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美国临床药师临床实践管见内容提要•美国医院从事药学技术工作的分类，配置的，比例和职责。•美国的住院药师（在临床工作的，相当国内的临床药师）如何参与临床药物治疗工作，保证患者用药安全、合理用药的；制度、资质、工作流程、绩效、酬报等，有无书面的文书，如药历等。•美国的住院药师在用药安全、合理方面做

出的成绩，课题，数据等。美国临床药师资质•本科•药学管理硕士•药学博士•住院药师训练•专业证书（BoardofPharmacotherapy)•BoardCertifiedPharmacotherapySpecialist

•BoardCertifiedOncologySpecialist•BoardCerfitifiedAmbulatoryCareSpecialist•BoardCertifiedNutritionSupportSpecialist•BoardCerfitif

edPediatricSpecialist•BoardCertifiedInfectiousDiseaseSpecialist美国临床药师分类•政府机关•教学机构•保险公司•医药公司的药物信息部•医院住院部•门诊（独立门诊和医院门诊）

•药店（独立或连锁）医院临床药师分类职能•住院部•中心药房•普通病房•专科病房（ICU,各个专科-心脏，肾脏，儿科，肿瘤，流行病，心理精神）•门诊部•内科和家庭医生门诊•各个专科推广临床药师的数据•五个花钱追多的病症•五个返诊率最高的疾病•五个门诊病人最集中的科室2010DiseaseT

argetsGregoryDill,CentersforMedicare&MedicaidServices,RegionVAssociateRegionalAdministratorforFinancialManagementandFee-for-ServiceOperations2010Mul

tipleChronicDiseases“Sponsorscannotrequiremorethan3chronicdiseasesastheminimumnumberofmultiplechronicdiseases”and“spon

sorsmusttargetatleastfourofthesevencorechronicconditions:”HypertensionHeartFailureDiabetesDyslipidemiaRespiratoryDiseases(Asthma,COPD,Chr

onicLungdisorders)BoneDisease-Arthritis(Osteoporosis,RA,OA)MentalHealthissues(Depression,Schizophrenia,BipolarDisorder,others)GregoryDill

,CentersforMedicare&MedicaidServices,RegionVAssociateRegionalAdministratorforFinancialManagementandFee-for-ServiceOperationsHennepinCountyMedi

calCenter药师配置•465张病床•药房管理人员-•全职：主任，住院部经理，临床药学部经理，门诊部经理，特种药房经理，用药安全经理•兼职：药物治疗学经理，住院药师经理，药学博士生经理，•中心药房•临床药师•普通病房•

专科病房•门诊药师•普通门诊•专科门诊•住院药学博士•技术员•药学院学生临床药师参与医院工作介绍•临床用药安全经理-用药安全•医院用药安全决策（院办，临床药物治疗）•领导各级用药安全委员会（用药安全，医疗事故，临床药学，护理）•临床药物治疗经理-合理用药•药物种类•药物使用分析•临床用药政

策临床药师在用药安全上对医疗体系的影响患者出院药学查房案例分析（危机）挑战•In2007,multipleuntowardeventsoccurredtopatientsdischargedtonursinghomes•Complaintsf

romnursinghomepatientsaboutconfusingdischargeorders•Augustananursinghome•Benedictinehealthcaresystem•Transplan

tclinic•Outpatientdialysisunit•Extendedcare12追根溯源•Oneunitwithoneteamover12weeks•Documentmedicalrecordnumber,numberofmedications,timespent•Errorsw

erereportedinHCMC’seventreportingsystemandtrackedbythemedicationsafetycommittee13追根溯源•Reviewed37patientsdischargedtoSN

F•17dischargemedsperpatient•Averagingabout20minutesperpatient,plusadditionalcommunicationtimewiththet

eammembers,mostlyphysicians追根溯源•Investigationconfirmsexistingproblem•Ofthe37patients,only3(8%)wereerror-free•Commonthemesnoted:•Formulationerrors

(extendedreleaseetc)•Inappropriateduplicates•Incorrectdoses(e.g.antibioticathalfdose,anticoagulantatdoublethedose)•Missingmed

ications(e.g.missedBPmed)•Insulindosingerrors(missingss,duplicateorders,etc)15问题在哪里？•Multipleresidentphysiciansta

kingcareofonepatient•Physiciansdonothaveenoughtimefordischargepaperwork•Missingcoordinationatdischarge•TheexistingEMRprocessesall

owedforerrors.Note:MedRecwascompleted90+%ofthetime相关文献•Dischargeerrorsoftenresultedinreadmissionstothehospital1-3•Medicationerrorsinterferewith

thepatient’sconfidenceintheirmedicalservices4•1.GillespieU,AlassaadA,HenrohnD,etal.Acomprehensivepharmacistinterventiontoreducemo

rbidityinpatients80yearsorolder:arandomizedcontrolledtrial.ArchInternMed.2009;169(9):894-900.•2.KoehlerBE,

RichterKM,YoungbloodL,etal.Reductionof30-daypost-dischargehospitalreadmissionoremergencydepartment(ED)visitratesinhigh-riskelderlymedicalpatien

tsthroughdeliveryofatargetedcarebundle.JHospMed.2009;4(4):211-218.•3.SchnipperJL,HamannC,NdumeleCD,etal.Effectofanel

ectronicmedicationreconciliationapplicationandprocessredesignonpotentialadversedrugevents:acluster-randomizedtrial.ArchInternMed

