Pharmacy Department, Naas General Hospital, Naas, County Kildare, Ireland.
Int J Clin Pharm. 2013 Feb;35(1):14-21. doi: 10.1007/s11096-012-9696-1. Epub 2012 Sep 13.
Medication reconciliation has been mandated by the Irish government at transfer of care. Research is needed to determine the contribution of clinical pharmacists to the process.
To describe the contribution of emergency department based clinical pharmacists to admission medication reconciliation in Ireland.
Frequency of clinical pharmacist's activities.
Two public university teaching hospitals.
Adults admitted via the accident and emergency department, from a non-acute setting, reporting the use of at least three regular prescription medications, were eligible for inclusion. Medication reconciliation was provided by clinical pharmacists to randomly-selected patients within 24-hours of admission. This process includes collecting a gold-standard pre-admission medication list, checking this against the admission prescription and communicating any changes. A discrepancy was defined as any difference between the gold-standard pre-admission medication list and the admission prescription. Discrepancies were communicated to the clinician in the patient's healthcare record. Potentially harmful discrepancies were also communicated verbally. Pharmacist activities and unintentional discrepancies, both resolved and unresolved at 48-hours were measured. Unresolved discrepancies were confirmed verbally by the team as intentional or unintentional. A reliable and validated tool was used to assess clinical significance by medical consultants, clinical pharmacists, community pharmacists and general practitioners.
In total, 134 patients, involving 1,556 medications, were included in the survey. Over 97 % of patients (involving 59 % of medications) experienced a medication change on admission. Over 90 % of patients (involving 29 % of medications) warranted clinical pharmacy input to determine whether such changes were intentional or unintentional. There were 447 interventions by the clinical pharmacist regarding apparently unintentional discrepancies, a mean of 3.3 per patient. In total, 227 (50 %) interventions were accepted and discrepancies resolved. At 48-hours under half (46 %) of patients remained affected by an unintentional unresolved discrepancy (60 % related to omissions). Verbally communicated discrepancies were more likely to be resolved than those not communicated verbally (Chi-square (1) = 30.029 p < 0.05). Under half of unintentional unresolved discrepancies (46 %) had the potential to cause minor harm compared to 70 % of the resolved unintentional discrepancies. None had the potential to result in severe harm.
Clinical pharmacists contribute positively to admission medication reconciliation and should be engaged to deliver this service in Ireland.
爱尔兰政府已要求在患者转院时进行用药核对。因此，需要开展相关研究以明确临床药师在这一过程中的作用。
描述爱尔兰急诊科临床药师在患者入院时进行用药核对的工作内容。
药师工作的开展频率。
两所公立大学附属医院。
符合条件的患者为非急症环境下因急症就诊、至少使用三种常规处方药的成年人。临床药师在患者入院后 24 小时内随机为其提供用药核对服务，具体内容包括收集金标准的入院前用药清单、核对清单与入院医嘱并沟通任何差异。差异定义为金标准入院前用药清单与入院医嘱之间的任何差异。药师将差异记录在患者的医疗记录中。48 小时时，药师还会记录潜在有害差异的口头沟通情况，以及差异的解决情况。药师活动和 48 小时时仍未解决的差异（包括已解决和未解决差异）也将被记录。未解决的差异由团队通过电话再次与医生确认是有意还是无意的。由医学顾问、临床药师、社区药剂师和全科医生使用可靠且经过验证的工具评估差异的临床意义。
共有 134 名患者（涉及 1556 种药物）纳入调查。超过 97 %（涉及 59 %的药物）的患者在入院时经历了药物变化。超过 90 %（涉及 29 %的药物）的患者需要临床药师参与来确定这些变化是有意还是无意的。临床药师共对 447 例看似无意的差异进行了干预，平均每人 3.3 次。共 227 次（50 %）干预被接受，差异得到解决。48 小时时，仍有近一半（46 %）的患者存在未解决的无意差异（60 %与遗漏有关）。口头沟通的差异比未口头沟通的差异更有可能得到解决（卡方（1）= 30.029，p < 0.05）。与已解决的无意差异（46 %）相比，近一半（46 %）未解决的无意差异可能会造成轻微伤害，而 70 %的已解决无意差异可能会造成严重伤害。但这些差异都没有造成严重伤害的风险。
临床药师积极参与入院用药核对，爱尔兰应聘请临床药师来提供这项服务。
