*HQRPLQHHUGH)3=SULMV,PSOHPHQWHUHQYDQPHGLFDWLRQ UHFRQFLOLDWLRQ6W/XFDV$QGUHDV=LHNHQKXLV .RUWHEHVFKULMYLQJYDQKHWSURMHFW +HWSURMHFW0HGLFDWLRQUHFRQFLOLDWLRQLVRSJH]HWRPPHGLFDWLHIRXWHQELM RYHUGUDFKWVPRPHQWHQWHYRRUNRPHQ,QKHW6LQW/XFDV$QGUHDV=LHNHQKXLVFRQWUROHHUWHHQ IDUPDFHXWLVFKFRQVXOHQWELMGHRSQDPHpQKHWRQWVODJYDQHHQSDWLsQWRIHUGLVFUHSDQWLHV ]LMQWXVVHQGHWKXLVPHGLFDWLHHQGH]LHNHQKXLVPHGLFDWLH'HUHVXOWDWHQYDQGH]HFRQWUROH ZRUGHQRYHUOHJGPHWGHDUWV$OVKHWQRGLJLVSDVWGH]HGHPHGLFDWLHDDQ$OVGHSDWLsQW PHWRQWVODJJDDWVWHPWGHIDUPDFHXWLVFKFRQVXOHQWGHPHGLFDWLHDIPHWGHSDWLsQW2RN YUDDJWKLM]LMQDKRHGHSDWLsQWGHPHGLFDWLHJHEUXLNW7RWVORWVWXXUWGHIDUPDFHXWLVFK FRQVXOHQWGHRQWVODJLQIRUPDWLHGRRUQDDUGHHHUVWHOLMQ+LHULQVWDDWRRNZDDURPGH PHGLFDWLHLVJHZLM]LJG ,QOHLGLQJ 8LWHHQSDWLsQWWHYUHGHQKHLGVRQGHU]RHNYDQ]RUJYHU]HNHUDDU$JLVEOHHNGDWRQ]HSDWLsQWHQ RQWHYUHGHQZDUHQRYHUGHJHULQJHLQIRUPDWLHGLH]HNUHJHQELMRQWVODJPHWEHWUHNNLQJWRW KXQPHGLFDWLHJHEUXLN9HHOSDWLsQWHQIDPLOLHEOHNHQQDRQWVODJWHUXJWHEHOOHQQDDUGH DIGHOLQJRPGDWHUELMYRRUEHHOGRQGXLGHOLMNKHGHQZDUHQRYHUGHRQWVODJPHGLFDWLHHQGH YHUDQGHULQJHQLQGHWKXLVPHGLFDWLH:DWKLHURRNHHQUROLQVSHHOWLVGDWHHQ]LHNHQKXLV GRRUKHWIRUPXODULXPEHOHLGPHWJHQHHVPLGGHOHQZHUNWGLHHUYRRUGHSDWLsQWDQGHUVXLW]LHQ GDQGLHYDQGHRSHQEDUHDSRWKHHN'LWVFKHSWELMSDWLsQWHQYHHOYUDJHQHQRQ]HNHUKHGHQ 9HUGHUZDVDOODQJHUGXLGHOLMNGDWHUYHHOPHGLFDWLHIRXWHQYRRUNRPHQLQGH PHGLFDWLHRYHUGUDFKW'LWNZDPRQGHUDQGHUHGRRUHHQJHEUHNNLJHFRQWUROHYDQGH PHGLFDWLHELMGHRSQDPHHQKHWRQWVODJ(HQDQGHUHUHGHQLVGDWGHSDWLsQWRQYROGRHQGH ZHUGEHWURNNHQKHLGELMGHRYHUGUDFKWVPRPHQWHQ2RNZDVGHPHGLFDWLHRYHUGUDFKWLQGH YRUPYDQHHQRQWVODJEULHIRIRQWVODJUHFHSWRQYROOHGLJ=RZDVELMYRRUEHHOGRQEHNHQG ZDDURPHHQWKHUDSLHZHUGJHZLM]LJG 9LVLHYDQGHDSRWKHHN 'H]LHNHQKXLVDSRWKHHNVWUHHIWFRQWLQXHYHUEHWHULQJYDQGHIDUPDFHXWLVFKHGLHQVWYHUOHQLQJ QD6SHHUSXQWLVKHWYHUEHWHUHQYDQGHYHLOLJKHLGYRRUGHSDWLsQWHQKHWYHUEHWHUHQYDQGH NZDOLWHLWYDQRQ]HZHUNZLM]H0HWGLWSURMHFWKHEEHQZHGH1DWLRQDOH3DWLsQWYHLOLJKHLG $ZDUG JHZRQQHQ1DDVWKHWKLHUEHVFKUHYHQSURMHFWGRHQZHYHHOPHHURSGLWJHELHG 2Q]HDSRWKHHNSDUWLFLSHHUWRQGHUDQGHUHLQKHW906SURJUDPPDYDQGHRYHUKHLG2RN ZLOOHQZHGH*03]VWDWXVEHKDOHQ *RRG0DQXIDFWXULQJ3UDFWLFH]LHNHQKXLVIDUPDFLH 'LWLV GHVWDQGDDUGYRRUKHWEHUHLGHQYDQJHQHHVPLGGHOHQLQGH1HGHUODQGVH]LHNHQKXLVDSRWKHHN $QGHUHDFWLYLWHLWHQRSGLWJHELHGLQKHW6LQW/XFDV$QGUHDV=LHNHQKXLV]LMQ 