在急诊科进行用药史采集及药物相关问题识别
Drug history taking and the identification of drug related problems in an accident and emergency department.
作者信息
Akwagyriam I, Goodyer L I, Harding L, Khakoo S, Millington H
机构信息
Department of Pharmacy, King's College London.
出版信息
J Accid Emerg Med. 1996 May;13(3):166-8. doi: 10.1136/emj.13.3.166.
OBJECTIVE
To determine the incidence of drug related problems that fail to be noted on casualty cards in patients subsequently admitted, and to compare medication histories as recorded by accident and emergency (A&E) senior house officers (SHOs) and a pharmacist.
METHODS
An initial retrospective survey of 1459 acute inpatient admissions through A&E over a three month period was followed by a prospective study of 33 elderly patients.
RESULTS
In the retrospective survey, 52 medication related problems were confirmed after examination of the medical records, of which only 16 were identified in A&E. In the prospective study, 125 currently prescribed items were identified by the pharmacist compared to 77 by A&E SHOs; 66% of the missed information was clinically relevant. Of 17 previous adverse drug reactions identified by the pharmacist only six were also recorded by the A&E officer. Only four over the counter medicines were identified by the A&E SHOs compared to 30 by the pharmacist.
CONCLUSIONS
More accurate recording of drug history on casualty cards should be undertaken, particularly in respect of over the counter medication and the identification of drug related problems.
目的
确定随后入院患者伤亡卡上未记录的药物相关问题的发生率，并比较急诊（A&E）高级住院医师（SHOs）和药剂师记录的用药史。
方法
对三个月内通过A&E的1459例急性住院患者进行初步回顾性调查，随后对33例老年患者进行前瞻性研究。
结果
在回顾性调查中，检查病历后确认了52个与用药相关的问题，其中在A&E中仅发现16个。在前瞻性研究中，药剂师识别出125种当前处方药物，而A&E SHOs识别出77种；66%遗漏的信息具有临床相关性。药剂师识别出的17例既往药物不良反应中，A&E医生仅记录了6例。A&E SHOs仅识别出4种非处方药，而药剂师识别出30种。
结论
应更准确地在伤亡卡上记录用药史，特别是在非处方药和药物相关问题的识别方面。
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