Conciliação medicamentosa na admissão de pacientes transplantados renais em um hospital universitário / Medication reconciliation in the admission of kidney transplant patients to a university hospital

Introdução:O presente estudo considerou conciliações medicamentosas realizadas na admissão hospitalar de pacientes transplantados renais e intervenções farmacêuticas decorrentes desse processo.Métodos:Trata-se de um estudo transversal realizado no período de julho de 2018 a julho de 2019 no Hospital de Clínicas de Porto Alegre. Foram coletadas as características dos pacientes, as conciliações medicamentosas realizadas pelo farmacêutico clínico, as discrepâncias identificadas pelo mesmo (intencionais e não intencionais) e o resultado das intervenções. Os medicamentos foram classificados de acordo com a Anatomic Therapeutic Chemical (ATC).Resultados:Dos 719 pacientes acompanhados pelo farmacêutico clínico, 175 tiveram a conciliação medicamentosa de admissão realizada, desses, 56 apresentaram discrepâncias não intencionais. Encontramos a média de 2,2 medicamentos omissos por prescrição com desvio padrão de 1,3 medicamentos. No total, foram realizadas 122 intervenções farmacêuticas, sendo que em 61,5% houve adesão por parte da equipe médica. A classe terapêutica com maior ocorrência (43,4%) de discrepâncias não intencionais foi a que atuava sobre o aparelho cardiovascular. As variáveis observadas foram sexo, número de medicamentos nas intervenções (ambas com associação significativa com a adesão médica), idade, tempo de internação, número de medicamentos na internação e número de medicamentos de uso prévio (estas últimas sem associação significativa com a adesão médica). Conclusões:A conciliação medicamentosa previne possíveis erros de medicação, uma vez que a identificação das discrepâncias não intencionais na prescrição médica gera sinalizações que são levadas pelo farmacêutico clínico à equipe assistente, a fim garantir o uso seguro e correto dos medicamentos durante a internação hospitalar.

Introduction:This study considered medication reconciliations performed on hospital admission of kidney transplant patients and pharmaceutical interventions resulting from this process.Methods:This is a cross-sectional study carried out from July 2018 to July 2019 at Hospital de Clínicas de Porto Alegre. The characteristics of the patients, the medication reconciliations performed by the clinical pharmacist, the discrepancies identified by the same (intentional and unintentional) and the result of the interventions were collected. The drugs were classified according to the Anatomic Therapeutic Chemical (ATC). Results:Of the 719 patients monitored by the clinical pharmacist, 175 had medication reconciliation on admission performed, of which 56 had unintentional discrepancies. We found an average of 2.2 missing medications per prescription with a standard deviation of 1.3 medications. In total, 122 pharmaceutical interventions were performed, and in 61.5% there was adherence by the medical team. The therapeutic class with the highest occurrence (43.4%) of unintentional discrepancies was that which acted on the cardiovascular system. The variables observed were gender, number of medications in interventions (both with a significant association with medical adherence), age, length of stay, number of medications in hospitalization and number of medications previously used (the latter without a significant association with medical adherence).Conclusions:Medication reconciliation prevents possible medication errors, since the identification of unintentional discrepancies in the medical prescription generates signals that are taken by the clinical pharmacist to the assistant team, in order to guarantee the safe and correct use of medications during hospitalization.

Medication reconciliation in pediatrics: a validation of instruments to prevent medication errors / Conciliación medicamentosa en pediatría: validación de instrumentos para la prevención de errores en la medicación / Reconciliação medicamentosa em pediatria: validação de instrumentos para a prevenção de erros na medicação

ABSTRACT Objectives: to develop and validate the content of two instruments for promoting medication reconciliation for the transition of care of hospitalized children. Methods: methodological study, conducted in five stages: scope review for conceptual structure; elaboration of the initial version; content validation with five specialists using the Delphi technique; reassessment; and construction of the final version of the instruments. A content validity index of at least 0.80 was adopted. Results: three rounds of evaluation were carried out to reach the validity index of the proposed contents, whereas a new analysis of 50% of the 20 items of the instrument aimed at families, and 28.5% of the 21 items aimed at professionals was necessary. The instrument aimed at families reached an index of 0.93, and the instrument for professionals, 0.90. Conclusions: the proposed instruments were validated. It is now possible to proceed with practical implementation studies to identify their influence on safety during medication reconciliation at transition of care.