'HRQWZLNNHOLQJYDQHHQHLJHQVHWYHLOLJKHLGVQRUPHQZDDUYDQKHWSURMHFWµ9HLOLJ PHGLFLMQHQGHOHQ¶HHQRQGHUGHHOLV HULVHHQSLORWJDDQGHRSYLHUDIGHOLQJHQ 1RHPHQVZDDUGLJLVRRNKHWWUDLQHQYDQDUWVHQLQKHWHOHNWURQLVFKYRRUVFKULMYHQ9HUGHU ZHUNWKHW]LHNHQKXLVDOPHWHOHNWURQLVFKHWRHGLHQLQJUHJLVWUDWLH:HZHUNHQPRPHQWHHOWRH QDDUHHQUHJLVWUDWLHV\VWHHPZDDUELMRRNKHWSLOOHWMH]HOIZRUGWJHVFDQGYRRUKHWDDQGH SDWLsQWZRUGWJHJHYHQ $QDO\VHYDQKHWSUREOHHP 9RRUEHUHLGLQJHQ 'LWSURMHFWLVRQGHUGHHOYDQHHQSURPRWLHRQGHU]RHN7HUYRRUEHUHLGLQJLVQDWLRQDOHHQ LQWHUQDWLRQDOHOLWHUDWXXURYHUGLWRQGHUZHUSEHVWXGHHUG+LHUXLWEOLMNWGDWPHGLFDWLHIRXWHQ YHHOYRRUNRPHQELMRYHUGUDFKWVPRPHQWHQ]RDOV]LHNHQKXLVRSQDPHHQ±RQWVODJ2PIRXWHQ WHYRRUNRPHQZRUGWPHGLFDWLRQUHFRQFLOLDWLRQWRHJHSDVW0HGLFDWLRQ5HFRQFLOLDWLRQLVPHHU GDQYHULILsUHQHQHULVJHHQJRHGH1HGHUODQGVHYHUWDOLQJYRRU+HWEHVWDDWXLWYLHUVWDSSHQ YHULILFDWLRQ GLVFUHSDQWLHVHOLPLQHUHQ ELMYRRUEHHOGIRXWLHYHGRVHULQJ FODULILFDWLRQ GHPHGLFDWLHRSWLPDOLVHUHQ ELMYRRUEHHOGGHYRRUJHVFKUHYHQGRVHULQJLVQLHW JHVFKLNWYRRUSDWLsQWPHWYHUPLQGHUGHQLHUIXQFWLH UHFRQFLOLDWLRQ QLHXZHPHGLFDWLHFRQWUROHUHQHQZLM]LJLQJHQGRFXPHQWHUHQ WUDQVPLVVLRQ GHRQWVODJLQIRUPDWLHFRPPXQLFHUHQQDDUGHYROJHQGH]RUJYHUOHQHU V :DWRSYDOWDDQEHVWDDQGHRQGHU]RHNHQ±QDWLRQDDOHQLQWHUQDWLRQDDOLVGDWHUYRRUDO
)3=SULMV,PSOHPHQWHUHQYDQPHGLFDWLRQUHFRQFLOLDWLRQ6W /XFDV$QGUHDV=LHNHQKXLV DDQGDFKWLVYRRUKHWRYHUGUDFKWVPRPHQWELMRSQDPHHQKHWZHJQHPHQYDQGLVFUHSDQWLHV WXVVHQGHWKXLVPHGLFDWLHHQGHLQKHW]LHNHQKXLVYRRUJHVFKUHYHQPHGLFDWLH YHULILFDWLH 'H SDWLsQWZRUGWKLHUELMQLHWDOWLMGDFWLHIEHWURNNHQ HUZRUGWDOOHHQJHEUXLNJHPDDNWYDQGH PHGLFDWLHOLMVWHQYDQDSRWKHHNRIKXLVDUWV+HWLVQRJRQGXLGHOLMNZHONW\SHPHGLFDWLHIRXW ]LFKYRRUGRHWELMYHUVFKLOOHQGHRYHUGUDFKWVPRPHQWHQ2RNLVRQGXLGHOLMNZHONHUROGH SDWLs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sQWHQEHWUHNNHQELMGHYHUVODJOHJJLQJRYHUKXQPHGLFDWLH 'HSDWLsQWEHWHULQIRUPHUHQ (HQ]LHNHQKXLVDSRWKHHNGLHEHNHQGVWDDWDOVJRHGH]RUJYHUOHQHU]RZHOELQQHQKHW ]LHNHQKXLV]HOIDOVEXLWHQKHW]LHNHQKXLV 0HHUVDPHQZHUNLQJPHWDUWVHQYHUSOHHJNXQGLJHQHQGHHHUVWHOLMQ YRRUDOGHKXLVDUWVHQ RSHQEDUHDSRWKHHN %DUULqUHV +HWSURMHFWYHUODQJGHGDWGHORJLVWLHNRSHHQDIGHOLQJZHUGYHUDQGHUG=RLVKHWYRRURQV ZHUNELQQHQGLWSURMHFWQLHWPHHUJHZHQVWGDWSDWLsQWHQDGKRFQDDUKXLVPRJHQ'LWVWDDW HFKWHUKDDNVRSKHWYULMPDNHQYDQEHGGHQ 'RRUKHWSURMHFWNRPHQDUWVHQYHHOPHHULQDDQUDNLQJPHWGHWKXLVPHGLFDWLHHQQLHWPHHU DOOHHQPHWGHDIGHOLQJVVSHFLILHNHPHGLFDWLH'HDUWVHQ]LMQGLWQLHWJHZHQG=LMZLOOHQGDQ RRNQLHWDOWLMGEHVOLVVHQRYHUGHWKXLVPHGLFDWLH 'RHOYDQKHWSURMHFW +HWGRHOLVGULHOHGLJ KHWRQGHU]RHNHQYDQKHWDDQWDOHQKHWW\SHLQWHUYHQWLHVLQHHQPHGLFDWLRQUHFRQFLOLDWLRQ SURMHFWELMRSQDPHHQRQWVODJ GHUROYDQGHSDWLsQWLQKHWYHUVWUHNNHQYDQLQIRUPDWLHKHWLQNDDUWEUHQJHQ KHWYHUPLQGHUHQYDQGHPHGLFDWLHIRXWHQPHWSURFHQWELMRSQDPHHQRQWVODJELQQHQ PDDQGHQQDGHVWDUWYDQKHWSURMHFW +HWODDWVWJHQRHPGHGRHOLVJHIRUPXOHHUGQDDUDDQOHLGLQJYDQKHW YHLOLJKHLGVPDQDJHPHQWV\VWHHPGDWYHUSOLFKWLVSHULQGH]LHNHQKXL]HQ 1HWZHUN %HWURNNHQ]RUJYHUOHQHUV 9HUSOHJLQJ YRRUKHWDFKWHUKDOHQYDQDOOHUJLHsQHQKHWYUDJHQQDDUHHQFRQWDFWSHUVRRQ ELMHHQSDWLsQWGLHGH1HGHUODQGVHWDDOQLHWVSUHHNWRIFRJQLWLHIYHUPLQGHUGLV7HYHQV RRNYRRUGHORJLVWLHNHLQEHGGLQJYDQKHWSURMHFW'HYHUSOHJLQJJHHIWRSVRPPLJH DIGHOLQJHQDDQGHVHFUHWDUHVVHVGRRUZHONHSDWLsQWHQPHWRQWVODJJDDQ $IGHOLQJVKRRIGHQWHDPOHLGHUV YRRUKHWRS]HWWHQYDQKHWSURMHFWHQGHORJLVWLHNH LQEHGGLQJHUYDQ 0HGLVFKVSHFLDOLVWHQ YRRUKHWRS]HWWHQHQKHWDIVWHPPHQYDQKHWSURMHFW ZDWJLQJHU ELMYRRUEHHOGYRRUKHWVWDUWHQYDQKHWSURMHFWYDDNIRXW" $UWVDVVLVWHQWHQ YRRUKHWRS]HWWHQYDQKHWSURMHFWHQGHORJLVWLHNHLQEHGGLQJHUYDQ 6HFUHWDUHVVHQ YRRUKHWGRRUJHYHQYDQGHQLHXZHRSQDPHQHQRQWVODJHQ =LHNHQKXLV DSRWKHNHUV YRRUKHWLPSOHPHQWHUHQHQRQGHUVWHXQHQYDQKHWSURMHFW
3DJLQDYDQ
)3=SULMV,PSOHPHQWHUHQYDQPHGLFDWLRQUHFRQFLOLDWLRQ6W /XFDV$QGUHDV=LHNHQKXLV
)DUPDFHXWLVFKFRQVXOHQWHQ YRRUKHWLPSOHPHQWHUHQHQXLWYRHUHQYDQKHWSURMHFW 2SHQEDUHDSRWKHNHUVLQKHWDGKHUHQWLHJHELHGYDQKHW6LQW/XFDV$QGUHDV=LHNHQKXLV :LMKHEEHQKHQWLMGHQVSUHVHQWDWLHVLQUHJLRYHUJDGHULQJHQDGYLHVJHYUDDJGRYHUGH LQKRXGYDQKHWRQWVODJUHFHSW2RNLVEHVSURNHQZHONHSUREOHPHQ]LMHUYDUHQELM RQVODJPHGLFDWLH RQGXLGHOLMNKHGHQVXEVWLWXWLHEHOHLGHQ] +XLVDUWVHQLQKHWDGKHUHQWLHJHELHGYDQKHW6LQW/XFDV$QGUHDV=LHNHQKXLV]LMQYLD HQTXrWHVJHSHLOGQDDUKXQLQIRUPDWLHEHKRHIWHRPWUHQWRQWVODJPHGLFDWLH9HUGHULVKHQ JHYUDDJGKRH]LMGHRQWVODJPHGLFDWLH]RXGHQZLOOHQRQWYDQJHQ2RNKHEEHQZHGH KXLVDUWVHQJHYUDDJGRI]HIDUPDFRWKHUDSHXWLVFKHDGYLH]HQ]RXGHQZDDUGHUHQ ELMYRRUEHHOGFRQWUROHYDQHHQEORHGVSLHJHOQDRQWVODJ %LMQD SURFHQWYDQGH KXLVDUWVHQJDIDDQGLHDGYLH]HQWHZLOOHQRQWYDQJHQ'LWKHEEHQZHGXVRRN JHwPSOHPHQWHHUG
