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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•BoardCertifiedOncologySpeci

alist•BoardCerfitifiedAmbulatoryCareSpecialist•BoardCertifiedNutritionSupportSpecialist•BoardCerfitifedPediatricSpecialist•BoardCertified

InfectiousDiseaseSpecialist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2010DiseaseTargetsGregoryDill,Centers

forMedicare&MedicaidServices,RegionVAssociateRegionalAdministratorforFinancialManagementandFee-for-ServiceOperations2010MultipleC

hronicDiseases“Sponsorscannotrequiremorethan3chronicdiseasesastheminimumnumberofmultiplechronicdiseases”and“sponsorsmusttargetatleas

tfourofthesevencorechronicconditions:”HypertensionHeartFailureDiabetesDyslipidemiaRespiratoryDiseases(Asthma,COPD,Chron

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

ersforMedicare&MedicaidServices,RegionVAssociateRegionalAdministratorforFinancialManagementandFee-for-ServiceOperationsHennepinCountyMedic

alCenter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,multipleuntowarde

ventsoccurredtopatientsdischargedtonursinghomes•Complaintsfromnursinghomepatientsaboutconfusingdischargeorders•Augustananursin

ghome•Benedictinehealthcaresystem•Transplantclinic•Outpatientdialysisunit•Extendedcare12追根溯源•Oneunitwithoneteamover12weeks•Documentmed

icalrecordnumber,numberofmedications,timespent•ErrorswerereportedinHCMC’seventreportingsystemandtrackedbythemedicationsafetycommittee13追根溯源•Review

ed37patientsdischargedtoSNF•17dischargemedsperpatient•Averagingabout20minutesperpatient,plusadditionalcommunicationtimewit

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

rmulationerrors(extendedreleaseetc)•Inappropriateduplicates•Incorrectdoses(e.g.antibioticathalfdose,anticoagulantatdoublethedo

se)•Missingmedications(e.g.missedBPmed)•Insulindosingerrors(missingss,duplicateorders,etc)15问题在哪里？•Multipleres

identphysicianstakingcareofonepatient•Physiciansdonothaveenoughtimefordischargepaperwork•Missingcoordinationatdischarge•TheexistingEMRprocessesal

lowedforerrors.Note:MedRecwascompleted90+%ofthetime相关文献•Dischargeerrorsoftenresultedinreadmissionstothehospital1-3•Medicationerr

orsinterferewiththepatient’sconfidenceintheirmedicalservices4•1.GillespieU,AlassaadA,HenrohnD,etal.Acomprehen

sivepharmacistinterventiontoreducemorbidityinpatients80yearsorolder:arandomizedcontrolledtrial.ArchInternMed.2009;169(9):894-900.•2.Koehler

BE,RichterKM,YoungbloodL,etal.Reductionof30-daypost-dischargehospitalreadmissionoremergencydepartment(ED

)visitratesinhigh-riskelderlymedicalpatientsthroughdeliveryofatargetedcarebundle.JHospMed.2009;4(4):211-218.•3.Sch

nipperJL,HamannC,NdumeleCD,etal.Effectofanelectronicmedicationreconciliationapplicationandprocessredesignonpotentialadver

sedrugevents:acluster-randomizedtrial.ArchInternMed.2009;169(8):771-780.•4.BurroughsTE,WatermanAD,Ga

llagherTH,etal.Patients'concernsaboutmedicalerrorsduringhospitalization.JtCommJQualPatientSaf.2007Jan;33(1):5-14.减少患者再次入院率•Oneoutoffiv

epatientsdischargedfromaUShospitalwillbereadmittedin30days•17.4billion(outof102.6billion,17%)ofMedicareannualcostJ

encks,SF,Williams,MV,Coleman,EA.RehospitalizationsamongPatientsintheMedicareFee-for-ServiceProgram.NEnglJMed2009;360:1418-1428.行动方案•Reported