RESUMEN Objetivos: elaborar y validar contenido de dos instrumentos para la promoción de conciliación medicamentosa en la transición de atención de niños hospitalizados. Métodos: estudio metodológico realizado en cinco etapas: revisión de ámbito para estructura conceptual; elaboración de versión inicial; validación del contenido con cinco especialistas utilizando la Técnica Delphi; re-evaluación; y construcción de versión final de los instrumentos. Adoptado índice de validez de contenido, como mínimo, 0.80. Resultados: fueron realizadas tres rondas de evaluación para alcance de índice de validez en los contenidos propuestos, siendo necesario nuevo análisis de 50% de los 20 ítems del instrumento destinado a familias, y 28,5% de los 21 ítems destinados a profesionales. Instrumento dirigido a familias alcanzó índice de 0,93; y el instrumento, a profesionales, 0,90. Conclusiones: instrumentos propuestos fueron validados, siendo posible proseguir con estudio de implementación práctica para identificar influencia en la seguridad durante la conciliación medicamentosa en la transición de atención.

RESUMO Objetivos: elaborar e validar o conteúdo de dois instrumentos para a promoção da reconciliação medicamentosa na transição dos cuidados de crianças hospitalizadas. Métodos: estudo metodológico realizado em cinco etapas: revisão de escopo para estrutura conceitual; elaboração da versão inicial; validação do conteúdo com cinco especialistas utilizando a Técnica Delphi; reavaliação; e construção da versão final dos instrumentos. Adotou-se o índice de validade de conteúdo de, no mínimo, 0.80. Resultados: foram realizadas três rodadas de avaliação para alcance de índice de validade nos conteúdos propostos, sendo necessária nova análise de 50% dos 20 itens do instrumento destinado às famílias, e 28,5% dos 21 itens destinados aos profissionais. O instrumento direcionado às famílias atingiu índice de 0,93; e o instrumento, aos profissionais, 0,90. Conclusões: os instrumentos propostos foram validados, sendo possível prosseguir com estudo de implementação prática para identificar influência na segurança durante a reconciliação medicamentosa na transição dos cuidados.

Conciliação medicamentosa em hospital universitário: estratégia de segurança em pacientes neurocirúrgicos / Medication reconciliation in a university hospital: safety strategy in neurosurgical patients / Conciliación de medicamentos en un hospital universitario: estrategia de seguridad en pacientes neuroquirúrgicos

Esse trabalho teve como objetivo identificar as discrepâncias medicamentosas, por meio do serviço de conciliação de medicamentosa, em pacientes admitidos na clínica cirúrgica de uma unidade especializada no atendimento de doença relacionadas ao sistema neuromuscular na cidade de Manaus, Amazonas. Trata-se de um estudo descritivo e prospectivo, realizado no período de setembro a dezembro de 2020 em pacientes submetidos a conciliação medicamentosa. Na primeira etapa realizou-se a anamnese farmacêutica em formulário semiestruturado e foi elaborada a melhor história possível de medicamentos (MHPM). Os medicamentos prescritos na admissão foram comparados com a MHPM e as discrepâncias foram identificadas e classificadas quanto a intencionalidade e tipo. Ao total 54 pacientes foram incluídos no estudo, sendo que para 32 foi realizada a conciliação medicamentosa por usarem medicamentos de uso contínuo. Foram identificadas 20 discrepâncias intencionais, 3 discrepâncias intencionais não documentadas e 12 discrepâncias não intencionais. Omissão de medicamentos foi o tipo de discrepância mais comum (86%). Diante do exposto, concluímos que a conciliação medicamentosa mostrou-se um importante recurso para identificação de discrepâncias na transição de cuidado de pacientes com doenças neurológicas, principalmente no que se refere à omissão de medicamentos. As intervenções farmacêuticas a partir das discrepâncias encontradas, conseguiram mitigar erros de medicação e possíveis eventos adversos, aumentando a segurança do paciente.

This work aimed to identify medication discrepancies, through the medi- cation reconciliation service, in patients admitted to the surgical clinic of a unit special- ized in treating diseases related to the neuromuscular system in the city of Manaus, Ama- zonas. This is a descriptive and prospective study, carried out from September to Decem- ber 2020 in patients undergoing medication reconciliation. In the first stage, the pharma- ceutical anamnesis was carried out in a semi-structured form and the best possible medi- cation history (MHPM) was prepared. Medications prescribed on admission were com- pared with the MHPM and discrepancies were identified and classified according to in- tentionality and type. 54 patients were included in the study, and for 32 medication rec- onciliation was performed because they used continuous medication. A total of 20 inten- tional discrepancies, 3 intentional undocumented discrepancies and 12 unintentional dis- crepancies were identified. Medication omission was the most common type of discrep- ancy (86%). We conclude that medication reconciliation proved to be an important re- source for identifying discrepancies in the transition of care for patients with neurological diseases, especially with regard to medication omission. Pharmaceutical interventions, based on the discrepancies found, managed to mitigate medication errors and possible adverse events, increasing patient safety.

Este estudio tuvo como objetivo identificar las discrepancias de medicación a través del servicio de reconciliación de medicamentos, en pacientes internados en la clínica quirúrgica de una unidad especializada en el tratamiento de enfermedades relacio- nadas con el sistema neuromuscular en la ciudad de Manaus, Amazonas. Este es un estu- dio descriptivo y prospectivo, realizado de septiembre a diciembre de 2020 en pacientes en conciliación de medicación. En la primera etapa se realizó la anamnesis farmacéutica de forma semiestructurada y se elaboró el mejor historial de medicación posible (MHPM). Los medicamentos prescritos al ingreso se compararon con el MHPM y se identificaron las discrepancias y se clasificaron según la intencionalidad y el tipo. Un total de 54 pacientes fueron incluidos en el estudio, y a 32 se les realizó conciliación de medi- cación por utilizar medicación continua. Se identificaron un total de 20 discrepancias in- tencionales, 3 discrepancias intencionales no documentadas y 12 discrepancias no inten- cionales. La omisión de medicamentos fue el tipo más común de discrepancia (86%). Concluimos que la conciliación de medicamentos demostró ser un recurso importante para identificar discrepancias en la transición de la atención a pacientes con enfermedades neurológicas, especialmente en lo que respecta a la omisión de medicamentos. Las inter- venciones farmacéuticas, en base a las discrepancias encontradas, lograron mitigar errores de medicación y posibles eventos adversos, aumentando la seguridad del paciente PALABRAS CLAVE: Conciliación de Medicamentos; Seguridad del Paciente; Servicio de Farmacia Hospitalaria; Neurología.

Practice of clinical pharmacist developing in medication reconciliation for the inpatients in cardiovascular medi- cine department / 中国药房

OBJECTIVE To analyze the medication reconciliation for the inpatients in cardiovascular medicine department ，to provide reference for the establishment of working mode of clinical pharmacists in the department of cardiovascular medicine and to provide a basis for clinical pharmacists and community pharmacists developing pharmaceutical care for patients after transfering to community health center. METHODS From October 2020 to September 2021，newly admitted or newly transferred inpatients with chronic disease were selected from Shiyan People ’s Hospital of Shenzhen Bao ’an District. Medication reconciliation was conducted by clinical pharmacists after pharmaceutical consultation. According to the Pharmaceutical Care Network Europe （PCNE） classification system V 9.1，the existing drug-related problems （DRPs）were classified and summarized. The effectiveness and safety evaluation，medication education and other measures were provided ，and the acceptance of intervention was analyzed at the same time. RESULTS A total of 100 patients were included ，including 54 males and 46 females. The average age was （60.21±9.69） years，the average number of chronic diseases was （2.84±0.83），and the median number of drugs was 5.00. Among them ，110 treatment drug deviations were found in 74 patients，involving 10 categories and 61 drugs. Top three drugs in the list of accumulative drug deviation were cardiovascular system drugs （35 deviations），digestive medicine drugs （16 deviations）and endocrine system drugs （15 deviations）. The above treatment drug deviation may cause 122 DRPs， mainly “treatment effectiveness”problems（74 DRPs），and the causes were “inappropriate medication time ormedication interval ”（32 DRPs）， followed by “inappropriate drug combination ”（10 DRPs）. Interventions to DRPs mainly concentrated on patient level ，drug level （58）and doctor level （58），155 of which （84.70％）were fully accepted and implemented. CONCLUSIONS Some patients have a weak awareness of medications according to doctor ’s advice；drug reconciliation led by clinical pharma- cists at admission can fully understand the potential drug problems of patients ，and help doctors improve the drug compliance of patients and ensure their medication safety .

