Venous thromboembolism (VTE) is a preventable condition associated with an increased risk of morbidity and mortality in hospitalized patients. Pharmacological and/or mechanical prophylaxis can prevent thromboembolism events. Guidelines recommend the use of scores for risk assessment in hospitalized patients. These scores are based on a variety of risk factors, including age, reduced mobility, and type of surgery. They help determine the most appropriate prophylaxis method for each patient. However, VTE prophylaxis is still a challenge, and there are limitations associated with it. In this scenario, clinical pharmacists may play a key role in improving VTE prophylaxis. The main aim of this real-life study was to evaluate the contribution of the clinical pharmacist to thromboembolism prophylaxis in a large sample of clinical and surgical patients. This is an observational and retrospective study using hospital-based data. The study included 4031 patients, and we evaluated how pharmacist interventions contributed to the appropriate indication and correct use of VTE prophylaxis in clinical and surgical patients. We included 1093 clinical patients and 2938 surgical patients. Following clinical pharmacist involvement (262 pharmacist interventions), there were improvements in the adequacy rate: 62.0% for clinical patients and 55.0% for surgical patients. The intervention of the clinical pharmacist can contribute to improved rates of adherence to VTE protocols.

Large language models (LLMs) are an application of artificial intelligence and generate responses to user inquiries that vary in accuracy and completeness. Methods of improving LLM response quality are poorly evaluated in the context of clinical pharmacy practice. This was a single-center, observational, prospective study conducted through internal medicine admitting services. A clinical pharmacy specialist developed 50 case questions reflective of usual practice, which were processed through LLM-based systems in a two-by-two factorial design. The first variable was the selection of a general-purpose LLM, ChatGPT 4o (GPT, OpenAI Inc., San Francisco, California, USA), or a health care provider domain-specific LLM with retrieval-augmented generation (RAG) features, OpenEvidence (OpenEvidence, Miami, Florida, USA). The second variable was the inclusion of a prompt engineering template with specific instructions and parameters to refine the system output. Responses were evaluated by two pharmacists and reconciled with a third pharmacist. The primary endpoint was a composite of response accuracy and completeness. Secondary outcomes included accuracy, completeness, reference validity, reproducibility, and extraneous information. Logistic regression modeling demonstrated no statistically significant interactions between the two LLM-based systems and use of a prompt engineering template for accuracy and completeness. Predicted probabilities for meeting the primary outcome were as follows: GPT no Template 0.54, GPT with Template 0.60, OpenEvidence no Template 0.64, and OpenEvidence with Template 0.52. OpenEvidence reference validity was higher than GPT regardless of prompt engineering template use (p < 0.001 for all comparisons). Neither the use of health care provider domain-specific LLM with RAG nor a prompt engineering template was found to improve LLM-based system accuracy and completeness. OpenEvidence's ability to cite relevant and correct references more frequently than GPT shows promise for practice applications. There is a need for further evaluation of methods to improve LLM utility as artificial intelligence becomes further integrated in clinical pharmacy practice. University of Maryland, Baltimore IRB; HP-00112497.

Obesity, diabetes, and cardiovascular disease often co-exist in people with chronic kidney disease, placing them at high risk for adverse health outcomes. Availability of highly effective medications that span cardiovascular-kidney-metabolic (CKM) conditions, but limited uptake in real world settings, calls for a new transformative practice paradigm. We sought to identify key gaps, barriers, and facilitators to implementing a standardized CKM-focused comprehensive medication management (CMM) intervention, including needs/solutions among various care team members involved in CKM care in diverse health systems across the United States. This was a qualitative study guided by the Consolidated Framework for Implementation Research (CFIR) deployed in five health care systems across the United States. Clinical pharmacists, pharmacist administrators, primary care and specialty (nephrology, cardiology, endocrinology) physicians, and advanced practice professionals were interviewed using open-ended questions that were informed by results from three mainly quantitative online surveys. A total of 26 interviews were conducted with 42 participants. Practitioners and administrators reported many similar challenges to successfully implement CMM for people with CKM including lack of standardized CMM practice and workflow across the health system, electronic medical record integrated tools to identify and track patients with CKM, automatic pharmacist referrals, broad clinical practice agreements, and holistic CKM performance metrics, as well as pharmacist time constraints and limited reimbursement. Participants also highlighted CMM-CKM practice facilitators including recognition across most health care professionals that CKM should be a system priority, requiring strong supportive professional relationships among physician and/or administrator champions, and tools, knowledge, and resources that could be shared with others. Successful implementation of a transformative, holistic CMM-CKM interprofessional team-practice will require a tailored implementation strategy for each health system including consolidated tools such as a CMM-CKM Change Package, integrated with coaching, field experts, and peer-to-peer learning.

