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。     

药物治疗管理在结直肠肿瘤病人围手术期营养支持治疗中的实践

目的评价临床药师运用药物治疗管理参与结直肠肿瘤病人围手术期营养支持治疗的效果,探索临床药师如何运用药物治疗管理为结直肠肿瘤病人围手术期提供更满意的药学服务。方法选取 2019年 1月至 2020年 3月黄山市人民医院收治的 100例行结直肠癌根治术的病人,采用随机数字表法分为对照组和试验组,各 50例。对照组由临床医师和护士负责病人的围手术期营养治疗管理,试验组由临床药师应用药物治疗管理对病人围手术期营养治疗进行干预。比较两组病人术后营养状况,临床疗效,治疗依从性和不良反应发生率。结果与对照组相比,试验组病人术后第 7天营养指标血红蛋白,白蛋白、黄醇结合蛋白水平提高,炎症指标 C反应蛋白水平降低( P<0.05);术后 7d营养风险发生率试验组( 8/50,16%)低于对照组( 18/视50,36%)(P<0.05);试验组术后出现并发症发生率( 7/50,14%)和药物不良反应发生率(4/50,8%)低于对照组( 22/50,44%)(15/ 50,30%)(P<0.05);治疗依从性良好率试验组( 42/50,84%)优于对照组( 18/50,36%)(P<0.05);住院天数试验组( 18.22±4.71)d少于对照组( 22.58±8.45)d(P<0.05)。结论药物治疗管理在围手术期病人营养支持治疗中的应用,可以有效改善病人围手术期营养情况,提高用药依从性,降低药物不良反应发生率,促进病人术后早期康复。     

临床药师开展药物重整服务在防范用药差错中的作用与实践

目的探讨临床药师开展药物重整服务在防范用药差错中的作用与实践。方法结合具体临床案例分析药物重整中发现的常见问题及其在防范用药差错中的作用。结果药物重整可减少发生药物遗漏或重复给药、用法用量不适宜、药物选择不适宜、停药不及时、血药浓度监测不连贯、药物相互作用等现象。结论药物重整服务在减少用药差错中具有重要作用,为临床药师参与临床提供了一种新的方式。     

药疗事故成因分析

目的 通过分析药疗事故成因,提出防范药疗事故的有效措施.方法 回顾性分析2002年9月至2009年12月由上海市医学会判定为药疗事故的23个案例的事故成因.结果 23例事故中,一级事故13例,二级事故2例,三、四级事故各4例.事故原因方面,以违反药物禁忌证或慎用原则构成事故比例为最多(4例),其次为药物剂量过失、药物配伍错误、给药途径不当(各3例).另外,给药时间不当、违反操作规定、用药期间未按规定监测指标、用药适应证不当及其他原因各有2例.结论 医药工作者和临床医师应高度重视合理用药以防范药疗事故的发生.

Abstract：

Objective To put forward an effective procedure to prevent the medication incidents by analyzing the cause of it. Methods A retrospective analysis was performed to observe the causes of 23 medication incidents in Shanghai Medical Association from 2003 to 2009. Results The main cause of medication incidents was violation of drug contraindications, followed by improper drug dosage, improper drug compatibility, improper administration route. Conclusion Medical workers and clinicians should pay great importance to the rational use of medicines to prevent medication incident.     

361份药品说明书服药时间与服药方法的调查与分析

目的调查口服药品说明书中关于服药时间与服药方法的标注情况,探讨如何保证患者正确使用药物。方法收集我院361份口服西药说明书,按有无标注服药时间进行统计;46种缓控释及肠溶制剂按有无标注服药方法进行统计。结果 361份药品说明书中,标注服药时间的143份,占全部品种的39.61%;46种缓控释及肠溶制剂中,标注服药方法的30种,占全部品种的65.22%。结论为保证患者正确使用药物,应规范药品说明书的书写,同时药师应善于归纳总结,做好用药指导,保证患者的用药安全、有效。     

Accuracy of medication histories collected by pharmacy technicians during hospital admission

Background

Transitioning activities that do not require clinical judgment from pharmacists to pharmacy technicians has been endorsed as a strategy to increase patient access to clinical pharmacy services. One role becoming increasingly common is using pharmacy technicians to collect the medication history within medication reconciliation processes.