.2009;169(8):771-780.•4.BurroughsTE,WatermanAD,GallagherTH,etal.Patients'concernsaboutmedicalerrorsduringhospitalizat

ion.JtCommJQualPatientSaf.2007Jan;33(1):5-14.减少患者再次入院率•OneoutoffivepatientsdischargedfromaUShospitalwillbereadmittedin30days•17.4billion(outof102.6

billion,17%)ofMedicareannualcostJencks,SF,Williams,MV,Coleman,EA.RehospitalizationsamongPatientsintheMedicareFee-for

-ServiceProgram.NEnglJMed2009;360:1418-1428.行动方案•Reportedtothehospitalexecutivecommittee•Presentedasolution•Collaboratedwithamul

tidisciplinaryteam•Medicationsafetymanager执行方案•TaketheadvantageofnewtechnologyPDSAModelLangleyGL,NolanKM,NolanTW,NormanCL,ProvostLP.TheImprov

ementGuide:APracticalApproachtoEnhancingOrganizationalPerformance(2ndedition).SanFrancisco:FailureModesandEffectsAnalysis(FMEA)•Identify

patientdischargingtoSNFatrounds•SocialWorker(SW)obtainsbedandimmediatelypagesClinicalCoordinator(CC),MD,andPharmD•MDhas4

hourswithinwhichtowritethedischargeorders.Ifnotifiedafter2:00p.m.,MDmusthaveordersexceptI/Pdischargeinbefore

8:00a.m.thenextday.•CCscansordershourlyandpagesPharmD22FMEAProcess•PharmDandCChave2hourswithinwhichto

completereview:•PharmDreviewsmedicationorders.Ifissue,pagesMDtoreconcile.IfOK,sonotes:MarksasreviewedinMedRecscreen•CCreviewso

therorders.Ifissue,pagesMDtoreconcile.•CCchecksforI/Pdischarge;notifiesbedsidenurseandPSCwhenorderscompleted2

3方案实施•Individual1-1communicationbyPharmDtoorderingresidentandRNcoordinator.•Communicationsenttoallatt

endingphysicians,notingthattheyareaccountabletoreviewresidents’dischargeordersandwillbenotifiediferrorsarefoundbypharmacists.多边合作

再检查•PharmDreportserrors(nearmiss)usingeventreportingprocess•NotifiedPM&Iofthisrisk•NotifiedPatientCareV.P.’s•ReporttoExecutiveLeadershipTeam临床药学的

大规模推广和应用MDDischargeOrdersPharmDandCCReviewSNFWithEPICupdate,Errorratewithoutreview-70%ofdischargesErrorrateafterreview-0%27病情危重与

再入院率的关系AllCauseReadmissionRelatedReadmissionSeverityofIllnessControlCaseControlCaseMinor14.29%(18/126)0%(0/1)7.94%(10/126)0%(0/1)Moderate19.03%(11

4/599)13.64%(3/22)7.85%(47/599)4.55%(1/22)Major26.54%(280/1055)31.37%(16/51)10.62%(112/1055)5.88%(3/51)Minor+Mo

derate+Major23.15%(412/1780)25.68%(19/74)9.49%(169/1780)5.40%(4/74)Extreme33.23%(104/313)38.46%(5/13)9.90%(31

/313)23.08%(3/13)Overall24.65%(516/2093)31.03%(27/87)9.56%(200/1893)8.05%(7/87)Horn,SDetal.SeverityofIllnesswithinDRGs:Impactonprospec

tivepayment.AmJPublicHealth.1985;75,1195-9患者再入院率临床药学对医疗质量的影响•Physiciansrequestittobeappliedtoallourpati

ents•Improvedpatientsatisfaction•Improvedcustomerservice•Reducedreadmissionrateby47%(5.7%vs10.2%)30经济分析•HCMChasapproximately1850SNFdischargespe

ryear;witheachpatient,medicationreconciliationtakesonaverage24minutesinmind,thisequivalentto700hoursclinicalpha

rmacytimeannually.•Pharmaciststohelpwithmedicationreconciliationintheemergencyroom•Medicationsafetymanager31药事管理•Costtoincreasestaffing$112,000•R

eductioninexpenses$587,000•(ReducedReadmissionsby47%)•TheUSpaymentsystemisintransitionfromafeeforservicetopayforperformance.•Imp

rovedQualityforthePatient32TheJointCommissionNationalPatientSafetyGoals国家认证“…theNPSGonreconcilingmedicationinfor

mation(originallyNPSG.08.01.01,butnowNPSG.03.06.01)wasstreamlinedandfocusedtoplaceaspotlightoncriticalriskpointsint

hemedicationreconciliationprocess.NPSG.03.06.01iseffectiveJuly1,2011”.小结•Needforachange-Identifythep

roblem•Meansforachange•-Executivecommittee(budgetandsupport)•-Actionplanandmodification(PDSA)•Teamfo

rachange-multidisciplinaryteam(MD,RN,RPhSocialServiceandclinicalclerks)34临床药学小结•ClinicalPharmacistsinvolve

mentinateambasedmodel•Realtimefeedback•Empoweringfrontlinestafftosuggestandenactsolutions•Standardizingworkandprocesses广而告之•ISMP-C

anada•NCPDP•NAPH•IHI•NQF•CMS•AJHPLuY.CliffordP,BjornebyA,ThompsonB,VanNormanS,WonK,LarsenK,QualityImprovementCaseStudy:Reconcili

ationforSkilledNursingFacilityDischargesinaSafetyNetTeachingHospital.AmJHealth-SystPha美国临床药师对临床药学影响•数据•政策•其他行业支持•医生•护士•医助•高

级护师为中国临床药学进言•天时地利人和•国家政策引领，专家进言•星星之火可以燎原•重点突出，以点带面谢谢观赏