Abstracts 13th PCNE Working Conference “Pharmacies' new roles in pharmaceutical care: bridging research and practice”

Abstract

Poster abstractsPCNE abstract number 576Medication adherence assessment in patients with rare diseases—a scoping reviewMaria Kamusheva1, Iva Haygarova1, Nikolay Ganov1, Marina Pesheva1, Konstantin Tachkov1, Guenka Petrova1 1Faculty of Pharmacy, MU-Sofia, BulgariaEmail: mkamusheva@pharmfac.mu-sofia.bgBackground Medication adherence (MA) is a key factor in the achievement of therapeutic goals for patients with rare diseases (RDs). Collecting and analyzing the existing information on different aspects of MA would bring value for better and adequate support to this specific group of patients.Purpose To critically appraise, consolidate and present an overview of the scientific literature focused on MA assessment methods, influencing factors and interventions that can support patients with RDs to improve MA. The findings could be informative about the available approaches and the most studied aspects of MA in the selected group of patients.Method A scoping review was performed. The sources searched were PubMed and Google Scholar with no limit on date. A specific combination of keywords was used: medication adherence OR compliance, AND interventions OR methods, AND assessment OR evaluation, AND rare diseases AND orphan medicines OR orphan drugs. A number of inclusion and exclusion criteria were defined: studies were not excluded by publication date and type of study design. We included only English-language articles focused on methods for assessment and improvement of MA in RDs and MA importance. Studies that presented other aspects of RDs treatment and monitoring without considering MA were excluded.Findings Out of 167 screened paper, 9 were included. Twelve more studies met the criteria and were analyzed. The patients' groups varied regarding the type of RD: growth hormone deficiencies (n = 3), cystic fibrosis (n = 2), type 1 Hereditary Tyrosinemia (n = 2), acromegaly (n = 2) etc. Most studies were systematic reviews (n = 5), followed by cross-sectional studies (n = 4) and quantitative, descriptive, national cohort surveys using claims data (n = 4). The main observed aspects related to MA were the level of adherence and the influencing factors. No specific recommendations for MA improvement were given in most of the studies. Both objective (n = 1) and subjective (n = 21) methods were applied to assess the level of MA. Morisky scale and other questionnaires were the most commonly used subjective methods followed by the objective methods (dose counts, pharmacy records). The level of MA varied in different studies based on the type of therapy and RD: between 44.8% and 92.1%.Conclusion Considering the variation in MA levels, most of the authors highlighted the need for improvement of MA in patients with RDs. Development and implementation of government-supported programs and other diseases-specific methods, involving various medical specialists, are needed. FUNDING: The Bulgarian National Science Fund approved and financed the study (No. KП-06- 361 КOCT/6/14.06.2022).PCNE abstract number 579Identifying patients at high risk for drug-related problems: preliminary results of the MediPORT-studyStephanie Buchegger1, Clara Simon1, Olaf Rose2, Bernhard El-Masri1, Georg Zimmermann3, Christina Dückelmann1, Maria Flamm4, Johanna Pachmayr1 1Institute of Pharmacy, Pharmaceutical Biology & Clinical Pharmacy, Paracelsus Medical University, Salzburg, Austria, 2impac2t research, Maximilianstr. 31-33, 48147, Münster, Germany. rose@elefantenapo.de, 3Team Biostatistics and Big Medical Data, IDA Lab Salzburg, Paracelsus Medical University, Salzburg, Austria, 4Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, AustriaEmail: stephanie.buchegger@pmu.ac.atBackground Prioritizing pharmaceutical care is needed to make pharmaceutical service more efficient and available for high-risk patients. Little is known about risk factors associated with drug-related problems (DRP) of patients in hospitals.Purpose The aim of this study was to identify objective and easily ascertainable factors correlated with DRP in patients undergoing elective surgery. Results contribute to the development of a Pre-Operative Risk-prediction Tool for medication review (MediPORT) at hospital admission.Method The study was a retrospective, single centre case control study. Patients ≥ 18 years, participating in a medication review (PCNE type 3) and undergoing elective surgery in 2021 were included. The sample size was calculated to reach a representative sample out of a defined study population (n = 1500), considering 5% precision and 95% CI. Outcome measures were defined on the basis of a focused literature review and of applicability on real clinical practice data. Frequencies, ranges, means and SD were used for descriptive analysis. The χ2-test, Mann–Whitney-U-Test and two sample t-test were used to measure differences in the prevalence