Exploring pharmacy professionals insights for advancing the pharmacy curriculum: A qualitative study.

BRAF inhibitors and MEK inhibitors (MEKi) have reshaped the treatment of BRAFV600-mutant malignancies; however, cutaneous adverse drug reactions (ADRs) remain a frequent and clinically impactful toxicity. Although clinical trials provide insight into their safety profiles, real-world data on dermatologic ADRs are limited. We conducted a retrospective pharmacovigilance analysis of the WHO VigiAccess database, examining individual case safety reports (ICSRs) for seven BRAF and MEKi up to May 2025. Disproportionality analyses (reporting odds ratio (ROR), proportional reporting ratio (PRR), with 95% confidence intervals (CIs)) were performed for high-frequency dermatologic ADRs. Shannon entropy was used to assess the diversity of toxicity profiles across agents. Among 72,720 ICSRs, skin-related ADRs accounted for 39.78% of reports with vemurafenib, 16.49% with dabrafenib, and 14.62% with encorafenib. Among MEKi, the proportion of skin-related ADRs was highest for selumetinib (40.03%) and cobimetinib (34.31%). Rash was the predominant ADR across agents, but selumetinib demonstrated a significant disproportionality for dermatitis acneiform (ROR = 6.46, 95% CI [5.10, 8.18]). Photosensitivity reactions were most frequently reported with vemurafenib (11.31%) and cobimetinib (12.02%). Shannon entropy analysis identified two groups with differing ADR profile diversity: a higher-diversity group (cobimetinib, H = 3.66; dabrafenib, H = 3.60) and a lower-diversity group (trametinib, H = 3.51; binimetinib, H = 3.47); all cross-group comparisons were statistically significant after Holm-Bonferroni correction (p < 0.05). Chi-squared tests confirmed significant differences in skin ADR frequencies among agents (BRAF inhibitors: χ2(2) = 1393.21, p < 0.001, Cramér's V = 0.255; MEKi: χ2(3) = 1129.77, p < 0.001, Cramér's V = 0.175), with effect sizes indicating clinical relevance. Cutaneous ADRs are a defining toxicity of MAPK pathway inhibitors, with substantial interagent variability in frequency and phenotype. Real-world pharmacovigilance data underscore the necessity for agent-specific dermatologic monitoring strategies. Clinical pharmacists play a pivotal role in early ADR detection and management, enhancing adherence and optimizing therapeutic outcomes.

From dispensing to caring: Enhancing patient-provider relationships through parallel chart writing in a pharmacist-managed clinic.

Systematic Review and Meta-Synthesis of Post-registration Education Program Evaluations for Pharmacists in Australia.

A Crisis of Clarity: When Everyone Is Ordering From a Different Menu.

