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1、美国临床药师的临床实践管见,第十一届中国临床药师论坛 陆芸,1,美国临床药师的临床实践管见,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。,2,美国临床药师的临床实践管见,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 （Board of Pharmacotherapy) Board Certified Pharmacothe
2、rapy Specialist Board Certified Oncology Specialist Board Cerfitified Ambulatory Care Specialist Board Certified Nutrition Support Specialist Board Cerfitifed Pediatric Specialist Board Certified Infectious Disease Specialist,3,美国临床药师的临床实践管见,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
3、 （独立或连锁）,4,美国临床药师的临床实践管见,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,5,美国临床药师的临床实践管见,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,6,美国临床药师的临床实践管见,2010 Disease Targets,Gregory Dill, Centers for Medicare 169(9):894-900. 2.Koehler BE, Richter KM, Youngblood L, et a
4、l. Reduction of 30-day post-discharge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4(4):211-218. 3.Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconci
5、liation application and process redesign on potential adverse drug events: a cluster-randomized trial. Arch Intern Med. 2009;169(8):771-780. 4. Burroughs TE, Waterman AD, Gallagher TH, et al. Patients concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf. 2007 Jan;33(1):5-
6、14.,17,美国临床药师的临床实践管见,减少患者再次入院率,One out of five patients discharged from a US hospital will be readmitted in 30 days 17.4 billion (out of 102.6 billion, 17%) of Medicare annual cost,Jencks, SF, Williams, MV, Coleman, EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Eng
7、l J Med 2009; 360:1418-1428.,18,美国临床药师的临床实践管见,行动方案,Reported to the hospital executive committee Presented a solution Collaborated with a multidisciplinary team Medication safety manager,19,美国临床药师的临床实践管见,执行方案,Take the advantage of new technology,20,美国临床药师的临床实践管见,PDSA Model,Langley GL, Nolan KM, Nolan
8、 TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance(2nd edition). San Francisco: Jossey-Bass Publishers; 2009: 23-24,21,美国临床药师的临床实践管见,Failure Modes and Effects Analysis (FMEA),Identify patient discharging to SNF at rounds Social Worker (SW)
9、 obtains bed and immediately pages Clinical Coordinator (CC), MD, and PharmD MD has 4 hours within which to write the discharge orders. If notified after 2:00 p.m., MD must have orders except I/P discharge in before 8:00 a.m. the next day. CC scans orders hourly and pages PharmD,美国临床药师的临床实践管见,FMEA P
10、rocess,PharmD and CC have 2 hours within which to complete review: PharmD reviews medication orders. If issue, pages MD to reconcile. If OK, so notes: Marks as reviewed in Med Rec screen CC reviews other orders. If issue, pages MD to reconcile. CC checks for I/P discharge; notifies bedside nurse and
11、 PSC when orders completed,美国临床药师的临床实践管见,方案实施,Individual 1-1 communication by PharmD to ordering resident and RN coordinator. Communication sent to all attending physicians, noting that they are accountable to review residents discharge orders and will be notified if errors are found by pharmacists.
12、,24,美国临床药师的临床实践管见,多边合作,25,美国临床药师的临床实践管见,再检查,PharmD reports errors (near miss) using event reporting process Notified PM 75, 1195-9,28,美国临床药师的临床实践管见,患者再入院率,29,美国临床药师的临床实践管见,临床药学对医疗质量的影响,Physicians request it to be applied to all our patients Improved patient satisfaction Improved customer service Red
13、uced readmission rate by 47% (5.7% vs 10.2%),美国临床药师的临床实践管见,经济分析,HCMC has approximately 1850 SNF discharges per year; with each patient, medication reconciliation takes on average 24 minutes in mind, this equivalent to 700 hours clinical pharmacy time annually. Pharmacists to help with medication rec
14、onciliation in the emergency room Medication safety manager,美国临床药师的临床实践管见,药事管理,Cost to increase staffing $ 112,000 Reduction in expenses$ 587,000 (Reduced Readmissions by 47%) The US payment system is in transition from a fee for service to pay for performance. Improved Quality for the Patient,美国临床药
15、师的临床实践管见,The Joint Commission National Patient Safety Goals 国家认证,“ the NPSG on reconciling medication information (originally NPSG.08.01.01, but now NPSG.03.06.01) was streamlined and focused to place a spotlight on critical risk points in the medication reconciliation process. NPSG.03.06.01 is effe
16、ctive July 1, 2011”.,33,美国临床药师的临床实践管见,小结,Need for a change - Identify the problem Means for a change - Executive committee (budget and support) - Action plan and modification (PDSA) Team for a change- multidisciplinary team (MD, RN, RPh Social Service and clinical clerks),美国临床药师的临床实践管见,临床药学小结,Clinic
17、al Pharmacists involvement in a team based model Real time feedback Empowering frontline staff to suggest and enact solutions Standardizing work and processes,35,美国临床药师的临床实践管见,广而告之,ISMP- Canada NCPDP NAPH IHI NQF CMS AJHP,Lu Y. Clifford P, Bjorneby A, Thompson B, Van Norman S, Won K, Larsen K, Quali
18、ty Improvement Case Study: Discharge Order Reconciliation for Skilled Nursing Facility Discharges in a Safety Net Teaching Hospital. Am J Health-Syst Pharm, (in press).,36,美国临床药师的临床实践管见,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,37,美国临床药师的临床实践管见,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,38,美国临床药师的临床实践管见,