Son Heeyoun, Kim Jeongmee, Kim Caroline, Ju Jonathan, Lee Youngmee, Rhie Sandy Jeong
Graduate School of Clinical Health Sciences, Ewha Womans University, Seoul, Republic of Korea.
Department of Pharmacy, Samsung Medical Center, Seoul, Republic of Korea.
Eur J Hosp Pharm. 2018 Jan;25(1):21-25. doi: 10.1136/ejhpharm-2016-000937. Epub 2016 Dec 20.
Medication reconciliation is a key part of transitional care. This study examined the implementation of a pharmacist-led medication reconciliation programme for short-term hospitalised patients and explored the barriers and benefits.
A prospective study was conducted in patients admitted to a gynaecological oncology department. Medications were reconciled on admission using a 'comprehensive medication review (CMR)' strategy. Patients received a reminder text message and were asked to bring their medications a day before admission for scheduled chemotherapy. Upon admission, a pharmacist reviewed patients' admission prescriptions and home medications, including non-prescription medications, based on clinical status and laboratory test results. Drug-related problems and unused or expired medications were assessed. Satisfaction with the CMR service and reasons for non-compliance were surveyed by an individual interview. The cost of the unused or expired medications was calculated based on the average drug acquisition cost.
Sixty-four interventions in 95 patients were performed during the study-namely, correction of treatment duration (34 cases, 53.1%), recommendation of medications for untreated indications (18 cases, 28.1%), correct drug selection (5 cases, 7.8%), discontinuation of duplicate medications (4 cases, 6.3%), correction of dose, provision of alternatives for drug-drug interactions, unintended omissions (1 case each, 1.6%). The difference in the cost of unused or expired drugs before and after programme implementation was about US$1700.
Pharmacist-led medication reconciliation targeting short-term hospitalised patients improved drug use, prevented medication waste and reduced healthcare costs.
用药核对是过渡性护理的关键部分。本研究考察了针对短期住院患者实施的由药剂师主导的用药核对计划，并探讨了其中的障碍和益处。
对妇科肿瘤科室收治的患者进行了一项前瞻性研究。入院时采用“全面用药评估（CMR）”策略进行用药核对。患者会收到一条提醒短信，并被要求在预定化疗入院前一天带上自己的药物。入院时，药剂师根据临床状况和实验室检查结果审查患者的入院处方和家庭用药，包括非处方药。评估药物相关问题以及未使用或过期的药物。通过个人访谈调查对CMR服务的满意度和不依从的原因。根据药品平均采购成本计算未使用或过期药物的费用。
在研究期间，对95例患者进行了64次干预，即治疗时长校正（34例，53.1%）、针对未治疗适应症推荐用药（18例，28.1%）、正确选择药物（5例，7.8%）、停用重复用药（4例，6.3%）、剂量校正、提供药物相互作用替代方案、意外遗漏（各1例，1.6%）。计划实施前后未使用或过期药物费用的差异约为1700美元。
针对短期住院患者由药剂师主导的用药核对改善了药物使用情况，防止了药物浪费并降低了医疗成本。
