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系統識別號 U0026-0308201016540900
論文名稱(中文) 藥師進行住院病人用藥史詢問之探討
論文名稱(英文) Verification of Inpatient Medication History by Pharmacist
校院名稱 成功大學
系所名稱(中) 臨床藥學研究所
系所名稱(英) Institute of Clinical Pharmacy
學年度 98
學期 2
出版年 99
研究生(中文) 黃怡華
研究生(英文) Yi-Hua Huang
學號 s6697102
學位類別 碩士
語文別 中文
論文頁數 89頁
口試委員 口試委員-張家銘
口試委員-林文亮
指導教授-高雅慧
共同指導教授-葉鳳英
中文關鍵字 用藥差異  用藥史  藥師  老年人  住院  遺漏用藥 
英文關鍵字 discrepancies  omission  pharmacist  medication histories 
學科別分類
中文摘要 研究背景:
美國醫療機構評鑑聯合會(JCAHO)自2005年的病人安全目標中,首度提出關於藥物整合的議題,而執行藥物整合的第一步就是要取得完整且正確的病人用藥史紀錄。自藥物整合提出後,國外即有許多探討病人用藥史紀錄的研究發表,這些研究結果顯示將近一半的病人會發現至少一項用藥不一致的情況,從這些研究中,也發現由藥師執行用藥史的詢問,能獲得更完整且正確的病人用藥史資料。根據臺灣中央健保局統計,國人用藥量約為美國的六倍,更有發生用藥疏失的危機,而老年人又因為有多重共病及多項用藥,更屬於高危險族群,因此若能獲得完整正確的用藥史資料,有助於老年人住院醫療照護的安全。但由文獻搜尋發現目前國內相關研究報告較少。

研究目的:
了解台灣地區住院病人用藥史紀錄的正確程度以及探討藥師進行病人用藥史詢問及藥物整合之成效。

研究設計:
本研究為橫斷觀察性研究,於2010年1月至2010年5月在國立成功大學醫學院附設醫院之內科病房進行。主要針對65歲以上、三種以上共病症、四種以上住院醫囑藥物之新住院患者,並排除有精神疾病或失智、無意願、意識昏迷、有溝通障礙、或醫護人員認為不適合者。訪談藥師先從住院電腦系統及病歷篩選適合病患,並藉由病歷了解病患基本資料,於病患住院48小時內進行用藥史詢問,記錄下來並比對住院醫囑,評估兩者之間有無用藥不一致,若觀察到任何不一致再與醫師討論,確認是否為用藥疏失,並視為一項用藥差異。觀察變項包含藥師記錄的用藥史與醫囑處方的用藥差異(型態、發生頻率、藥理分類)、訪談耗費時間…等。

研究結果:
總共收錄118位病人,平均年齡約76歲,其中65位的病患(55.1%)發現至少一項用藥差異,總共205筆用藥差異。最常見的用藥差異型態為遺漏用藥,約82.4%,最常見為腸胃道藥物遺漏(28%)),次之為心血管用藥(20%);針對遺漏用藥,59%的遺漏用藥醫師認為非必需用藥,28.4%需加上使用,而12.4%的藥物不應使用。藥師認為46%的用藥差異對病人沒有影響,僅1筆用藥差異可能危及病人生命。藥師認為96%腸胃道遺漏藥物對病人沒有影響;80%血液系統藥物及所有降血糖藥物,皆對病人有嚴重影響;94%心血管用藥有輕微或嚴重影響。

結論:
不完整的用藥史紀錄在老年人剛住院時是個常見的問題,而藥師進行用藥史的詢問,可以有效改善病人用藥史紀錄的完整及正確性。

關鍵詞:用藥差異、用藥史、藥師、老年人、住院、遺漏用藥。
英文摘要 Background:
Since 2005, the JCAHO has highlighted “Medication Reconciliation” as the annual “National Patient Safety Goal”. To identify the most accurate and complete list of all medications is suggested to be the first step. That has drawn much attention of clinicians and administrators in finding ways to obtain accurate medication histories over the past few years. And, they found that about 50% had at least one error in the medication histories in the hospital medical record. According to previous reports, more medications a prescribed to patient in Taiwan. That may lead to higher error risk. However,re the extent of medication discrepancies remains unknown in Taiwan.

Objectives:
This study aimed to assess the accuracy of medication records of newly admitted elderly patients in Taiwan, and to evaluate the performance of pharmacist-acquired medication history.

