药物治疗追踪服务纪录.ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,Drug Utilization Evaluation,for,Antimicrobial,Agents,(,藥物治療追蹤服務紀錄,),藥 劑 部,陳本源 主任,2005.03.30,藥物治療追蹤服務記錄,日期,:,2003.01.01 2003.12.31,藥物類別:,抗微生物製劑,合計,:,1102,件,性別,:,M(693):F(409),抗微生物製劑用藥問題類別,日期,:,2003.01.01 2003.12.31,總計,:,1102,件,藥品劑型:,101,給藥頻次:,54,電腦操作錯誤:,39,用法不當18,劑量疏失:,8,給藥途徑:,3,藥物錯誤:,2,處方不清楚,:,223,劑量疏失,A 72y/o male,she suffered from VAP after one week,Rx:,Piperacillin,2.25gm Q6H,由於,Piperacillin,每,vial,之劑量為,2,gm,而,Tazocin(Piperacillin/Tazobactam,),每,vial,之劑量才是,2.25gm,故建議將,Piperacillin,改為,2,gm Q6H,用法不當,A 64y/o woman,she suffered from,erythematous,skin change over right flank for 1 week.Under the impression of r/o herpes,zoster,she was admitted.,Serum,creatinine,=,6.0 mg/dl,Rx:,Acyclovir inj,.125mg QD(997,元,/,AMP),Dosage adjustments are recommended in patients with,Clcr,10ml,/mim,50%of the usual dose every 24,hours,or,the full standard dose every 48 hours,(Laskin,et al,1982).,由於,Acyclovir inj,.,稀釋後在,室溫下只保有,12,hrs,安定性,且無法冷藏,故建議調整為,250,mg,Q2D,use,.,給藥頻次,A 72y/o male,diagnosed by cervical,spondylosis,with,myelopathy,.His sputum/c=,H.,influenzae,.,Serum,creatinine,=0.7 mg/dl,Rx:,Augmentin inj,.2vial Q12H,The usual dose interval of,Augmentin,is every,8hrs,.,故建議調整為,2vial Q8H,藥品劑型,A 73y/o male,diagnosed by pulmonary TB,Rx:,Rifadin,(300mg)cap 450mg QD/AC,由於,Rifadin,每次服用,450,mg,故建議改用,Rifadin,450mg/cap,之劑型,.,電腦操作錯誤,A 49y/o male,diagnosed by l,iver cirrhosis with,hepatoencephalopathy,Rx:,Nystatin,oral tab.,10TAB x TID,for Gargling,5%G/W 500cc,1 BOT x TID,for Gargling,由於處方開立為,standing order,每日會入帳,30TAB,Nystatin,oral tab.,及,3,BOT 5%G/W 500cc,故建議將,order,改成,X-type,開立(,Nystatin,oral tab.,X,10,QID,for Gargling AND 5%G/W,X,500CC QID,for Gargling.,藥物劑量,:,422,劑量過高,:312,(73.9%),劑量過低,:110,(26.1%),劑量過高,(,I),A 71y/o male,body weight=,35kg,h,e was diagnosed by hospital acquired pneumonia,bilateral with respiratory failure s/p,tracheostomy,&mechanical,ventilatior,Serum,creatinine,=1.5 mg/dl,預估,Clcr,=22.4ml/min,Rx:,Ciprofloxacin,(100mg)400mg Q12H,The usual dosage of,Ciprofloxacin,=200-400mg Q12H,故建議將,order,調整為,300,mg Q12H,劑量過高,(,II),A 39y/o female,diagnosed by,CBD stone with,cholangitis,and septic shock,Rx:,Metronidazole inj,.500mg Q8H,Because patient poor liver function(,Bil,.T=15.4;AST/ALT=179/89)and,Scr,=1.8mg/dl,reduce dosage in,severe liver disease,or,Clcr,50 ml/min,60%to 90%of the normal dose every 8 to 12 hrs;GFR 10 to 50 ml/min,30%to 70%of the dose every 12 hrs;,GFR,normal value 10 times),建議先停用,Fluconazole,.,相關檢驗,(,抗生素藥物血中濃度測定,),Aminoglycosides,:,Gentamicin,Amikacin,Glycopeptides,:,Vancomycin,After 4-5 doses(steady state),Peak conc.,=at least 30min.IV infusion,then after 30min.,(,Gentamicin,Amikacin,)and,1hour IV infusion,then after 30-60min.,(,Vancomycin,),Trough conc.,=before next