Patients' medication reconciliation in a university hospital

Abstract Medication reconciliation is a strategy to minimize medication errors at the transition points of care. This study aimed to demonstrate the effectiveness of medication reconciliation in identifying and resolving drug discrepancies in the admission of adult patients to a university hospital. The study was carried out in a 300-bed large general public hospital, in which a reconciled list was created between drugs prescribed at admission and those used at pre-admission, adapting prescriptions from the pharmacotherapeutic guidelines of the hospital studied and the patients' clinical conditions. One hundred seven patients were included, of which 67,3% were women, with a mean age of 56 years. Two hundred twenty-nine discrepancies were found in 92 patients; of these, 21.4% were unintentional in 31.8% of patients. The pharmacist performed 49 interventions, and 47 were accepted. Medication omission was the highest occurrence (63.2%), followed by a different dose (24.5%). Thirteen (26.5%) of the 49 unintentional discrepancies included high-alert medications according to ISMP Brazil classification. Medication reconciliation emerges as an important opportunity for the review of pharmacotherapy at transition points of care, based on the high number of unintentional discrepancies identified and resolved. During the drug reconciliation process, the interventions prevented the drugs from being misused or omitted during the patient's hospitalization and possibly after discharge.

Medication errors in critical patients during medication reconciliation: analyses and clinical management

Abstract Medication errors (ME) are frequent in the admission of patients to the ICU and can be identified and prevented through medication reconciliation (MR). Our aim was to evaluate the incidence, type and severity of MEs and associated factors, identified during MR in the ICU. This is a prospective, analytical approach, performed in the ICU of a private hospital, where the MRs were evaluated from April to June 2016. The SPSS and Stata programs were used to analyse the data. Logistic regression was performed to determine the factors associated with MEs. MR was performed with 136 patients, of whom 126 (92.6%) used drugs regularly. The incidence of MEs was 16.3% (95% CI 11.5-21.2). The main classes of drugs involved were those acting on the nervous and cardiovascular systems. There were 128 pharmaceutical interventions (acceptance: 71.1%). Regarding severity, 65.5% (n=80) of the errors reached the patient, but there was no harm. The risk factors for MEs identified were: age ≥60 years, number of comorbidities >1 and previous use of drugs ≥9. The incidence of MEs found and the significant association with age, comorbidities and polymedication alert to the need for specific attention to prevent admission errors in the most susceptible patient groups.

Medication discrepancies in a hospital in Southern Brazil: the importance of medication reconciliation for patient safety

Medication discrepancies are of great concern in hospitals because they pose risks to patients and increase health care costs. The aim of this study was to estimate the prevalence of inconsistent medication prescriptions to adult patients admitted to a hospital in southern Santa Catarina, Brazil. This was a patient safety study on patients recruited between November 2015 and June 2016. The participants were interviewed and had their medical records reviewed. Discrepant medications were considered those that did not match between the list of medicines taken at home and the prescribed drugs for treatment in a hospital setting. Of the 394 patients included, 98.5% took continuous-use medications at home, with an average of 5.5 medications per patient. Discrepancies totaled 80.2%, The independent variables associated with the discrepancies were systemic arterial hypertension, hypercholesterolemia, vascular disease, number of medications taken at home, and poor documentation of the medications in the medical record. Findings from this study allowed us to conclude there was a high rate of prescription medication misuse. Medication reconciliation is crucial in reducing these errors. Pharmacists can help reduce these medication-related errors and the associated risks and complications.

Clinical Pharmacist-Led Program On Medication Reconciliation And Patient Counseling In The Department Of Gastroenterology

Objective: To study the effects of medication reconciliation and patient counseling on the overall health benefits of the patients in the department of gastroenterology. Methods: This study is a prospective interventional study, was conducted in a 500 bedded MNR Hospital. The sample size taken was 150 patients and the study population comprised of patients aged 18-80 y, admitted in the hospital during the study period of six months. Results: Out of 150 patients, there were 98 (65.33%) male patients and 52 (34.67%) female patients. Patients between 18 and 30 y of age were 29(19.33%), between the age of 30 and 50 y were 71 (47.33%) and above 50 were 50(33.33%). Pancreatitis was most prevalent with 21% of total prevalence, followed by CLD and cholelithiasis with 17%, then IBD 16%, PUD and Gastritis 5%, GERD 4% and other diseases 15%. Conclusion: The basic role of the pharmacist, is to help in minimizing the errors and to perform medication reconciliation. In patient counseling, pharmacists provide information about the disease, and the medications to increase patient safety and the changes in the behavior for the better outcome.

Development of Medication Reconciliation Model for Chronic Kidney Disease in Our Hospital / 中国药学杂志

OBJECTIVE: To develop the model of medication reconciliation (MR) service provided by clinical pharmacist for chronic kidney disease (CKD). METHODS: The definition, working process, development of MR were analyzed and the medication problems we reviewed were classified and intervened according to the newest Pharmaceutical Care Network Europe (PCNE) V9.0 classification scheme which was constructed for drug related problems (DRPs) to analysis and summary. We stated and summarized procedure of MR by several cases based on the realities of our hospital. RESULTS: A new closed loop model of outpatient clinic to hospital, then to home was developed, a working process was made according to three settings consist of outpatient clinic, hospital and home. CONCLUSION: The procedure of MR of several cases was summarized based on the realities on our hospital.

