社團法人臺灣臨床藥學會

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【原著】提升腎功能不全病患用藥安全─藥師執行藥物劑量調整服務之成效
Hospital Pharmacist Intervention in Drug Dosage Adjustment for Patients with Renal Impairment
腎衰竭、腎功能不全、藥物劑量調整、藥事服務、renal failure, renal impairment, dosage adjustment, pharmacist service.
李佳利Chia-Li Lee*1 、陳惠貞 Hwei-Jen Chen2 、吳美麗 Meei-Li Wu2 、陳立奇 Lih-Chi Chen1
1臺北市立聯合醫院 忠孝院區藥劑科 、2臺北市立聯合醫院 藥劑部
目的:運用電腦監測藥物系統,藥師介入監測腎不全住院病患用藥劑量,以期降低用藥劑量錯   誤案件,本文探討此項臨床藥事服務成效。
方法:自 95 年 1 月起開始持續進行監測,於系統設定 27 項抗感染類藥品(Antiinfective agents),由電腦篩選使用病患,再查詢 Serum creatinine(SCr>1.5mg/dl)資料,計算 Creatinine clearance≦50ml/min 之患者,進一步評估用藥劑量適當性。本研究樣本取自  96 年  7-12 月(第二年)執行監測資料,與 95 年同期(第一年)作分析比較。
結果:96 年 7-12 月藥師介入評估 382 筆,65 歲以上病患佔 81.94%(平均 75±14 歲);SCr 數值為 1.6~5 mg/dl 佔 85.60%( 平 均 3.28±2.2 mg/dl);ClCr 為 10-30 ml/min 居 多 佔 67.02%(平均 18.07±9.84 ml/min);藥品以 Cefazolin 最多佔 41.36%。需照會醫師筆數共 193 筆,照會率為  50.52%,醫師接受度為   70.98%。處方修改結果,45.99%停藥、29.93%修改間隔或劑量、12.41%改藥。與 95 年同期(總計評估 557 筆)比較,需照會率下降  15.37%, 醫師接受度提升 7.49%。
結論:電腦自動提示篩檢警訊系統未建置前,藥師例行監測腎不全病人用藥,可提高醫師對於   用藥更加謹慎,尤其是老年族群,以預防藥物造成傷害。

Background: We evaluated a computer-based pharmacist intervention system meant to reduce dosing errors in renal-impaired inpatients.
Methods: From Jan. 2006, adult inpatients received at least 1 of 27 renal-excreted Antiinfective agents were included in the study. Eligible patients were identified by computer daily. Serum creatinine concentration(SCr>1.5mg/dl) was used to evaluate creatinine clearance(Cockcroft and Gault method) by clinical pharmacists. Drug dosage appropriateness was based on creatinine clearance(Clcr≦50ml/min) and the recommended dosages in the literature. Pharmacist contacted the patient’s prescriber if the dosage was inappropriate. To determine if the percentage of pharmacist intervention changed over time, the results from Jul. to Dec. 2007 were compared to a control period one year ago(Jul. to Dec. 2006).
Results: From Jul. to Dec. 2007, the drug dosage appropriateness of total 382 prescriptions were assayed. 81.94% of patients were over 65  years old (mean 75±14  y),  85.60% had a serum creatinine concentration 1.6~5 mg/d (mean 3.28±2.2 mg/dl) and 67.02% had a creatinine clearance 10-30ml/min (mean 18.07±9.84  ml/min).  Cefazolin  (41.36%)  was  the  most  frequently prescribed drug. Dosage adjustment recommendations were made for 193 prescriptions(50.52%); 70.98% of them were accepted by prescribers. Comparing with the control group(N = 557), the study group had 15.37% less of requirements for dosage adjustment and got 7.49% more of prescribers’ acceptance for dosage adjustment recommendations from phamacists.
Conclusions: Before implementing a computer system with reminders at the time of prescription, pharmacist routine intervention can significantly raise prescribers’ attention to drug dosage in renal-impaired patients, especially the elderly, and prevent drug-induced injury.
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