of sociodemographic and clinical parameters in the presence of DRP. Variables were explored via binary logistic regression. Analyses were performed with IBM SPSS statistics V.27. The study protocol was approved by the local ethics committee of Salzburg County, Austria (ID: 1158/2021) and was registered in the German Clinical Trials Register (DRKS00028763).Findings According to the literature review, age, allergies, Body Mass Index (BMI), the calculated Carlson Comorbidity Index (CCI) and gender were chosen as primary outcome factors. Overall, 460 participants consisting of 169 cases (defined as patients with at least one DRP identified by pharmacists) and 291 controls (defined as patients without any detected DRPs) were analysed. Mean age of participants was 59.9 years (± 18.87). Most individuals were men (55.1%) and persons without allergies (66.1%). Mean index of chronic conditions was 1.76 (± 2.11) and mean BMI was 26.6 kg/m2 (± 5.59). Age showed a positive association with the occurrence of allergies (p = 0.010). Preliminary results of the adjusted model indicated that age and the calculated CCI were associated with a higher risk of DRP. However, these should be interpreted as associations rather than determination of causal relationships.Conclusion Risk factors for the appearance of DRP in patients undergoing elective surgery could be identified. Measures appear to be easily assessable in clinical settings and are a promising approach for the development of the MediPORT-tool.PCNE abstract number 580Evaluation of impacts of a structured counseling approach on pharmacy students’ communication confidence and skills: A mixed-mode researchYen-Ming Huang1, Yunn-Fang Ho1, Hsun-Yu Chan2, Ling-Ling Hsieh3, Ling-Jie Chen4 1Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan, 2Department of Industrial Education, National Taiwan Normal University, Taipei, Taiwan, 3School of Pharmacy, College of Medicine, National Taiwan University, Taipei City, Taiwan, 4Chen-Fang Pharmacy, Yilan County, TaiwanEmail: yenming927@ntu.edu.twBackground Using standardized instructional methods to teach communication skills in pharmacy education is strategic to ensure high instructional quality and accountability. We provided pharmacy students with a 5-step structured counseling approach to reinforce their ability to practice counseling on over-the-counter (OTC) medications.Purpose This study engaged senior pharmacy students in applying a structured approach to counseling on over-the-counter medications during advanced experiential training. By using a mixed-mode assessment technique, we aimed to evaluate the impact of this approach on pharmacy students’ confidence and skills in counseling on over-the-counter medications.Method The structured counseling approach (SAIDS) comprised five elements: (1) Surfacing Symptoms and medication history, (2) inquiring Allergy, (3) providing medication Indication, (4) Directing correct medication use, and (5) Supporting Self-care. During six-week Advanced Community Pharmacy Practice Experiences (ACPPEs), each student provided consumers with conventional counseling and SAIDS approach on OTCs during the first three and the last three weeks, respectively. Consumer participants were recruited at six community pharmacies in Taiwan between 2020 and 2022. Self-administered questionnaires were deployed to assess consumers’ understanding of OTC use and to evaluate students’ confidence and skills in the provision of OTC counseling.Findings One hundred and fifty-nine customer participants received conventional counseling while 133 individuals got SAIDS counseling services. Consumers receiving the SAIDS medication counseling showed a significant understanding of the cautions needed to pay attention to the OTCs they purchased (p < 0.001). Thirty-one pharmacy students participated in the study and reported significantly improved confidence (p < 0.001) in OTC counseling during the 6-week ACPPE. They indicated the ACPPE provided them with opportunities to practice medication counseling independently (p = 0.023). The qualitative findings showed the SAIDS helped students prompt questions to understand consumers’ needs, recommend proper OTCs, and provide relevant information to OTC counseling. The students mentioned the SAIDS approach directed them to empathize with consumers’ discomfort, provided shared decision-making, completed the counseling loop, and empowered consumers’ self-medication. Students also pointed out consumers may not reconcile conflicting information from different channels or lack knowledge of ailments. The SAIDS approach allowed students to engage consumers in conversation to clarify key information on OTC use.Conclusion Pharmacy students reported enhanced confidence in OTC counseling and improved consumers’ understanding of OTC use under the structured SAIDS approach. Using a structured counseling approach to involve pharmacy students in OTC counseling is viable to cultivate their communication