品管圈在改进医院药学服务质量中的探索

目的:分析医院药学服务现状,评价品管圈在医院药学服务质量改进中的应用效果。方法:计划、实施"质效圈"活动;采用行为观察法,在活动前1周、品管圈实施后1个月后某一周,随机观察100次配方、100次制剂、100次摆药所需要消耗的时间,调查活动前2个月至前1个月,活动后1个月~2个月,配方差错率、处方差错率、制剂差错率、摆药差错率,临床药学活动次数。结果:活动后,配方时间、制剂时间、摆药时间低于活动前,差异具有统计学意义(P0.05);活动后,配方、处方、制剂、摆药差错率低于活动前,差异具有统计学意义(P0.05);改进后,个体化用药方案设计增幅107.73%、科室患者药学咨询量增幅20.48%。结论:开展品管圈活动后,药师工作效率、质量明显提高,参与临床药学工作意愿明显增强。     

静脉用药调配中心分阶段分模块带教的体会

探讨静脉用药调配中心(PIVAS)药学实习生、进修人员分阶段分模块带教的培训管理模式。根据《静脉用药配中心质量管理规范》、《静脉用药调配管理教程》、《处方管理办法》、《临床静脉用药调配与使用指南》等培训内容,通过不断探索,制订了我中心阶段式培训内容、重点知识模块化、培训方法、考核标准等。从而初步建立我中心实习、进修人员规范化培训体系,改善了PIVAS的药学实习生的带教质量,为我中心推行实习生、进修生规范化培训工作打下了基础,积累了经验。学员能全部按计划完成培训内容,考核成绩合格。     

全医嘱静脉药物配置中心配送时效的优化

目的 运用现代物流管理方法,对运输人员进行工作量分析和运送人力分析,以满足静脉药物配置中心长期医嘱和临时医嘱的药品配送需求。方法 根据自身硬件和软件条件,利用统计学方法对运输工作量和运输人员的人力等方面进行分析,再利用现代物流管理理念和方法对药品配送中的硬件准备和路径选择拟定PIVAS所配药品的运送需求。结果 从硬件准备到路径选择,同时结合统计学计算运输工作量和运输人员的人力分析,从实际出发使医院内部物流能满足PIVAS所配药品的运送需求。结论 PIVAS配置长期医嘱,同时也能承接临时医嘱的配置,完善的物流配送是保证其正常动作的基础。     

品管圈活动在提高住院药房工作质量中的探索与实践

???? 在住院药房进行品管圈活动推进工作,通过系统培训,按照品管圈活动的主要步骤实施,即主题选定、现状把握、目标设定、解析、对策拟定与实施、效果确认、作业标准化等。病区对住院药房投诉频次由改善前的平均8.4次/天降到3.9次/天,病区药学服务质量得到明显改善,提高了病区对住院药房工作的满意度,工作人员的软环境也得到了相应改善。     

基于知识库和商业智能的临床用药指引及监测系统

目的 有效规范临床用药，进行合理用药指标的监控，降低临床用药风险。方法 依据临床用药知识库，将用药规范和制度与医嘱系统流程融合；采用商业智能技术，抽取医院管理、医嘱、检验等临床业务数据库，建立主题模型，监测临床用药的各项指标。结果 软件化定制了临床用药规范和制度，在医嘱系统中实现提醒和审批流程。实时、精细化展示合理用药指标报表，并能进行潜入分析。结论 减少不合理用药医嘱，同时极大提高了合理用药数据统计、分析的效果和效率。     

以静脉药物配置中心为平台的静脉用药医嘱干预

目的 以静脉药物配置中心为平台,对用药医嘱进行分析和干预,提高用药医嘱的合理性,促进临床合理用药。方法 对静脉药物配置中心服务的6个病区用药医嘱中的不合理医嘱进行统计分析。结果 不合理医嘱明显减少,用药医嘱合理性大幅度提高差异有显著性（P＜0.01）。结论 通过对用药医嘱干预,能促进临床合理用药,保证患者用药安全。     

静脉药物集中配置中心的质量控制和管理

目的探讨静脉药物集中配置的质量控制方法和管理效果。方法我院自2013年成立静脉药物集中配置中心(PIVAS)后,建立与完善质量控制小组、制度建设、人员培训和管理,并对药品和器材、环境卫生、配置等方面进行严格管理,不断进行总结分析改进药物配制方法。结果完善药物配制质量控制措施后,未发生因药物配置引起的输液反应,无1例配错药等静脉用药不良事件发生,而且不合理用药情况、药品流失现象较PIVAS成立前显著减少,同时也节约了临床护士近40%的人力资源。结论对PIVAS进行质量控制和管理,可提高用药安全和输液质量,提高患者的满意度,促进医院社会效益和经济效益的提高。     

