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驻科药师制度下主动式出院带药医嘱审核和用药教育服务模式

研究
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孙闻续 ，游欣月，江 弦，吴逢波（四川大学华西医院临床药学部，成都 610041）
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中图分类号 R969.3 文献标志码 A 文章编号 1001-0408（2025）10-1243-05
DOI 10.6039/j.issn.1001-0408.2025.10.16

摘 要 目的 构建主动式出院带药医嘱审核和用药教育服务的药学服务模式（以下简称“主动式药学服务模式”），并评价其效
果。方法 回顾性收集我院风湿免疫科 2023 年 1－6 月和 2024 年 1－6 月出院的患者资料。按患者接受药学服务模式的不同将
2024年1－6月出院的患者归为干预组（489例），2023年1－6月出院的患者归为对照组（535例）。对照组患者接受传统药学服务
模式，干预组患者在对照组基础上接受主动式药学服务模式。比较两组患者的主要结局指标[出院带药品种数、用药错误及不良
药物相互作用（DDI）发生情况]和随访结局指标（因无法耐受而调整用药方案、非计划入院、出院后主动寻求药学服务情况）；记录
主动式药学服务模式患者的出院带药医嘱审核情况、多重用药患者的不良DDI发生情况及床旁用药教育情况。结果 2024年1－
6月，累计完成住院患者出院带药医嘱审核1 052例次，发现用药错误174例次；579例患者出现多重用药，发生率为55.04%；多重
用药患者的不良DDI发生率显著高于非多重用药患者（P＜0.001）；药师完成居家用药错误高风险患者带药指导394例次。干预
组患者的出院带药品种数，用药错误、用药与诊断不符、用法用量错误、不良DDI及因无法耐受而调整用药方案发生率均显著低于
对照组（P＜0.05），出院后主动寻求药学服务发生率显著高于对照组（P＜0.05）；两组患者的非计划入院发生率比较，差异无统计
学意义（P＞0.05）。结论 所建主动式药学服务模式有效降低了患者的用药错误，提高了患者对药学服务的认可度，保障了患者居
家用药的安全性。
关键词 驻科药师；药学服务；出院带药；医嘱审核；用药教育

Research on proactive pharmaceutical service model of discharge medication order review and medication
education under resident pharmacist system
SUN Wenxu，YOU Xinyue，JIANG Xian，WU Fengbo（Dept. of Clinical Pharmacy， West China Hospital of
Sichuan University， Chengdu 610041， China）

ABSTRACT OBJECTIVE To develop a pharmaceutical service model for discharge medication order review and medication
education （hereinafter referred to as the “proactive pharmaceutical service model”）， and evaluate its effects. METHODS The data
of discharged patients were collected retrospectively from Rheumatology and Immunology Department of our hospital during
January to June 2023 and January to June 2024. Patients discharged from January to June 2024 were classified as the intervention
group （489 cases）， while patients discharged from January to June 2023 were classified as the control group （535 cases） based on
the different pharmaceutical service models they received. The control group received traditional service model， and the intervention
group additionally got proactive pharmaceutical service model based on the control group. The primary outcome measures [the
number of discharge medications， the number of medication errors， and the occurrence of adverse drug-drug interaction （DDI）] and
follow-up outcome measures （the adjustment of medication regimen due to intolerance， unplanned hospital admissions， and
proactive seeking of pharmaceutical services after discharge） were compared between the two groups. The discharge medication
order review status， the occurrence of adverse DDI in patients with polypharmacy， and bedside medication education status for
patients receiving the proactive pharmaceutical service model were all recorded. RESULTS From January to June 2024， a total of
1 052 discharge medication order review for inpatients were reviewed， and 174 instances of medication errors were identified.
Polypharmacy was observed in 579 patients， with an incidence rate of 55.04%. The incidence of adverse DDI was significantly
higher in patients with polypharmacy compared to those without polypharmacy （P＜0.001）. Pharmacists completed medication
guidance for 394 instances of high-risk patients prone to the
Δ 基金项目 四川省科普培训项目（No.2024JDKP0102） incidence rate of medication errors at home. The number of
＊第一作者 主管药师，硕士研究生。研究方向：临床药学。E-mail：
discharge medications， the incidence rate of medication errors，
476245291@qq.com
# 通信作者 主任药师，博士。研究方向：临床药学、医院药学。 instances of medication not matching the diagnosis， dosage
E-mail：fbwu2013@163.com and administration errors， adverse DDI， and the incidence rate

中国药房 2025年第36卷第10期 China Pharmacy 2025 Vol. 36 No. 10 · 1243 ·