skills to assist the public in using OTC safely and effectively.PCNE abstract number 584Exploration of pediatric adverse drug reactions in Taiwan: illustrated by antibiotic- and anticonvulsant-associated liver injuryYu-Ting Huang1, Yen-Ming Huang1, Yunn-Fang Ho1 1National Taiwan UniversityEmail: r09423022@ntu.edu.twBackground Drug-induced liver injury (DILI) is an adverse reaction to medications that lead to expected or unexpected hepatotoxicity. Most DILIs in pediatrics are caused by treatment with antibiotics or anticonvulsants, while the pattern of DILI in pediatrics remains unclear in Taiwan.Purpose The study aimed to evaluate drug class, pattern, and risk of DILI among pediatrics in Taiwan.Method A retrospective analysis of the data, from May 1998 to July 2017, archived in the Taiwan National Adverse Drug Reactions Reporting System was performed. The Standardised MedDAR Queries (SMQ) was applied to obtain suspected DILI cases. The data were analyzed descriptively. We used disproportionality analysis and presented reporting odds ratio (ROR) to compare individual antibiotic or anticonvulsant DILI reports with respective antibiotic or anticonvulsant non-DILI reports.Findings A total of 484 (2.8%) suspected DILI cases out of 17,248 reports were identified, comprising 214 drugs. Suspected DILI cases were 8.0 years old (SD: 6.1; 0–18 years), predominantly girls (52.9%; boys 39.7%), and reported mainly by health professionals (71.9%). These suspected DILI cases were mainly (74.0%) designated as serious, including death, life-threatening, caused or prolonged hospitalization, and other serious adverse reactions (medically important). The most frequently observed drug classes were antibiotics (23.0%) and anticonvulsants (7.9%). Oxacillin (20.7%; ROR 5.33; CI 3.14–8.78; p-value < 0.001), isoniazid (9.0%; ROR 23.77; CI 8.83–67.92; p-value < 0.001), and rifampicin (9.0%; ROR 13.97; CI 5.71–33.48; p value < 0.001) ranked top three for antibiotics DILI. All three antibiotics were shown to be associated with DILI significantly under disproportionality analysis. Phenobarbital (31.9%), valproic acid (26.3%), and phenytoin (23.7%) were the most frequently reported anticonvulsant DILI. However, only the ROR (3.23; CI 1.39–7.02; p value = 0.008) of valproic acid truly demonstrated statistical significance.Conclusion The DILI in pediatric is rare but serious. Among common culprit antibiotics and anticonvulsants, oxacillin, isoniazid, rifampicin, and valproic acid pose greater risks for pediatric DILI and deserves clinicians’ special attention in patient care.PCNE abstract number 585Facilitating implementation of medication reviews in the community pharmacy setting: an application of the Implementation Research Logic ModelDorothee E Michel1, Antonella P Tonna1, Dorothee C Dartsch2, Anita E Weidmann3 1Robert Gordon University, Aberdeen, Scotland, 2Cap Campus Pharmazie GmbH, Hamburg, Germany, 3Universität Innsbruck, Innsbruck, AustriaEmail: doro.michel@gmx.netBackground Previous research has identified both determinants and potential strategies to facilitate implementation of medication reviews (MR). A conceptual model which links determinants, strategies to support implementation and mechanisms of change to execute implementation, with projected outcomes is helpful to plan the approach and facilitate MR-implementation.Purpose The aim of this research was to apply the Implementation Research Logic Model (ILRM) for the implementation of medication reviews in the German community pharmacy setting, and thus illustrate the links between determinants, strategies, and implementation outcomes. The resulting map is meant to inform and facilitate MR-implementation.Method The IRLM was populated with determinants (barriers and facilitators structured using the Framework for Implementation of Services in Pharmacy, FISpH), proposed strategies (according to the Expert Recommendations for Implementing Change, ERIC) and mechanisms of change which were identified in an interview study with 21 German pharmacy owners. The research team linked these with 8 implementation outcomes derived from Proctor: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, sustainability.Findings Twenty strategies from the interview study were mapped against 32 determinants. All strategies were hypothesised to impact on one or several of the 8 implementation outcomes. Depending on pharmacies’ implementation stage (exploration, preparation, implementation, and sustainment) the importance of strategies was expected to vary. Strategies such as educational meetings and learning collaboratives can increase perceived appropriateness and boost adoption of MRs which is particularly important for pharmacies in the early exploration stage. Strategies such as receiving support from external implementation advisors as well as recruiting and training internal implementation leaders were deemed particularly important for pharmacies at the preparation stage to strengthen