Holland Deirdre M
Health Service Executive, Dublin Mid-Leinster, Naas General Hospital, Naas, Co. Kildare, Republic of Ireland,
Int J Clin Pharm. 2015 Apr;37(2):310-9. doi: 10.1007/s11096-014-0059-y. Epub 2015 Jan 17.
Medication reconciliation is a basic principle of good medicines management. With the establishment of the National Acute Medicines Programme in Ireland, medication reconciliation has been mandated for all patients at all transitions of care. The clinical pharmacist is widely credited as the healthcare professional that plays the most critical role in the provision of medication reconciliation services.
To determine the feasibility of the clinical pharmacist working with the hospital doctor, in a collaborative fashion, to improve the completeness and accuracy of discharge prescriptions through the provision of a pharmacist led discharge medication reconciliation service.
243-bed acute teaching hospital of Trinity College Dublin, Ireland.
Cross-sectional observational study of discharge prescriptions identified using non-probability consecutive sampling. Discharge medication reconciliation was provided by the clinical pharmacist. Non-reconciliations were communicated verbally to the doctor, and documented in the patient's medical notes as appropriate. The pharmacist and/or doctor resolved the discrepancies according to predetermined guidelines.
Number and type of discharge medication non-reconciliations, and acceptance of interventions made by the clinical pharmacist in their resolution. Number of discharge medication non-reconciliations requiring specific input of the hospital doctor.
In total, the discharge prescriptions of 224 patients, involving 2,245 medications were included in the study. Prescription non-reconciliation was identified for 62.5 % (n = 140) of prescriptions and 15.8 % (n = 355) of medications, while communication non-reconciliation was identified for 92 % (n = 206) of prescriptions and 45.8 % (n = 1,029) of medications. Omission of preadmission medications (76.6 %, n = 272) and new medication non-reconciliations (58.5 %, n = 602) were the most common type. Prescription non-reconciliations were fully resolved on 55.7 % (n = 78) of prescriptions prior to discharge; 67.9 % (n = 53) by the doctor, 26.9 % (n = 21) by the clinical pharmacist, and 5.2 % (n = 4) by the joint input of doctor and pharmacist. All communication non-reconciliations were resolved prior to discharge; 97.1 % (n = 200) by the pharmacist, and 2.9 % (n = 6) by both doctor and pharmacist.
This study demonstrates how interdisciplinary collaboration, between the clinical pharmacist and hospital doctor, can improve the completeness and accuracy of discharge prescriptions through the provision of a pharmacist led discharge medication reconciliation service at an Irish teaching hospital.
用药核对是优质药品管理的一项基本原则。随着爱尔兰国家急性药品计划的建立，要求在所有护理转接环节对所有患者进行用药核对。临床药师被广泛认为是在提供用药核对服务方面发挥最关键作用的医疗保健专业人员。
确定临床药师与医院医生以协作方式工作，通过提供由药师主导的出院用药核对服务来提高出院处方的完整性和准确性的可行性。
爱尔兰都柏林三一学院的一家拥有243张床位的急性教学医院。
采用非概率连续抽样对出院处方进行横断面观察研究。出院用药核对由临床药师提供。未核对的情况以口头方式告知医生，并酌情记录在患者病历中。药师和/或医生根据预定指南解决差异。
出院用药未核对的数量和类型，以及临床药师在解决过程中所采取干预措施的接受情况。需要医院医生特别关注的出院用药未核对数量。
本研究共纳入224例患者的出院处方，涉及2245种药物。62.5%（n = 140）的处方和15.8%（n = 355）的药物存在处方未核对情况，而92%（n = 206）的处方和45.8%（n = 1029）的药物存在沟通未核对情况。入院前用药遗漏（76.6%，n = 272）和新用药未核对（58.5%，n = 602）是最常见的类型。55.7%（n = 78）的处方在出院前完全解决了处方未核对问题；其中67.9%（n = 53）由医生解决，26.9%（n = 21）由临床药师解决，5.2%（n = 4）由医生和药师共同解决。所有沟通未核对问题在出院前均得到解决；97.1%（n = 200）由药师解决，2.9%（n = 6）由医生和药师共同解决。
本研究表明，在爱尔兰一家教学医院，临床药师与医院医生之间的跨学科合作如何通过提供由药师主导的出院用药核对服务来提高出院处方的完整性和准确性。
