Over the past decades, Hospital Pharmacy Departments (HPDs) in Spain have undergone significant growth and transformation, driven by the increasing demand for specialized pharmaceutical care and the dedication of hospital pharmacists. Notable recent advancements include the integration of pharmacists into clinical teams, the adoption of advanced technologies not only in logistics and dispensing but also in processing and traceability, as well as the pharmacist's leadership in clinical pharmacokinetics and pharmacogenetics.1–3 More recently, pharmacists have also taken on a key role in the management of advanced therapies.4

Surveys by the Spanish Society of Hospital Pharmacists (SEFH) have assessed these specific developments. In 2015, the Report on the Situation of Hospital Pharmacy Services in Spain: Infrastructure, Resources, and Activities, known as the White Paper on Hospital Pharmacy, was published. Its goal was to inform the administration, society, and pharmacy services about the scope and characteristics of hospital pharmacy as a specialty, focusing on healthcare, technology, education, and research. The report highlighted the high level of development of hospital pharmacy in Spain while identifying areas for improvement and strategies for growth.5

The most relevant findings of the second edition, published in 2019 in two issues of the Journal of Farmacia Hospitalaria highlighted the limited number of hospital pharmacists in Spain, despite their growing involvement in clinical units. Progress in logistics automation was noted, but there remains significant potential for improvement in robotic systems and preparation traceability. Non-hospitalized patient care and medication preparation received considerable attention, while clinical pharmacokinetics lagged behind. Despite a strong commitment to teaching, scientific output remained limited, even with an annual increase in PhD-trained professionals.6,7

Given the value of previous editions, a third survey was conducted in 2022 with a similar focus on infrastructure, resources, professional development, and activities. This edition introduced an interactive approach, allowing participants to review their results and compare them with other hospitals.

The purpose of this article is to present the results of SEFH's 2022 national survey and to discuss the evolution of Spanish Hospital Pharmacy Departments, in terms of healthcare, staffing, material resources and technology, information systems, education and research.

A total of 191 responses were received, resulting in a 54.1% response rate. Publicly owned hospitals accounted for 62.6% of the total, with most having 101–250 beds (26.2%). The regions most represented were Madrid and Catalonia (18.3% each) followed by the Basque country (9.0%).

The last SEFH National Survey in 2019, which had a high response rate, demonstrated the strong engagement and sense of belonging among Spanish HPDs since the first survey in 2014.5–7 This commitment persisted in 2022, with a similar response rate exceeding 50%. Other pharmacist surveys since 2021, whether by SEFH or other scientific societies, reported lower response rates between 14% and 36%.8–12 Our current survey received the same response rate from public and private hospitals.

Effective HPD performance requires adequate staffing, infrastructure, and technology. Only 10% operated 24/7, unchanged from 2019, and nearly half lacked a continuing care module—also consistent with previous data.6 Nearly all hospitals in the sample provided outpatient care and dispensation, which contrasts with the model in the United States (U.S), where outpatients medication supply is completely different.12,13 In the ASHP 2022 National Survey, pharmacists worked in ambulatory or care clinics in 51.6% of hospitals with outpatient services, ranging from 27.0% to 90.9% depending on hospital size.12 In our sample, all HPDs operated at least five days a week, and over 55% offered care both morning and afternoon, over 30% more than in 2019.6

A strong interest in continuous improvement was evident, with a 13% increase in HPD accredited to a quality standard compared to 2019.6 ISO 9000 certifications were the most common, achieved by over two-thirds of HPD. Notably, nearly 15% obtained Joint Commission International accreditation in 2021, underscoring pharmacists' strong commitment to medication and patient safety in Spanish hospitals.14

