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首页> 外文期刊>The American journal of geriatric pharmacotherapy >Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.
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Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.

机译：评估老年患者医院用药调节过程的安全性增强。

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BACKGROUND: Medication history taking is important because clinicians rely on the information that is collected; however, medication histories are often inaccurate and incomplete. The use of a medication at home without a corresponding disease or condition in the patient's records (ie, "unspecified" medication) warrants investigation of the need for that medication. The process of reconciling medications with current diseases or conditions on hospital admission has not been officially advocated by The Joint Commission, but it could help clinicians better assess the continued need for home medications and possibly decrease the use of polypharmacy. OBJECTIVES: The objectives of this study were to expand on a previous study conducted at our institution by estimating the prevalence of discrepancies between medication histories and reported diseases or conditions in a larger and more diverse patient population, and to determine whether a pharmacist could clarify the reasons for the unspecified medications, thereby enhancing the medication reconciliation process. METHODS: Patients >or=50 years of age who were taking >or=4 home medications were randomly selected within 24 hours of hospital admission. Medical chart information and home medication lists, obtained shortly after admission, were reviewed retrospectively for the selected patients. Patients were excluded if they were admitted directly to an intensive care unit. Only home medications that the patient continued to take after admission were included in the analysis. Therapeutic hospital formulary substitutes (eg, atorvastatin given instead of pravastatin) were considered to be the same medication. Nonprescription medications, "as needed" medications, and vitamins/supplements taken at home were excluded from analysis. If an unspecified medication was found, a pharmacist proceeded through an algorithm designed to clarify the reason for the unspecified medication. In the event of a common off-label (unapproved) use of a drug, the drug was not considered unspecified. RESULTS: Home medication lists were available for 300 patients (154 women, 146 men; mean [SD] age, 69 [10.6] years; >98% white) admitted to a 541-bed university hospital between December 2007 and June 2008; a total of 114 patients (38%) had >or=1 unspecified medication. Of the 200 unspecified medications reported in patient charts, the 2 most frequently reported drug classes were proton pump inhibitors and selective serotonin reuptake inhibitors, used by 21% and 11% of patients, respectively. Patients with unspecified medications received a higher mean number of home medications (9.7 vs 7.6 per patient; odds ratio = 1.18; 95% CI, 1.11-1.28; P < 0.001). Rates of discordance were independent of age, sex, and pathway to admission to the emergency department. Ultimately, the study pharmacist was able to clarify 96% of the unspecified medications by applying the study algorithm. Answers were provided by patients (80%), old clinic or hospital chart notes (12%), or physicians (4%); 4% could not be clarified. CONCLUSIONS: Many of the unspecified medications that were identified in this study have been associated with polypharmacy in the literature. The results of this study suggest that matching home medications with indications for those medications on admission to the hospital enhanced the medication reconciliation process. Direct patient questioning by the pharmacist clarified medication use and contributed to more accurate and complete medication history taking.
机译：背景：服药史很重要，因为临床医生依赖所收集的信息。但是，用药史常常不准确也不完整。在家中使用患者病历中没有相应疾病或状况的药物（即“未指定”药物）可确保对该药物的需求进行调查。联合委员会尚未正式倡导使药物与当前疾病或住院条件相符的过程，但这可以帮助临床医生更好地评估对家用药物的持续需求，并可能减少多药店的使用。目的：本研究的目的是通过估计在更大和更多样化的患者群体中用药史与报告的疾病或状况之间的差异患病率，并确定药剂师是否可以阐明药物治疗史，从而扩大在我们机构进行的先前研究。未指定药物的原因，从而增强了药物对账过程。方法：入院24小时内随机选择≥50岁且服用≥4种家庭用药的患者。入院后不久获得的病历信息和家庭用药清单，针对所选患者进行了回顾性审查。如果患者被直接送往重症监护室，则将其排除在外。分析仅包括患者入院后继续服用的家庭用药。医院治疗处方替代品（例如，使用阿托伐他汀代替普伐他汀）被视为同一药物。分析中不包括非处方药，“按需”药物以及在家服用的维生素/补充剂。如果发现未指定的药物，则药剂师将执行旨在阐明未指定药物原因的算法。如果使用通用的标签外药品（未经批准），则认为该药品未指定。结果：2007年12月至2008年6月间，有541张床位的大学医院就诊的300例患者（154名女性，146名男性;平均[SD]年龄，69 [10.6]岁;> 98％的白人）可获得家庭用药清单。共有114位患者（38％）接受了≥1的未指定药物治疗。在患者图表中报告的200种未指定药物中，最常报告的2类药物是质子泵抑制剂和选择性5-羟色胺再摄取抑制剂，分别有21％和11％的患者使用。使用未指定药物的患者接受家庭用药的平均数更高（每位患者9.7 vs 7.6;优势比= 1.18; 95％CI，1.11-1.28; P <0.001）。不和谐的发生率与年龄，性别和进入急诊室的途径无关。最终，研究药剂师通过应用研究算法，能够澄清96％的未指定药物。患者（80％），旧诊所或医院病历笔记（12％）或医生（4％）提供了答案;无法澄清4％。结论：本研究中确定的许多未指定药物与文献中的多药业有关。这项研究的结果表明，将家庭用药与入院时那些用药的适应症相匹配，可以改善用药协调过程。药剂师对患者的直接询问明确了用药情况，有助于更准确，完整地记录用药史。

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