feasibility and fidelity. In later stages (implementation and sustainment) pharmacies were thought to benefit from provision of clinical feedback, obtaining and using patient feedback and re-examining implementation to achieve high fidelity, penetration, and sustainability of MR-provision. Some strategies such as fixed payment and stable delivery contracts were deemed pre-requisites for implementation irrespective of the stage the pharmacy was at.Conclusion The application of the Implementation Research Logic Model illustrated the relations between determinants, strategies, mechanisms, and implementation outcomes. Future research is needed to ascertain that strategies work as planned and achieve the projected implementation outcomes.PCNE abstract number 586Pregnancy prevention while using oral retinoids: a questionnaire survey in DenmarkDana Backran1, Sophia Ahmad1, Johanne Hansen1, Anna Birna Almarsdóttir1, Ramune Jacobsen1 1University of CopenhagenEmail: ramune.jacobsen@sund.ku.dkBackground The use of oral retinoids during pregnancy is associated with teratogenic effects and malformations in newborn babies. The European Medicine Agency (EMA) provided recommendations regarding the restrictive use of oral retinoids during pregnancy in 2003, and updated these recommendations in 2018 by introducing a pregnancy prevention program (PPP).Purpose This study aimed to investigate the awareness of oral retinoid teratogenicity and the adherence to the PPP by physicians, pharmacists and patients in Denmark.Method As part of the EMA initiated multi-country survey, web-based questionnaires were distributed among Danish dermatologists and general practitioners, community pharmacists, and women of childbearing age, who were not pregnant and were using or had used oral retinoids within the past five years. Questionnaires were distributed via respective professional and patient organizations’ social media.Findings Convenient samples of 62 physicians, 96 pharmacists, and 50 oral retinoid using women responded to their questionnaires; 95%, 100%, and 98%, respectively, were aware of the teratogenic risks of oral retinoids. For physicians, the most applied PPP measures were the usage of the patient (44%) and the healthcare professional (19%) guides, while the least applied measure was signing medication risk form (3%). The majority of the physicians discontinued oral retinoids in women who wanted to become pregnant (90%). Performing pregnancy tests and monthly follow-ups with women using oral retinoids were practiced by appr. two thirds of the physicians. Among the pharmacists, the warning sign on the outer medication package was the most used measure (45%), the other measures showed a use of 12.0% or lower; 79% of the pharmacists often or always provided information about the importance of effective contraception when dispensing oral retinoids, and 74% advised women to contact their prescriber if they suspected being pregnant. Among the women, a majority (90%) had read the patient information leaflet included in the medication package and 72% discussed the use of contraception with their healthcare provider, while risk awareness forms and patient cards were seen by only few.Conclusion The study showed that in Denmark physicians, pharmacists and medicine users are aware about the teratogenic effects of oral retinoids. Adherence to pregnancy prevention measures varied considerably for different measures, suggesting a lack of access or unwillingness to use the measures that require patients’ signatures. Feasibility and accessibility of the PPP measures need to be improved to help increase their adherence and improve the safety of oral retinoid prescribing, dispensing, and use.PCNE abstract number 587How medicines are playing out for patients in daily life—a qualitative analysis of drug related problems identified at the pharmacy counterSusanne Kaae1, Ellen van Loon3, Katja Taxis3, Ulla Hedegaard2, Stijn Crutzen3, Ramune Jacobsen1, Armin Andersen1 1Social and Clinical Pharmacy, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark, 2University of Southern Denmark, 3University of GroningenEmail: armin.andersen@sund.ku.dkBackground Up to 80% of patients with chronic illness experience drug related problems (DRPs), which decreases their quality of life and is costly for society. To tackle DRPs, more insights into what they involve is needed. Besides insights measuring the effects of a controlled pharmacist intervention, or pertaining to poly-pharmacy, insights into how all types of patients experience DRPs in their daily life are also needed.Purpose To holistically investigate the DRPs that patients are experiencing in a daily life context across therapeutic areas and existing DRP categories.Method The data material in this study was part of a larger study evaluating a new education in patient-centered communication offered to pharmacy staff in Denmark. The extracted data consisted of short written descriptions of DRPs detected