회진시 약사참여가 약물부작용을 경감시킬수 있다는 논문

CMAJ • February 3, 2004; 170 (3)
© 2004 Canadian Medical Association or its licensors

--------------------------------------------------------------------------------
Do pharmacists' presence on rounding teams reduce preventable adverse drug events in hospital general medical units?
Edward Etchells

Patient Safety Service and Department of Medicine, Sunnybrook
and Women's College Health Sciences Centre, Toronto, Ont.

Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. .

Background: Pharmacists on rounding teams in intensive care units (ICUs) reduce adverse drug events. However, there are no studies of the impact of including pharmacists on rounding teams in non-ICU settings.

Design: In this single-blinded nonrandomized controlled trial, patients received care from either a rounding team that included a pharmacist (study group) or a rounding team without a pharmacist (control group). Follow-up was for the duration of hospitalization. The primary outcome measure was preventable adverse drug events, defined as undesirable reactions to medications that may have been prevented by appropriate drug selection or management. Two senior pharmacists and a physician, unaware of the treatment assignment, assessed each case for preventable adverse drug events.

Results: A total of 165 patients were included in the study: 86 in the study group and 79 in the control group. Pharmacists provided 150 interventions during the rounding process, 147 of which were accepted by the physicians. The most common interventions involved recommendations for dosage or frequency adjustments and for the addition of an indicated drug. There were 11 preventable adverse drug events: 2 in the study group and 9 in the control group (p = 0.02). The reliability of the reviewers for identifying such events was high ( = 0.71–0.87). The length of stay, drug charges and readmission rates did not differ significantly between the 2 groups.

Commentary: Preventable adverse drug events were significantly reduced in the study group, and physicians were receptive to pharmacists' suggestions. Similar benefits were observed in a previous study of pharmacist participation on rounds in an ICU setting.1 Inadequate dissemination of drug knowledge to physicians is a leading cause of preventable adverse drug events,2 so pharmacist expertise on rounds is a logical preventive 'treatment.' Of interest, study pharmacists frequently identified and addressed errors of omission. As a result, drug charges were slightly higher in the study group than in the control group. One important limitation is that the intervention ward had 2 pharmacy staff during the study period, whereas the control ward had only 1. Therefore, the observed benefits may be explained by better staffing rather than simply by better teamwork.

This study raises the intriguing possibility that a pharmacist on a rounding team may be more effective than computerized physician order entry (CPOE). One recent review concluded that CPOE substantially reduced medication error rates (by about 80%),3 but studies have not been powered to detect differences in preventable adverse drug events. By contrast, this is the second study to show a significant reduction in preventable adverse drug events because of pharmacist participation on rounds. Physicians may be more receptive to a friendly pharmacist than to a computer workstation, and pharmacist attendance on rounds involves less of a system change than a new CPOE system.

Practice implications: This small study from a single hospital cannot be used to make broad recommendations to change practice. However, promoting close teamwork with a pharmacist is unlikely to lead to harm or unintended negative consequences. The main barriers are staffing, competing demands and coordination of daily work schedules. Enthusiastic physicians should consider inviting their ward pharmacist on rounds for a couple of weeks, keeping a list of all of the recommendations made. Following this 'intervention,' the team can estimate the potential harm averted and time saved by intercepting problem orders. This simple exercise may provide enough local data to inform a change in practice while we await larger confirmatory studies.

Edward Etchells Patient Safety Service and Division of General Internal Medicine Sunnybrook and Women's College Health Sciences Centre Toronto, Ont.

References


Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282(3):267-70.[Abstract/Free Full Text]
Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995;274(1):35-43.[Abstract]
Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003; 163(12):1409-16.[Abstract/Free Full Text]










> 【미국·솔트레이크시티】 입원환자에 대한 약제 선택, 투여량의 결정, 약제치료 모니터링에서 발생하는 실수를 방지하기 위한 컴퓨터시스템이 별 효과를 얻지 못하는 것으로 밝혀졌다. 재향군인솔트레이크시티보건개호시스템(VASLC HCS) 노인병연구·교육·임상센터의 조나단 네베커(Jonathan R. Neberker) 박사는 컴퓨터 시스템을 갖춰도 부작용을 일으키는 투약 실수는 줄어들지 않는다고 Archives of Internal Medicine(2005; 165:1111-1116)에 발표했다.
>
>52%서 유의한 부작용
>
>VASLC HCS는 컴퓨터화 추진에 앞장서 왔으나 이번 조사에서는 컴퓨터화된 시스템에도 여러가지 문제점이 있음을 확인했다.
>
>조사에서는 2000년에 VASLC HCS에 20주 이상 입원한 환자 중 무작위로 추출한 937례에 대해 검토한 결과, 483례(52%)에 임상상 유의한 부작용이 확인됐다.
>
>이 시설에서는 투약지시의 컴퓨터 입력, 바코드에 따른 약제 처방, 진료카드의 완전 전자화, 약물상호작용의 자동체크, 알레르기 체크와 경고의 컴퓨터화 등 다방면으로 전자화를 추진해 왔으나 부작용 발생률은 앞서 설명한 것처럼 높은 비율로 나타났다.
>
>부작용에 따라서는 치료방침을 변경해야 할만큼 임상적으로 유의한 경우도 있었다. 또한 부작용 가운데 9%는 심각한 경우였으며 나머지 91%는 중등도였다.
>
>중등도란 모니터링이나 치료, 처방제의 투여중지나 투여량변경이 필요한 경우를 말한다.
>
>투약 오류 가운데 가장 많았던 것은 1)예상되는 약제반응에 대한 대처부족(36%)이다. 예를들어 이뇨제 투여시 저칼륨혈증 예방을 위해 칼륨을 처방하는 등의 대책이 미흡했던 경우다. 2)처방시 투여량의 잘못(33%) 3)부적절한 약제 처방(7%)― 등을 들 수 있다.
>
>잘못이 발생하는 단계 역시 다양했다. 주문 단계에서 61%, 모니터링 단계에서 25%로 나타난 반면 조제 단계에선 1%에 불과했다.
>
>컴퓨터 과신은 금물
>
>네베커 박사는 “잘 정비된 시스템이라도 의사와 다른 의료관계자는 컴퓨터 시스템에 지나치게 의존하는 것은 금물”이라고 설명한다.
>
>“컴퓨터 시스템을 도입하려는 병원은 채택한 시스템에 탑재돼 있는 제안 결정지원 시스템이 약제투여 과정에 얼마나 잘 작동하는지를 점검해야 한다”고 제안한다.
>
>박사는 또 투약오류의 중대성에 대해서도 다루고 있다. 과거 15년간 일부 연구에서는 투약오류는 전체 입원의 41%에 이르며 이로인해 연간 20억달러가 투입되고 있다고 지적됐다.
>
>이들 연구는 그러나 약제처방의 컴퓨터 입력과 관련 컴퓨터 시스템에 의해 이러한 잘못은 줄어들 것이라고 보고하고 있다.
>
>메디칼트리뷴
>
>
>
>
>