Management of medical devices by HPD has remained stable since 2019,6 not exceeding 15% in public hospitals. In contrast, medical gas management increased by nearly 18%, reflecting greater public hospital involvement, as also seen with radiopharmaceuticals. Notably, almost one in four HPDs reported participation in advanced therapies—a rapidly expanding area. Marzal-Alfaro et al. underscore the pharmacist's key role in CAR-T therapy, ensuring regulatory compliance, treatment efficacy, and patient safety within multidisciplinary teams.15 Although the pharmacist-to-100-bed ratio is still used as a reference indicator, it is not the most accurate measure of HPD activity. Similarly, metrics like the number of outpatients treated or compounded preparations fall short, as what truly matters are health outcomes and patient satisfaction. The data from our survey, analyzed in this study, reveal an increase in the number of specialist pharmacists per HPD, with the current average standing at 7, representing a 32% increase compared to 2019. There has been an increase across all types of hospitals, regardless of ownership or size. Notably, hospitals with 501 to 999 beds have experienced the most significant growth with their specialist pharmacist workforce doubling.6 Despite these improvements, a considerable gap remains compared to the U.S., where in 2022 the average was 16.9 full-time pharmacists per 100 occupied beds. However, 4.7% of pharmacist positions and 12.3% of pharmacy technician posts remained unfilled due to workforce shortages.12 Regarding non-pharmacist staff in HPD, pharmacy technicians are the most common profile, with a nearly 75% increase. This contrasts with 2019, when nursing care assistants were the largest group. The American survey mentioned referred to a mean of 16.1 for pharmacy technicians.16 In 2022, the total number of professionals working in HPD nationwide, including resident pharmacists, reached 9936, marking 28% compared to 2019.6

The integration of pharmacists into multidisciplinary hospital teams is a strategic priority for Spanish HPD and professional societies due to its impact on optimizing medication management.17 This approach has also been highlighted by the Independent Authority for Fiscal Responsibility (AIReF), which recommends strengthening the role of hospital pharmacists in clinical teams to enhance the efficiency and safety of pharmacological treatments and to ensure patient-centered pharmaceutical care.18 The current survey shows a notable increase – over 50% - with an average of 3.8 pharmacists per HPD spending at least part of their time in clinical units. They are primarily assigned to oncology, hematology, infectious diseases, emergency, and intensive care, in that order. However, there has also been notable integration into other areas, such as cardiology, and, especially, home hospitalization, with 35 pharmacists joining the latter in 2022.

A 2021 study assessing clinical pharmacy services in Germany, with a 34% response rate, found that 63% of responding HPD provided some clinical care. On average, these hospitals had 2.4 full-time equivalent (FTE) clinical pharmacists, ranging from 0.2 to 22.0 FTE. However, when extrapolated to all surveyed hospitals, the integration rate fell to 22%. Unlike in Spain, where pharmacist is more involved in oncology/hematology, in Germany, they primarily work in surgical and intensive care units.19 In Spain, we are gradually moving to U.S. model, with increasing pharmacists' involvement increasingly not only in oncology and hematology, but also across other medical and surgical specialties.13

According to our survey, 66% of pharmacists are between 30 and 50 years old, and only 6% are over 60. In contrast to the aging trend among European healthcare professionals—40% of whom are over 50, with one-third retiring by 2025—Spanish hospital pharmacists show a notably younger profile. This reflection aligns with the findings of Negro-Vega et al., who describe the coexistence of four generations in hospital pharmacy services, with Generation Y being the most represented.20

A key focus for HPD over the past two decades has been the automation of dispensing, compounding, traceability, and pharmaceutical care for both inpatients and outpatients. A major advancement is the widespread adoption of semi-automatic carousels, especially vertical ones, now present in nearly all HPD. The number of beds managed through ADS has also grown, covering one in five beds overall—and one in two in larger hospitals. Most centers have also implemented ADS in non-hospitalization units. Robotic systems for outpatient dispensing have doubled in presence since 2019, now reaching 70% of HPD with over 1000 beds.6 In comparison, the latest ASHP survey reports ADS as the primary distribution method in 74.5% of U.S. hospitals, a notably higher implementation than in Spain.21

One of the main functions of HPD is the preparation and centralization of sterile compounds within the hospital pharmacy. There has been an increase of 30% in clean rooms compared to 2019, particularly for chemotherapy or other intravenous drugs. Sterile preparations increased by over 80% since 2019, with growth across all categories. Chemotherapy preparations have doubled in the past four years.6 This trend highlights the need for drug compounding and preparation in day hospitals, and the shift toward centralization within HPD, with medications delivered ready-to-use to nursing units and patients.

Repackaging activity in 2021 reached over 100 million units, doubling the 2019 figure.7 It is essential to urge both the pharmaceutical industry and health authorities to promote unit-dose packaging—not only to address this challenge but also as a key strategy to optimize resources and enhance the efficiency, safety, and sustainability of pharmaceutical processes.