Methods:
This study was a cross-sectional observation study conducted from January 2010 to May 2010 in the medical center of National Cheng Kung University Hospital. Patients who were new admissions, and over the age of 65, received four or more regular medications (exclude antibiotics and emergency agents), had three or more clinical co-morbidities were included. Patients who were dementia, not willing to participate, unable to communicate, or had mental illness were excluded. The pharmacist used the electronic system of NCKU hospital to select suitable patients. Then, the medication records were used to collect the information of the patient. Patients were interviewed within 48 hours after admission. The discrepancies were assessed by comparing the documented information and progression note. All the discrepancies were discussed with the attending physicians to verify its clinical significance.

Results:
A total of 118 patients were included in this analysis. About 55.1% patients had one or more discrepancies. Total of 205 discrepancies were found, and the most common type were omissions of medications (82.4%). Most omissions were medications that were indicated for gastrointestinal disease (28%), and approximately 20% were used to treat cardiovascular disorders. Physicians thought 59% omissions were not necessary for patients, 28.4% were added, 12.4% were not be used. The pharmacist thought 96% gastrointestinal omissions had no impact on patients. 94% cardiovascular omissions had minor or severe impact on patients.

Conclusion:
Medication discrepancies were frequently present in the medical records of senior patients during hospital admission. Pharmacists’ participation in obtaining medication histories improved the completeness and accuracy of patient medication records.

Keywords: discrepancies, omission, pharmacist, medication histories.
論文目次 中文摘要 I
Abstract III
誌謝 V
目錄 VII
表目錄 X
圖目錄 XII
第一篇 藥師進行住院病人用藥史詢問之探討 1
第一章 研究背景 1
第二章 文獻回顧 3
第一節 用藥整合 3
第二節 國外的用藥史詢問研究 3
2.1針對一般病患進行的研究 4
2.2針對老人族群所做的用藥史詢問研究13
2.3比較藥師及其他醫療人員詢問用藥史的效果15
2.4藥學生進行用藥史詢問的成效19
第三節 臺灣的用藥史研究報告 20
3.1臺灣用藥疏失情況 20
3.2萬芳醫院研究報告 21
3.3台大臨藥所研究論文報告 25
第三章 研究目的 27
第四章 研究方法 28
第一節 研究設計 28
1.1研究類型 28
1.2研究單位及期間 28
1.3納入對象 28
1.4排除條件 28
1.5研究材料與工具 28
第二節 研究流程 29
第三節 變項與操作定義 30
3.1用藥差異 30
3.2用藥差異之型態 31
3.3 ATC藥理分類 31
3.4醫師處理方式 32
3.5用藥差異嚴重程度分析 32
第四節 資料彙整與分析方法 32
4.1統計分析軟體 32
4.2統計分析方法 33
第五章 研究結果 34
第一節 病人基本資料特徵分布情形 34
1.1病人住院主診斷 37
1.2病人住院醫囑用藥之藥理分析 38
1.3住院前用藥之藥理分類分析 39
第二節 用藥差異分析 40
2.1用藥差異數量分析 40
2.2用藥差異數量與各變項相關性分析 40
2.3用藥差異型態分析 44
2.4 用藥差異的藥理分析 46
2.5 醫師對於用藥差異之處理分析48
2.6用藥差異之嚴重程度 50
第六章 研究討論 53
第一節 病人基本資料特徵分布情形 53
第二節 用藥差異分析 53
2.1用藥差異數量分析 53
2.2用藥差異數量與各變項相關性分析 54
2.3用藥差異型態分析 55
2.4遺漏用藥的藥理分類分析 56
2.5用藥差異處理分析 57
2.6用藥差異之嚴重程度 57
第三節 藥師進行用藥史詢問的探討 58
第四節 執行用藥史詢問的要點 59
41 訪談中能獲得的資料輔助 59
42 藥物過敏史紀錄 60
43訪談耗費時間 60
第五節 醫謢人員對藥師訪談滿意度問卷調查結果 60
第七章 研究限制 65
第一節 研究類型 65
第二節 臨床重要性 65
第三節 病人配合度 65
第八章 結論與建議 66
第二篇 臨床藥事服務 68
第一章 服務背景 68
第二章 服務方法 69
第三章 服務結果 70
參考文獻 77
附錄一 80
附錄二 83
附錄三 86
自述 89
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