5DQGYRRUZDDUGHQ .HQQLVHQPRWLYDWLHYDQGHIDUPDFHXWLVFKFRQVXOHQWHQ]LMQRSQLYHDXJHEUDFKWGRRUKHW YROJHQYDQRQGHUDQGHUHFRPPXQLFDWLHHQIDUPDFRWKHUDSLHFXUVXVVHQ'DDUQDDVWKHEEHQ GHSURPRYHQGXVHQHHQ]LHNHQKXLVDSRWKHNHUELMGHVWDUWYDQKHWSURMHFWGHIDUPDFHXWLVFK FRQVXOHQWHQLQWHQVLHIEHJHOHLGW=LMKHEEHQHHQRQWVODJUHFHSWHHQPHGLFLMQNDDUWHQGLYHUVH FKHFNOLVWHQRQWZLNNHOG'DDUQDDVWKHEEHQ]LMGHRQWVODJJHVSUHNNHQHHUVW]HOIXLWJHYRHUG 'DDUQDKHEEHQGHFRQVXOHQWHQPHHJHORSHQHQ]LMQ]LMYHUGHUEHJHOHLG+LHUGRRUNRQYHHO IHHGEDFNRYHUHQZHHUZRUGHQJHJHYHQRSGHYHUVFKLOOHQGHZHUN]DDPKHGHQELQQHQKHW SURMHFW 'HDIGHOLQJLVJHwQIRUPHHUGHQJHPRWLYHHUGGRRUSUHVHQWDWLHVWHJHYHQ'HDUWVHQ YHUSOHHJNXQGLJHQHQVHFUHWDUHVVHQKHEEHQ$NDDUWMHVRQWYDQJHQPHWGDDURSGH VWURRPVFKHPD¶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wQIRUPHHUGRYHUGHJHERHNWHUHVXOWDWHQ :DWLVHUJHUHJHOGRSKHWJHELHGYDQGHRUJDQLVDWLHYRRUDDQYDQJYDQKHWSURMHFW" GHDIGHOLQJEHUHLGYLQGHQRPQLHWDOOHHQQDDUGHDIGHOLQJVPHGLFDWLHWHNLMNHQ9LDGH ]LHNHQKXLVDSRWKHHNNULMJWGHDIGHOLQJHHQYROOHGLJEHHOGYDQGHPHGLFDWLH HULVHHQJRHGHVDPHQZHUNLQJWRWVWDQGJHEUDFKWWXVVHQGHDSRWKHHNHQGHDIGHOLQJ +HWSURMHFWPRHWYRRUDORSORJLVWLHNJHELHGJRHGLQJHEHGZRUGHQ'DWYHUJWKHOGHUH DIVSUDNHQPHWGHDIGHOLQJ2RNPRHWHUVDPHQJHZHUNWZRUGHQDDQYHUEHWHULQJ(HQ YRRUEHHOGYDQHHQDIVSUDDNLVGDWHUQXXXUYDQWHYRUHQZRUGWGRRUJHJHYHQZHONH SDWLsQWHQPHWRQWVODJJDDQ LQFOXVLHIDOOH³LQSULQFLSH´RQWVODJHQ (U]LMQDIVSUDNHQJHPDDNWRYHULHGHUVYHUDQWZRRUGHOLMNKHGHQ'H]LHNHQKXLVDSRWKHHN EHJHOHLGWGHSDWLsQWPDDUOHJWDOWLMGYHUDQWZRRUGHOLMNKHLGDIDDQGHEHKDQGHOHQGDUWV 'HDUWVRQGHUWHNHQWGXVDOWLMGQRJKHWPHGLFDWLHRYHU]LFKW 9RRUDILVJRHGHFRPPXQLFDWLHPHWGHHHUVWHOLMQRSJDQJJHEUDFKWRPHQHU]LMGV JHJHYHQVRSWHYUDJHQHQDQGHU]LMGVJHJHYHQVRYHUWHGUDJHQ'LWLVJHGDDQPHWGHDO HHUGHUJHQRHPGHSUHVHQWDWLHVHQHQTXrWHV ,QGLFDWRUHQ :HKHEEHQELMJHKRXGHQZHONHLQWHUYHQWLHVZHGRRUYRHUHQPHWKHWPHGLFDWLRQUHFRQFLOLDWLRQ SURMHFW'H]HKHEEHQZHLQJHGHHOGLQKRRIGHQVXENODVVHQ 3UHVFULSWLHJHUHODWHHUG VWDUWHQYDQHHQJHQHHVPLGGHOGRVHULQJIRUPXOHULQJDDQSDVVLQJ VZLWFKHQ RP]HWWHQ YDQHHQJHQHHVPLGGHOHQKHWVWRSSHQYDQHHQJHQHHVPLGGHO'H]H LQWHUYHQWLHVNXQQHQGRRUJHYRHUGZRUGHQRP o GLVFUHSDQWLHVWXVVHQGHWKXLVPHGLFDWLHHQLQKHW]LHNHQKXLVYRRUJHVFKUHYHQ
3DJLQDYDQ
)3=SULMV,PSOHPHQWHUHQYDQPHGLFDWLRQUHFRQFLOLDWLRQ6W /XFDV$QGUHDV=LHNHQKXLV
PHGLFDWLHWHHOLPLQHUHQ o GHIDUPDFRWKHUDSLHWHRSWLPDOLVHUHQELMYRRUEHHOGGRRURYHUHQRQGHUEHKDQGHOLQJWH YRRUNRPHQRIHHQGRVHULQJDDQWHSDVVHQDDQHHQYHUPLQGHUGHQLHUIXQFWLH 0HGLFDWLHJHEUXLNJHUHODWHHUGRPKHWPHGLFDWLHJHEUXLNWHRSWLPDOLVHUHQ DGYLHVJHYHQ RYHUPHGLFDWLHXLWOHJJHYHQRYHUPHGLFDWLHHQFRQWUROHUHQYDQGHPHGLFLMQGRRVMHVGLH HHQSDWLsQWKHHIWPHHJHQRPHQQDDUKHW]LHNHQKXLV 7UDQVIHUJHUHODWHHUGRPGHHHUVWHOLMQYROOHGLJHUWHLQIRUPHUHQRYHUGH RQWVODJPHGLFDWLH ZLM]LJLQJHQLQGHPHGLFDWLHHQRYHULJ ZHHNOHYHULQJDOOHUJLHFRQWUD LQGLFDWLHHWF