To co-design a digital intervention (eTAPER) to support safe and timely opioid tapering after surgery in primary care, integrating behavioural theory and stakeholder perspectives. Qualitative co-design study using two online co-design workshops and one in-person stakeholder engagement event guided by the Experience-Based Co-Design (EBCD) methodology and mapped to the Theoretical Domains Framework. Qualitative data were collected during the two online co-design workshops, while the in-person stakeholder engagement event was used to sense-check and validate the findings from the workshops. No new data were collected during the stakeholder engagement event. Two online co-design workshops and one in-person stakeholder event were conducted as part of the EBCD process. 8 adult post-surgical patients with experience of opioid use and 12 healthcare professionals (general practitioners, clinical pharmacists and anaesthetists) involved in pain management participated. Among patients, 5/8 were female and 5/8 were white British; ages ranged from 25 to 84 years. Among healthcare professionals, 7/12 were female; participants included pharmacists and doctors working across primary care, secondary care and academic settings, with most reporting >10 years of professional experience. Five key behavioural domains were identified as influencing opioid tapering (environmental context and resources, skills, social/professional role and identity, knowledge and beliefs about consequences). Corresponding behaviour change techniques were embedded within the prototype eTAPER tool. Barriers included poor continuity of care, limited tapering guidance and workforce pressures, while enablers included pharmacist-led reviews and digital education tools. The intervention was refined through iterative workshops to ensure feasibility, usability and alignment with clinical workflows. This study demonstrates how EBCD can translate lived experience into a scalable digital health intervention. The eTAPER tool offers a theory-informed, co-designed approach to supporting safe opioid tapering after surgery. Further evaluation is needed to assess its effectiveness, usability and transferability across healthcare settings.

Federally qualified health centers (FQHCs) use core quality measures to guide care and secure funding. One core measure is "Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet." A pilot program at an FQHC utilized the clinical pharmacy team to improve appropriate aspirin prescribing. Clinical pharmacy technicians identified eligible patients through a best practice advisory (BPA) in the electronic health record and contacted individuals with IVD not prescribed aspirin to schedule a clinical pharmacist appointment. Pharmacists then conducted medication reconciliations and ordered aspirin when indicated. This study evaluated the impact of incorporating pharmacy technicians into the clinical pharmacy workflow on the IVD quality measure. This retrospective chart review compared aspirin prescriptions ordered from June to November 2023 between patients contacted by pharmacy technicians and those who were not. Demographics, outreach attempts, aspirin orders, and diagnosis codes were collected. Descriptive statistics and Fisher's exact test were used for analysis. Pharmacy technicians attempted to contact 65 eligible patients, with 49 successfully reached. Aspirin was prescribed for 3.1% of control patients vs 30.6% in patients successfully contacted by the pharmacy team (P < .001). Resolved BPAs increased to 53.8% in the intervention group. A clinical pharmacy team significantly increased aspirin therapy among eligible patients with IVD, demonstrating the value of pharmacy team involvement on quality metrics. Future research should explore expanded integration of clinical pharmacy team services to enhance patient care.

The creation of the Inpatient Psychiatric Pharmacy Intern Shift (INSPY) program at an urban, tertiary care children's hospital is described. In 2021, the INPSY was created at the Pediatric Mental Health Institute (PMHI) at Children's Hospital Colorado (CHCO) with the goal of delivering psychotropic medication information to pediatric patients on an inpatient psychiatry unit, optimizing psychotropic medication outcomes for adolescents, and exposing pharmacy interns to child and adolescent psychiatry early in their pharmacy school training. The CHCO pharmacy intern program includes an average of 20 first- through fourth-year pharmacy interns on staff each academic year. The overarching goal of the pharmacy intern program is to provide high-performing pharmacy interns with opportunities to practice at the top of their scope while functioning as clinical extenders for clinical pharmacists. Two lead pharmacy interns support INPSY shift coordination, maintenance, and academic projects (eg, poster presentations) with mentorship from 3 psychiatric pharmacists and the pharmacy intern program director. After program participation, pharmacy interns report greater confidence designing medication education materials, facilitating medication education groups, identifying patients' psychotropic medication-related problems, applying motivational interviewing techniques, and responding to patient questions or concerns related to their mental illness and/or psychotropic medications. The INPSY program was demonstrated to have feasibility and acceptability as a training strategy that aligns with national pediatric psychiatric workforce needs by building practical competence, strengthening perceived professional impact, and increasing exposure to high-level psychiatric pharmacy activities.

