社團法人臺灣臨床藥學會

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【原著】建構藥物血中濃度異常早期預警系統暨成效分析
Effects of an Early Alert System of Therapeutic Drug Monitoring
藥物血中濃度監測、臨床藥師、用藥安全
劉人瑋Jen-Wei Liu 、王春玉Chun Yu Wang*
1新光醫療財團法人新光吳火獅紀念醫院藥劑部
目的: 藥物血中濃度監測是普遍的臨床藥事服務。傳統上,臨床藥師在血中濃度異常後提出建議,不但受限於時效性,也未能保障用藥安全。本研究目的在於建構藥物血中濃度異常早期預警系統,並期縮短病人暴露於不適當藥物血中濃度時間。
方法: 試驗期間(2010年6月至2011年6月),先收集文獻與教科書資料,經由醫師、藥師、醫檢師與護理師組成的跨領域團隊建立應監測藥物血中濃度篩選條件及標準作業流程。再由電腦每日篩選符合條件病人及臨床藥師依標準作業流程評估,向醫師提出監測建議。主要試驗終點為病人暴露於不適當血中濃度時間差異,次要試驗終點包括臨床藥師評估需監測比例、建議接受度與臨床藥師建議監測且監測結果異常比例。
結果: 試驗期間共484 位住院患者符合電腦篩選條件,其中170 位 (35.1%) 經臨床藥師評估後建議監測並向醫師提出建議。監測結果中28.7%(33件)異常、71.3%(82 件)正常。建議時效性方面,自病人曝險到檢驗結果報告,由臨床藥師建議病例的曝險時間平均為47.51 ± 41.3 小時,相較於醫師自行監測為89.1 ± 67.6 小時 (p = 0.033),二者平均時間差異為41.6 小時(縮短46.7%)。試驗期間,45 件藥物血中濃度異常病例中,11 件發生相關併發症。
結論: 本研究顯示經由電腦篩選配合臨床藥師評估患者是否需要監測藥物血中濃度是可行的,且可顯著縮短病人暴露於異常血中濃度時間。
 
Objectives: Therapeutic drug monitoring is a common pharmaceutical service in hospital. Traditionally,clinical pharmacists tend to provide suggestions after test results came out. On the basis of preventing medication errors, it is ineffective and not time-efficient. The goal of this study is to establish an early alert system to shorten time exposure in inappropriate drug concentration.
Methods: We organized a multidisciplinary advisory committee (physicians, pharmacists, nurses, and medical technologists) to review literatures and textbooks, and to construct screening guidelines of hospitalized patients. We developed standardized protocols for clinical pharmacists to assess needs for measuring drug concentration and provide recommendation to physicians. The primary endpoint of the study is time difference away from patients at risk to examination report between clinical pharmacist suggested and physician ordered. Other endpoints included the rate of patients assessed as high risk for inappropriate drug concentration, suggestion acceptance rate by the physicians and the rate of suggestion accepted but drug concentration was not measured.
Results: Four hundred and eighty-four patients met screening criteria and enrolled in the study. Of these, 170 (35.1%) patients were assessed as high risk of being exposure under abnormal drug concentration. In patients with drug concentration reports, 28.7% (33 cases) were inappropriate.
There was a statistically significant shorten time difference (41.6 hours, 46.7%, p = 0.033) away from patients who were at risk to drug concentration reported by the clinical pharmacists suggested (47.51 ± 41.3 hours) than the physician ordered (89.1 ± 67.6 hours). In this study,only 11 out of 45 patients with abnormal drug concentration occurred significant adverse events.
Conclusions: Computerized screening and clinical pharmacist assessment are feasible and can significantly shorten time exposure under inappropriate drug concentration.
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