临床药师在骨科老年患者中的药物重整实践

目的:临床药师通过在骨科住院的老年患者中实施药物重整服务,识别和修正用药偏差,避免潜在的用药错误,从而保障药物治疗的有效性和连续性。方法:以2014年10月-2015年10月在某院骨科住院的60岁以上患者作为研究对象,由临床药师主导,制订患者的药物重整方案。结果:共获得625例患者的完整用药史,实施药物重整103例,药物重整共涉及491条药物医嘱,存在用药偏差232条,其中131条药物医嘱若不经处理可造成较为严重后果。药物重整患者中例均用药偏差(2.3±1.6)个,药师例均重整时间65 min。在用药不一致的种类中,以用药禁忌最为常见,重整的药物种类以心血管药物居多。患者自带药品数越多,发生用药偏差的可能性越大。结论:实施药物重整服务,可在药物伤害事件发生前有效地识别并修正用药偏差。医、药、护、患之间应加强沟通和交流,保障患者用药安全。     

基于Beers标准回顾性评价我院老年住院患者潜在不适当用药

目的:通过对老年人不适当用药的调查评价,为我院老年人规范用药提供参考.方法:依据Beers标准(2012版)对我院290份60岁以上的老年住院患者病历进行回顾性评价,分析老年患者的不适当用药情况.结果:患者平均年龄(74.6±4.6)岁,平均用药15种;其中81例(发生率为27.93%)存在潜在的不适当用药,19例(发生率为6.55%)存在特定疾病的潜在不适当用药,11例(发生率为3.79%)发生药物不良反应.结论:我院老年住院患者不适当用药比例较高,药师和医师应重视以保证老年人的合理用药.     

临床药师在慢性肾功能不全患者中的药物重整实践

目的:探讨临床药师在药物重整中的作用。方法:选择2015年8-10月收入或转入我院肾病内科的住院患者200例,在入科后48 h内,由临床药师主导,通过查阅电子病历、问诊、查询患者自备药品和既往病史等方式收集其1年内的用药史,并进行药物重整。结果:临床药师获得的药物清单中,药物品种共987种,只有9.63%(95种)的药物在医师的病历中有记录;不良反应共5例,只有40.00%(2例)的不良反应在医师的病历中有记录。200例患者中,有45例患者需进行药物重整,重整率为22.50%;200例患者的492条医嘱中有103条医嘱存在用药偏差,例均用药偏差为(2.3±1.8)个,主要包括用量错误、重复用药、溶剂错误和存在药物相互作用等,其潜在危害等级以1级为主(53条,51.46%)。103条重整医嘱中,重整方案以停药为主(78例,75.73%),其次为改药(17例,16.50%)和加药(8例,7.77%);共90条重整医嘱被医师采纳,干预成功率为87.38%。结论:与医师相比,临床药师可获得更详细、准确的药物治疗清单。通过临床药师的药物重整,可减少临床用药偏差,最大程度地保证患者用药安全。     

临床药师在肾内科实施入院药物重整的实践

目的：临床药师通过在肾内科实施入院药物重整服务,总结入院重整常见的用药错误并给予干预,探讨肾内科药物重整的工作模式及作用。方法：以2016年3月-2016年12月收入某院肾内科的住院患者为研究对象,在入院24 h内,获得患者入院前的用药史,并与患者入院后医师开取的医嘱进行对比。分析评估患者入院前用药和入院后医师医嘱有无用药错误。结果：共对128例患者进行了药物重整,存在用药错误的有62例,用药错误发生率为48.4%。涉及药物医嘱838条,发生用药错误的医嘱为81条。入院前患者服药时间错误,入院后用药频次错误,需停用药物未停用为最常见的用药错误。发生用药错误的药物中,前3位分别为消化道及代谢药物、心血管系统药物、抗肿瘤药和免疫机能调节药。81条用药错误中患者服药时间错误及患者随意改变推荐剂量共34条,临床药师及时给予患者进行教育和指导,均被患者接受。其余的47条用药错误,临床药师全部反馈给医师,40条被医师接受并修改,接受率为85.1%。结论：实施药物重整,可以发现并纠正患者服药时间错误、随意改变推荐剂量等用药问题;可以有效地减少医师在入院及转科等医疗转接点用药错误的发生,促进患者安全合理地使用药物。     

