Hellström Lina M, Bondesson Åsa, Höglund Peter, Eriksson Tommy
eHealth Institute and School of Natural Sciences, Linnaeus University, Kalmar, Sweden.
BMC Clin Pharmacol. 2012 Apr 3;12:9. doi: 10.1186/1472-6904-12-9.
An accurate medication list at hospital admission is essential for the evaluation and further treatment of patients. The objective of this study was to describe the frequency, type and predictors of errors in medication history, and to evaluate the extent to which standard care corrects these errors.
A descriptive study was carried out in two medical wards in a Swedish hospital using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. A clinical pharmacist identified each patient's most accurate pre-admission medication list by conducting a medication reconciliation process shortly after admission. This list was then compared with the patient's medication list in the hospital medical records. Addition or withdrawal of a drug or changes to the dose or dosage form in the hospital medication list were considered medication discrepancies. Medication discrepancies for which no clinical reason could be identified (unintentional changes) were considered medication history errors.
The final study population comprised 670 of 818 eligible patients. At least one medication history error was identified by pharmacists conducting medication reconciliations for 313 of these patients (47%; 95% CI 43-51%). The most common medication error was an omitted drug, followed by a wrong dose. Multivariate logistic regression analysis showed that a higher number of drugs at admission (odds ratio [OR] per 1 drug increase = 1.10; 95% CI 1.06-1.14; p < 0.0001) and the patient living in their own home without any care services (OR = 1.58; 95% CI 1.02-2.45; p = 0.042) were predictors for medication history errors at admission. The results further indicated that standard care by non-pharmacist ward staff had partly corrected the errors in affected patients by four days after admission, but a considerable proportion of the errors made in the initial medication history at admission remained undetected by standard care (OR for medication errors detected by pharmacists' medication reconciliation carried out on days 4-11 compared to days 0-1 = 0.52; 95% CI 0.30-0.91; p=0.021).
Clinical pharmacists conducting LIMM-based medication reconciliations have a high potential for correcting errors in medication history for all patients. In an older Swedish population, those prescribed many drugs seem to benefit most from admission medication reconciliation.
入院时准确的用药清单对于患者的评估和进一步治疗至关重要。本研究的目的是描述用药史错误的频率、类型和预测因素，并评估标准护理纠正这些错误的程度。
在瑞典一家医院的两个内科病房进行了一项描述性研究，采用基于隆德综合药物管理（LIMM）的用药核对。临床药师在患者入院后不久通过进行用药核对过程确定每位患者最准确的入院前用药清单。然后将该清单与医院病历中的患者用药清单进行比较。医院用药清单中药物的增减、剂量或剂型的改变被视为用药差异。无法确定临床原因的用药差异（无意的改变）被视为用药史错误。
最终研究人群包括818名符合条件患者中的670名。进行用药核对的药师为其中313名患者（47%；95%可信区间43 - 51%）识别出至少一处用药史错误。最常见的用药错误是漏服药物，其次是剂量错误。多因素逻辑回归分析显示，入院时药物数量较多（每增加1种药物的比值比[OR]=1.10；95%可信区间1.06 - 1.14；p<0.0001）以及患者独自居住且无任何护理服务（OR = 1.58；95%可信区间1.02 - 2.45；p = 0.042）是入院时用药史错误的预测因素。结果还表明，非药剂师病房工作人员的标准护理在入院后四天部分纠正了受影响患者的错误，但入院时初始用药史中相当一部分错误仍未被标准护理发现（与第0 - 1天相比，第4 - 11天进行的药师用药核对检测到用药错误的OR = 0.52；95%可信区间0.30 - 0.91；p = 0.021）。
进行基于LIMM的用药核对的临床药师在纠正所有患者用药史错误方面具有很大潜力。在瑞典老年人群中，那些开具多种药物的患者似乎从入院用药核对中获益最大。