9DVWOHJJHQ 9RRUKHWYHU]DPHOHQYDQGH]HJHJHYHQV]LMQFKHFNOLVWHQRQWZLNNHOGZDDURSGH IDUPDFHXWLVFKFRQVXOHQWHQNXQQHQDDQJHYHQZHONHLQWHUYHQWLHV]HKHEEHQXLWJHYRHUGELM RSQDPHRQWVODJWLMGHQVKHWFRQVXOWPHWGHSDWLsQWHQLQKHWLQIRUPHUHQYDQGHHHUVWHOLMQ 'H]HLQWHUYHQWLHV]LMQYDVWJHOHJGLQ06([FHO 6WDSSHQSODQ +HWSURMHFWLVGULHMDDUJHOHGHQJHVWDUWRSGHORQJDIGHOLQJ5XLPHHQMDDUJHOHGHQ]LMQZHHU RRNPHHEHJRQQHQRSGHDIGHOLQJFDUGLRORJLH6LQGVNRUWGRHQZHKHWSURMHFWRRNRSGH DIGHOLQJLQWHUQHJHQHHVNXQGH+HWZRUGWRSLHGHUHDIGHOLQJHQZHHUQHWHYHQDQGHUV XLWJHYRHUGRPGDWZHQRJDDQKHWH[SHULPHQWHUHQ]LMQZDWGHEHVWHZHUNZLM]HLV 2QGHUVWDDQGHVWURRPVFKHPDJHHIWGHZHUNZLM]HRSGHDIGHOLQJFDUGLRORJLHZHHU'H JHWRRQGHUHVXOWDWHQKLHURQGHU]LMQRRNYDQGH]HDIGHOLQJ Bij opname: allergieën en contactpersoon achterhalen (verpleging en farmaceutisch consulent) De verpleging vult bij opname een formulier in. De farmaceutisch consulent voert de allergie (na verificatie dat het een allergie is) in in het ziekenhuisapotheeksysteem. Bij opname en ontslag: medication reconciliation (farmaceutisch consulent en arts) Verification: discrepanties elimineren door de thuismedicatie te vergelijken met de in het ziekenhuis voorgeschreven medicatie (bijv. verschillen in dosering). Clarification: geschiktheid van de therapie voor de individuele patiënt evalueren (bijv. indicatie, onderbehandeling). Reconciliation: controle nieuwe medicatie en wijzigingen in de therapie documenteren (bijv. reden voor wijzigingen, duur therapie). Æ farmaceutisch consulent overlegt met de arts waarna indien nodig de medicatie aangepast kan worden Bij ontslag: medicijnkaart en ontslagrecept/medicatieoverzicht genereren (farmaceutisch consulent en arts) Farmaceutisch consult verwerkt welke medicatie gewijzigd/gestaakt is en eventuele redenen. Verder kunnen labwaarden genoteerd worden, kunnen adviezen aan de huisarts (bijv. in de gaten houden nierfunctie) en openbare apotheek ( bijv. herhalen inhalatie-instructie) gegeven worden. Æ de arts ondertekent het ontslagrecept/medicatieoverzicht ter goedkeuring. Bij ontslag: ontslaggesprek met de patiënt (farmaceutisch consulent) Verification: controle of er discrepanties zijn (bijv. zelfzorg medicatie, patiënt gebruikt medicatie anders). Clarification: medicijngerelateerde problemen bediscussiëren en geschiktheid van de therapie evalueren (bijv. bijwerkingen, therapietrouw, medicatie nog nodig?). Reconciliation: controle of de wijzigingen in de therapie duidelijk zijn (bijv. reden van wijzigingen, duur therapie, vragen beantwoorden). Æ eventuele problemen worden overlegd met de arts waarna de medicatie aangepast kan worden. Voor ontslag: transmission; informatieoverdracht naar de eerste lijn (farmaceutisch consulent) Ontslagmedicatie (bijv. reden wijzigingen) en gerelateerde informatie (bijv. allergieën, monitoren) communiceren middels een fax naar de openbare apotheek en per mail naar de huisarts
3DJLQDYDQ
)3=SULMV,PSOHPHQWHUHQYDQPHGLFDWLRQUHFRQFLOLDWLRQ6W /XFDV$QGUHDV=LHNHQKXLV 2SGHPHGLFLMQNDDUWHQKHWRQWVODJUHFHSWVWDDWKHWWHOHIRRQQXPPHUYDQKHW DSRWKHHNVHUYLFHSXQW]RGDWSDWLs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sQWGH]LHNHQKXLVPHGLFDWLH QLHWVWURRNWHPHWGHWKXLVPHGLFDWLH'DWZDVUHGHQJHQRHJRPKHWSURMHFWGLUHFWWH LPSOHPHQWHUHQ 9ROJHQHQYDVWOHJJHQYRRUWJDQJ +HWSURMHFWLVGULHMDDUJHOHGHQRSGHORQJDIGHOLQJRQWZLNNHOG(ULVGHVWLMGVPDDQGHOLMNV RYHUOHJJHYRHUGPHWGHDIGHOLQJ2RNZHUGHQGHIDUPDFHXWLVFKFRQVXOHQWHQLQJHZHUNW,Q KHWEHJLQKHEEHQZHJHWUDFKWGHYHUSOHHJNXQGLJHQELMKHWSURMHFWWHEHWUHNNHQ=LMJDYHQ HFKWHUDDQGDW]HEHSHUNWWLMGKDGGHQHQYRRUDONHQQLVKDGGHQYDQGHDIGHOLQJVVSHFLILHNH PHGLFDWLH%HSDDOGHWDNHQ]RDOVQDYUDJHQYDQDOOHUJLHsQELMGHSDWLsQWGRHQZHRSGH ORQJDIGHOLQJGDDURPQX]HOI$OOHHQRSGH]HDIGHOLQJYRHUHQZHHHQRSQDPHJHVSUHNPHWGH SDWLsQW 2SGHORQJDIGHOLQJ]LMQZHYHUGHUDDQKHWH[SHULPHQWHUHQGRRUELMYRRUEHHOGGHDIGHOLQJHHQ DIVSUDDNLQWHODWHQSODQQHQPHWHHQIDUPDFHXWLVFKFRQVXOHQWELMRSQDPH]RGDWGH FRQVXOHQWQLHWGHSDWLsQWKRHIWWH³]RHNHQ´(YHQWXHOHJRHGHHUYDULQJHQRSGHORQJDIGHOLQJ ]XOOHQZHRRNLPSOHPHQWHUHQRSGHDQGHUHDIGHOLQJHQ+HWSURMHFWRSGHDIGHOLQJ FDUGLRORJLHHQLQWHUQHJHQHHVNXQGHNHQWJHHQRSQDPHJHVSUHNPHWGHSDWLsQW+LHUZRUGW ELMRSQDPHDOOHHQJHZHUNWPHWGHDSRWKHHNOLMVWHQ%LMRQWVODJLVZHOHHQJHVSUHNPHWGH SDWLsQW'HRRU]DDNKLHUYDQLVHHQJHEUHNDDQPDQNUDFKW'DDUQDDVW]LMQZLMYDQPHQLQJ GDWKHWRQWVODJPRPHQWULVLFRYROOHULVGDQGDWYDQRSQDPH0RFKWGHSDWLsQWLQKHW ]LHNHQKXLVRQYHUKRRSWGHYHUNHHUGHPHGLFLMQHQNULMJHQGDQ]DOGLWHHUGHUYHUKROSHQ ZRUGHQGDQWKXLVRPGDWGHSDWLsQWLQKHW]LHNHQKXLVXXUSHUGDJRQGHUFRQWUROHVWDDW 