临床药师主导的慢病管理在出院老年精神病患者用药错误防范中的作用

The Role of Chronic Disease Management Led by Clinical Pharmacists in the Prevention of Medication Errors in Discharged Elderly Psychiatric Patients

摘要: 目的：探讨临床药师主导的慢病管理在出院老年精神病患者用药错误防范中的作用。方法：研究对象选自2019年3月至2020年9月在衢州市第三医院老年精神科住院、年龄60~85岁的精神病患者。在入院时对患者进行遴选，记录入组患者的基本信息，包括性别、年龄、支付方式、文化水平、职业、合并慢性病种及通讯信息。入组患者在住院期间由老年科临床药师对其进行同质化药学服务，出院时被随机分为干预组和对照组，出院后均接受为期24周的随访。干预组患者出院后第1~12周每2周随访1次，第13~24周每4周随访1次；对照组患者在出院后第12和24周末各随访1次。随访内容包括体重、血清泌乳素水平、血压、血糖、血脂、心肝肾功能、血药浓度等指标的检测结果，所应用药物的名称及用法用量，是否按时服药，有无药物不良反应，以及生活环境或监护人有无改变等。若发现患者出现用药错误，用专用表格记录用药错误的发现时间、内容、级别、次数及涉及药品的分类。临床药师在随访过程中对患者及其家属进行个体化用药指导，发现用药错误后及时进行干预、纠正。结果：干预组纳入患者54例，对照组54例，患者基本信息的差异均无统计学意义(均P ≥ 0.05)。24周随访期内，发现干预组有15例、对照组有10例患者出现用药错误，2组用药错误发现率差异有统计学意义[27.78% (15/54)比18.52% (10, 54, χ2 = 0.043, P = 0.032]。2组患者共发现用药错误44例，干预组30例次(68.18%)，对照组14例次(31.82%)；随访12周内，由药师发现的干预组和对照组的用药错误分别为28例次(93.33％)和12例次(85.71%)，差异有统计学意义(P = 0.002)。2组患者出现不同用药错误内容占比的差异无统计学意义(P > 0.05)，2组患者出现不同用药错误内容占比的差异无统计学意义(P > 0.05)，干预组以给药时间错误占比最高[干预组40.0% (12/30)，对照组以用药频次错误占比最高21.43% (3/14)]。在44例次用药错误中，43例次(97.73%)属于第2层级错误(有错误无伤害)，包括32例次C级错误和11例次D级错误；1例次(2.27%)属于第3层级错误(有错误有伤害)，为F级错误。经临床药师干预，第2层级错误均被纠正，第3层级错误导致患者再次入院治疗，经药师与主管医生再次向患者家属强调重复用药的危害性，遵医嘱用药的重要性后，患者未再出现用药错误。用药错误涉及的药品共8类(抗精神分裂症药、抗抑郁药、抗焦虑药、抗癫痫药(主要作心境稳定剂)、抗痴呆药、降糖药、抗心律失常药以及抗胆碱能药物)。结论：临床药师主导的精神病慢病管理有助于及时发现和纠正出院老年精神病患者的用药错误。

Abstract: Objective: To explore the role of chronic disease management led by clinical pharmacists in the prevention of medication errors in discharged elderly psychiatric patients. Methods: The subjects were psychiatric patients aged 60~85 years old who were hospitalized in the Department of Geriat-ric Psychiatry of Quzhou Third Hospital from March 2019 to September 2020. The patients were selected at the time of admission, and the basic information of the enrolled patients was recorded, including gender, age, payment method, educational level, occupation, combined chronic diseases and communication information. The patients in the group received homogenized pharmaceutical care by the clinical pharmacist of geriatrics during hospitalization. They were randomly divided in-to intervention group and control group at discharge. They were followed up for 24 weeks after discharge. The patients in the intervention group were followed up every 2 weeks from the 1st week to the 12th week after discharge, and every 4 weeks from the 13th week to the 24th week; the patients in the control group were followed up once at the 12th and 24th weekend after discharge. The follow-up contents include the test results of body weight, serum prolactin level, blood pressure, blood glucose, blood lipid, heart, liver and kidney function, blood drug concentration and other indicators, the name, usage and dosage of the drugs used, whether the drugs are taken on time, whether there are adverse drug reactions, and whether the living environment or guardians have changed. If the patient is found to have medication errors, use a special form to record the discovery time, content, level, times of medication errors and the classification of drugs involved. Clinical pharmacists provide individualized medication guidance to patients and their families during follow-up, and timely intervene and correct medication errors. Results: There were 54 patients in the intervention group and 54 patients in the control group. There was no significant difference in the basic information of patients (all P ≥ 0.05). During the follow-up period of 24 weeks, it was found that 15 patients in the intervention group and 10 patients in the control group had medication errors. The difference in medication error detection rate between the two groups was statistically significant [27.78% (15/54) vs. 18.52% (10/54), χ 2 = 0.043, P = 0.032]. 44 cases of medication errors were found in the two groups, 30 cases in the intervention group (68.18%) and 14 cases in the control group (31.82%); within 12 weeks of follow-up, the medication errors found by pharmacists in the intervention group and the control group were 28 cases (93.33%) and 12 cases (85.71%) respectively, with significant difference (P = 0.002). There was no significant difference in the proportion of different medication errors between the two groups (P > 0.05), and there was no significant difference in the proportion of different medication errors between the two groups (P > 0.05). The proportion of medication time errors in the intervention group was the highest [40.0% (12/30) in the intervention group, and 21.43% (3/14) in the control group]. Among 44 medication errors, 43 (97.73%) belonged to level 2 errors (with errors and no harm), including 32 Level C errors and 11 level D errors; one case (2.27%) belongs to level 3 error (with error and injury), which is level F error. After the intervention of the clinical pharmacist, the level 2 errors were corrected, and the level 3 errors led to the patient’s readmission for treatment. After the pharmacist and the competent doctor again emphasized the harm of repeated medication to the patient’s family members and the importance of medication according to the doctor’s advice, the patient did not have medication errors again. There are 8 types of drugs involved in medication errors (anti schizophrenic drugs, antidepressants, anti anxiety drugs, anti epileptic drugs (mainly used as mood stabilizer), anti dementia drugs, hypoglycemic drugs, antiarrhythmic drugs and anticholinergic drugs). Conclusion: Clinical pharmacist led chronic psychiatric disease management is helpful to find and correct the medication errors of discharged elderly psychiatric patients in time.