The adoption of robotic systems for compounding cytotoxic drugs, nutritional solutions, and other intravenous admixtures has grown from 3–4% to 10% over the last four years. Similarly, sterile workflow management technology in HPDs has increased significantly, nearly doubling the figures reported in 2019. However, traceability systems for preparing parenteral nutrition and other intravenous admixtures remained less widespread, although their implementation has also doubled in recent years.6,7 The latest ASHP survey indicates that 21.3% of hospitals use a workflow system, a lower percentage than in Spain. Implementation varies significantly by hospital size, like the trend observed in Spain, where 73% of larger hospitals have a traceability system, and 21.9% of hospitals with more than 600 beds in the U.S. do not use a workflow system. The use of smart infusion pumps has grown significantly, now reaching over 62% of hospitals, approaching the U.S. adoption rate.21

By 2019, remote pharmaceutical care was available in 15% of hospitals. However, partly due to the impact of the SARS-CoV-2 pandemic and the publication of a practical guide for the implementation and use of Pharmaceutical Care through telepharmacy-targeted at healthcare professionals and patients across different areas of application, its adoption has significantly increased.22 According to our study, 58% of the HPD have implemented telepharmacy, with approximately 10% of outpatients receiving treatment through this method.

The hospital pharmacy service portfolio includes actions focused on medications and patients, ensuring treatments are tailored to clinical needs. To achieve this, an HPD must provide pharmaceutical care services alongside drug selection, procurement, dispensing, and compounding. Among the activities related to medicine evaluation in the HPD, those involving special situations—mostly off-label use—stand out. This was carried out in nearly all HPD within our healthcare system, with increases exceeding 70% over four years.7 Off-label use, due to its frequency, is sometimes seen as a routine concept. Although present for many years, it remains relevant due to unmet clinical needs, posing challenges for professionals.

In the field of pharmaceutical dispensing, our latest survey highlights the involvement of HPD and pharmacists in home hospitalization units, with more than half of HPD participating. In over one-third of the centers, this involvement included PC, particularly in larger hospitals. Studies have demonstrated the benefits of multidisciplinary home hospitalization units, including reduced hospital stays and shorter treatment durations. In these models, pharmacists are fully integrated and play a key role in the pharmacotherapeutic process.23 A recent meta-analysis evaluated the safety and effectiveness of home hospitalization units based on the type of care model: early discharge with home follow-up, or admission avoidance through direct home care. The first model showed similar mortality and readmission rates to conventional hospitalization, but with shorter stays. The second indicated a trend toward lower mortality and costs, with similar or slightly reduced readmission rates.24 In the U.S., only 8.7% of hospitals reported offering hospital-at-home services.12

Although monitoring serum drug levels is a common practice for individualizing the dosing of certain medications, it did not appear widely implemented across most HPD. However, the survey showed progress in clinical pharmacokinetics, with increases of over 30% in HPD performing pharmacokinetic level determinations and over 45% in the dosage adjustment reports, compared to 2019.6,7 Compared with ASHP survey data,24 notable differences emerged: in more than half of U.S. hospitals, pharmacists have the authority to order drug level tests and other laboratory analyses. Regarding pharmacogenetics, the results showed that the number of HPDs issuing pharmacogenetic reports had doubled. In the case of our American counterparts, although progress was also noted, only 12% of hospitals carried out any pharmacogenetics-related activity from their HPD.25

Various organizations and institutions recognize the leadership of HPD as a key to the success of patient safety programs. In our context, Challenge No. 10 of the SEFH 2030 Project emphasizes the crucial role of the pharmacist in managing medication safety.17 As in previous surveys, the involvement of hospital pharmacists in medication safety activities has remained consistent, including the detection and reporting of medication errors and the communication of suspected adverse drug reactions. Furthermore, in 76% of public hospitals, pharmacists were members of the Clinical Safety Committee, compared to 55% in 2019.7 According to the 2022 report on safe medication use practices in Spanish hospitals, 56.2% of centers had systems for reporting medication errors and analyzing them through multidisciplinary teams, with the aim of improving processes and support professionals in performing their duties more safely.26