Harm reduction vending machines (HRVMs) can expand low-barrier access to overdose prevention, sexual health, safer-use, and basic self-care supplies; however, practical guidance for implementing HRVMs in health system and supportive housing settings is limited. This practice report describes a clinical pharmacist practitioner (CPP)-led deployment of 15 HRVMs across a Veterans Affairs (VA) system and Veterans supportive housing in California. Beginning in December 2021, the CPP conducted site engagement, market research, and funding applications; convened cross-departmental stakeholders (logistics, engineering, biomedical, environmental management, information security/technology); and completed contracting. Contracts were awarded to VendNovation, LLC, for HRVMs which were placed in 7 community-based outpatient clinics, 6 supportive-housing sites, and 2 hospital locations. The CPP designed the HRVM wrap and interior layout; curated product assortments (eg, fentanyl/xylazine test strips, syringes, safer-sex supplies, wound-care, and hygiene items; naloxone added after launch) based on prior quality improvement interventions and Veteran feedback surveys; and established barcode-based user access and software-enabled inventory management. Implementation challenges included staff concerns (eg, stigma, not in my backyard attitudes), connectivity barriers (eg, Wi-Fi requirements), and added costs for deliveries to non-VA locations. HRVMs within VA clinics were accessible during business hours; supportive-housing HRVMs operate 24/7. Planning and installation required nearly 2 years, underscoring the need for dedicated staffing (CPP plus logistics technician), braided funding for start-up and recurring costs, and standardized purchasing and installation pathways. HRVMs seem feasible and acceptable in VA clinical and housing settings and may increase anonymous, low-barrier access to harm-reduction supplies. Implications for scale-up include development of centralized or prevetted procurement pathways, clearer implementation guidance, and operational supports to reduce site-level contracting burden.

ABSTRACT Introduction Model-Informed Precision Dosing (MIPD) has improved individualized therapy, but in critical illness its reliance on intermittently updated data creates a temporal mismatch between pharmacokinetic (PK) models and rapidly evolving physiology. Areas covered Synthesizing population pharmacokinetic (popPK) and data science literature, we examine the limitations of snapshot-based dosing, using vancomycin as example. We propose the Dynamic Living Digital Twin (DLDT) framework, which integrates high-frequency electronic health record data into adaptive state-space models such as Kalman filtering. Rather than adding more covariates, the DLDT reframes patient physiology as a continuously evolving latent state that can be updated using temporally dense clinical data. Methodological, infrastructural, and regulatory Software as Medical Device (SaMD) barriers are also evaluated. A non-systematic PubMed search identified relevant publications available up to March 2026. Expert opinion The next advance in precision dosing will come from temporally adaptive PK reasoning. In this paradigm, patient physiology is treated as an evolving latent state, and clinical pharmacists may increasingly interpret exposure trajectories rather than isolated dose recommendations. Although technically feasible, implementation remains constrained by data interoperability and workflow integration challenges. Clinical pharmacists may therefore increasingly act as stewards of dynamic model outputs, using anticipated exposure trajectories to preempt PK shifts.

Recent advances in medication therapies for inflammatory bowel disease (IBD), including biologics and targeted small molecules, have been demonstrated to significantly improve patient outcomes; however, they have also increased the complexity of care of patients with IBD. The objective of this report is to describe an integrated clinician and specialty pharmacy service model in IBD care to inspire other health systems to adopt similar approaches that could enhance patient care. Multidisciplinary and integrated models of care for patients with IBD have been shown to improve patient outcomes and enhance quality of care. Specifically, pharmacists have demonstrated their ability to provide patient education, prevent interruptions to IBD therapy, improve medication adherence, and improve medication access. Ochsner Health System has developed a system for integrated pharmacy services with the Ochsner specialty pharmacy (OSP) and the Ochsner IBD clinic-based pharmacists. The OSP and IBD clinic-based pharmacists provide comprehensive services to patients with IBD, including medication evaluation for clinical appropriateness, patient education, benefits investigation and financial assistance, and appropriate monitoring of therapy once treatment is started. These services have demonstrated high rates of medication adherence, with the average proportion of days covered at 84.6%, and have expanded patient services within the IBD clinic. Integrated pharmacy services enhance patient care by improving therapy access, adherence, and monitoring. With the continued growth of specialty medications, adoption of integrated clinic pharmacy practice models and specialty pharmacies should be prioritized by health systems, clinics, and payers. These approaches cultivate multidisciplinary patient care and address the complex needs of individuals with IBD.