during counter conversations when dispensing medicines, as recorded by the pharmacy staff. The content of these stories were subjected to an inductive content analysis to understand the problems patients face with their medicines in daily life as they are happening.Findings 297 short descriptions made by 28 pharmacy staff members from 11 different pharmacies were analyzed. Results showed that establishing and maintaining good medication treatment involves considerable efforts from both the patient and the prescriber. Three overall DRP themes were identified. Firstly, problems of actually receiving the medicines were observed. These pertained both to patients not picking up the medicine (for example due to the price or forgetfulness), a missing prescription or lack of prescription renewal, or problems with the medicine distribution system. Secondly, situations with lack of clarity about how to take the medicine were identified. This entailed patients not knowing why to take the medicine, how to administer the medicine or how to coordinate the intake with food/supplementary products. Thirdly, problems with getting satisfactory effects were registered. This included negative experiences with the medicine and concern of future side effect or lack of effect leading to strong worries and undertreatment.Conclusion DRPs are widespread and impact patients’ daily lives practically, emotionally and health-wise. The DRP descriptions in this study clarified fundamental problems with the medicines, which have not been registered using other approaches: Before even considering whether the medicine has the desired effects, it’s necessary to ensure that basic conditions are in place, such as a continued supply of medicine and that the patient knows the treatment plan.PCNE abstract number 588RetinoidRiskAware Study: AWARENESS AND IMPLEMENTATION OF PHARMACOVIGILANCE MEASURES FOR THE SAFE USE OF ORAL RETINOIDS AMONG PATIENTS, PHARMACISTS AND PRESCRIBERS IN SLOVENIA.Nanča Čebron Lipovec1, Mitja Kos1 1University of Ljubljana, Faculty of PharmacyEmail: nanca.cebron.lipovec@ffa.uni-lj.siBackground Retinoids are a class of compounds derived from vitamin A. Oral and topical forms are used to treat numerous dermatologic conditions such as severe acne, eczema, psoriasis, and certain cancers. Due to teratogenicity, the use of oral retinoids is contraindicated during pregnancy. In 2018, the European Medicines Agency introduced a pregnancy prevention programme and revised educational materials to ensure that patients treated with oral retinoids are fully informed about the risks and the need to avoid pregnancy.Purpose To determine patients' and healthcare professionals' awareness of the teratogenic potential of oral retinoids and their adherence to the pregnancy prevention programme in Slovenia.Method This was a mixed-methods study in which both quantitative and qualitative data were collected and analysed. A cross-sectional web-based survey was developed and conducted among physicians, pharmacists, and female patients receiving oral retinoids. The study is part of the international RetinoidRiskAware study, which was conducted in eight European countries. We are presenting the results for Slovenia in relation to the aggregated study results.Findings The study included 30 patients (mean age 27 years), 60 community pharmacists, and 35 physicians prescribing retinoids in Slovenia (mainly dermatologists and general practitioners). Awareness of teratogenic risks was high among patients, pharmacists, and physicians (83%, 100%, and 94%, respectively), both in Slovenia and overall. The materials most frequently used by patients were the information leaflet (60%) and the warning symbol on the packaging (50%), the other measures were less known. Pharmacists found the warning symbol on the packaging (78%) most useful. The other measures were used less frequently. Only 17% of pharmacists used the pharmacist checklist when dispensing medications. Among physicians, the risk acknowledgement form was most used (60%), as was the patient reminder card (37%). Most pharmacists (87%) and physicians (80%) advise on the importance of effective contraception during retinoid treatment. Similar trends in program adherence were also observed in the overall study results. Healthcare professionals in Slovenia reported that the main barrier to adherence to the programme was lack of accessibility to the materials and lack of time for patient counselling.Conclusion The study shows that awareness of the teratogenic risks of retinoids is high among both patients and healthcare professionals in Slovenia. However, risk minimisation measures are not sufficiently implemented in clinical practice.PCNE abstract number 590Interprofessional Education and Collaboration between Pharmacy Technician Students and University College Copenhagen StudentsTina Bolvig1, Jytte Muszynski1, Lise Rølmer Nissen1, Mette Skjøtt1, Bente Annie Sørine Andersen2, Sofie Brøndal Grünfeld3, Mira