品管圈活动对手术室护士的持续影响

目的探讨品管圈活动对手术室护士综合素质的持续影响。方法 2014年6~10月我科8名护士自愿继续开展第二期品管圈活动,并对活动前后进行无形成果自我评分,分析实施第二期品管圈活动后对护士综合素质的影响。结果 8名手术室护士对无形成果自我评分中,活动后成长最低为0.7,最高为1.1。结论品管圈活动可持续提高手术室护士综合素质,有利于个人成长,护士应坚持每年参加品管圈活动。     

品管圈在持续改进药事质量管理的实践效果评价

目的 完善医院药学品质监管体制的核心在于借助监管工具实现经验监管到科学监管的过渡,探讨质量管理工具对医院药事质量管理的影响。方法 对医院品管圈的理论基础、流程、运营环境等进行讲解,整理医院开展的QCC活动,对该项目最终取得的成果进行剖析。结果 活动改善后患者取药时间明显低于对照组(P＜0.05);药品账物相符率、患者用药依从性差异有统计学意义(P＜0.05)。结论 在医院对药学部质量管理实施品管圈模式,及时发现和改进药事管理中的不足,为全面提高医院药事服务质量提供可靠依据。     

静脉药物配置中心差错分析

目的:通过对静脉药物配置中心出现的各类差错进行分析探讨,发现其在工作中存在的问题,总结经验教训,为促进临床合理用药、减少和避免药疗差错提供参考.方法:根据药品说明书<中国药典>,<临床用药须知>等相关规定,对2007～2008年我院静脉药物配置中心出现的各类差错进行回顾性分析.结果:静脉药物配置中心的差错率主要发生在医师医嘱、护士录入医嘱、药护排药、药护配置、成品核对等工作环节.结论:药学服务是提供负责的药物治疗,其目的在于实现改善患者生活质量的既定结果,这些结果包括治愈疾病,消除或减轻症状,阻止或延缓疾病进程及防止疾病或症状的发生.由此可见,药师在处方审核和临床合理用药方面起着至关重要的作用.     

Quality of Pharmaceutical Care in Surgical Patients

Background

Surgical patients are at risk for preventable adverse drug events (ADEs) during hospitalization. Usually, preventable ADEs are measured as an outcome parameter of quality of pharmaceutical care. However, process measures such as QIs are more efficient to assess the quality of care and provide more information about potential quality improvements.

Objective

To assess the quality of pharmaceutical care of medication-related processes in surgical wards with quality indicators, in order to detect targets for quality improvements.

Methods

For this observational cohort study, quality indicators were composed, validated, tested, and applied on a surgical cohort. Three surgical wards of an academic hospital in the Netherlands (Academic Medical Centre, Amsterdam) participated. Consecutive elective surgical patients with a hospital stay longer than 48 hours were included from April until June 2009. To assess the quality of pharmaceutical care, the set of quality indicators was applied to 252 medical records of surgical patients.

Results

Thirty-four quality indicators were composed and tested on acceptability and content- and face-validity. The selected 28 candidate quality indicators were tested for feasibility and ‘sensitivity to change’. This resulted in a final set of 27 quality indicators, of which inter-rater agreements were calculated (kappa 0.92 for eligibility, 0.74 for pass-rate). The quality of pharmaceutical care was assessed in 252 surgical patients. Nearly half of the surgical patients passed the quality indicators for pharmaceutical care (overall pass rate 49.8%). Improvements should be predominantly targeted to medication care related processes in surgical patients with gastro-intestinal problems (domain pass rate 29.4%).

Conclusions

This quality indicator set can be used to measure quality of pharmaceutical care and detect targets for quality improvements. With these results medication safety in surgical patients can be enhanced.     

美国FDA医药产品CGMP相关警告信统计分析及启示

对述20了1罕2 年见—病2及0孤16儿年药上的半定年义美和国研F发D意A 义发,出重的点人介用绍产了品美(国尤针其对是孤医儿药药产开品发)的动现态有生制产度质法量规管、理激规励范政(策CG及M管P理)经相验关,警并告以信实进例行 分统析计从分研析发,、总注结册并和解上析市这等类角警度告探信讨中了所美提国及孤的儿常药见开缺发陷的项策目略,,探旨讨在FD为A从对事医孤药儿产药品开的发监工管作重的点人,士同提时供提参出考对。我国医药企业的启示,为我 [国关企键业词把握] 世孤界儿医药药;罕产见品病质;量激管励理政的策趋;势开和发改策进略自身生产质量管理水平,提供参考。     

Differences in the Volume of Pharmaceutical Advertisements between Print General Medical Journals

Background

Pharmaceutical advertisements have been argued to provide revenue that medical journals require but they are intended to alter prescribing behaviour and they are known to include low quality information. We determined whether a difference exists in the current level of pharmaceutical advertising in print general medical journals, and we estimated the revenue generated from print pharmaceutical advertising.

