目的：探讨临床药师主导的慢病管理在出院老年精神病患者用药错误防范中的作用。方法：研究对象选自2019年3月至2020年9月在衢州市第三医院老年精神科住院、年龄60~85岁的精神病患者。在入院时对患者进行遴选，记录入组患者的基本信息，包括性别、年龄、支付方式、文化水平、职业、合并慢性病种及通讯信息。入组患者在住院期间由老年科临床药师对其进行同质化药学服务，出院时被随机分为干预组和对照组，出院后均接受为期24周的随访。干预组患者出院后第1~12周每2周随访1次，第13~24周每4周随访1次；对照组患者在出院后第12和24周末各随访1次。随访内容包括体重、血清泌乳素水平、血压、血糖、血脂、心肝肾功能、血药浓度等指标的检测结果，所应用药物的名称及用法用量，是否按时服药，有无药物不良反应，以及生活环境或监护人有无改变等。若发现患者出现用药错误，用专用表格记录用药错误的发现时间、内容、级别、次数及涉及药品的分类。临床药师在随访过程中对患者及其家属进行个体化用药指导，发现用药错误后及时进行干预、纠正。结果：干预组纳入患者54例，对照组54例，患者基本信息的差异均无统计学意义(均P ≥ 0.05)。24周随访期内，发现干预组有15例、对照组有10例患者出现用药错误，2组用药错误发现率差异有统计学意义[27.78% (15/54)比18.52% (10, 54, χ2 = 0.043, P = 0.032]。2组患者共发现用药错误44例，干预组30例次(68.18%)，对照组14例次(31.82%)；随访12周内，由药师发现的干预组和对照组的用药错误分别为28例次(93.33％)和12例次(85.71%)，差异有统计学意义(P = 0.002)。2组患者出现不同用药错误内容占比的差异无统计学意义(P > 0.05)，2组患者出现不同用药错误内容占比的差异无统计学意义(P > 0.05)，干预组以给药时间错误占比最高[干预组40.0% (12/30)，对照组以用药频次错误占比最高21.43% (3/14)]。在44例次用药错误中，43例次(97.73%)属于第2层级错误(有错误无伤害)，包括32例次C级错误和11例次D级错误；1例次(2.27%)属于第3层级错误(有错误有伤害)，为F级错误。经临床药师干预，第2层级错误均被纠正，第3层级错误导致患者再次入院治疗，经药师与主管医生再次向患者家属强调重复用药的危害性，遵医嘱用药的重要性后，患者未再出现用药错误。用药错误涉及的药品共8类(抗精神分裂症药、抗抑郁药、抗焦虑药、抗癫痫药(主要作心境稳定剂)、抗痴呆药、降糖药、抗心律失常药以及抗胆碱能药物)。结论：临床药师主导的精神病慢病管理有助于及时发现和纠正出院老年精神病患者的用药错误。

药师，老年人，精神病，病人出院，随访研究，用药错误

Zhizhen Hua, Haiyan Xie, Yunyu Chen, Shouya Zhang

Clinical Pharmacy Department of the Third Hospital of Quzhou City, Quzhou Zhejiang

Received: Jan. 27^th, 2022; accepted: Mar. 16^th, 2022; published: Mar. 23^rd, 2022

