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。

Practice of Medication Reconciliation Services among Clinical Pharmacists

OBJECTIVE： To explore the further participation of clinical pharmacists in medication reconciliation services by summarize the practice of medication reconciliation services among clinical pharmacists in the department of cardiology. METHODS： The medication reconciliation services for patients newly admitted to cardiology department was carried out mainly through the way of interrogation. The differences between the results of pharmacist＇ s interrogation and doctor＇ s were analyzed statistically, and the causes of the differences were analyzed. RESULTS： The medication information of 39 patients was collected. The medication information of 33% patients gathered by pharmacist was accurate completely. There were great differences in terms of adverse drug actions. CONCLUSIONS： Although there are some defects about the medication reconciliation services of clinical pharmacists, it has certain effect on medication management and reduction of therapy error. In the future, clinical pharmacists should pay attention to the combination of the information gathered by interrogation and retrieval, and strengthen the ability of interrogation to improve patient compliance and establish a complete medication reconciliation system.