药学主导的用药核对对内科住院的影响：两家三级教学医院的经验。
Impact of pharmacy-led medication reconciliation on admission to internal medicine service: experience in two tertiary care teaching hospitals.
机构信息
Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O. Box S-23, Byblos, Lebanon.
Saint George Hospital - University Medical Center, Pharmacy Department, Beirut, Lebanon.
出版信息
BMC Health Serv Res. 2019 Jul 16;19(1):493. doi: 10.1186/s12913-019-4323-7.
BACKGROUND
The Institute for Healthcare Improvement identifies medication reconciliation as the shared responsibility of nurses, pharmacists, and physicians, where each has a defined role. The study aims to assess the clinical impact of pharmacy-led medication reconciliation performed on day one of hospital admission to the internal medicine service.
METHODS
This is a pilot prospective study conducted at two tertiary care teaching hospitals in Lebanon. Student pharmacists who were properly trained and closely supervised, collected the medication history, and pharmacists at the corresponding sites performed the reconciliation process. Interventions related to the unintended discrepancies were relayed to the medical team. The main outcome was the number of unintended discrepancies identified. The time needed for medication history, and the information sources used to complete the Best Possible Medication History were also assessed. The unintended discrepancies were classified by medication class and route of medication administration, by potential severity, and by proximal cause leading to the discrepancy. For the bivariate and multivariable analysis, the dependent variable was the incidence of unintended discrepancies. The "total number of unintended discrepancies" was dichotomized into yes (≥ 1 unintended discrepancy) or no (0 unintended discrepancies). Independent variables tested for their association with the dependent variable consisted of the following: gender, age, creatinine clearance, number of home medications, allergies, previous adverse drug reactions, and number of information sources used to obtain the BPMH. Results were assumed to be significant when p was < 0.05.
RESULTS
During the study period, 204 patients were included, and 195 unintended discrepancies were identified. The most common discrepancies consisted of medication omission (71.8%), and the most common agents involved were dietary supplements (27.7%). Around 36% of the unintended discrepancies were judged as clinically significant, and only 1% were judged as serious. The most common interventions included the addition of a medication (71.8%) and the adjustment of a dose (12.8%). The number of home medications was significantly associated with the occurrence of unintended discrepancies (ORa = 1.11 (1.03-1.19) p = 0.007).
CONCLUSIONS
Pharmacy-led medication reconciliation upon admission, along with student pharmacist involvement and physician communication can reduce unintended discrepancies and improve medication safety and patient outcomes.
背景
医疗改善协会将药物重整确定为护士、药剂师和医生的共同责任，每个角色都有明确的分工。本研究旨在评估在患者入院内科服务的第一天，由药剂师主导的药物重整对临床的影响。
方法
这是在黎巴嫩的两家三级教学医院进行的一项试点前瞻性研究。经过适当培训和密切监督的实习药剂师收集药物史，相应地点的药剂师进行药物重整。与非预期差异相关的干预措施转达给医疗团队。主要结果是确定非预期差异的数量。还评估了完成最佳药物治疗史所需的药物史时间和信息来源。根据药物类别和给药途径、潜在严重程度以及导致差异的近端原因对非预期差异进行分类。在双变量和多变量分析中，因变量为非预期差异的发生率。“非预期差异总数”被分为是（≥1 个非预期差异）或否（0 个非预期差异）。测试与因变量相关的自变量包括：性别、年龄、肌酐清除率、家庭用药数量、过敏、既往药物不良反应以及获取 BPMH 的信息来源数量。当 p 值 <0.05 时，结果被认为具有统计学意义。
结果
在研究期间，共纳入 204 名患者，共发现 195 例非预期差异。最常见的差异包括药物漏用（71.8%），最常见的药物为膳食补充剂（27.7%）。约 36%的非预期差异被认为具有临床意义，只有 1%被认为是严重的。最常见的干预措施包括添加药物（71.8%）和调整剂量（12.8%）。家庭用药数量与非预期差异的发生显著相关（ORa=1.11（1.03-1.19）p=0.007）。
结论
入院时由药剂师主导的药物重整，加上实习药剂师的参与和与医生的沟通，可以减少非预期差异，提高药物安全性和患者结局。
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