Understanding the meaning of medications for patients: The medication experience

Objective: To understand and describe the meaning of medications for patients. Methods: A metasynthesis of three different, yet complementary qualitative research studies, was conducted by two researchers. The first study was a phenomenological study of patients’ medication experiences that used unstructured interviews. The second study was an ethnographic study of pharmaceutical care practice, which included participant observation, in-depth interviews and focus groups with patients of pharmaceutical care. The third was a phenomenological study of the chronic illness experience of medically uninsured individuals in the United States and included an explicit aim to understand the medication experience within that context. The two researchers who conducted these three qualitative studies that examined the medication experience performed the meta-synthesis. The process began with the researchers reviewing the themes of the medication experience for each study. The researchers then aggregated the themes to identify the overlapping and similar themes of the medication experience and which themes are sub-themes within another theme versus a unique theme of the medication experience. The researchers then used the analytic technique, “free imaginative variation” to determine the essential, structural themes of the medication experience. Results: The meaning of medications for patients was captured as four themes of the medication experience: a meaningful encounter; bodily effects; unremitting nature; and exerting control. The medication experience is an individual’s subjective experience of taking a medication in his daily life. It begins as an encounter with a medication. It is an encounter that is given meaning before it occurs. The experience may include positive or negative bodily effects. The unremitting nature of a chronic medication often causes an individual to question the need for the medication. Subsequently, the individual may exert control by altering the way he takes the medication and often in part because of the gained expertise with the medication in his own body. Conclusion: The medication experience is a practice concept that serves to understand patients’ experiences and to understand an individual patient’s medication experience and medication-taking behaviors in order to meet his or her medication-related needs.     

The effectiveness of medication reconciliation to prevent medication error: A systematic review and meta-analysis

BackgroundThe impact of medication reconciliation (MR) in low-middle-income countries, including Thailand, may differ from other developed countries.ObjectiveTo evaluate the effect of medication reconciliation (MR) on the reduction of medication error in Thailand.MethodsA systematic search was conducted in the following databases: PubMed, CENTRAL, CINAHL, Scopus, Thai Journals Online, Thai index Medicus, Thai Medical Index, and Health Science Journal in Thailand from inception to January 2018. Studies that evaluated the effect of MR compared to usual care within hospitals in Thailand and reported the occurrence of medication error were included. Meta-analyses were performed using random-effects model.ResultsOf the 107 articles retrieved, 7 articles involving 1581 patients were included in quantitative synthesis. Three of the included studies were randomized controlled trials (RCT). Overall, the risk of medication error in patients who received MR in all transitions of care was 75% lower than those receiving usual care (RR 0.25; 95%CI 0.15–0.43). The effect on the reduction of medication error appeared higher when MR was provided to ambulatory patients (RR 0.17 [95%CI 0.04–0.80] compared with hospitalized patients during admission (RR 0.37 [95%CI 0.20–0.65]) and discharge (RR 0.27 [95%CI 0.17–0.43]). Effects on reducing medication error was greater when MR was provided in secondary care hospitals compared with primary care hospitals both during admission (RR 0.49 [95%CI, 0.34–0.69] vs RR 0.25 [95%CI, 0.05–1.26]), and discharge transition (RR 0.19 [95%CI, 0.09–0.39] vs RR 0.30 [95%CI, 0.12–0.79]).ConclusionOverall, current evidence indicates that the provision of MR in Thailand is effective in reducing medication errors in all transitions of care. However, to promote patient safety, appropriate strategies should be developed to support MR in specific transition of care and hospital setting so patients can benefit most from this service.     

The medication discrepancy taxonomy (MedTax): The development and validation of a classification system for medication discrepancies identified through medication reconciliation

