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。     

Impact of Students Pharmacists on the Medication Reconciliation Process in High-Risk Hospitalized General Medicine Patients

Objective. To compare the accuracy of medication lists obtained by student pharmacists, nurses, and physicians, and quantify the number of discrepancies identified as part of the medication reconciliation process.Methods. Between May and July 2012, patients admitted to an internal medicine team at a 350-bed tertiary academic medical center were assessed for inclusion in the study. Physicians and/or nurses conducted medication reviews for these patients at the time of admission, while student pharmacists conducted medication reconciliation. Results. Eighty-six patients were assessed, and 52 met all inclusion criteria. A total of 268 discrepancies were identified as part of the medication reconciliation performed by the student pharmacists, approximating 5 discrepancies per patient (range 0-13). Student pharmacists identified 532 preadmission medications, significantly more than did nurses (355) or physicians (368), p=0.006.Conclusion. Student pharmacists, with appropriate oversight, can be used in several tasks that previously may have been designated to pharmacists only, such as medication reconciliation.     

Pharmacy-Based Medication Reconciliation Program Utilizing Pharmacists and Technicians: A Process Improvement Initiative

Background:

Pharmacists and pharmacy technicians have an opportunity to impact the quality of the medication histories and improve patient safety by ensuring accurate medication lists are obtained and complete reconciliation has occurred with the admission medication orders by owning the admission medication reconciliation process.

Objective:

To compare the quality of a pharmacy-based medication reconciliation program on admission utilizing pharmacists and technicians to the usual multidisciplinary process.

Methods:

This was a retrospective chart review process improvement study at a 186-bed tertiary care inpatient facility. Primary outcomes included both the accuracy of pre-admission medications listed and the reconciliation of those medications with admission inpatient orders. Technicians obtained patient medication histories. Pharmacists checked the technician-obtained medication histories and ensured reconciliation of those medications with admission orders.

Results:

Medication accuracy increased from 45.8% to 95% per patient (P < .001) and medication reconciliation increased from 44.2% to 92.8% (P < .001) and remained above benchmark.

Conclusion:

A pharmacy-based medication reconciliation program utilizing both pharmacists and technicians significantly increased the accuracy and reconciliation of medications on admission. These gains were maintained for the duration of the 6-month period studied and beyond per continued process improvement data collection.     

药学问诊在药物重整服务中的作用

目的:探讨药学问诊在药物重整服务中的作用。方法:临床药师通过药学问诊,对患者进行药物重整服务,并分析评价临床药学实践中的问诊案例及取得的效果。结果与结论:药学问诊可侧重于患者既往用药史、不良反应史、过敏史、伴发疾病的药物治疗、自备药品的使用情况等方面。通过药学问诊,可详细了解患者病情、药物治疗情况、用药依从性、不良反应发生史,结合现有的药物治疗方案,分析其治疗效果不佳的原因,判断发生药物相互作用和不良反应的风险,为协助医师调整治疗方案提供依据,最大程度地保证患者用药安全,在药物重整工作中发挥作用。     

Clinical and Financial Impact of Pharmacist Involvement in Discharge Medication Reconciliation at an Academic Medical Center: A Prospective Pilot Study

Background:

Medication reconciliation is one of the more challenging aspects of inpatient care, and its accuracy is paramount to safe transitions of care. Studies have shown that pharmacists have a role in medication reconciliation through improving patient safety and avoiding costs associated with medication errors. The wide-scale use of pharmacists in this process has been limited by time constraints, cost, and lack of resources.

Objective:

This study evaluates the impact of pharmacists in resolving medication errors, decreasing readmission rates, and reducing institutional costs during the discharge medication reconciliation process.

Methods:

Pharmacists evaluated discharge medication reconciliation documentation for patients to determine its accuracy, the accuracy of the admission reconciliation documentation, and any potential issues unrelated to accuracy. Analysis of these data determined the time required for pharmacist involvement, the number of errors identified by pharmacists, the quality of pharmacist interventions, the cost avoidance for each error, and the overall impact on hospital readmission.

Results:

During the 7-week study period, pharmacists performed 67 discharge medication reviews and identified 84 errors. Seventy-five percent were considered to be significant and 6% were considered to be serious. The 30-day readmission rate in the study cohort was 18% compared with 20% in the control group. Based on the clinical severity scale and pharmacist salaries, pharmacist interventions resulted in $42,300 in cost avoidance.

Conclusion:

Pharmacists involved in this pilot discharge process identified and resolved significant errors on medication reconciliation orders that resulted in a financial benefit to the institution.     

