hospital Pharmacy, galenic and magistral formulations are made according to the valid pharmacopeias and magistral prescriptions. These preparations are made for the specific needs of patients.
The pharmacopeia is the fundamental official regulation for the quality, production, testing, and storage of medicines and medicinal substances. A pharmacopeia is a legally binding collection of standards and quality specifications drawn up by a national or regional authority for medicinal products used in that country or region. A quality specification is composed of a set of appropriate tests that will confirm the identity and purity of the product, ascertain the strength (or amount) of the active substance and, if necessary, its performance characteristics. The Croatian Pharmacopeia is official in Croatia and is based on the European Pharmacopeia. It is available in electronic form and is regularly updated by the Agency for Medicinal Products and Medical Devices (HALMED).

The pharmacopeia consists of two parts:

GENERAL PART – contains an introduction, instructions, definitions, characteristics, and other general rules that apply to all monographs

MATERIA MEDICA – includes monographs of all individual substances, medicinal substances and drugs legally approved and listed in the pharmacopeia.

By signing the Convention on the Establishment of the European Pharmacopeia, adopted in Strasbourg on July 22, 1964, on September 14, 1994, the Republic of Croatia undertook to accept and apply all standards published in the European Pharmacopeia (Ph. Eur.).
With the publication of the Croatian Pharmacopeia, the obligations arising from the Convention were fulfilled and the European Pharmacopeia was implemented in the Republic of Croatia.

Magistral preparations

Magisterial medicine is made for specific patient’s needs from active substances and excipients in the appropriate medicinal form. They are made according to a doctor’s prescription or according to a formulation in pharmaceutical reference books or the Pharmacopeia. Medicinal products prepared in this way are dispensed in suitable pharmaceutical packaging with an appropriate signature label. A white label is used if the medicinal product is intended for internal use and a red label for external use. The label contains the name of the medicinal product, the instructions for use and storage, thedate of manufacture, the name of the pharmacy and the signature of the pharmacist who prepared the medicinal product.
Medicinal forms of magistral preparations that are usually made are solutions, suspensions, drops, ointments, and creams. Medicinal forms of magisterial preparations are adapted to the individual needs of a particular patient.

Galenic preparations

 Galenic preparations are made according to recipes from specialist manuals or the regulations of the Pharmacopeia, defined manufacturing procedures, and according to the criteria of Good Manufacturing Practice. They are made in small batches in galenic laboratories. These are usually various eye drops, ointments, creams, oral solutions, powders and syrups. Galenic preparations are usually produced without preservatives, in smaller quantities, have a shorter expiration date, and are therefore not industrially produced.
Pharmacists specializing in drug analysis and substance control carry out substance and drug analyzes in the laboratory. The pharmacist specializing in drug analysis and substance control selects the appropriate analytical procedures, methods and equipment for the laboratory analyzes and carries out the corresponding procedures for receiving, processing and storing the samples.
In the laboratory of the Hospital Pharmacy, magistral and galenic preparations are made using a sterile procedure: aseptic preparation or the terminal sterilization procedure with an autoclave.

3. Pharmacy section for receiving and dispensing medicines and medical devices

The Hospital Pharmacy ensures a correct medication cycle: ordering, receipt, storage, preparation and distribution. The Hospital Pharmacy supplies the hospital’s wards with medicines and medical products.
The hospital pharmacists ensure the pharmaceutical supply through a range of pharmaceutical activities: Selection, procurement, dispensing, advice on prescribing and administration, monitoring the use and effects of treatment, storage of medicines and pharmacovigilance.
Pharmacy technicians participate in pharmaceutical activities under the supervision of hospital pharmacists.
Hospital pharmacists are healthcare professionals who have been specially trained in the safe, effective and rational use of medicines.
Hospital pharmacists also monitor the consumption of medicines in hospital departments and prepare the necessary regular reports for the hospital, the Agency for Medicinal Products and Medical Devices (HALMED), the Interdisciplinary Department for the Control of Antibiotic Resistance (ISKRA), the Ministry of Health of the Republic of Croatia and the Croatian Health Insurance Fund (CHIF).
Hospital pharmacists have specialist information on medicines (indications, contraindications, pharmacokinetic and pharmacodynamic properties, interactions, dose adjustment according to the renal and liver function, side effects, preparation for administration, storage of medicines, incompatibilities) and pass this on to other healthcare professionals.
Hospital pharmacists also provide information on the status of medicines in the latest National list of medicines of the Croatian Health Insurance Fund (CHIF), on the current availability of medicines on the market and other related professional and legal information.
Hospital pharmacists participate in the work of the Hospital Medicines and Therapeutics Committee, the Antimicrobial Therapy Management Team, the Hospital Infection Committee and the Hospital Healthcare Quality Committee, and cooperate with other healthcare professionals.
The hospital pharmacy strives to ensure the continuous improvement of care and treatment outcomes for the patients of Dubrava University Hospital, particularly with regard to the use of medicines through continuous learning, research, practice and the sharing of knowledge and responsibility with other healthcare professionals. 