Reconciliação de medicamentos: processo de implantação em um complexo hospitalar com a utilização de sistema eletrônico / Medication reconciliation: implantation process in a hospital complex with the use of electronic system

RESUMO Este estudo avaliou a implantação da reconciliação de medicamentos em um hospital multibloco, filantrópico e de ensino com a utilização de um sistema eletrônico para realizar o registro da atividade com atuação multiprofissional. Foram capacitados 438 profissionais da enfermagem sobre a reconciliação de medicamentos. De outubro de 2017 a março de 2018, foram registradas pelo enfermeiro, no prontuário eletrônico, a informação sobre uso prévio de medicamentos para 1.379 pacientes. Foram reconciliados pelo farmacêutico apenas 347 destes registros, sendo que 106 precisaram de intervenção com médico prescritor. O número de pacientes que tiveram o medicamento informado como de uso prévio prescrito sem nenhuma alteração foi de 180, os que tiveram o medicamento prescrito com alguma alteração foram 47, e os que não possuíam os medicamentos informados prescritos foram 106. A utilização de sistemas informatizados pode ser útil para as equipes executarem a reconciliação medicamentosa, mas depende da correta utilização do sistema e treinamento das equipes. O acompanhamento diário do farmacêutico clínico aumenta a segurança do paciente quanto ao uso de medicamentos dentro dos hospitais, entretanto, para executar a atividade, é necessário realizar algumas medidas de melhoria para obter o cumprimento da reconciliação de medicamentos dos pacientes na sua totalidade.

ABSTRACT This study evaluated the implementation of medication reconciliation in a philanthropic, teaching, and multi-block hospital with the use of an electronic system to record the multidisciplinary activity. A total of 438 nursing professionals were trained on medication reconciliation. From October 2017 to March 2018, the information about previous use of drugs for 1,379 patients was registered by the nurse in the electronic system. Only 347 of those records were reconciled by the pharmacist, and 106 needed intervention of the prescribing doctor. The number of patients who had the medication prescribed without any change was 180, 47 had the medication prescribed with some change, and 106 did not have the prescribed the medications of previous use. The use of computerized systems can be useful for the teams to perform medication reconciliation, but it depends on the correct use of the system and training of the teams. The daily follow-up of the clinical pharmacist increases patient safety regarding the use of drugs within the hospitals, but to perform the activity some improvement measures are necessary to obtain compliance with the patients' medication reconciliation in their entirety.

Evaluation and Medication Reconciliation of Preoperative Medication in 210 Selective Surgery Elderly Patients / 中国药房

OBJECTIVE： To investigate and evaluate perioperative medication in elective surgery elderly patients， and to provide reference for perioperative medication management of clinical pharmacists for elderly patients. METHODS： Totally 210 elective surgery elderly patients were selected from Beijing Tsinghua Chang Gung Hospital during Oct. 2015 to Oct. 2016. Pharmacists carried out drug reconstitution， obtained information about their diseases and medication， analyzed and evaluated perioperative medication （indication， usage and dosage， interaction， drug selection， if these drugs should be stopped before surgery） according to Optimal Guidelines for Preoperative Evaluation of Elderly Patients so as to put forward related medication suggestions. RESULTS： Among 210 patients， there were 132 males （62.86％） and 78 females （37.14％） with an average age of （69.96±7.67） years； 43.81％ of patients had more than 3 kinds of diseases， and 13.33％ of patients suffered from more than 5 kinds of diseases； 31.43％ of patients took more than 5 kinds of drug for long term before surgery； 38.10％ patients had more than 2 drug-induced risks； The preoperative medication of 110 patients （52.38％） included drugs that should be avoided before surgery （such as antiplatelet aggregation agents）， 23 patients （10.95％） had potentially inappropriate medication （such as proton pump inhibitors）， 12 patients （5.71％） should use drugs （such as aspirin） cautiously， 35 patients （16.67％） should use drugs （β receptor blocker） continuously during perioperative period. The pharmacists provided 177 times of medication suggestions such as stopping some medications for patients and physicians through medication reconciliation and preoperative medication evaluation （71 times for patients， 106 times for physicians）； the final adoption rates were 100％ and 95.28％， respectively. CONCLUSIONS： The elderly patients have many preoperative complications， various risk factors， multiple medications， so it is vital for their preoperative medication management. The medication reconciliation is an effective way to evaluate preoperative medication in elderly patients， preoperative medication evaluation and analysis in elderly patients is of great significance to ensure the safety of clinical medication.