BackgroundMedication discrepancies directly impact patient safety and can adversely impact quality of care and resource utilization at transitions of care.ObjectivesTo develop a common nomenclature and taxonomy for classifying and reporting medication discrepancies and to assess the content validity and reliability of the taxonomy.MethodsThe taxonomy was developed following a multi-stage process. The content of the taxonomy was then assessed using expert opinion through a two-round modified Delphi process. The expert panel comprised 10 experts who were selected based on pre-defined selection criteria. Six experienced pharmacists were then invited to classify medication discrepancies from a number of fictitious cases (adapted from authentic cases) using the taxonomy.ResultsThe medication discrepancy taxonomy (MedTax) comprises 12 main types and 28 sub-types of discrepancies. A set of operational instructions and definitions to aid the use of the taxonomy was formulated. The overall Average content validity index (Ave-CVI) was 0.93 and interrater reliability was 0.67 (multirater κfree), indicating substantial agreement. An excellent internal consistency of the taxonomy was established (Kuder–Richardson Formula 20 (KR-20) = 0.92).ConclusionsA content valid and reliable taxonomy for classifying medication discrepancies was developed. The MedTax may be used to classify medication discrepancies identified following medication reconciliation services. The clear and consistent reporting of medication discrepancies arising from medication reconciliation services may be of value to policy makers, healthcare professionals and researchers, when evaluating such services. The MedTax was designed to fill an essential void in global endeavors to reinforce standardization of medication reconciliation practices and to improve medication safety across transitions of care.     

Evaluation of a community pharmacy-based medication therapy management programme: A study protocol of a pilot randomized controlled trial with an embedded qualitative study

ObjectivesThe main objectives are: to evaluate the feasibility and effectiveness of a community-pharmacy based medication therapy management programme; to explore patients’ experiences and views towards medication therapy management service delivered by community pharmacists.Research design and methodsA mixed-methods research design consisting of a pilot randomized controlled trial embedded with qualitative study will be used in this study. The study consists of two phases: a 6-month follow-up pilot randomized control trial (quantitative approach) to assess the feasibility and effectiveness of a community pharmacy-based medication therapy management programme. The primary outcome is HbA1C and secondary outcomes include: clinical and health services utilization and process measures, medication adherence, diabetes distress as well as satisfaction with care. Phase two consists of an embedded qualitative study using semi-structured interviews to explore patients’ experiences and views with the medication therapy management programme. Study data collection will be collected between April 2021 and December 2021.Ethics considerationThe study has been approved by institutional review boards from Princess Nourah bent Abdulrahman University (Approval # 20–0240), King Fahad Medical City (Approval # 20-388E) and Birmingham University (Approval # ERN_20-0768).     

妊娠期用药对胎儿的影响与危害性初步研究

目的 研究分析妊娠期用药对胎儿的影响及危害性.方法 择取2013年1月至2014年1月于本院用药干预的130例孕妇,回顾性探析用药干预对胎儿的影响及危害性.结果 全部孕妇均严格遵守美国食品和药品管理局(FDA)的标准,并结合妊娠期时间谨慎用药,分娩后胎儿均正常,均未出现畸形、异常症状,短期内无严重后果.结论 临床应该严格掌握孕妇的用药禁忌,了解药物对胎儿的影响,结合妊娠期谨慎用药,确保孕妇及胎儿的健康及安全.     

遮盖疗法联合药物治疗大龄儿童弱视的效果观察

目的分析遮盖疗法联合药物治疗大龄儿童弱视的临床效果,为临床治疗提供依据。方法将已确诊为弱视(9～16岁)的门诊患者140例168眼,并随机分为观察组70例86眼和对照组70例82眼,所有患者均进行验光配镜纠正,及遮盖疗法治疗3个疗程;观察组在此基础上联用胞二磷胆碱250mg肌肉注射,观察两组的临床效果。结果观察组86眼中,总有效率为95.35%(82/86),其中基本治愈42眼;对照组总有效率为86.59%(71/82),其中基本治愈34眼,两组比较差异有统计学意义(P<0.01)。结论遮盖疗法联合药物治疗大龄儿童弱视不但能持续提高视力,而且安全性高,副作用少,还能延长视觉发育期,是治疗大龄儿童弱视的可取方法。     

Retrospective analysis of medication incidents reported using an on-line reporting system