国外临床药师药物重整工作简介

根据笔者6个月的美国临床药师培训工作的见闻,结合相关参考文献,对美国及其它相关的药物重整工作的情况进行简介,包括药物重整工作的定义、目的、发展情况和存在问题。供中国的临床工作者特别是临床药师在日常工作中学习和实践。     

临床药师在药物整合服务中的实践总结

目的：通过总结临床药师在心内科对药物整合服务的实践,以探索临床药师对药物整合服务的进一步参与。方法：对2012年8月20日-11月26日期间心内科新入院的患者进行药物整合服务,主要通过问诊的方法获取用药信息。统计分析药师问诊结果和医师问诊结果的差异,并分析差异存在的原因。结果：共获取39位患者的用药信息,33％（n=13）的患者药师问诊信息是完全正确的,药品不良反应的问诊结果差异较大。结论：目前临床药师的药物整合服务还存在一定的缺陷,但在加强用药管理、降低药物治疗差错方面已经显现出一定作用。提示今后药师应注意问诊结果与检索信息的结合,加强问诊能力,提高患者依从性,逐步构建完善的药物整合体系。     

210例老年择期手术患者术前用药情况评价及药物重整

目的:调查并评价老年择期手术患者术前用药情况,为临床药师对老年患者术前用药的管理提供参考。方法:以2015年10月-2016年10月在北京清华长庚医院进行择期手术的210例老年患者为研究对象,药师对其进行药物重整,获取其疾病及用药信息,并依据《老年患者最佳术前评估指南》对术前用药情况(如用药适应证、用法用量、相互作用、药物选择及术前是否需要停用等)进行分析及评价,提供相关用药建议。结果:在210例患者中,男性132例(62.86%)、女性78例(37.14%),平均年龄(69.96±7.67)岁;43.81%的患者患有3种以上疾病,13.33%的患者患有5种以上疾病;31.43%的患者术前长期用药≥5种;38.10%患者存在2种以上用药风险;110例(52.38%)患者术前用药中包含术前应避免使用的药物(如抗血小板聚集药),23例(10.95%)患者存在潜在不适当用药(如质子泵抑制药),12例(5.71%)患者存在应谨慎使用的药物(如阿司匹林),35例(16.67%)患者包含术前应继续使用的药物(如β受体阻滞药);药师通过药物重整及术前用药评估为患者和医师提出如停药等用药建议共计177例次(患者71次、医师106次),最终采纳率分别为100%、95.28%。结论:老年患者术前合并疾病多、用药风险因素多、多重用药常见,应重视术前用药管理;药物重整是开展老年患者术前用药管理的有效途径,老年患者术前用药评估及分析对保证临床用药安全具有重要意义。     

药师干预对冠心病患者用药依从性的影响

目的 探讨临床药师干预对冠心病患者用药依从性的影响。加深冠心病患者对冠心病用药的认知程度,提高冠心病患者的用药依从性和降低心血管病发病风险。方法 选取2013-12~2014-03在本院心血管内科住院的冠心病患者50例为研究对象,临床药师对冠心病患者给予以用药指导为主的健康教育介入干预,观察对患者用药依从性的影响。结果 药师干预后,患者的用药依从性佳的比率从16%提高至92%,80%患者可控制危险因素降低至1~2项。结论 临床药师的干预可有效提高冠心病患者的用药依从性,值得临床推广应用。     

药品生产过程中的物料平衡检查

对药品生产过程中的输入、输出进行"物料平衡(Reconciliation)"检查,是国际通行的要求,并被规定于各国"药品生产质量管理规范"(GMP)中.我国对此的要求为:企业应对每批产品按产量和数量的物料平衡进行检查.即对产品或物料的理论产(用)量与实际产(用)量进行比较,并允许适当的正常偏差.如有显著差异,必须查明原因,在得出合理解释,确认无潜在质量事故后,可按正常产品处理.所称"理论产量"(theoretical yield),是设输入总量在生产过程中无任何损耗,全数转化为输出产品量.     

药物整合在呼吸内科患者用药差错防范中的应用

目的：探讨开展药物整合服务在促进合理用药、防范呼吸内科患者用药差错及风险中的作用。方法：临床药师通过回顾性病历调查分析,收集患者既往用药史、整理入院药物治疗医嘱清单,对2014年12月-2015年9月收住呼吸内科的95例患者进行药物整合,并探查临床用药中不合理问题及存在的风险。结果：临床药师问诊针对用药品种、用法用量及不良反应方面更详细;通过药物整合,发现不合理用药及风险共109例次,重复用药占42.20%,药物遗漏占11.01%,药物使用无指征占8.26%,不良相互作用占8.26%;针对药师发现的问题,87.16%被医师采纳并调整给药。结论：药物整合对促进合理用药、防范用药差错及风险具有重要的作用,为临床药师开展药学服务提供了一种新的方式。     