4. Unit Dose Drug Distribution System

In order to increase treatment standards in the Croatian healthcare system, under the leadership of Professor Vesna Bačić Vrca, a clinical pharmacy specialistwe were the first and the only ones in Croatia to introduce the Unit Dose Drug Distribution System (UDDDS), a pharmacy-coordinated method of dispensing and controlling medicines in organized healthcare facilities. UDDDS is a system for dispensing drugs to individual patients in single doses for 24-hour therapy.
UDDDS started as a pilot project at the Department of Cardiac and Transplant Surgery of the Dubrava University Hospital in cooperation with the American Texas Heart Institute. It has been expanded to the Department of Abdominal Surgery and the Department of Vascular Surgery, and the trend continues to grow.
The pilot project has resulted in significant pharmacoeconomic savings, a reduction in drug utilization up to 40% in defined daily doses (DDDs), a significant shift towards more rational pharmacotherapy and a significant reduction in medication ward stocks. The European Association of Hospital Pharmacists (EAHP) recommends the integration of UDDDS into the hospital system.

UDDDS increases patient safety by avoiding medication errors due to the dual monitoring system of therapy, which leads to a better treatment outcome and improves the overall quality of hospital care.

According to the American Society of Health-System Pharmacists (ASHP), the main advantages of UDDDS are as follows:

• reduction in the incidence of medication errors,
• reduction in the total cost of medication-related activities,
• more efficient utilization of pharmacy staff, allowing for more direct patient-care involvement by pharmacists,
• improved overall drug control and drug use monitoring,
• more accurate billing of medicines to patients,
• the elimination or minimization of drug credits,
• greater pharmacist control over the pharmacy,
• workload patterns and staff scheduling,
• reduction in the size of drug inventories located in patient-care areas,
• better adaptability to computerized and automated procedures.

In practice, for every patient hospitalized in one of the wards mentioned above, the prescribed pharmacotherapy is monitored by analyzing the accuracy and appropriateness of pharmaceutical form of drug, dose, and dosing interval, and is checked for possible clinically significant drug-drug interactions.
Pharmacists optimize the prescribed pharmacotherapy in collaboration with the doctors. The hospital pharmacist prepares the daily pharmacotherapy according to the agreed individual plan for each patient. Safety is also ensured by the fact that the prepared pharmacotherapy is transported to the patient on a specially designed trolley. Each container on this trolley is labeled with the patient’s first and last name and has sections with a time stamp indicating the hour at which the medication is to be administered. Each medication, which is in its own container, is properly packaged and labeled so that the patient can be educated about the purpose, method of administration and the type of medication they will continue to use after discharge.
In the UDDDS, clinical pharmacy specialists monitor and analyze the prescribed pharmacotherapy in order to prevent medication errors and optimize therapy. Recommended changes, pharmacotherapy optimizations, and pharmacists’ interventions are presented to the prescribing physician or expert panel in a document known as Pharmacotherapy analysis. The Pharmacotherapy analysis primarily includes monitoring the accuracy and appropriateness of the chosen drugs, the dose, the dosing interval, and pharmaceutical form. It also includes the evaluation of possible clinically significant drug-drug interactions. This process significantly improves the quality of healthcare and patient safety, and at the same time represents a rational approach to  prescribing and administration of drugs in the hospital system.