dose,不符合健保規定,(,I),A 23y/o male,diagnosed by Upper Respiratory Infection,Rx:,Ampicillin,inj,.500mg Q6H (THD),由於健保規定病患出院帶藥應以口服劑型藥物為主,故,建議將,Ampicillin inj,.,更正為,Ampicillin,cap.500mg Q6H,不符合健保規定,(,II),A 71y/o female,diagnosed by,l,ung cancer,RLL,advanced stage,s/p op and R/T and C/T,Rx:,Nystatin,oral suspension 2CC QID(for gargling),由於,Nystatin,oral suspension,含100,000,U/ml(24ml,/Bot,),此為兒科劑型,故,建議將,Nystatin,suspension,更正為,Nystatin,oral,tab,X10 QID,+D5W,X,500CC QID,for,gargling,.,注射劑型換成口服劑型,Conversion from intravenous to oral medications,Arch Intern Med.2003,Many hospitalized patients continue to receive intravenous medications longer than necessary.Earlier conversion from the intravenous to the oral route could increase,patient safety,and,comfort,reduce costs,and,facilitate earlier discharge from the hospital,without compromising clinical care,Antibiotics IV to Oral Conversion Guideline,Eligibility Criteria,Patients have one of the following infection:,UTI,skin/soft tissue,lower respiratory,bone and joint,Patients can take oral medication,Patients is,afebrile,for 48 hours on IV antibiotics,Patients has received at least 72 hours of IV antibiotics,Pathogens is sensitive to antibiotics per culture and sensitivity results,Patients is responding to IV therapy with showing signs and symptoms of clinical,improvment,Exclusion Criteria,Patients with serious infections that have a high rate of treatment failure such as,meningitis,sepsis,endocarditis,undrained,abscesses,and,MRSA,or,Enterococcus spp,.,bacteremia,.,Patients with,neutropenia,Patients with,immunocompromised,Patients with positive blood culture within two days,Patients with positive CSF culture within ten days,Patients with unstable in,hemodynamic,monitoring or changes in mental status,Dosage Guidelines and Clinical Equivalency,IV Drug and Dose Oral Drug and Dose,Ampicillin,1gm Q6H,Amoxicillin,500mg Q8H,Unasyn,1.5gm Q8H,Augmentin,375mg Q8H,Aztreonam,(any dose),Ciprofloxacin,500-750mg Q12H,Cefazolin,1gm Q8H,Ceflexin,500mg Q6H,Ceftazidime,(any dose),Ciprofloxacin,500750mg Q12H,Ciprofloxacin,400mg Q12H,Ciprofloxacin,500-750mg Q12H,Clindamycin,300-600mg Q8H,Clindamycin,300-450mg Q6H,Oxacillin,1-2gm Q6H,Prostaphlin,0.5-1gm Q6H,Erythromycin 500mg Q6H Erythromycin 500mg Q6H,Metronidazole,500mg Q8H,Metronidazole,500mg Q8H,Timentin,(any dose),Augmentin,375mg Q8H,結 果,醫師接受建議,:1081(98.1%),醫師拒絕建議,:21(1.9%),醫師拒絕之用藥問題類別分析,日期,:,2003.01.01 2003.12.31,總計,:,拒絕,21,件/總建議,1102,件,臨床藥事照顧之效益,美國1995年藥物經濟學研究文章結論,，,針對門診病患因藥物導致傷害與死亡,，,在1994年預估花掉766億美金的醫療資源而當年的藥物總花費是730億美金,藥師執行藥事照顧估計可減少53-63%藥物導致的傷害與死亡,，,而一年可避免約456億美金醫療花費的支出,臨床藥事照顧之效益,降低病人住院次數與天數,減少至急診的次數,降低藥物副作用的發生及所花之費用,總額給付及論人計酬制度實施時必需因應之策略,結 論,醫院藥師應秉持著“服務病患”之宗旨，積極推展各項藥事專業，以提供高品質之藥事服務，確保病患能得到有效、安全、合理及符合經濟效益的藥物治療；進而期望能達到,提昇醫療服務品質,，,降低醫療費用,之目標。,Thanks for Your Attention,!,