基于“问药师”平台的用药咨询服务实践

目的:总结在"问药师"平台进行的用药咨询服务实践,为药师参与药学服务提供参考。方法:收集本文作者于2017年10月-2018年7月在"问药师"平台上对502例关于儿童、孕期和哺乳期妇女用药咨询服务的数据,对用药患者的一般情况及主要用药情况、咨询药物的种类、咨询的用药问题类型及其中的不合理用药类型进行统计与分析,并通过典型实例介绍药师基于循证理念指导患者合理用药的服务实践。结果:在502例咨询中,男性、女性分别为147(29.3%)、355(70.7%)例,年龄分布以20～40岁患者为主(291例,58.0%);同时用药1～2种、3～4种、5种及以上占比分别为45.4%、41.4%、13.2%,且同时服用5种及以上药物者均为儿童患者;在用药咨询内容中,儿童用药、哺乳期用药、孕期用药占比分别为42.0%、40.6%、17.4%,咨询药物的种类以抗菌药、中成药和抗病毒药占比最大,分别为25.6%、17.8%、12.1%,咨询的用药问题类型主要是药物适应证、用量与疗程、药物安全性与不良反应,占比分别为31.9%、17.5%、13.6%;不合理用药类型包括选药不合理、重复用药、无适应证用药,占比分别为44.1%、21.0%、14.9%;在典型实例中,药师严格按照循证理念进行系统地证据查询并解答患者的用药咨询,循证的主要流程包括制订检索策略、检索相关文献资料、严格评价证据(真实性、可靠性和适应性)并依据其证据级别从高到低依次筛选、综合评价证据并应用于实践。药师基于循证方法而提出的用药指导信息,不但纠正了患者的不合理用药,且收到了患者良好的反馈评价,满意度评价中5星评分占比为95.5%。结论:在"问药师"平台基于循证方法提供的用药咨询服务,可为药师进行有针对性的药学服务提供参考。     

Evaluating the Potential Impact of Pharmacist Counseling on Medication Adherence Using a Simulation Activity

Objective. To evaluate the impact of counseling in a simulated medication adherence activity.Design. Students were randomized into 2 groups: patient medication monograph only (PMMO) and patient medication monograph with counseling (PMMC). Both groups received a fictitious medication and monograph. Additionally, the PMMC group received brief counseling. A multiple-choice, paper-based survey instrument was used to evaluate simulated food-drug interactions, adherence, and perceptions regarding the activity’s value and impact on understanding adherence challenges.Assessment. Ninety-two students participated (PMMC, n=45; and PMMO, n=47). Overall, a significantly higher incidence of simulated food-drug interactions occurred in the PMMO group (30%) vs the PMMC group (22%) (p=0.02). Doses taken without simulated food-drug interactions were comparable: 46.2% (PMCC) vs 41.9% (PMMO) (p=0.19). The average number of missed doses were 3.2 (PMMC) vs 2.8 (PMMO) (p=0.55). Approximately 70% of the students found the activity to be valuable and 89% believed it helped them better understand adherence challenges.Conclusion. This activity demonstrated the challenges and important role of counseling in medication adherence.     

药师干预对慢性病患者用药依从性的影响

目的综述药学干预对慢性患者用药依从性的影响。方法查阅国内外相关文献,进行总结、归纳。结果与结论慢性病患者的用药依从性与用药数量、频次、饮食等因素相关,而药师干预可提高患者的用药依从性。     

临床药师参与药物治疗实践的体会和感受

总结笔者自2004年做专职临床药师以来,特别是带教卫生部临床药师培训试点基地的学员和师资以来的临床药物治疗实践的体会和感受,与各位同行进行交流和讨教,也供新入职的临床药师在实践中参考,共同推进这个新兴职业的健康发展.     

患者用药依从性与药师相关因素的调查研究

目的:为提高患者用药依从性,提升药学服务质量提供参考。方法:回访两家医疗机构的30名调剂药师及经其调配的150例抗幽门螺杆菌(Hp)治疗患者,单因素分析患者用药依从性与药师间的相关因素,将有统计学意义的相关因素进行Logistic回归分析。结果:单因素分析显示,患者的用药依从性与调剂药师的性别、年龄、学历、职称无相关性(P>0.05),与患者的交流时间、服务态度、继续教育、常用抗Hp治疗药物的知晓度有相关性(P<0.05)。Logistic回归分析显示,患者的用药依从性与交流时间、常用抗Hp治疗药物的知晓度呈正相关。结论:应加强调剂药师的培训,提高药师的综合素质;药师应向患者提供1 min以上有效的药学服务,提高其用药依从性。     

A Quantitative Evaluation of Medication Histories and Reconciliation by Discipline

Background/Objective:

Medication reconciliation at transitions of care decreases medication errors, hospitalizations, and adverse drug events. We compared inpatient medication histories and reconciliation across disciplines and evaluated the nature of discrepancies.