7KXLVVWDDWKLMHUDOOHHQYRRU LQGLHVLWXDWLHPRHWKLMJRHGZHWHQZDWKLMPRHWLQQHPHQHQ ZDDUKLMRSPRHWOHWWHQ 5HVXOWDDW 'HUHVXOWDWHQYDQKHWRQGHU]RHNRSGHORQJDIGHOLQJ]LMQLQMXQL JHSXEOLFHHUG ]LH ELMODJH 2SGHFDUGLRORJLHDIGHOLQJKHEEHQZHHHQREVHUYDWLRQHOHVWXGLHXLWJHYRHUG$OOHSDWLsQWHQ GLHLQGHSHULRGHMXQL±MXOL]LMQRSJHQRPHQRSGHDIGHOLQJFDUGLRORJLHNZDPHQLQ DDQPHUNLQJYRRUGHHOQDPH([FOXVLHFULWHULDZDUHQ JHHQPHGLFDWLHJHEUXLNELMRQWVODJ RQWVODJELQQHQXXURQWVODJEXLWHQNDQWRRUXUHQ PLWVQLHWDDQRQVGRRUJHJHYHQ QLHW DDQVSUHHNEDUHSDWLsQW1LHWDDQVSUHHNEDDURPGDWGHSDWLsQWWHUPLQDDOLVFRJQLWLHILV YHUPLQGHUGRIHUHHQWDDOEDUULqUHLV RRNELMGHIDPLOLH ,QIRUPDWLHRYHUPHGLFLMQJHEUXLN YDQGH]HSDWLsQWHQYHUJDUHQZHLQGHSUDNWLMNYLDGHIDPLOLHRIHHQFRQWDFWSHUVRRQ9RRUGH YHUJHOLMNLQJLQGLWRQGHU]RHNKHEEHQZH]HHFKWHUQLHWPHHJHQRPHQ (U]LMQSDWLsQWHQJHwQFOXGHHUG ]LHWDEHO :HKHEEHQELMJHKRXGHQKRHYDDNPHGLFDWLHDDQJHSDVWZHUGELM]LHNHQKXLVRSQDPHHQ± RQWVODJDOVJHYROJYDQGHIHHGEDFNYDQGHIDUPDFHXWLVFKFRQVXOHQWDDQGHDUWV7HYHQV KHEEHQZHJHNHNHQZDWGHLQYORHGLVYDQKHWFRQVXOWPHWGHSDWLsQWHQKRHYHHO DDQYXOOHQGHLQIRUPDWLHZHPRHWHQYHUVWXUHQQDDUGHYROJHQGH]RUJYHUOHQHU'LW]LMQYHHODO
3DJLQDYDQ
)3=SULMV,PSOHPHQWHUHQYDQPHGLFDWLRQUHFRQFLOLDWLRQ6W /XFDV$QGUHDV=LHNHQKXLV GHKXLVDUWVHQRSHQEDUHDSRWKHHNVRPVRRNYHUSOHHJKXLVDUWVHQWKXLV]RUJ %LMRSQDPHKHEEHQZHELM YDQGHSDWLsQWHQHHQLQWHUYHQWLHXLWJHYRHUGYRRUDORPGDW HUYHUVFKLOOHQEHVWRQGHQWXVVHQGHWKXLVHQLQKHW]LHNHQKXLVYRRUJHVFKUHYHQPHGLFDWLH %LMRQWVODJKHEEHQZHELM YDQGHSDWLsQWHQJHwQWHUYHQLHHUG(UZDUHQYHUVFKLOOHQPHW GHWKXLVPHGLFDWLH(HQYRRUEHHOGLVGDWGHWLMGHOLMNJHVWDDNWHPHGLFDWLHQDRQWVODJQLHW ZRUGWKHUVWDUW%LMRQWVODJLVRRNYHHODOGHIDUPDFRWKHUDSLHJHRSWLPDOLVHHUG (HQ ELMYRRUEHHOGKLHUYDQLVKHWVWDNHQYDQHHQVODDSPLGGHO 7LMGHQVKHWFRQVXOWPHWGHSDWLsQWQDPHQZHELM YDQGHSDWLsQWHQHHQLQWHUYHQWLH ZDDURPGDWSDWLsQWHQKXQPHGLFDWLHDQGHUVJHEUXLNWHQRIDDQJDYHQZHONHPHGLFDWLHQRJ ZHORIMXLVWQLHWQRGLJZDV9HUGHUEOHNHQYHHOSDWLsQWHQRRNXLWOHJQRGLJWHKHEEHQRYHUGH PHGLFDWLH %LM YDQGHSDWLsQWHQYHUVWXXUGHQZHDDQYXOOHQGHLQIRUPDWLHQDDUGHHHUVWHOLMQRYHU YRRUDOZHONHPHGLFDWLHJHZLM]LJGRIJHVWDDNWLVHQGHHYHQWXHOHUHGHQHQ %LMDOOHSDWLsQWHQKHEEHQZHPLQLPDDOLQWHUYHQWLHJHUHJLVWUHHUG 7DEHO Type interventies op verschillende momenten in het project (n=171 cardiologieafdeling) Type interventie
Prescriptie 1
Opname
Ontslag
Consult
Transfer
(% pat)
(% pat)
(% pat)