Analysis and Practice of Reliability and Validity Evaluation of Medication Compliance in Patients with Chronic Cardiovascular Disease by Chinese Version of MMAS- 8 / 中国药房

OBJECTIVE： To analyze the reliability and validity of Chinese version of MMAS-8 in evaluating the medication compliance of patients with chronic cardiovascular diseases， and to evaluate the effects of medication reconciliation on medication compliance. METHODS： Totally 97 patients with chronic cardiovascular diseases were selected as observation group. The reliability and validity of the questionnaire were analyzed and medication reconciliation was carried out. Totally 91 patients with chronic cardiovascular diseases were selected as control group， and given routine medical services. 8-item Morisk Medication Compliance Scale used to evaluate the drug compliance of the two groups at different time points. RESULTS： The F-test and t-test of the average score of 8 items in 27％ of questionnaire score ranking head and tail of the two extreme groups had statistical significance （P＜0.001）. Correlation coefficient between the 8 items and the total scores was higher than 0.400， and the 8 items were significantly correlated with total scores （P＜0.001）. Internal consistency reliability coefficient was 0.763； the structure validity KMO value was 0.742； the Bartlett’s spherical test value was 266.007； factor analysis method was adopted to extract 2 common factors， and explained total variance was 58.907％. Compared with control group， medication compliance of observation group was improved significantly at the first week after discharge and one month after discharge （P＜0.05）. CONCLUSIONS： The Chinese version of MMAS-8 has good reliability and validity in evaluating drug compliance of patients with chronic cardiovascular disease； medication reconstitution service can improve medication compliance of patients.

Effects of Medication Reconciliation and Cost Avoidance Analysis by Clinical Pharmacists in a Neurocritical Care Unit

BACKGROUND: The role of clinical pharmacists in medication therapy to improve clinical and economic outcomes has been reported in the literature. This study was conducted to analyze the changes in details of medication interventions before and after the introduction of clinical pharmacists into the care of neurocritical care unit (NCU) patients, and to evaluate the economic effects of clinical pharmacists by calculating the avoidance cost. METHODS: A retrospective study was conducted reviewing the electronic medical records from June 2013 to May 2014 (before), and from June 2016 to May 2017 (after). We calculated the number and rates of intervention, the acceptance rates of it, and also reviewed the list of interventions. We calculated avoidance cost if there was no intervention. RESULTS: The monthly mean number of interventions increased from 8.0 (±5.7) to 31.7 (±12.8) (P < 0.001) and the frequency of intervention also increased from 0.8% to 1.6% (P=0.003). The most frequently provided pharmacist intervention was nutritional support before introduction of clinical pharmacists and discussions on the medication plan after. The number of classified interventions was 14 before introduction of clinical pharmacist services and 33 after. The calculated cost avoidance associated with a clinical pharmacists' integration was 77,990,615 won per year. CONCLUSION: Introduction of clinicals pharmacist into the NCU was associated with increased intervention rates and expanded types of clinical interventions. The cost avoidance achieved by the pharmacists' interventions can be further explored to evaluate if similar expansions of pharmacists' services achieve similar results in other settings.

Primary Medication Reconciliation Service Provided by Clinical Pharmacist for Chronic Kidney Disease in Our Hospital / 中国药学杂志

OBJECTIVE: To evaluate the efficacy of medication reconciliation (MR) service provided by clinical pharmacist for chronic kidney disease(CKD).METHODS: Patients with CKD administered in department of nephrology between Dec, 2017 and Mar. Total of 2018 who met the inclusion criteria were given MR service, and the newest Pharmaceutical Care Network Europe (PCNE) V8.02 classification scheme was constructed for drug related problems (DRP) to analysis and summary.RESULTS: MR was conducted 48 times (accounted for 80%) on 60 patients during the study period. Total of 59 medication DRP were identified. The most common DRP was treatment effectiveness (accounted for 84.75%), there were 54 causes (accounted for 76.06%) were prescribing in 71 causes, all the causes were classified as likely to cause level 1 harm (accounted for 84.75%), clinical pharmacists made 145 interventions, 102 (70.34%) of these were completely accepted and implement.CONCLUSION: DRPs are common in CKD patients, clinical pharmacists should provide MR for CKD patients, and conducted as routine work.