Methods:

We conducted a prospective cohort study of patients admitted from the emergency department at our 760-bed hospital. Eligible patients had their medication histories conducted and reconciled in order by the admitting nurse (RN), certified pharmacy technician (CPhT), and pharmacist (RPh). Discharge medication reconciliation was not altered. Admission and discharge discrepancies were categorized by discipline, error type, and drug class and were assigned a criticality index score. A discrepancy rating system systematically measured discrepancies.

Results:

Of 175 consented patients, 153 were evaluated. Total admission and discharge discrepancies were 1,461 and 369, respectively. The average number of medications per participant at admission was 8.59 (1,314) with 9.41 (1,374) at discharge. Most discrepancies were committed by RNs: 53.2% (777) at admission and 56.1% (207) at discharge. The majority were omitted or incorrect. RNs had significantly higher admission discrepancy rates per medication (0.59) compared with CPhTs (0.36) and RPhs (0.16) (P < .001). RPhs corrected significantly more discrepancies per participant than RNs (6.39 vs 0.48; P < .001); average criticality index reduction was 79.0%. Estimated prevented adverse drug events (pADEs) cost savings were $589,744.

Conclusions:

RPhs committed the fewest discrepancies compared with RNs and CPhTs, resulting in more accurate medication histories and reconciliation. RPh involvement also prevented the greatest number of medication errors, contributing to considerable pADE-related cost savings.Key Words: admission, evaluation study, discharge, medication reconciliationObtaining medication histories and conducting medication reconciliation are challeng ing tasks with the advent of new molecular entities and orphan drugs.¹ As Franklin reported, “Patients who once came into the [physician] office carrying their medications in a purse, or pocket, now need a shopping bag.”² The importance of accurate medication histories cannot be overemphasized; nearly 27% of all hospital prescribing errors originate from incorrect admission medication histories, over 70% of drug-related problems are only discovered through patient interview, and more than 50% of discharge discrepancies are associated with admission discrepancies.^3–6In 2010, an Institute of Medicine report estimated that if hospitals prevented adverse drug events (pADEs) and redundant tests, the associated cost savings would be nearly $25 billion annually.⁷ One organization decreased inpatient care costs by 30% when no medication reconciliation errors were reported over 24 months. ⁷Multiple organizations have supported medication reconciliation to improve quality of care, reduce preventable hospital admissions and readmissions, and decrease the incidence of adverse health care- associated conditions.^8–11 Although The Joint Commission does not indicate the discipline to perform this role, evidence supports the role of registered pharmacists (RPhs), pharmacy students, and pharmacy technicians in collecting accurate medication histories. RPhs should be involved when high-risk medications are identified, more than 5 medications are reported, or patients are elderly.^6,8,11–40 Therefore, our primary study objective was to compare inpatient medication histories and reconciliation processes across disciplines and to evaluate the nature of discrepancies using a novel method.     

开展药物整合教学 深化临床药学教育改革

阐述药物整合概念以及临床药师通过药物整合开展临床药学服务的意义,探讨如何在临床药学教学中开展药物整合教学,以培养具有实践能力的临床药师,体现临床药师的价值,深化临床药学教育改革。     

临床用药差错归因分析及药师的干预效果评价

目的:对用药差错进行归因分析,并评价用药差错可能造成的危害,以减少因用药差错而导致的药品不良事件的发生。方法:将我院2010年3月1日-5月30日的患者病历设为基准期,2011年同期患者病历设为干预期,分析引起用药差错的各种因素,并对用药差错的潜在危害和药师干预效果进行评估。结果:共收到168份用药差错报告,其中基准期115份、干预期53份,用药差错率分别为2.26%(115/5084)和0.94%(53/5637),二者比较差异有统计学意义(P<0.05);潜在危害程度严重者16份(0.32%)和5份(0.09%),中度者46份(0.90%)和25份(0.44%),轻度者53份(1.04%)和23份(0.41%),差异均有统计学意义(P<0.05);用药差错主要表现在药品使用、频次、时间、剂量等方面;干预期53份报告中46份被临床采纳,采纳率达86.8%。结论:用药差错会给患者的药物治疗带来较大风险,临床药师干预可有效降低用药差错所导致的风险。