老年多重用药住院患者的用药现状评估及药师干预效果评价

目的:评估老年多重用药住院患者的用药状况,评价临床药师开展药学服务的效果,为老年患者临床用药合理化提供参考。方法:选择2018年10月-2019年2月于首都医科大学附属北京友谊医院住院且存在多重用药的老年患者,通过老年综合评估团队构建并开展老年住院患者的药学服务流程;结合欧洲医药保健网分类系统对药物相关问题进行分析,采用Bayliff工具评价药物相关问题的危害程度以评价其用药现状;采用Morisky调查问卷分析患者用药依从性,并随访患者出院3个月后的用药情况以评价药师干预的效果。结果:共纳入71例存在多重用药现象的老年住院患者,其中52例患者(73.24%)存在54个药物相关问题,其中32个(59.26%)与治疗有效性相关,13个(24.07%)为发生药物不良事件(可能存在),9个(16.67%)为不必要的药物治疗问题。药物相关问题发生原因共有69个,其中医嘱原因有58个(84.06%),以药物选择(36.23%)、药物剂量(24.64%)和药物剂型(20.29%)为主。临床药师共进行了143次干预,干预成功102次,成功率为71.33%。干预接受程度最高的是药物不良事件上报(100%),其次涉及患者层面(97.56%)、医师层面(65.12%)和药物层面(52.83%)。54个药物相关问题中潜在危害程度以1级危害最多,有35个(64.81%)。经临床药师用药教育后,患者用药依从性评分为(6.19±0.58)分,显著高于其入院初期评分(4.13±1.62)分(P<0.05)。随访结果显示,有6例患者自行停药,13例患者自行加服药物。结论:该院大部分老年多重用药住院患者普遍存在药物相关问题。临床药师可根据临床实际情况建立适合临床需求的可行的药学服务流程,同时可借助相关用药标准、药品说明书和用药软件等评估工具,根据患者的生理病理情况,与医师共同为老年患者选择适宜的治疗药物,减少多重用药和不合理用药,以提高老年患者用药的有效性和安全性。     

临床药师干预医师用药61例分析

目的:提高临床药师干预医师用药的成功率。方法:分析2008年10月-2009年10月期间临床药师干预医师用药61例情况,包括干预方式、医师接受程度、干预失败所涉及的用药问题和原因分析。结果:临床药师干预医师用药成功率为85.25%(52/61),与医师面对面讨论后干预用药成功率提高(95.00%),医师较主治医师及以上者接受度高,干预成功率分别为88.37%、77.78%;干预失败所涉及用药问题中药物选择方面(药物选择违反相关规定+无依据联合用药)比例较高(52.94%),其次是用药疗程过长(35.29%);分析干预失败原因:医师不重视药师意见、过分相信自己的临床经验。结论:应加强对医师尤其是高年资医师用药相关知识的宣教,提高其合理用药的认知度;药师应提高其自身业务素质,以提升其在用药方面的权威性;临床药师及时、主动干预医师用药值得推广实践。     

242例老年患者用药错误回顾性分析

目的:调查北京积水潭医院上报的242例老年患者用药错误报告,探讨保障老年患者用药安全、防止用药错误的对策。方法:根据北京积水潭医院安全用药监测网上报老年患者(≥65岁)用药错误报告,对错误发生场所、错误因素、差错内容、患者原患疾病等项目进行统计分析。结果:老年患者用药错误内容主要以用量(18.22%)、适应证(13.77%)、禁忌证(11.34%)为主;导致用药错误(medication error,ME)发生的因素主要为知识欠缺(18.72%)、疲劳(18.58%)及培训不足(14.86%);涉及的药物中以抗感染药物、内分泌系统用药及心血管系统用药为多,按剂型大多为片剂及注射液。结论:医务人员应加强老年用药相关知识的学习,药师应着重审核老年患者用药中的用量、适应证及禁忌证,医疗机构应建立有效的慢病管理制度。     