This study aimed to evaluate the prevalence of enteral feeding tube-related medication administration errors in intensive care units (ICUs) and to assess the impact of structured education combined with clinical pharmacist interventions on reducing these errors. This multicenter, prospective before-after study was conducted over 7 months (June-December 2025) in the intensive care units of 3 tertiary-care hospitals in Istanbul, Türkiye. Adult patients (≥18y) hospitalized for ≥24 hours and receiving at least one medication through an enteral feeding tube were included. The study comprised pre-education (3mo), education (15d), and post-education (3mo) periods. During the education phase, clinical pharmacists delivered structured training supported by a decision-support flowchart for enteral medication administration. Active pharmacist recommendations were provided throughout the post-education period. Errors were defined as the administration of dosage forms inherently unsuitable for enteral tube delivery-specifically, modified-release and enteric-coated formulations that should not be crushed, split, or otherwise manipulated. A total of 242 patients were analyzed (pre-education: n=136; post-education: n=106). The proportion of patients experiencing at least one enteral feeding tube-related medication administration error decreased significantly from 92.6% to 55.6% after education ( P <0.001), with a further reduction to 52.8% following pharmacist recommendations. The median number of errors per patient declined from 2 (interquartile range 1-3) to 1 (interquartile range 0-2) ( P <0.001). Enteral feeding tube-related medication administration errors were highly prevalent in the studied intensive care units, and structured educational interventions combined with clinical pharmacist involvement effectively reduced their frequency. Whether these findings are generalizable to other settings warrants further investigation.

To assess patient trust in AI-generated medication information, examine associated behavioral safety risks, and evaluate patient expectations regarding the role of clinical pharmacists in preventing medication-related harm. A cross-sectional survey was conducted among adult patients attending outpatient clinics and community pharmacies in Abha, Saudi Arabia. Data were collected across 3 sites (King Khalid University Hospital outpatient department and 2 affiliated community pharmacies) over a 10-week period (December 2025-January 2026), after ethical approval (KKU-147-2025-31). A structured questionnaire assessed demographic characteristics, AI use patterns, trust in AI-generated medication information, verification behaviors, and perceptions of pharmacist involvement. Psychometric evaluation demonstrated good internal consistency of the trust in AI scale. Data were analyzed using descriptive statistics, nonparametric tests, exploratory factor analysis, and ordinal logistic regression. Among 167 participants, trust in AI-generated medication information varied significantly across demographic groups and AI platforms, with higher trust reported for large language model-based tools. Participants without health care backgrounds demonstrated higher trust than health care professionals. Increasing trust was associated with higher behavioral risk, including acting on AI-generated medication advice without verification (P=0.002). Factor analysis identified distinct cognitive trust and behavioral engagement dimensions. Strong support was observed for pharmacist involvement in verifying AI-generated medication information. Patient trust in AI-generated medication information is closely linked to behaviors that may increase medication-related safety risks. Clinical pharmacists play a critical role as a safety barrier, underscoring the need to integrate pharmacist-led verification into AI-informed medication counseling to enhance patient safety.

To provide an overview of the manifestation and diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CM) and the treatment option acoramidis, including its pharmacology and clinical trial data. ATTR-CM is a progressive, life-threatening cause of heart failure, resulting from destabilization of transthyretin (TTR), a tetrameric transport protein. TTR destabilization leads to monomers that misfold, aggregate, and deposit as amyloid fibrils in cardiac and other tissues. ATTR-CM is underdiagnosed, and the common cardiovascular manifestations associated with it are frequently misattributed to other types of heart disease, delaying diagnosis. ATTR-CM management has historically been largely supportive, but disease-modifying therapies, including TTR stabilizers and gene silencers, have become available in the past decade. Acoramidis, a next-generation oral TTR stabilizer, was approved in 2024 for the treatment of adults with wild-type or variant ATTR-CM based on the results of the phase 3 ATTRibute-CM trial. Acoramidis has been shown to achieve near-complete (≥90%) TTR stabilization, increase levels of serum TTR, reduce rates of cardiovascular-related mortality and hospitalization, and improve patient quality of life. Clinical pharmacists play a central role in the timely diagnosis and treatment of ATTR-CM, including facilitating access to therapies, monitoring safety concerns, and providing patient counseling. It is important for pharmacists to become familiar with the clinical manifestations of ATTR-CM and available treatment options. This review provides comprehensive information on ATTR-CM and the treatment landscape, focusing on the treatment option acoramidis.