Methods

Six print general medical journals in Canada, the United States, and the United Kingdom were sampled between 2007 and 2012. The number of advertisements and other journal content in selected issues of the Canadian Medical Association Journal (CMAJ), Canadian Family Physician (CFP), Journal of the American Medical Association (JAMA), New England Journal of Medicine (NEJM), British Medical Journal (BMJ), and Lancet were determined. Revenue gained from pharmaceutical advertising was estimated using each journal''s 2013 advertising price list.

Findings

The two Canadian journals sampled (CMAJ, CFP) contained five times more advertisements than the two American journals (JAMA, NEJM), and two British journals (BMJ, Lancet) (p<0.0001). The estimated annual revenue from pharmaceutical advertisements ranged from £0.025 million (for Lancet) to £3.8 million (for JAMA). The cost savings due to revenue from pharmaceutical advertising to each individual subscriber ranged from £0.02 (for Lancet) to £3.56 (for CFP) per issue.

Conclusion

The volume of pharmaceutical advertisements differs between general medical journals, with the two Canadian journals sampled containing the most advertisements. International and temporal variations suggest that there is an opportunity for all general medical journals to reduce the number of pharmaceutical advertisements, explore other sources of revenue, and increase transparency regarding sources of revenue.     

Audit of the Medical Audit Committee.

We reviewed 39 medical audits started in one institution between 1981 and 1985 to determine whether they monitored the quality of health care in a scientific manner, whether recommendations were made that could improve the quality of health care and, if so, whether the recommendations were acted on. Thirty-three audits (85%) were completed; 21 (64%) failed to state their objectives, 30 (91%) failed to compare their results with those in the literature, 9 (27%) made no recommendations that could improve the quality of health care, and 9 were poorly researched and written. The number of patients in each audit was usually adequate. Feedback was rarely received by the Medical Audit Committee concerning the Medical Advisory Committee''s response to the audit. Information concerning the implementation of recommendations was available for 17 of the 24 audits that made recommendations; 7 (41%) had failed to implement half or more of the recommendations. Despite these problems, 8 (24%) of the audits were considered to be of a quality that could improve health care. We present recommendations to improve the audit procedure and foster the growing confidence among doctors in the medical audit.     

Medical Audit,Continuing Medical Education and Quality Assurance

Medical audit and continuing medical education (CME) are now the mainstays of quality assurance in hospitals. Audits should address problems that have serious consequences for patients if proper treatment is not given. The single most important step is the selection of essential or scientific criteria that relate process to outcomes. CME does less than commonly believed to improve care. Today, quality assurance increasingly means a near-guarantee to every patient of appropriate treatment and fewest possible complications. Maintenance of the public trust rests on a firm commitment of the medical staff and board to this principle, implemented through an organized program of quality assurance. Under these conditions, medical audit and CME can effectively improve care by improving physician performance.     

基于品管圈的单孔腹腔镜胆囊切除术知晓率 ——以提高老年患者知晓率为例

目的 提高老年患者对单孔腹腔镜胆囊切除术的知晓率。方法 开展品管圈活动,找出老年患者对该术知晓率低的原因,制定并实施相应措施。结果 经医生判断符合该术标准的老年患者,对手术的知晓率、选择率显著增加;术后疼痛评分降低,住院时间缩短,家属的负担减轻,对护理工作的满意度提高;护理人员的专业知识、解决问题及人际关系能力、创新精神提高。结论 品管圈活动提高老年患者对单孔腹腔镜胆囊切除术的知晓率和护理人员的综合素质。     

Continuous Quality Improvement in Daily Clinical Practice: A Proof of Concept Study

Continuous Quality Improvement (CQI) is an iterative process of: planning to improve a product or process, plan implementation, analyzing and comparing results against those expected, and corrective action on differences between actual and expected results. It is little used in clinical medicine. Anemia, a complex problem in End Stage Renal Disease patients, served to test the ability of an unique electronic medical record (EMR) optimized for daily care to empower CQI in practice. We used data collected during daily care, stored in the EMR, and organized to display temporal relationships between clinical, laboratory, and therapeutic events. Our aims were optimal hemoglobin with minimum epoetin, and maintaining stable hemoglobin and epoetin. The study was done on 250 patients treated by maintenance hemodialysis (HD), receiving epoetin prior to February 1, 2010 and followed to July 31, 2011. Repleting iron, ensuring iron sufficiency, slow epoetin reduction, and decision support tools enabling data display over long periods in patient-centered reports were key elements. Epoetin dose, adjusted 6–8 weekly, was based on current clinical conditions and past responses. Hemoglobin increased by months 1–2; epoetin decreased from month 4. By months 16–18, epoetin had decreased 42% to 9,720 units/week while hemoglobin increased 8% to 123.6 g/L. Hemoglobin and epoetin were stable from month 7 onward. New epoetin orders decreased 83%. Transferrin saturation increased after the study start. Individual patient hemoglobin variation decreased by 23%, range by 27%. Mortality, 11.78 per 100 patient years, was 42% less than United States dialysis patient mortality. Allowable epoetin charges decreased by $15.33 per treatment and were $22.88 less than current Medicare allowance. The study validates the hypothesis that an EMR optimized for daily patient care can empower CQI in clinical medicine and serve to monitor medical care quality and cost.     

