临床药师开展内科住院患者入院药物重整的药学服务实践

目的:探讨临床药师在慢性疾病患者药物治疗中的重要性和必要性以及开展药物重整(MR)的可行性,为临床药学内科工作模式的建立提供依据。方法:以2016年5-7月于我院呼吸内科住院的患者为研究对象,介绍临床药师在患者入院当日进行详细的药学问诊后,分别对患者的长期用药进行MR的情况。结果:通过临床药师对住院患者用药过程中存在的问题进行分类归整,共获得98例住院患者的入院MR记录,涉及296条药物医嘱,其中存在用药差错96条。参与MR的患者中,依从性好者仅有44例(占44.9%),其他患者均存在部分用药差错,主要表现为用药随意、用法用量不当、担心药物副作用而拒绝用药、因不良反应而停药、特殊疾病未随访导致用药剂量过量或不足、与医师沟通不畅导致用药错误、忘记服药/漏服和过度医疗等。发生用药差错的药物种类以心血管系统药物最常见,其次为呼吸系统药物和内分泌系统药物。结论:临床药师开展入院MR,有利于识别和纠正患者用药差错,避免潜在的用药差错,且有助于疾病控制,可作为内科病区药学服务工作的项目之一。     

临床药师防范心内科患者用药差错的实践

目的探讨临床药师在防范临床用药差错中的作用和工作模式。方法结合在心内科的实际工作,通过案例分析介绍临床药师开展防范用药差错的工作内容与方法。结果临床药师运用自己掌握的知识,协助医护人员参与患者的药物治疗,可减少临床用药的风险,提高患者用药的安全性。结论临床药师参与疾病治疗工作可提高药物疗效,促进临床合理用药,对患者的治疗起到了积极作用。     

临床药师开展药物重整的药学服务实践

目的:为临床药师开展药物重整的药学实践提供参考。方法:探讨临床药师在实践工作中如何通过掌握用药史,及引入诺氏评估量表进行不良反应分析为切入点实现药物重整的药学服务实践。结果和结论:临床药师在药物重整工作中扮演着重要的角色。在临床实践中,临床药师获取精确的用药清单,加强专业知识地学习,借助一些适当的工具,才能实现药物重整。     

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。     

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。     

临床药师参与1例高龄患者治疗的药物重整

目的:探讨药物重整在临床药师开展药学监护工作中的作用。方法:临床药师参与1例高龄患者治疗的药学监护,就患者的抗感染药物、心血管系统药物、电解质等治疗药物进行重整:停用非必需药物血必净注射液、康尔心胶囊、蛇胆川贝软胶囊、枸橼酸莫沙必利片;调整氢氯噻嗪片、氯化钾缓释片剂量;停用非一线治疗药物利血平片,降低潜在的用药风险;根据病情转归及时停用呋塞米片、乳果糖口服溶液和开塞露。结果与结论:临床药师通过药物重整,可避免重复用药,优化用药方案,减少用药品种和药品费用,降低潜在的药品不良反应风险,保障患者用药安全、有效。     

对内分泌科70岁以上2型糖尿病患者开展入院药物重整的实践探索

摘 要 目的：通过临床药师在内分泌科对患者入院药物重整,探讨药物重整对防范用药差错、促进合理用药中的作用。方法: 对2016年1~4月内分泌科新入院的70岁及以上2型糖尿病患者进行药物重整,对24 h内用药医嘱的连续性及合理性进行审核和评价,将医嘱中存在的问题及干预结果进行汇总和分析。结果: 共有84位患者纳入研究,平均年龄为（76.3±5.0）岁;平均合并疾病（3.5±1.2）种;患者入院前平均服用西药（6.7±2.9）种,22.6%的患者服用中药,4.76%的患者服用保健品;24 h内医嘱需要干预的患者占27.38%;需要干预的医嘱条数占3.67%;临床药师干预成功率为100%。结论:70岁及以上2型糖尿病患者合并疾病多、服药种类多,临床药师在24h内开展药物重整服务,可有效防范用药差错,促进合理用药。     