Objective To examine the types of prescribing, administration and dispensing incidents reported to an on-line incident-reporting scheme and determine the types of healthcare professionals responsible for reporting such incidents. Method Retrospective analysis of medication-related incidents reported to an on-line incident-reporting scheme in a large (1000-bed) teaching hospital in the UK. Main outcome measures Frequency and type of incidents, the discipline of the health care professional who reported the incident and the stage in the medication use process (prescribing, dispensing, or administration) at which the incident occurred. Results Over a 26-month study period, there were 495 medication-related incidents reported, of which 38.6% (191) were classified to be a “near miss”. Medication-related incidents were reported most often at the stages of administration (230, 46.5%) and prescribing (192, 38.8%), whilst incidents involving dispensing or supply of medication were reported less often (73, 14.7%). Of all the incidents, pharmacists reported 51.9% (257), nursing staff reported 37.6% (186), and doctors reported 9.1% (45). Cardiovascular (149, 30.1%), central nervous system (106, 21.4%), and antibiotic/anti-infective medication (71, 14.3%) were the most common therapeutic categories associated with reports of medication-related incidents. Conclusion An on-line reporting scheme can be used to monitor medication-related incidents at key stages in the medication-use process in secondary care. The types of incidents reported by health care professionals differ markedly, with fewer medication-related incidents being reported by doctors. Future research should explore the prevailing safety culture amongst the different health care disciplines, and examine the impact that information technology has on the willingness of health care professionals to report adverse incidents.     

对患者用药依从性调查分析

目的:通过对患者用药依从性的调查,分析目前病人对医嘱的依从程度.方法:随机对门诊、住院患者及家属采用问卷的形式进行现场调查,以收回的完整问卷为有效问卷,共收回289份资料,内容包括性别、年龄、是否依从医嘱及不依从医嘱的原因.结果:289份问卷中,男女比例为139/150,年龄从5个月婴儿到79岁老人,依次分为幼儿组、少儿组、青少年组、青年组、中年组及老年组,其依从性由高到低是青年组、幼儿组、少儿组、中年组、青少年组及老年组,老年组的不依从比最高,达到31.82%.结论:通过分析患者不依从性的原因,结果发现不同年龄段的患者,依从性有较大程度的差异(P＞0.05),为医务工作者更好地为患者服务提供参考.     

烟碱致病性和药用研究进展

目的：通过研究分析全面了解人体摄入烟碱后所产生的影响,并对烟草戒除方法和烟碱使用有一个科学的认识。方法：通过研究各方面的文献报道进行综述。结果：烟碱或受体激动剂具有改善人体中枢神经系统退变疾病的症状,从而起到保护神经的作用。烟碱对阿尔茨海默病、帕金森综合症、精神分裂症、癫痫和一些炎症具有治疗效果,并对提高记忆功能、学习及注意力具有一定作用。但吸烟对慢性阻塞性疾病、动脉粥样硬化、心血管疾病、肺气肿、肺癌等疾病有诱导作用。结论：通过吸烟摄入烟碱显然是不科学的,而以其它方式将烟碱在临床应用和药用需谨慎,尤其针对未曾有吸烟史的病患,以将其副作用减至最小。     

The federal standard medication plan in practice: An observational cross-sectional study on prevalence and quality

BackgroundMedication plans are instruments used to document drug therapies, guide patients, and ensure medication safety. In Germany, patients who take at least 3 long-term medications are eligible to receive a medication plan. It has been statutory to use the federal standard layout (German: “Bundeseinheitlicher Medikationsplan”) since April 2017.ObjectivesThis study explores the prevalence, availability, medication discrepancies, and conformance with statutory regulations of medication plans since the introduction of the format of the federal standard medication plan in Germany.MethodsMedication reconciliation was performed for hospitalized patients according to the Best Possible Medication History principle. The collected medication lists were analyzed for medication discrepancies and conformance with the statutory regulations. The medication discrepancies were (1) omitted drugs, (2) additional drugs, and (3) dosing errors.ResultsAfter hospitalization, 524 patients taking drugs were included. The majority (n = 424 patients) were eligible for a medication plan. While 241 medication lists were present, only 24.1% (n = 58) matched the federal standard format. The mean number of drugs was 6.3 ± 3.6, with 3315 medications (3046 long-term and 269 as needed) reconciled totally. The 84 medication lists with omitted or additional drugs included 166 medication discrepancies upon 774 drugs listed. Of the 253 patients with dosing errors, 146 had a medication list. Inappropriate dosages were due to single dose (n = 195), daily dose (n = 225) or frequency of application (n = 255).ConclusionMedication plans are valuable tools for patients and health care providers. This study shows that the introduced paper-based federal standard medication plan in Germany falls short of its expectations regarding availability and correctness. Switching to an electronic patient record system may overcome some of the current pitfalls.