临床药师对心内科住院患者的药物重整实践

Clinical Pharmacist-led Medication Reconciliation in Patients from Department of Cardiology

目的:探讨心内科患者住院期间发生的非故意用药差异,探讨临床药师在药物重整方面的作用。方法:以2017年2月—2017年5月在山西省心血管病医院心内科住院的成年患者作为研究对象,确定最佳可能用药清单与医嘱之间的差异,将差异分为故意用药差异和非故意用药差异,评估非故意用药差异的潜在危害。结果:共纳入400例患者,存在用药差异者302例(占75.50%)。121例患者(占用药差异患者数的40.07%)出现1种以上非故意用药差异,合计152例次,其中最常见的为药物遗漏(78例次,占51.32%);90例次(占59.21%)的非故意用药差异会导致中度及以上不适或临床恶化的可能。结论:临床药师主导的药物重整服务可在识别并修正非故意用药差异方面发挥重要的作用,本研究建立的标准化的药物重整模式可广泛应用于其他医疗机构。

OBJECTIVE： To probe into the unintentional medication discrepancies in department of cardiology at hospital admission, so as to probe into the role of clinical pharmacists in clinical medication reconciliation.METHODS： Adult patients admitted into department of cardiology at Shanxi Cardiovascular Hospital from Feb. 2017 to May 2017 were extracted as reach objectives. Discrepancies between pharmacists＇ Best Possible Medication History（ BPMH） and physicians＇ admission orders were detected and were classified as intentional or unintentional. All discrepancies were classified according to the potential harm. RESULTS： Totally 400 patients were included,and 302 patients（ 75. 50%） had discrepancies. One or more unintentional medication discrepancy was found in 121 patients（ 40. 07%）,totally 152 cases,and the most common type of unintentional medication discrepancy was drug omission（ 78 cases,51. 32%）. 90 cases（ 59. 21%） of the identified unintentional medication discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration. CONCLUSIONS： Clinical pharmacist-led medication reconciliation plays an important part in detecting and preventing medication discrepancies. And this standardized medication reconciliation process can be widely applied to other health care organizations and clinical settings.