女性更年期患者的用药特征与药学管理

目的:介绍我院更年期综合门诊患者用药情况以及临床药师参与的用药管理模式。方法:分析就诊的255例患者疾病及用药情况,药师提供咨询、指导教育及档案建立等系统的用药管理服务。结果:患者为年龄(50.3±6.9)岁的更年期女性,药物治疗主要涵盖降糖药(6.8%)、性激素(10.1%)、调脂药(11.8%)、骨质疏松治疗药物(12.3%)、精神障碍治疗药物(14.7%)、降压药(20.3%)和植物药(26.1%)等。药师对255例患者进行用药管理,协助处置药品不良反应15例,对随访的38例重点患者进行全程监护和评估。结论:更年期患者用药复杂;临床药师参与用药管理提高了药物治疗的正确率、依从性,优化了临床获益。     

144例老年早期乳腺癌住院患者用药干预分析

目的探讨临床药师参与乳腺癌药物治疗管理的策略和关注点。方法回顾分析2019年1月至2020年12月中国医学科学院北京协和医学院肿瘤医院内科乳腺病区和特需病区接受化疗的老年早期乳腺癌患者的药学服务记录。结果共收集144例(均为女性)患者的用药重整和医嘱审核记录。疾病主要包括糖尿病(占83%)、高血压(占63%)和肝炎(占9%)等。140例患者存在219个用药相关问题(DRP)。其中,186(占84.9%)个DRP得到了医师或患者认可,成功干预124个(占57%)DRP,5个(占2%)DRP医师拒绝修改,155个(占70%)问题在治疗过程中重复出现。糖尿病(占83%)、高血压(占63%)和肝炎(占9%)是住院乳腺癌患者最常见的3种合并疾病,平均每位患者使用(2.5±1.4)种药品。药师发现的DRP,主要包括药物选择、用药剂量、用药依从性以及用药监测等问题。最常见的DRP是用药剂量,占总DRP的34.7%,其次,患者未规律监测血糖、血压值占所有DRP的24%。结论用药干预对促进合理用药效果良好。临床药师的用药干预有利于患者用药的有效性和安全性。     

医药联合门诊在老年患者合理用药管理中的工作模式探讨及成效分析

目的 介绍南京医科大学第二附属医院老年患者医药联合门诊的工作模式与成效,分析优点与不足,以期为其他药学门诊的建立提供参考。方法 选取2019年7月至2022年7月年于该门诊就诊并建立完整随访档案的680例患者,统计分析其一般情况、疾病及用药情况、药物治疗相关问题、药学服务内容等。结果680例患者中53.82%患有高血压,51.91%患者同时患有3种及以上慢性疾病,43.82%患者同时使用4～6种药物。680例患者中有441例存在854个药物治疗问题,平均1.94个/人。其中类型最多的是用药依从性问题,占38.17%。药师干预后患者依从性评分显著提高（P <0.05）。结论 药师通过建立医药联合门诊,参与老年患者慢性病药物治疗管理,显著改善患者依从性,提高药物治疗有效性和安全性,进一步促进合理用药。     

用药安全和用药差错报告系统

用药安全，是指依靠医护人员对药物不良反应和用药错误两种类型事件的报告，分析和评价这些事件，制定并执行有效措施，减少和（或）预防其再次发生。卫生部制定的处方管理办法把用药安全的责任赋予了药师。其中第36条规定，“药师经处方审核后，认为存在用药不适宜时，应当告知处方医师，     