High risk maternal factors related to fetal wastage in rural Bangladesh

An analysis of the relationship between fetal mortality (early fetal death and stillbirth), pregnancy order, maternal age, and previous fetal deaths in a rural Bangladesh population characterized by high fertility and mortality and the virtual absence of obstetric and other medical care indicates that early fetal wastage and stillbirth are higher among pregnancy orders 1 and 6, or higher than among orders 2 and 3, with the increased risk particularly apparent among those pregnancies following 2 or more previous fetal deaths. The data consist of the 21,144 pregnancies that occurred to the women in Matlab, Bangladesh, 1966-1969. By a multiple regression technique allowing for pregnancy order and previous fetal deaths, adjustments were made for age of the mother, and after allowances were made for previous fetal deaths, adjustments were made for pregnancy order. Results show the fewest fetal deaths in 2nd and 3rd pregnancies, and most at the highest parities. 10% of all pregnancy terminations 1966-1969 were registered as fetal deaths. Women in the higher pregnancy orders who have not experienced previous fetal deaths or only 1 fetal death have only a slight increase in the risk of fetal death compared to women in pregnancy orders 2 and 3. It is concluded that the virtual absence of medical care facilities is responsible for the large numbers of fetal deaths due to complications of gestation, delivery, and environmental influences. It also results in a higher maternal mortality of women with pregnancy complications related to fetal deaths. This absence of obstetric care and the high maternal mortality in this population may allow only women without reproductive impairments to reach the higher pregnancy orders.     

The use of information technology in improving medical performance. Part I. Information systems for medical transactions

Investment in medical information technologies reached $15 billion in 1996. However, these technologies have not had the wide impact predicted in streamlining bureaucracy, improving communications, and raising the effectiveness of care. In this series, we identify how such technologies are being used to improve quality and performance, the future directions for advancement, and the policy and research developments required to maximize public benefit from these technologies. Each of these articles focuses on a different type of information technology: (1) information systems to manage medical transactions; (2) physician-support technologies to improve medical practice; and (3) patient-focused technologies designed to change how people manage their own care. This first article of a 3-part series examines the successes of and opportunities for using advanced information systems that track and manage medical transactions for large populations to improve performance. Examples of such systems include: HEDIS, which gathers standardized data from health plans on quality of care; the USQA Health Services Research Program, which tracks treatment patterns and outcomes for 14 million insurance members; Ford's program to collect medical data for over 600,000 employees; and Harvard Pilgrim Health Care's system of computerized laboratory, pharmacy, ambulatory, and hospital admission records for its 1.5 million members. Data from these systems have led to modest improvements in knowledge and practice patterns for some diseases. Significant barriers are slowing efforts to add outcomes data to these databases and broaden the databases to cover larger populations. Nonetheless, existing data in currently evolving systems could be used to greater benefit in tracking public health and in identifying more effective treatments and causes of diseases.     

Genome-wide analysis reveals the effects of artificial selection on production and meat quality traits in Qinchuan cattle

A new strain of Qinchuan cattle (QNS) has been obtained after more than forty years of selective breeding, and it shows good performance and production traits. To characterize the genetic changes that have resulted from breeding, we sequenced 10 QNS and 10 of the original breed Qinchuan cattle (QCC) for the first time, with average of 12.5-fold depth. A total of 31,242,284 and 29,612,517 SNPs were identified in the QCC and QNS genomes, 47.81% and 44.36% of which were found to be novel, respectively. Furthermore, population structure analysis revealed the selection that these cattle had experienced. Then, 332 and 571 potential selected genes were obtained, associated with enhanced immunity and acclimatization in QCC (CD5, SMARCA2, CATHL2, etc.) and production or meat quality traits in QNS (PLCD3, MB, PPARGC1A, etc.). These results revealed the efforts of selective breeding for Chinese Qinchuan cattle, and will be helpful for future cattle breeding.