ABSTRACT Background Clinical pharmacist-led antimicrobial stewardship (AMS) programs have proven effective in tertiary care, yet rigorous pharmacoeconomic evidence from primary care remains limited. This study evaluates the cost-effectiveness of clinical pharmacist consultation in a Chinese county hospital setting. Research design and methods This retrospective cohort study analyzed 200 hospitalized patients (March to December 2024). The intervention group (n = 100) received pharmacist-led AMS including pre-prescription review and therapeutic monitoring. The control group (n = 100) received standard care without pharmacist consultation. Primary outcomes were antimicrobial therapy costs and duration. Results Pharmacist-led AMS reduced antimicrobial costs by 52% (mean difference: ¥290.43, 95% CI: −428.29 to −152.56; p < 0.001) and therapy duration by 23% (7.0 vs. 9.1 days; p < 0.001). Cost savings were most pronounced in patients without obvious infection focus (97% reduction). Clinical efficacy was comparable between groups despite higher baseline severity in the intervention group. Conclusions Clinical pharmacist-led AMS achieves substantial cost containment and prescribing optimization in county-level hospitals without compromising clinical safety. These findings support expanding clinical pharmacy services as a cost-effective strategy for antimicrobial resistance containment in resource-limited settings.

From bedside observations to clinical decision support system (CDSS) rules: using real-world adverse drug events (ADEs) data to identify high-risk iatrogenic situations.

Building upon continuous pharmaceutical care (CPC) models led solely by clinical pharmacists, this study evaluated a collaborative pharmacy team model for reducing drug-related problems (DRPs) in coronary heart disease (CHD) patients during care transitions. In a randomized controlled trial, 60 hospitalized CHD patients were allocated equally to a CPC group or a usual-care control group. The CPC group received structured pharmaceutical interventions in which clinical pharmacists led hospital care and community pharmacists led post-discharge care during key care transition periods: within 24 hours of admission (T0), 24 hour pre-discharge (T1), 24-72 hour post-discharge (T2), and at 1-month follow-up (T3). DRPs were identified using the Pharmaceutical Care Network Europe (PCNE) classification. Mean DRPs per patient were comparable at T0 (Control: 3.03 ± 1.16 vs. CPC: 3.10 ± 1.24; p = 0.827). Subsequently, the CPC group showed significantly fewer DRPs than the control group at T1 (0.17 ± 0.59 vs. 2.13 ± 1.04), T2 (0.03 ± 0.18 vs. 1.97 ± 1.03), and T3 (0.67 ± 0.76 vs. 2.63 ± 1.13) (all p < 0.001). Pharmacist interventions in the CPC group had a high DRP acceptance rate 91.4% (181/198) and a resolution rate 89.1% (106/119). At 1-month follow-up, the CPC group demonstrated superior outcomes compared to the control group: LDL-C goal attainment (63.3% vs. 30.0%, p = 0.010), medication adherence (90.0% vs. 66.7%, p = 0.028), patient satisfaction (Numeric Rating Scale: 9.27 ± 0.52 vs. 8.59 ± 0.52, p < 0.001), and willingness to pay for pharmaceutical services (86.7% vs. 50.0%, p = 0.002). This collaborative pharmacy team model effectively reduced DRPs and improved lipid control and patient-reported outcomes in CHD patients, offering a scalable approach for integrated healthcare systems.Registered at the Chinese Clinical Trial Registry on July 1, 2024 (Registration number: ChiCTR2400086416; URL: https://www.chictr.org.cn/bin/project/edit?pid=235446).