Medication reviews

Recent years have seen a formalization of medication review by pharmacists in all settings of care. This article describes the different types of medication review provided in primary care in the UK National Health Service (NHS), summarizes the evidence of effectiveness and considers how such reviews might develop in the future. Medication review is, at heart, a diagnostic intervention which aims to identify problems for action by the prescriber, the clinican conducting the review, the patient or all three but can also be regarded as an educational intervention to support patient knowledge and adherence. There is good evidence that medication review improves process outcomes of prescribing including reduced polypharmacy, use of more appropriate medicines formulation and more appropriate choice of medicine. When 'harder' outcome measures have been included, such as hospitalizations or mortality in elderly patients, available evidence indicates that whilst interventions could improve knowledge and adherence they did not reduce mortality or hospital admissions with one study showing an increase in hospital admissions. Robust health economic studies of medication reviews remain rare. However a review of cost-effectiveness analyses of medication reviews found no studies in which the cost of the intervention was greater than the benefit. The value of medication reviews is now generally accepted despite lack of robust research evidence consistently demonstrating cost or clinical effectiveness compared with traditional care. Medication reviews can be more effectively deployed in the future by targeting, multi-professional involvement and paying greater attention to medicines which could be safely stopped.     

Medication errors

Medication errors cause substantial harm to patients. We need good methods for counting errors, and we need to know how errors defined in different ways and ascertained by different methods are related to the harm that patients suffer. As errors arise within the complex and poorly designed systems of hospital and primary care, analysis of the factors that lead to error, for example by failure mode and effects analysis, may encourage better designs and reduce harms. There is almost no information on the best ways to train prescribers to be safe or to design effective computerized decision support to help them, although both are important in reducing medication errors and should be investigated. We also need to know how best to provide patients with the data they need to be part of initiatives for safer prescribing.     

Avoiding Potential Medication Errors Associated with Non-intuitive Medication Abbreviations

Background:

Pharmaceutical companies use a variety of abbreviations to denote short- and long-acting medications. Errors involving the administration of these medications are frequently reported.

Objectives:

To evaluate comprehension rates for abbreviations used to denote short- and long-acting medications and to evaluate whether changes to medication labels could reduce potential errors in the selection and administration of medications.

Methods:

In phase 1 of the study, nursing staff were asked to define 4 abbreviations and then to categorize them by release rate. In phase 2, a simulation exercise, nursing staff were asked if it would be appropriate to administer a medication illustrated in a photograph (oxycodone CR 5-mg blister pack) on the basis of information highlighted in a screen shot of an electronic medication administration record (order for oxycodone 5 mg). Three different presentations were used to identify the medication in the medication administration record and on the drug label.

Results:

In phase 1, 10 (28%) of 36 nursing staff members knew what all 4 abbreviations meant, and 14 (39%) correctly classified all 4 abbreviations as indicating a short- or a long-acting medication. In the simulation exercise (phase 2), labelling changes reduced the likelihood of a potential medication administration error.

Conclusions:

Most abbreviations used to indicate short- versus long-acting medications were not correctly understood by study participants. Of more concern was the incorrect interpretation of some abbreviations as indicating the opposite release rate (e.g., “ER” interpreted as meaning “emergency release”, rather than “extended release”, with incorrect classification as a short-acting medication). This evaluation highlighted the potential consequences of using non-intuitive abbreviations to differentiate high-risk medications having different release rates.     

用药社会化现象初探

目的关注用药社会化现象。方法参阅相关文献,从社会药学角度分析影响用药社会化的各种社会因素。结果与结论患者、制药企业、政府职能部门、药理学家、新技术、医院和医师等社会因素都对用药社会化产生重要影响。发挥医药专业人员作用,提高全民合理用药意识,促进企业对社会效益的重视,加强政府的监管力度,坚持正确的舆论导向是防止用药过度社会化的有效途径。     

Medication overuse headache

Medication overuse headache (MOH) has developed into the third most common type of headache after tension-type headache and migraine. The prevalence of MOH is approximately 1% of the world's population and it shows an increasing trend as recent studies reveal a common involvement throughout the ages, even starting in childhood. All antiheadache drugs, such as triptans, analgesics, ergots and opioids, along with the common combination substances currently on the pharmacological market are capable of inducing MOH. New data on specific clinical features and mean critical monthly dosages and mean critical monthly intake frequencies are now available. The only effective treatment concept is consequent withdrawal therapy. Data of prospective studies on relapse rates and predictors of relapse after successful withdrawal therapy are presented.