El-Souri3, Rikke Nørgaard Hansen3, Charlotte Verner Rossing3 1Parmakon, Danish College of Pharmacy Technicians, 2University College Copenhagen, 3Pharmakon, Danish College of Pharmacy PracticeEmail: TB@pharmakon.dkBackground Since 2019, the Danish College of Pharmacy Technicians (CPT) has collaborated with University College Copenhagen (UCC) on a course where the students cooperate interprofessionally. The students from UCC are studying to become nurses, day-care teachers, school and after-school teachers, social workers, psychomotor therapists, or physiotherapists. The UCC students were presented with a challenge concerning a specific patient group at the community pharmacy. To solve the challenge, the UCC students worked in interprofessional groups. The CPT students did not participate in these groups, but they engaged in interprofessional communication in a sparring session, where they gave feedback and discussed the ideas, the different UCC students had developed.Purpose To identify the kind of learning the students from various educations acquire when they engage in an interprofessional course to discuss and solve health care challenges.Method Thirteen students from UCC and 43 students from CPT took part in the course and they were all were invited to answer electronic questionnaires. Five (38%) UCC students and 27 CPT students (63%) answered the questionnaires. The Data from the questionnaires was analysed quantitatively in Excel and qualitatively in NVivo version 13. The results were discussed at a workshop where teachers from the CPT and the UCC shared their reflections about the students’ learning from working with the challenge.Findings CPT students scored 5.4 and the UCC students scored 6.0 on average on a scale from 0 to 10, where 10 is the highest, on the question: “How much did working with the challenge contribute to your learning about interprofessional collaboration?”. The following themes were found from the students’ qualitative answers of the questionnaires and from the workshop with teachers:—CPT and UCC students found it useful to see their role and practice from another perspective—The CPT students’ professional identity was boosted in the process—UCC students acknowledged that they would face medicine-related challenges when working with patients—UCC students' knowledge of the pharmacy technician profession varied—Knowing each other’s strengths and competencies is important—Developing holistic solutions to the presented challenge was complex—A collaboration across sectors can be beneficial for patients in transition between health care sectors.Conclusion CPT students and UCC students learned how important interprofessional collaboration is, and that it is beneficial to meet each other during their educations. They learned about their own competencies and those of other professions and how they can complement each other in patient care.PCNE abstract number 591Challenges in medication safety experienced by employees and managers in Danish municipalities—a qualitative studyRikke Nørgaard Hansen1, Sofie Brøndal Grünfeld1, Bjørn Klinke2, Birthe Søndergaard3, Rikke Lundal Nielsen3, Mette Lisbeth Johansen2, Charlotte Verner Rossing1 1Pharmakon, Danish College of Pharmacy Practice, 2The Danish Association of Pharmaconomists, 3The Association of Danish Pharmacies, 3The Association of Danish PharmaciesEmail: mso@pharmakon.dkBackground 66% of the registered unintentional accidents from 2017 to 2019 in municipal institutions, such as nursing homes, home care and residential facilities, are due to medicine management according to a report from the Danish Patient Safety Authority. Until now no studies have identified how different municipal employees and managers experience medicine-related tasks, and which challenges they face.Purpose The aim of the study was to map challenges with medicine-related tasks in the municipalities identified by municipal managers and further explored by municipal employees. The aim of the study was also to use the results in investigating how pharmacy technicians from community pharmacies (CP) can contribute to strengthen medication safety in the municipalities.Method Semi-structured, in-depth qualitative interviews with two–three municipal managers from ten different municipalities were conducted. Six themes were identified from these interviews, and they were explored by visual storytelling by municipal employees. All interviews were transcribed verbatim before conducting a content analysis using NVivo version 13. The results were presented at a workshop with stakeholders where pharmacy technicians from CP contribution to medication safety in municipalities was discussed.Findings The following themes were identified from interviews with 27 municipal managers and visual storytelling with 17 municipal employees: 1. Challenges in several steps in the medication process. 2. Compliance with existing procedures and instructions related to medication handling is difficul