临床药师在肾内科实施入院药物重整的实践

Admission medication reconciliation in the department of nephrology by clinical pharmacists

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。

OBJECTIVE To summarize the common medication errors and further give interventions in patients by implementing admission medication reconciliation in the department of nephrology,explore the work mode and effect of medication reconciliation in the department of nephrology. METHODS The inpatients in our hospital from March 2016 to December 2016 were selected as the research subjects. The medication history of patients was obtained within 24 hours after admission and the comparative analysis was conducted between the records and the doctor＇s prescriptions after admission. An analysis was made to evaluate the patient＇s medication errors before admission and the doctor＇s orders after admission. RESULTS A total of 128 patients were conducted to the admission reconciliation medication. There were 62 cases of medication errors,and the incidence of medication errors was 48. 4 %. Totally 838 medical orders were involved in current study and 81 medical errors were found. Incorrect medication time,incorrect medication frequency,and untimely drug withdrawal were the most common medication errors. The top 3 drugs with medication errors were gastrointestinal and metabolic drugs,cardiovascular drugs,and antineoplastic agents and immunomodulatory drugs. Among the 81 cases of medication errors,34 cases were incorrect medication time or change of the recommended dose by patients. Clinical pharmacists gave education and guidance to patients in time,which were accepted by all patients. In addition,of the rest of 47 medication errors feedback to doctor by clinical pharmacists,40 were accepted and modified by doctors,the acceptance rate was 85. 1 %. CONCLUSION Implementation of medication reconciliation can find and correct medication problems,including the incorrect medication time,the change of the recommended dosage. In addition,it can effectively reduce the doctor＇s medication errors in the medical transfer points such as admission and transfer and further promote the safe and rational use of drugs.