Polypharmacy management and pharmaceutical care of clinical pharmacists participating in the team of comprehensive geriatric assessment / 中国药学杂志

OBJECTIVE: To clarify the importance of clinical pharmacists participating in the management of polypharmacy in comprehensive geriatric assessment. METHODS: The role of clinical pharmacists in the comprehensive geriatric assessment team was revealed through assessment of polypharmacy in one case of elderly outpatient's prescription. RESULTS: Clinical pharmacists successfully involved in the development of polypharmacy programs in the comprehensive geriatric assessment team. CONCLUSION: Comprehensive geriatric assessment can optimize the clinical treatment of elderly patients. Clinical pharmacist is an important member of the management of polypharmacy in the comprehensive geriatric assessment team. Hope that more clinical pharmacists to participate in this work, to provide quality pharmaceutical care for elderly patients.

Discrepâncias entre os registros de prontuários acerca da farmacoterapia de pacientes pediátricos com fibrose cística / Pharmacotherapy discrepancies in medical records of pediatric patients with cystic fibrosis

Introdução: Discrepâncias nos registros eletrônicos de medicamentos são frequentes e podem levar a erros relacionados a medicamentos. O objetivo deste estudo foi analisar as discrepâncias entre os registros médicos e farmacêuticos da terapia medicamentosa de pacientes com fibrose cística de um ambulatório multidisciplinar de pneumologia infantil do Sul do Brasil Métodos: Estudo transversal com coleta de dados retrospectiva através de prontuário eletrônico de pacientes que foram atendidos no ambulatório de um centro de referência para Fibrose Cística entre maio e junho de 2016. Os registros médicos e farmacêuticos foram comparados e as discrepâncias quantificadas e classificadas. Resultados: Foram analisados 81 registros de consultas ambulatoriais de 76 pacientes. Oitenta medicamentos constavam nos registros, sendo os mais frequentes polivitamínicos, enzimas pancreáticas, dornase alfa, ácido ursodesoxicólico e solução salina hipertônica. Foram identificadas discrepâncias em 96% dos registros, totalizando 245 discrepâncias, entre elas omissões de medicamentos no registro farmacêutico (102) e no médico (80), além de doses (41) e regimes terapêuticos (23) diferentes. Foram observadas omissões de dose no registro farmacêutico (63) e no médico (52) e omissões de regime (11) em ambos. Conclusão: A elevada taxa de discrepâncias corrobora com os resultados de diversos estudos. A conciliação tem o objetivo de promover o uso racional e diminuir os erros relacionados a medicamentos, podendo ser realizada de maneira sistematizada. A avaliação da qualidade do uso de medicamentos pode ser feita através da utilização de indicadores, sendo as discrepâncias um indicador sensível para este objetivo (AU)

Introduction: Discrepancies in electronic records of medication are frequent and may lead to drug-related errors. This study aims to analyze discrepancies between medical and pharmaceutical records of pharmacotherapy in patients with cystic fibrosis in a multidisciplinary pediatric pulmonology outpatient hospital in southern Brazil. Methods: Transversal study with retrospective data collection through electronic medical records of patients assisted in the outpatient room of a reference center for cystic fibrosis within May and June 2016. Both records, medical and pharmaceutical, were compared and unconformities were quantified and classified. Results: An amount of 81 records of 76 patients were analyzed. A total of 80 medications were observed in the records, most frequently multivitamins, pancreatic enzymes, dornase alpha, ursodesoxycholic acid and hypertonic saline solution. The discrepancies were present in 96% of records, totaling 245 discrepancies, among them omissions of medication in the pharmaceutical records (102) and in the medical records (80), doses (41) and different therapy regimes (23). We observed omissions in pharmaceutical records (63), in medical records (52) and in both (11). Conclusion: The high level of discrepancies endorses results of a variety of studies. Reconciliation has the objective of promoting rational use and diminishing errors related to medication, when performed systematically. The evaluation of quality use of medication might be performed through the use of indicators, considering the discrepancy a sensible indicator for this goal (AU)

The Analysis and Pharmacoutical Care of Antiplatelet Theropy for Patient with Acute Stroke / 中国药师

Objective:To provide reference for clinical monitoring and treatment of patients with gastric ulcer caused by antiplate-let therapy. Methods: Clinical pharmacists participated in the pharmaceutical care of antiplatelet therapy for a patient with acute stroke, and provided pharmaceutical recommendations in respects of antiplatelet therapy, antihypertensive therapy and nursing care by means of medication reconciliation and medication education. Results: The stomach bleeding in the patient was controlled, and the blood pressure was controlled within the target value. Conclusion: Clinical pharmacist can ensure the medication safety and improve the medication compliance through monitoring drug use, which can further improve clinical effectiveness.

