Choi Sebastian, Babiak Jaime
Consult Pharm. 2018 Apr 1;33(4):222-226. doi: 10.4140/TCP.n.2018.222.
To evaluate a recently implemented procedure of discharge medication reconciliation and patient counseling completed by pharmacists at a nursing facility.
This is a 138-bed nursing facility that houses long-term care residents as well as patients for subacute rehabilitation.
Discharge process involves the medical team (geriatrician, medical resident, medical students), social workers, and nurse coordinators.
Pharmacists are incorporated in the discharge process by completing medication reconciliation, patient counseling, and telephone follow-up, to improve patient understanding and satisfaction.
Medication discrepancies identified by pharmacists via medication reconciliation, number of patients who were counseled by pharmacist, and number of patients encountered for telephone follow-up.
Fifty-four patients were discharged during the study period. A total of 200 discrepancies were identified after discharge medication reconciliation by the pharmacist. On average, we found that there were 4 discrepancies per patient (range 0 to 16). Most of the discrepancies that were found were medication additions and omissions. Forty-five patients (83.3%) agreed to counseling and were then counseled by a pharmacist. Patients were often not counseled because of last-minute discharge, and no encounter was made.
Involving pharmacists in patient transitions of care may be beneficial as previous studies have demonstrated; however, additional studies in a nursing facility setting are needed to validate these benefits.
评估一家护理机构近期实施的由药剂师完成的出院用药核对及患者咨询程序。
这是一家拥有138张床位的护理机构，收治长期护理居民以及亚急性康复患者。
出院流程涉及医疗团队（老年病科医生、住院医师、医学生）、社会工作者和护士协调员。
药剂师通过完成用药核对、患者咨询和电话随访参与出院流程，以提高患者的理解度和满意度。
药剂师通过用药核对发现的用药差异、接受药剂师咨询的患者数量以及接受电话随访的患者数量。
研究期间有54名患者出院。药剂师在出院用药核对后共发现200处差异。平均而言，我们发现每位患者有4处差异（范围为0至16处）。发现的差异大多是用药增加和遗漏。45名患者（83.3%）同意接受咨询，随后由药剂师进行了咨询。患者常常因最后一刻出院而未接受咨询，且未进行随访。
正如先前研究所示，让药剂师参与患者护理转接可能有益；然而，需要在护理机构环境中进行更多研究来验证这些益处。
