美国临床药师的临床实践管见课件.pptx

1、1精选ppt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精选ppt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 Pharmacotherapy SpecialistBoard Certified Oncology SpecialistBoard Cerfitified Ambul

2、atory Care SpecialistBoard Certified Nutrition Support SpecialistBoard Cerfitifed Pediatric SpecialistBoard Certified Infectious Disease Specialist3精选ppt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）4精选ppt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精选ppt五个花钱最多的病症 糖尿病、心衰、高血压、高血脂

3、、肺气肿五个返诊率最高的疾病 心肌梗死、心衰、肾衰、呼吸系统疾病、精神病五个门诊病人最集中的科室 心脑血管疾病、肿瘤、糖尿病、关节炎、肥胖6精选pptGregory Dill,Centers for Medicare&Medicaid Services,Region V Associate Regional Administrator for Financial Management and Fee-for-Service Operations7精选ppt“Sponsors cannot require more than 3 chronic diseasescannot require mo

4、re than 3 chronic diseases as the minimum number of multiple chronic diseases”and“sponsors must target at least four of the seven four of the seven core chronic conditions:”1.Hypertension2.Heart Failure3.Diabetes4.Dyslipidemia5.Respiratory Diseases(Asthma,COPD,Chronic Lung disorders)6.Bone Disease-A

5、rthritis(Osteoporosis,RA,OA)7.Mental Health issues(Depression,Schizophrenia,Bipolar Disorder,others)Gregory Dill,Centers for Medicare&Medicaid Services,Region V Associate Regional Administrator for Financial Management and Fee-for-Service Operations8精选ppt465 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

6、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9精选ppt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10精选ppt患者出院药学查房案例分析11精选pptIn 2007,multiple untoward events occurred to patients discharged to nursing homesComplaints from nurs

7、ing home patients about confusing discharge ordersAugustana nursing homeBenedictine health care systemTransplant clinicOutpatient dialysis unitExtended care12精选pptOne unit with one team over 12 weeksDocument medical record number,number of medications,time spentErrors were reported in HCMCs event re

8、porting system and tracked by the medication safety committee13精选pptReviewed 37 patients discharged to SNF17 discharge meds per patientAveraging about 20 minutes per patient,plus additional communication time with the team members,mostly physicians14精选pptInvestigation confirms existing problemOf the

9、 37 patients,only 3(8%)were error-freeCommon themes noted:Formulation errors(extended release etc)Inappropriate duplicatesIncorrect doses(e.g.antibiotic at half dose,anticoagulant at double the dose)Missing medications(e.g.missed BP med)Insulin dosing errors(missing ss,duplicate orders,etc)15精选pptMu

10、ltiple resident physicians taking care of one patientPhysicians do not have enough time for discharge paper workMissing coordination at dischargeThe existing EMR processes allowed for errors.Note:Med Rec was completed 90+%of the time16精选pptDischarge errors often resulted in readmissions to the hospi

11、tal1-3Medication errors interfere with the patients confidence in their medical services41.Gillespie U,Alassaad A,Henrohn D,et al.A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older:a randomized controlled trial.Arch Intern Med.2009;169(9):894-900.2.Koehler BE,R

12、ichter KM,Youngblood L,et al.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 m

13、edication reconciliation 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.Patients concerns about medical errors

14、 during hospitalization.Jt Comm J Qual Patient Saf.2007 Jan;33(1):5-14.17精选pptOne out of five patients discharged from a US hospital will be readmitted in 30 days17.4 billion(out of 102.6 billion,17%)of Medicare annual cost Jencks,SF,Williams,MV,Coleman,EA.Rehospitalizations among Patients in the Me

15、dicare Fee-for-Service Program.N Engl J Med 2009;360:1418-1428.18精选pptReported to the hospital executive committee Presented a solutionCollaborated with a multidisciplinary teamMedication safety manager19精选pptTake the advantage of new technology20精选pptLangley GL,Nolan KM,Nolan TW,Norman CL,Provost L

16、P.The Improvement Guide:A Practical Approach to Enhancing Organizational Performance(2nd edition).San Francisco:Jossey-Bass Publishers;2009:23-2421精选pptIdentify patient discharging to SNF at roundsSocial Worker(SW)obtains bed and immediately pages Clinical Coordinator(CC),MD,and PharmDMD has 4 hours

17、 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 PharmD22精选pptPharmD and CC have 2 hours within which to complete review:PharmD reviews medication orders.If issue,pages MD

18、 to reconcile.If OK,so notes:Marks as reviewed in Med Rec screenCC reviews other orders.If issue,pages MD to reconcile.CC checks for I/P discharge;notifies bedside nurse and PSC when orders completed 23精选pptIndividual 1-1 communication by PharmD to ordering resident and RN coordinator.Communication

19、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.24精选ppt25精选pptPharmD reports errors(near miss)using event reporting processNotified PM&I of this risk Notified Patient Care V.P.sReport to Ex

20、ecutive Leadership Team26精选pptMD DischargeOrdersPharmD and CC ReviewSNFWith EPIC update,Error rate without review-70%of dischargesError rate after review-0%27精选ppt All Cause ReadmissionRelated ReadmissionSeverity of IllnessControlCaseControlCaseMinor14.29%(18/126)0%(0/1)7.94%(10/126)0%(0/1)Moderate1

21、9.03%(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

22、%(7/87)Horn,SD et al.Severity of Illness within DRGs:Impact on prospective payment.Am J Public Health.1985;75,1195-928精选ppt29精选pptPhysicians request it to be applied to all our patientsImproved patient satisfactionImproved customer serviceReduced readmission rate by 47%(5.7%vs 10.2%)30精选pptHCMC has

23、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 reconciliation in the emergency roomMedication safety manager31精选pptCost to incr

24、ease staffing$112,000Reduction 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 Patient32精选ppt33精选ppt“the NPSG on reconciling medication information(originally NPSG.08.01.01,but now NPSG.03.0

25、6.01)was streamlined and focused to place a spotlight on critical risk points in the medication reconciliation process.NPSG.03.06.01 is effective July 1,2011”.http:/www.jointcommission.org/assets/1/18/National_Patient_Safety_Goals_6_3_111.PDF34精选pptNeed for a change-Identify the problemMeans for a c

26、hange-Executive committee (budget and support)-Action plan and modification(PDSA)Team for a change-multidisciplinary team (MD,RN,RPh Social Service and clinical clerks)35精选pptClinical Pharmacists involvement in a team based modelReal time feedbackEmpowering frontline staff to suggest and enact solut

27、ionsStandardizing work and processes36精选pptISMP-CanadaNCPDPNAPHIHINQFCMSAJHPLu Y.Clifford P,Bjorneby A,Thompson B,Van Norman S,Won K,Larsen K,Quality Improvement Case Study:Discharge Order Reconciliation for Skilled Nursing Facility Discharges in a Safety Net Teaching Hospital.Am J Health-Syst Pharm,(in press).37精选ppt数据政策其他行业支持医生护士医助高级护师38精选ppt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39精选ppt