Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
Eur J Intern Med. 2011 Aug;22(4):382-5. doi: 10.1016/j.ejim.2011.03.010. Epub 2011 Apr 22.
Medication histories acquired upon admission are often incomplete. Using a standardized approach warrants more complete medication reconciliation, however, this is too time consuming to be performed. Other strategies guaranteeing complete medication histories should be explored. We developed a limited list of standardized questions and assessed its impact on completeness of medication histories.
This prospective study enrolled adults presenting to a tertiary care emergency department. In the control group, medication histories were conducted by physicians of general internal medicine conform standard care. In the intervention group, the physicians were obliged to use, besides the standard care, the 'limited questions list' for medication history acquisition. The clinical pharmacist re-obtained medication histories of the patients in both groups using a standardized approach. The primary outcome was the impact of the use of a 'limited questions list' on the frequency of drug omissions in medication histories.
260 consecutive patients were enrolled: 130 in the intervention group and 130 in the control group. There was a significant reduction of 49.3% in drug omissions in the intervention group. The omission rate per medication history was 1.1 for the control group, which was significantly lower (0.6) in the intervention group. Antithrombotics were most frequently forgotten in the control care group as opposed to dietary supplements in the intervention group.
Drug omission rate in medication histories can be significantly reduced if a limited list of simple questions is used during anamnesis. Widespread use of this tool should be considered to be implemented.
入院时获取的用药史常常不完整。采用标准化方法可以保证更完整的用药核对，但这太耗时，无法实施。应该探索其他能保证完整用药史的策略。我们开发了一份有限的标准化问题清单，并评估了其对用药史完整性的影响。
这项前瞻性研究纳入了就诊于三级护理急诊的成年人。在对照组中，用药史由普通内科医生根据标准护理进行采集。在干预组中，医生除了标准护理外，还必须使用“有限问题清单”获取用药史。临床药师使用标准化方法重新获取两组患者的用药史。主要结局是使用“有限问题清单”对用药史中药物遗漏的频率的影响。
共纳入 260 例连续患者：干预组 130 例，对照组 130 例。干预组药物遗漏显著减少 49.3%。对照组每个用药史的遗漏率为 1.1，干预组明显更低（0.6）。在对照组中，抗血栓药物最常被遗漏，而在干预组中，最常被遗漏的是膳食补充剂。
如果在病史采集过程中使用简单的有限问题清单，可以显著降低用药史中的药物遗漏率。应考虑广泛使用此工具来实施。