基于工作实践探讨药物重整的分级服务

目的 通过对慢病患者中开展的药物重整工作进行分析,探讨药物重整目标人群和分级服务。方法 2021年3月-2021年9月药师收集入住河南省国际医疗中心一病区诊断为高血压、糖尿病、冠心病患者的药物清单,开展药物重整工作并进行资料汇总分析。结果 共收集了252例患者的院外最可能收集的用药清单,共发现108个非故意用药差异（干预率42.85%）,对发现药物问题的患者进行Logistic因素分析发现老年、冠心病患者适宜开展药物重整,Ⅰ型干预中药物遗漏（40.00%）和用法用量差异（36.00%）比例较大,Ⅱ型干预主要集中在用法用量调整（31.00%）和依从性问题（21.00%）方面;Ⅰ型干预接受度为90.00%,Ⅱ型干预接受度为79.31%。结论 在老年及冠心病患者中适宜开展药物重整工作,建议通过信息化辅助和分级药学服务推动药物重整的广泛开展。     

肾内科临床药师在药物整合服务中的实践探索

目的通过临床药师在肾内科对药物整合(medication reconciliation)的实践,探讨临床药师在药物整合中的重要作用。方法对2014年1月18日-2月18日入院的20名患者进行药物整合,主要通过询问患者近1年内的用药情况,对比入院医嘱和药师询问结果,分析存在差异的原因。结果药品数量与入院医嘱不相符率占60%,药品产地不同占55%,药师问诊的准确率更高。结论临床药师在药物整合中起到重要的作用,通过加强医生和患者对药物整合的重视,以及加强医院系统网络建设等措施可以更好地帮助医务工作者实行药物整合服务,减少用药差错的产生。     

药物重整模式应用于严重药物性肝损伤患者的药学实践初探

目的探索国内药物重整服务的可行工作模式。方法对1例中药致严重肝损伤患者进行药物重整服务,主要通过收集用药史、整理药物治疗清单、用药信息传递3个环节制定药物重整流程,从激素应用、抗菌药物应用、口服用药顺序等多个方面对患者药物治疗清单中存在的问题进行干预。结果通过药物重整服务,避免了药物治疗差错的发生,保障了患者的用药安全。结论通过临床案例阐述了药物重整服务可行模式,诠释了药物重整这一新的药学服务理念,为药物重整的完善及药学服务的拓展提供参考。     

Cost-effectiveness of medication reconciliation performed by a pharmacist in pediatrics of a hospital: A randomized clinical trial protocol linked to a pharmacoeconomic study

IntroductionEach patient admitted to the hospital is subject to one medication error per day, since the occurrence of this one with the potential to cause harm is three times more common in pediatric hospitalized patients than in adults. These harms can result from inaccurate or incomplete drug use histories when patients undergo a clinical evaluation, which jeopardizes patient safety and compromises hospitalization costs. Thus, medication reconciliation (MC) emerges as a possible solution to avoid the occurrence of these in pediatric patients and directly contributes to reducing costs in the hospital environment and increasing quality of life). Therefore, this study proposes to determine whether pharmacist-led medication reconciliation is a cost-effective strategy to improve health outcomes in pediatric patients.MethodsA randomized clinical trial will be carried out, over eight months, to carry out the cost analysis. Micro-costing pharmacoeconomic model through a questionnaire and clinical interview to collect the variables necessary for the study and comparison of the control and intervention groups. Participants in this study will be children aged 0 days to 12 years, admitted to the hospital. The perspective adopted will be that of the hospital. To assess the economic outcomes of MC, the cost-effect pairs will be categorized and visually represented in the cost-effectiveness plan to compare the intervention and control groups. Monte Carlo simulation and univariate sensitivity analysis will be performed to test the robustness of the findings.Ethics and disseminationThe clinical trial was approved by the Research Ethics Committee of the Federal University of Sergipe (CAAE: 19625319.6.0000.5546 and opinion number: 3,630,579). This protocol fully adhered to the recommendations of the 2010 CONSORT Declaration and was registered in the Brazilian Registry of Clinical Trials (ReBEC): RBR-25dnqsk.     

