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Materials and Methods The study period lasted from September 2011 to January 2012 (inclusive), in a 420-bed hospital. Every day creatinine values over 130 mmol/l were filtered. Treatment was reviewed and we obtained creatinine clearance values (Crockcoft & Gault) of selected patients. After consulting the drug dose adjustment on the sheet and in Micromedex, a report was sent with the pharmaceutical recommendation. Results There were 68 interventions for the 2147 patients studied: Internal Medicine (34) Cardiology (1), Short Stay Unit (5), Orthopaedics (7), Urology (5), Haematology (7) Surgery (5), Neurology (1), Intensive Care Unit (ICU) (2) Oncology (1). 55.9% of notifications were for changes in the dose of enoxaparin (38), 11.8% of amoxicillin-clavulanic acid (8), piperacillin-tazobactam 14.7% (10), 8.8% levofloxacin (6), 2.9% meropenem (2), 2.9% ciprofloxacin (2), 1.5% imipenem (1) and 1.5% aztreonam (1). The proportion of suggested changes accepted was 58.8% (40). 5.9% (4) discontinued treatment, 5.9% (4) were discharged and 29.4% (20) not changed. Of the latter, five were for changes in the pattern of enoxaparin in trauma patients, another 5 from Internal Medicine and 2 more from Haematology and ICU. The rest of them were changes in the pattern of antibiotics (imipenem 1, 2 levofloxacin, 1 meropenem, 1 ciprofloxacin, piperacillin-tazobactam 3) that were given out in the different services. Conclusions A high percentage of doctors followed the recommendations. Part of the unaccepted tally corresponds to trauma patients whose prophylactic regimen of enoxaparin (40 mg/24 h) was not modified due to the service criteria. Some of the antibiotic prescriptions were not changed because of the severity of the patient's illness (1 levofloxacin and 1 Internal Medicine Meropenem Imipenem Oncology and 1). The rest were rejected without explanation. No conflict of interest.

BackgroundThe unit dose system of medication distribution (UDDS) is a pharmacy coordinated method of dispensing and controlling medications in organised healthcare settings. In our hospital, medications contained in single unit packages are delivered during the morning for a 24 h period.However, after delivery, many drugs are requested throughout the day for different reasons. Medication dispensed in this way is more susceptible to medication errors than those included at UDDS.PurposeTo assess drug requests (out of UDDS) from clinical units, identify the reason for the same and try to improve the process to reduce their numbers.Material and methodsRetrospective descriptive study over a 2 month period in which request forms from various clinical units (traumatology, rheumatology and pneumology) were analysed, quantified and classified into 7 subgroups.ResultsDuring the study period, 605 requests for drugs were analysed and we observed the following distribution:28%: drugs not prescribed.21%: drugs that theoretically were distributed at UDDS.18%: changes in treatment and new hospitalised patients.15%: drugs not included in the hospital pharmacotherapeutic guide.12%: drugs that are not distributed at UDDS for different reasons (multidose vials, drugs that must be given only in some situations like pain or insomnia).3%: drugs for an erroneous route of administration.3%: drugs that were not distributed at UDSS for different errors (human error, computer error).Conclusion55% of drug requests were not justified, with a high percentage of drugs that were notprescribed, which is often caused by verbal orders from doctors.45% of drug requests were justified, with a high percentage of new hospitalised patients and changes in treatment.To improve the drug distribution chain and patient safety, we have decided to implement electronic medication request forms through electronic medical order. In this way, we can reduce dispensations of drugs not prescribed and ensure safe and correct distribution for new hospitalised patients and changes in treatment.According to this study, this would reduce by approximately 55% the number of dispensations out of UDDS.References and/or AcknowledgementsWe would like to thank all members of the Department of Pharmacy for their effort and patience during the implementation of this study.No conflict of interest.

Conclusion and relevance It seems that adjusted doses of anthracyclines in obese paediatric patients can be effective and safety but due to limited data, this recommendation must be taken with caution. REFERENCES AND/OR ACKNOWLEDGEMENTS No conflict of interest.

BackgroundVancomycin is a drug with a narrow therapeutic range, in which accurate data on weight or renal function are indispensable for correct practice.PurposeTo analyse the minimum set of data necessary for a correct follow-up of patients on vancomycin treatment and to assess whether therapeutic drug monitoring (TDM) by the pharmacy service improves the quality of the data recorded in the electronic medical record (EMR).Material and methodsA retrospective clinical practice study of the case series treated with vancomycin and subsequently TDM or not during the period from 1 January 2016 to 31 December 2016.Following data was collected: TDM (yes/no), age, weight, creatinine at baseline and at the end, and Protein C Reactive (PCR) at the beginning and at the end. The data have been extracted from the EMR through the Selene®program and we used descriptive statistic using the SPSS® V23 program.ResultsOf the 264 patients treated with vancomycin, in 35% of them weight was not completed in EMR. 1.5% of the patients of the TDM group had not recorded the weight in EMR compared to 45% of patients of the non-TDM group (p<0.0001).Before the start of treatment with vancomycin, 5% of the patients had no creatinine data. None of them belonged to the TDM group versus 6.5% that belonged to the non-TDM group (p=0.0328).Thirteen per cent did not reflect the value of PCR at the start: 6.1% of the TDM group versus 15.6% of the non-TDM group (p=0.0315).At the end of treatment, 29.9% had not completed the PCR value (13.79% of the TDM group versus 55.90% of the non-TDM group) and 18.2% did not request the creatinine value: none of them belonged to the TDM group and 32% to the non-TDM group.ConclusionTDM by the pharmacist improves the quality of the data recorded in the EMR. Its implication in the follow-up of the patients ensures that the necessary data for the correct dosage and monitoring of the toxicity and effectiveness of the treatments are completed.References and/or AcknowledgementsThanks to my service for your unconditional supportNo conflict of interest