Objective: To explore the role of chronic disease management led by clinical pharmacists in the prevention of medication errors in discharged elderly psychiatric patients. Methods: The subjects were psychiatric patients aged 60~85 years old who were hospitalized in the Department of Geriatric Psychiatry of Quzhou Third Hospital from March 2019 to September 2020. The patients were selected at the time of admission, and the basic information of the enrolled patients was recorded, including gender, age, payment method, educational level, occupation, combined chronic diseases and communication information. The patients in the group received homogenized pharmaceutical care by the clinical pharmacist of geriatrics during hospitalization. They were randomly divided into intervention group and control group at discharge. They were followed up for 24 weeks after discharge. The patients in the intervention group were followed up every 2 weeks from the 1st week to the 12th week after discharge, and every 4 weeks from the 13th week to the 24th week; the patients in the control group were followed up once at the 12th and 24th weekend after discharge. The follow-up contents include the test results of body weight, serum prolactin level, blood pressure, blood glucose, blood lipid, heart, liver and kidney function, blood drug concentration and other indicators, the name, usage and dosage of the drugs used, whether the drugs are taken on time, whether there are adverse drug reactions, and whether the living environment or guardians have changed. If the patient is found to have medication errors, use a special form to record the discovery time, content, level, times of medication errors and the classification of drugs involved. Clinical pharmacists provide individualized medication guidance to patients and their families during follow-up, and timely intervene and correct medication errors. Results: There were 54 patients in the intervention group and 54 patients in the control group. There was no significant difference in the basic information of patients (all P ≥ 0.05). During the follow-up period of 24 weeks, it was found that 15 patients in the intervention group and 10 patients in the control group had medication errors. The difference in medication error detection rate between the two groups was statistically significant [27.78% (15/54) vs. 18.52% (10/54), χ 2 = 0.043, P = 0.032]. 44 cases of medication errors were found in the two groups, 30 cases in the intervention group (68.18%) and 14 cases in the control group (31.82%); within 12 weeks of follow-up, the medication errors found by pharmacists in the intervention group and the control group were 28 cases (93.33%) and 12 cases (85.71%) respectively, with significant difference (P = 0.002). There was no significant difference in the proportion of different medication errors between the two groups (P > 0.05), and there was no significant difference in the proportion of different medication errors between the two groups (P > 0.05). The proportion of medication time errors in the intervention group was the highest [40.0% (12/30) in the intervention group, and 21.43% (3/14) in the control group]. Among 44 medication errors, 43 (97.73%) belonged to level 2 errors (with errors and no harm), including 32 Level C errors and 11 level D errors; one case (2.27%) belongs to level 3 error (with error and injury), which is level F error. After the intervention of the clinical pharmacist, the level 2 errors were corrected, and the level 3 errors led to the patient’s readmission for treatment. After the pharmacist and the competent doctor again emphasized the harm of repeated medication to the patient’s family members and the importance of medication according to the doctor’s advice, the patient did not have medication errors again. There are 8 types of drugs involved in medication errors (anti schizophrenic drugs, antidepressants, anti anxiety drugs, anti epileptic drugs (mainly used as mood stabilizer), anti dementia drugs, hypoglycemic drugs, antiarrhythmic drugs and anticholinergic drugs). Conclusion: Clinical pharmacist led chronic psychiatric disease management is helpful to find and correct the medication errors of discharged elderly psychiatric patients in time.

Keywords:Pharmacist, The Aged, Mental Disease, Patient Discharge, Follow-Up Study, Medication Error

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精神分裂症是一组原因未明的重型精神病，通常病情迁延，治疗周期较长，并且容易反复发作甚至逐渐加重，目前临床上以药物治疗为主 [ 1 ]。伴随着老龄化的进程，55岁及以上的老年精神病患者在全部精神分裂症患者中所占的比例将约达到25% [ 2 ]。然而老年精神病患者因其生理特性如认知障碍、视力听力障碍等可增加用药风险；随着年龄的增加，往往伴有多种躯体疾病，多药治疗的同时，增加了潜在用药风险。马翔宇 [ 3 ] 等研究报告表明30.5%的老年人存在不适当用药，尤其是在患有精神疾病的患者中较为常见。熊甜 [ 4 ] 等对1167例内科出院老年患者调查结果显示，471例(40.4%)发生了用药错误。用药错误(medication error, ME)是指药品在使用及管理全过程中出现的任何可以防范的用药疏失，可导致患者发生潜在或直接的损伤 [ 5 ]。Kunac和Tatley [ 6 ] 基于新西兰药物警戒数据库数据的研究结果显示62.5%的ME发生于年龄 ≥ 65岁的老年患者。用药错误是影响患者安全最突出的问题，据WHO统计数据显示，全球约1/3的死亡是由于不合理用药而非疾病本身。防范用药错误是一个世界性课题，贯穿于患者的整个用药过程。但目前多数防范举措是在患者住院期间实施，出院后的用药错误防范往往被忽视，老年精神病患者用药错误风险的提高导致患者的用药不良事件增加，同时也增加了患者的经济负担，成为卫生公共事件。随着国家政策文件的出台以及药品费用控制需求，医疗机构开始执行4 + 7药品的采购政策，许多精神科药品产地做了更改，意味着药品的药片规格、剂型以及商品名都发生了很大变动，导致因药物产地、剂型、规格的改变致患者重复服药、超剂量服药等用药错误，尤其是在出院后的老年精神病患者中最为明显。

