순환기 내과 병동 담당 약사에 의한 자가약 관리 및 퇴원약 처방 중재 효과 = The benefit of pharmacists' intervention on self medications and discharge orders in the cardiology ward

다국어 초록 (Multilingual Abstract)

Background: Hospitalization and subsequent discharge often involve multiple changes in medication regimens and patients are at high risk of medication discrepancies. These discrepancies may result in failure to detect drug related problems or may lead to interrupted or inappropriate drug therapy during hospitalization and upon discharge. In our institution, pharmacists started to verify patient medication histories on admission and provide discharge order interventions based on the patient counseling in the cardiology ward.
Objective: The objective of this study was to evaluate the pharmacist’s intervention on preadmission medication use and discharge orders in the cardiology ward.
Methods: All patients discharged from the cardiology ward who received pharmacist counseling between March and September of 2008 were included. Preadmission medication, self medications which patients continued to take during hospitalization and after discharge by themselves, medication change during hospitalization and discharge order were analyzed. Medication reconciliation records by pharmacist were evaluated.
Results: During the 7 month period, a total of 897 patients received pharmacist’s counseling. Pharmacists had to intervene on self medication at discharge in 389 cases (43%). Most of the self medication interventions (358 cases) were to educate the patients on discontinuation or dosage change of the self medications and emphasize its importance. Pharmacists also clarified the continuation of unrecognized preadmission medications in 24 cases and identified therapeutic duplication with other self medication in 8 cases.
In 119 cases, pharmacists’ interventions on discharge order were accepted by physicians. The interventions included omission of medications (43 cases), inappropriate dosage and frequency (18 cases), inappropriate prescription duration (17 cases), and medication changes according to patient complaints on adverse drug reaction (13 cases).
Conclusion: Pharmacists’ interventions on a discharge medication order based on preadmission self medication assessment and patient counseling reduces unintended medication discrepancy. Therefore, greater roles for pharmacists in medication reconciliation should be considered.

참고문헌 (Reference)

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