Medication Reconciliation for Patients over 70 Years Old with Type 2 Diabetes in Endocrinology Depart-ment / 中国药师

Objective:To discuss the important role of clinical pharmacists in the prevention of medication errors and rational drug use through medication reconciliation in endocrinology department. Methods: The medication reconciliation was given to the diabetic patients over 70 years old newly admitted in the endocrinology department from January to April 2016, and the consistency and appro-priateness of medication orders were verified and the results were collected and analyzed by the pharmacists. Results: Totally 84 pa-tients were enrolled into the research with the average age of (76. 3 ± 5. 0) and the average number of combined diseases of (3. 5 ± 1. 2). The average medications taken by the patients before the admission were (6. 7 ± 2. 9), and 22. 6% of the patients took tradi-tional Chinese medicines and 4. 76% of the patients took health products. The patients whose medications for 24h needed intervention accounted for 27. 38%, the medications orders needed intervention accounted for 3. 67%, and the intervention success rate of clinical pharmacist was 100%. Conclusion:To the patients over 70 years old with type 2 diabetes and multiple diseases treated with a variety of medications, medication reconciliation in 24 hours can effectively prevent the medication errors and promote the rational drug use.

Practice of Medication Reconciliation among Chronic Renal Insufficiency Patients by Clinical Pharmacists / 中国药房

OBJCETIVE:To investigate the role of clinical pharmacists in medication reconciliation. METHODS:Totally 200 inpatients admitted or transferred to nephrology department of our hospital during Aug.-Oct. 2015 were selected. Within 48 h after admission,1-year medication history were collected by reviewing electronic medical records,consultation,querying self-prepared drugs and medical history;and then medication reconciliation was conducted by clinical pharmacists. RESULTS:Among drug lists collected by clinical pharmacists,there were 987 kinds of drugs,but only 9.63%(95 kinds) drugs were recorded in the medical records. There were 5 cases of ADR in total,and only 40.00% of them (2 cases) were recorded in the medical records. Among 200 patients,medication reconciliation was needed in 45 cases with reconciliation rate of 22.50%. Among 492 medical orders of 200 patients,medication errors were found in 103 medical orders;the number of medication errors per case was (2.3 ± 1.8), mainly including wrong dose,repeated medication,wrong solvent,drug interactions;the potential risk degree was mainly degree 1 (53 orders,51.46%). Among 103 medication reconciliation orders,main plans were drug withdrawal (78 cases,75.73%), followed by drug change(17 cases,16.50%)and drug supplement(8 cases,7.77%). A total of 90 reconciled medical orders were adopted by physicians,with success rate of 87.38%. CONCLUSIONS:Compared with physicians,clinical pharmacists can obtain more detailed and accurate drug list. It can reduce medication error and guarantee the safety of drug use to maximum extent that clinical pharmacists conduct medication reconciliation.

Pharmaceutical Care Practice for Admission Medication Reconciliation in the Internal Medicine Inpatient by Clinical Pharmacists / 中国药房

OBJECTIVE:To explore the importance and necessity of clinical pharmacists in drug therapy for chronic disease patients,the feasibility of developing medication reconciliation (MR),and to provide reference for establishing the internal medicine working model of clinical pharmacy.METHODS:During May to Jul.2016,inpatients were selected from respiratory department of our hospital as subjects.After detailed pharmaceutical consultation,clinical pharmacist conducted MR for newly inpatients at the first day in the hospital.RESULTS:Through clinical pharmacists classified and organized the problems of drug use in the inpatients during medication,MR records of 98 inpatients were collected,involving 296 medical orders and 96 items of medication errors.Among MR patients,there were only 44 cases of good compliance (44.9％);some problems about drug use existed in other cases,including optional medication,improper usage and dosage,fearing of drug side effects and refusing to use drugs,drug withdrawal due to ADR,follow-up failure of special disease leading to excessive or inadequate dose,poor communication with doctors leading to medication errors,forgetting to take medication or missing,excessive medical treatment and so on.Most common medication error-inducing drugs type was cardiovascular drug,followed by respiratory drug and endocrine system drug.CONCLUSIONS:The development of MR by clinical pharmacists is helpful to identify and correct medication error,avoid potential medication error,and control disease.It can be used as a project of pharmaceutical care in department of internal medicine.