tothehospitalexecutivecommittee•Presentedasolution•Collaboratedwithamultidisciplinaryteam•Medicationsafetymanager执行方案•Taketheadva

ntageofnewtechnologyPDSAModelLangleyGL,NolanKM,NolanTW,NormanCL,ProvostLP.TheImprovementGuide:APracticalApproachtoEnhancingOrganizationalPe

rformance(2ndedition).SanFrancisco:FailureModesandEffectsAnalysis(FMEA)•IdentifypatientdischargingtoSNFatrounds•S

ocialWorker(SW)obtainsbedandimmediatelypagesClinicalCoordinator(CC),MD,andPharmD•MDhas4hourswithinwhichtowritethedischargeorders.Ifnotifiedafter2:00p

.m.,MDmusthaveordersexceptI/Pdischargeinbefore8:00a.m.thenextday.•CCscansordershourlyandpagesPharmD22FMEAProcess•PharmDandCChave2hourswithinw

hichtocompletereview:•PharmDreviewsmedicationorders.Ifissue,pagesMDtoreconcile.IfOK,sonotes:MarksasreviewedinMedR

ecscreen•CCreviewsotherorders.Ifissue,pagesMDtoreconcile.•CCchecksforI/Pdischarge;notifiesbedsidenurseandPSCwhenor

derscompleted23方案实施•Individual1-1communicationbyPharmDtoorderingresidentandRNcoordinator.•Communicationsenttoallatte

ndingphysicians,notingthattheyareaccountabletoreviewresidents’dischargeordersandwillbenotifiediferrorsarefoundbypharmacists.多边合作再检查•PharmDrep

ortserrors(nearmiss)usingeventreportingprocess•NotifiedPM&Iofthisrisk•NotifiedPatientCareV.P.’s•ReporttoExecutiveLeadershipTeam临床药学的大规模推广和应用MD

DischargeOrdersPharmDandCCReviewSNFWithEPICupdate,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)Mod

erate19.03%(114/599)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+Moderate+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.SeverityofIll

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

ittobeappliedtoallourpatients•Improvedpatientsatisfaction•Improvedcustomerservice•Reducedreadmissionrateby47%(5.7%vs10.2%)30经济分析•HCM

Chasapproximately1850SNFdischargesperyear;witheachpatient,medicationreconciliationtakesonaverage24minutesinmind,thisequ

ivalentto700hoursclinicalpharmacytimeannually.•Pharmaciststohelpwithmedicationreconciliationintheemergencyroom•Medicationsafetymana

ger31药事管理•Costtoincreasestaffing$112,000•Reductioninexpenses$587,000•(ReducedReadmissionsby47%)•TheUSpaymentsystemisintransitionfromafe

eforservicetopayforperformance.•ImprovedQualityforthePatient32TheJointCommissionNationalPatientSafetyGoals国家认证“…theNPS

Gonreconcilingmedicationinformation(originallyNPSG.08.01.01,butnowNPSG.03.06.01)wasstreamlinedandfocusedtoplaceaspotlightoncriti

calriskpointsinthemedicationreconciliationprocess.NPSG.03.06.01iseffectiveJuly1,2011”.小结•Needforachange-Identifythe

problem•Meansforachange•-Executivecommittee(budgetandsupport)•-Actionplanandmodification(PDSA)•Teamforachange-multidisciplinaryteam(MD

,RN,RPhSocialServiceandclinicalclerks)34临床药学小结•ClinicalPharmacistsinvolvementinateambasedmodel•Realtimefeedback•Empoweringfrontlinesta

fftosuggestandenactsolutions•Standardizingworkandprocesses广而告之•ISMP-Canada•NCPDP•NAPH•IHI•NQF•CMS•AJHPLuY.CliffordP,BjornebyA,ThompsonB,VanNorman

S,WonK,LarsenK,QualityImprovementCaseStudy:ReconciliationforSkilledNursingFacilityDischargesinaSafetyNetTeachingHospital

.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