The survey also reflected a strong interest in gaining insight into all aspects of education and training within HPD, including undergraduate, postgraduate, and continuing education. Regarding undergraduate training, there was an increase in the number of agreements with universities to participate in the supervised internship program, as well as a rise in the number of students and associate faculty members, with the latter increasing by 10%.7

In healthcare professions, continuing education and professional development are essential to maintaining competencies and keeping knowledge up to date. The SEFH 2030 Project 20 includes a dedicated challenge focused on fostering a culture of training and professional growth as key pillars of development. Among the many initiatives related to education and training, support for BPS certification stands out. Over the past four years,7 the number of certified pharmacists has increased by 25% with certification expanding into areas beyond oncology and nutrition, although it still represents only 16% of all specialist pharmacists. Spain leads Europe in the number of BPS-certified pharmacists and is an international benchmark in oncology pharmacy certification.27 The growth of subspecialties and the high number of certified professionals reflect the strong commitment of pharmacists to advancing their clinical expertise. BPS certification is expected to play a key role in enhancing pharmaceutical care and, ultimately, patient outcomes.28 In the United States, 30% of pharmacists maintained their BPS credentials unchanged between 2019 and 2022.12

Regarding the four-year specialized health training program, one in three HPD was accredited to offer this training. In 2022, nearly 20% of departments provided three residency positions per year. While in Spain, it is mandatory to be a board-certified hospital pharmacist to work in a public or private hospital pharmacy, in the U.S., only 32.8% of pharmacists have completed a PGY1 residency, and just 9.7% have completed a PGY2.12

Finally, the growing interest of hospital pharmacists in research was reflected in the 75% increase in the number of PhD holders in hospital pharmacists compared to 2019, with growth observed across all hospital types, regardless of size or ownership.7 Hospitals with more than 1000 beds now have an average of over seven PhD-trained professionals. This encouraging trend highlights the increasing academic and scientific engagement of hospital pharmacists. Although the overall impact factor remains modest, the steady rise in publications demonstrates a strong and sustained commitment to research.

The survey results in this study have certain limitations, including its voluntary nature and the complexity and length of the questionnaire. Some questions were difficult to interpret, requiring respondents to deduce their meaning. Comparisons with the 2019 survey should be made cautiously, as the HPD sample differed from that of the 2019 survey.6,7

In short, the data from the 2022 SEFH survey suggest that the number of specialist pharmacists in Spanish hospital pharmacy departments has increased, with a very positive trend in their integration into multidisciplinary teams. However, this integration is still insufficient, given the broad scope of medication management and the demonstrated value of hospital pharmacists. There has been continued progress in the automation of medication dispensing logistics, as well as in the implementation of traceability systems for the preparation of sterile medications—particularly in the field of chemotherapy—aimed at making the compounding process safer and more traceable.

Access to these results can be highly valuable for HPD and for SEFH, helping to define strategic action plans that address the key issues identified in the survey. SEFH remains committed to regularly updating this information as part of its ongoing efforts to monitor and promote the advancement of hospital pharmacy in Spain.

We used artificial intelligence (ChatGPT) to help improve the English language and grammar in this text. We reviewed and approved the final version.

This study provides updated data on the organization and development of Spanish hospital pharmacy departments in 2022, covering healthcare services, staffing, technology, education, and research. Stratification by hospital size and ownership offers relevant comparisons, highlighting key advances and persistent disparities. These results contribute to the scientific literature by serving as a benchmarking reference and a strategic planning tool for enhancing the quality, efficiency, and equity of hospital pharmacy services.

Montserrat Pérez-Encinas: Writing – review & editing, Writing – original draft, Validation, Supervision, Formal analysis, Data curation, Conceptualization. Eva Negro-Vega: Validation, Supervision, Methodology, Formal analysis, Data curation, Conceptualization. Cecilia M. Fernández-Llamazares: Writing – review & editing, Validation, Formal analysis, Data curation, Conceptualization.

Ethics committee approval was not required, as no personal or clinical data were collected. Department heads were informed in advance about the study's purpose. Participation was voluntary and responses were submitted via a secure key-based system, ensuring confidentiality. Data were analyzed and presented in aggregate form.

This study was promoted by the Spanish Society of Hospital Pharmacists.