整合藥師臨床監測作業及電腦醫囑決策系統降低抗生素劑量疏失及藥物不良事件發生率

Integrated the Pharmacist Clinical Monitoring Practices and Decision-Guide Order Entry System to Reduce the Antibiotic Dosing Errors and Adverse Drug Events

背景：電腦醫囑輸入系統雖可減少字跡不清方面的醫囑疏失，但劑量鍵入錯誤，或因專業知識缺乏引起的醫囑錯誤並無法避免；而一個有決策引導功能的醫囑開藥系統卻能減少這方面的疏失。藥師臨床上的監測作業雖能有效防止醫囑疏失，卻因耗時耗力而成效有限。若將兩種方式整合應用，預期對病人用藥安全將有更大的效益。本研究即為探討整合電腦醫囑決策功能與藥師之臨床監測作業對改善抗生素劑量疏失之成效。材料與方法：1.於CPOEs嵌入13種與腎功能相關之抗生素劑量決策功能，使於醫囑開立時主動提示適當之劑量。2.再由臨床藥師透過全院抗生素劑量監測系統，掃描住院病人之抗生素劑量，進一步提供醫師適當的劑量建議。3.比較上述兩種方式整合前後，發生不適當抗生素劑量醫囑及相關之腎臟功能損傷風險趨勢，描述性分析醫師對劑量建議之接受度。結果與討論：在整合兩種方式4年後，不適當抗生素劑量醫囑發生率約下降80%，其相對風險（RR）介於0.23-0.18之間；抗生素相關之腎功能惡化發生率從整合前12.39%下降到9.47%。醫師對劑量決策功能建議之接受度由建立初期（2005年）的68.2%上升到94.7%，且醫師對藥師建議之抗生素劑量接受度平均高達97.65%。此研究結果證實整合藥師臨床監測作業及電腦醫囑決策系統確實能協助醫師正確開立醫囑，降低劑量錯誤所帶來的不良事件。

Background: Computerized physician order entry systems can reduce prescription writing errors, however, the typing error or lack of knowledge still can't be avoided. A decision-guide order entry system can really reduce these errors. Although the clinical drug monitoring by pharmacist can prevent medication error effectively, the time-consuming and labor-intensive limit this effectiveness. When integrate these ways of decision-guide order entry system and drug monitoring by pharmacist to avoid medication errors, the benefits of patient drug safety may be improved. The purpose of this study was to investigate the effectiveness of integrated the pharmacist clinical monitoring practices and decision-guide order entry system to reduce the antibiotic dosing errors and the incidence of adverse drug events.Material and methods: 1. The antibiotic dosage decision-guide calculators which have 13 antibiotics related renal functions was implemented into CPOE system. The appropriate dosage regimen can provide automatically when the antibiotics were been prescribed. 2. The clinical pharmacist could scan in patients' antibiotic dosage by ”antibiotic dosage monitoring system”, and further provided appropriate recommendations to physicians. 3. Compared the risk of inappropriate antibiotic dosage prescriptions and kidney impairment before and after these two ways were integrated. Use description method to analyze the physicians' acceptant rates of dosage recommendations from antibiotic dosage decision-guide calculators and pharmacists.Results and discussion: After these two ways were integrated for 4 years, the inappropriate antibiotic dosing errors were decreased about 80%, the relative risk (RR) were within 0.23-0.18. The incidence rates of antibiotic related renal function deterioration were decreased from 12.39% to 9.47% before and after integrated. The physician acceptant rates in dosage decision function were increased from 68.2% in 2005 to 94.7% in 2008, and 97.65% in pharmacist dosage recommendations. According to this study result, we can conclude that the integrated pharmacist clinical monitoring practices and decision-guide order entry system really to assist physicians prescribing correct antibiotic prescriptions, and reduce the adverse events due to dosage error.