The effect on medication errors of pharmacists charting medication in an emergency department

Objective To determine the frequency and clinical significance of medication errors when (a) pharmacists elicit medication histories in the Emergency Department after medications have been prescribed by doctors and (b) pharmacists obtain and chart medication histories prior to doctors’ approval. Setting The Queen Elizabeth Hospital, a 350 bed South Australian teaching hospital, serving the local adult community. Method Emergency Department patients at risk of medication misadventure were recruited in two phases with a ‘usual practice’ arm (6 weeks) and a ‘pharmacist medication charting’ arm (5 weeks) reflecting an alternative intervention. In the ‘usual care’ arm, medication histories were compiled by a pharmacy researcher after a doctor had completed the medication chart. The researcher-elicited medication histories were compared with the doctors’ medication charts and unintentional discrepancies were recorded. In the ‘pharmacist medication charting’ arm, the same process was followed except the researcher compiled the patients’ medication histories at triage, prior to patients seeing a doctor. The medication history was then transcribed onto a medication chart for authorisation by a doctor. In addition, whether resolution of unintentional discrepancies for patients in the ‘usual care’ arm had occurred by discharge was determined by examining patients’ medical records. Main outcome measure Frequency of unintentional discrepancies and medication errors. Results The study included 45 and 29 patients in the ‘usual care’ and intervention arms, respectively. In the ‘usual care’ arm, 75.6% of patients had one or more unintentional discrepancies compared with 3.3% in the ‘pharmacist medication charting’ arm. This resulted in an average of 2.35 missed doses per patient in the ‘usual care’ arm and 0.24 in the intervention arm. In addition, an average of 1.04 incorrect doses per patient were administered in the ‘usual care’ arm and none in the ‘pharmacist medication charting’ arm. The differences observed between the arms were statistically significant (P < 0.05) and deemed clinically significant by a multidisciplinary panel. Conclusion This study provides evidence for pharmacists eliciting medication histories to prepare medication charts at the earliest possible opportunity following a patient’s presentation to the Emergency Department     

三例精准用药门诊药物治疗管理案例分析

药物重整是药物治疗管理的一个重要部分,也是精准用药门诊的工作重点。专业药师运用专业知识为患者重整并优化药物治疗方案,开展用药教育并进行随访。本文主要分析3例在精准用药门诊实践中临床药师开展以药物重整为重点的药物治疗管理的案例。     

Pharmacist-directed reconciliation for reducing medication discrepancies: A pilot study in a nursing home setting in Taiwan

Nursing home residents are at risk for medication errors when being transferred between wards. Medication reconciliation is a process used to verify medication use, identify variations and rectify medication errors during transitions. This pilot study was performed to evaluate a pharmacist-directed medication-reconciliation program in a nursing home setting. The number and types of discrepancies 3 months before (the control period) and after (the study period) implementation of a medication-reconciliation program were compared. A pharmacist performed medication reconciliation and discussed discrepancies with care providers in the study period. There were 190/209 (90.9%) and 220/266 (82.7%) documented discrepancies during the control and study periods, respectively. The major discrepancies found in both periods were the addition or omission of drugs. Of the 46 undocumented discrepancies in the study period, 13 (28.3%) were confirmed to be intentional changes. The suggestions made by the pharmacist were accepted in 19 of the remaining 33 undocumented (and unintentional) discrepancies. Eleven of 12 harmful discrepancies in the study period were corrected in a timely manner as a result of the medication-reconciliation program, that is, 91.7% of the harmful discrepancies were successfully prevented. But five (26.3%) harmful unintentional discrepancies of the 19 undocumented discrepancies in the control period could not be prevented from affecting patients. Pharmacist-directed medication reconciliation can reduce medication discrepancies in a nursing home setting in Taiwan.