国务院《中国防治慢性病中长期规划(2017~2025年)》中指出，慢性病是严重威胁我国居民健康的一类疾病，已成为影响国家经济社会发展的重大公共卫生问题。规划中提出计划至2020年，65岁以上老年人中医药健康管理率达到65%，2025年达到80% [ 7 ]。慢病管理(Chronic disease management, CDM)是指组织专业医师、药师及护理人员，为慢性病患者提供全面、连续、主动的管理，以达到促进健康、延缓慢性病进程、减少并发症、提高生活质量并降低医药费用的一种科学管理模式 [ 8 ]。国外有学者报道，以药师为主导的干预防范模式可大幅降低医师导致的ME [ 9 ] [ 10 ]。目前我国慢病管理主要为慢病信息监测系统模式 [ 11 ]、慢病自我管理模式 [ 12 ]、慢病健康管理模式 [ 13 ] 等，这些管理模式多集中在社区，参与人员以护士为主导，主要工作形式为收集数据，建立档案和健康教育 [ 14 ]，药师参与管理的病种主要是高血压 [ 15 ]、糖尿病 [ 16 ]、冠心病 [ 17 ]，精神病的慢病管理，药师未参与并未主导。临床药师作为兼具药物知识和临床知识的医务人员，是为老年精神病患者提供慢病管理的合适人选。以精神病、慢病管理、药师等为检索词，检索中国知网、万方医学、博库科技等数据库近5年(本课题启动前)收录的文献，目前国内药师参与并主导老年精神病患者的慢病管理，防范潜在用药错误的相关研究较少。为此，我们选择在我院出院的老年精神病患者进行慢病管理的前瞻性研究，进行为期24周的随访，探讨药师在防范老年精神病出院患者用药错误中的作用和开展药学服务的必要性。报告如下。

本研究结果显示，以临床药师为主导的慢病管理有助于及时发现并纠正出院老年精神病患者的用药错误，对出院老年患者的用药安全具有积极意义。本研究也设计方案存在不足之处，导致2组入组研究人数偏少，对试验结论的说服力产生一定影响。因此，我们需要改进研究方案，设计多中心、大样本的研究。尽管住院期间和出院时对老年患者做了详细的用药指导，出院后随访时仍能发现患者出现用药错误。这提示药师用药安全教育工作不完全到位。今后对老年慢病患者进行用药安全管理时应缩短随访间隔，与老年患者沟通时，注意放慢语速，重要的内容应重复讲解，必要时可让老年患者重复药师强调的重点，给患者提供易于理解的用药宣传材料。同时，在老年患者住院、出院和随访时应尽可能对患者、家属或监护人同时进行用药指导。

衢州市指导性科技计划项目(2020116)。

华志珍,谢海燕,陈云郁,张守亚. 临床药师主导的慢病管理在出院老年精神病患者用药错误防范中的作用The Role of Chronic Disease Management Led by Clinical Pharmacists in the Prevention of Medication Errors in Discharged Elderly Psychiatric Patients[J]. 医学诊断, 2022, 12(01): 50-59. https://doi.org/10.12677/MD.2022.121009