(% pat)
Uitleg interventie (voorbeelden)
69,0
59,1
34,5
-
Elimineren discrepanties met de thuismedicatie
Start
60,2
19,9
21,6
-
Foutieve afwezigheid van medicatie (bisfosfonaten)
Dosis/schema
21,1
40,4
12,9
-
Verschil in dosering of formulering (vernevelaar in plaats van dosisaërosol)
Switch
2,3
21,6
1,2
-
Verschil in geneesmiddel (ipratropium in plaats van salbutamol)
-
-
9,4
-
Foutieve aanwezigheid van medicatie (reeds voor opname gestaakt)
2,9
72,5
13,5
-
Optimaliseren farmacotherapie
2,3
17,5
3,5
-
Onderbehandeling (laxans bij opioïde gebruik)
-
46,2
1,8
-
Dosering, formulering niet geschikt (te hoge dosis voor geriatrische patiënt)
Stop Prescriptie 2 Start Dosis/schema Switch Stop Medicatiegebruik Advies
-
11,7
2,3
-
Geneesmiddel niet geschikt (een NSAID vervangen door tramadol bij hartfalen)
0,6
35,7
7,6
-
Overbehandeling, geneesmiddel niet meer geïndiceerd (slaapmiddelen)
-
2,3
86,5
-
Optimaliseren medicatiegebruik door de patiënt
-
2,3
47,4
-
Advies aan arts of patiënt (monitoren therapie, advies over bijwerkingen)
Uitleg
-
-
68,4
-
Uitleg aan de patiënt (inhalatietechniek salbutamol, doel geneesmiddel)
Med.voorraad
-
-
14,0
-
Aanpassing medicatievoorraad (verwijderen gestaakte medicatie)
-
-
-
92,4
Optimaliseren overdracht naar eerste lijn (huisarts, openbare apotheek)
Transfer* Wijzigingen
-
-
-
91,8
Aanvullende informatie over therapiewijzigingen (nieuw, gestaakte medicatie)
Overig
-
-
-
26,9
Aanv. informatie over bv monitoren, allergie, contra-indicatie, weeklevering
69,6
90,6
94,7
92,4
-
Totaal / categorie Totaal
100
-
* De ontslagmedicatie wordt altijd gecommuniceerd naar de openbare apotheek en huisarts. %HVFKRXZLQJ 8LWGLWRQGHU]RHNEOLMNWGDWELMHONHSDWLsQWPLQLPDDOppQLQWHUYHQWLHLVJHGDDQELMKHW YROOHGLJGRRUORSHQYDQKHWPHGLFDWLRQUHFRQFLOLDWLRQSURFHV2SGHORQJDIGHOLQJ]LMQ VRRUWJHOLMNHUHVXOWDWHQJHYRQGHQ'HSDWLsQWEOLMNWKLHUELMHHQEHODQJULMNHLQIRUPDWLHEURQWH ]LMQ0HGLFDWLRQUHFRQFLOLDWLRQLVGXVEHODQJULMNELMYHUVFKLOOHQGHRYHUGUDFKWVPRPHQWHQRP GLVFUHSDQWLHVWHHOLPLQHUHQ GHPHGLFDWLHWHRSWLPDOLVHUHQ GHSDWLsQWHQGHHHUVWHOLMQYROOHGLJHUWHLQIRUPHUHQ
3DJLQDYDQ
)3=SULMV,PSOHPHQWHUHQYDQPHGLFDWLRQUHFRQFLOLDWLRQ6W /XFDV$QGUHDV=LHNHQKXLV +HWGRHOZDVRPGHPHGLFDWLHIRXWHQPHWSURFHQWWHYHUPLQGHUHQ'DWGRHOLV]HNHU EHKDDOG+HWSURMHFWGUDDJW]HHU]HNHUELMDDQKHWYHUKRJHQYDQGHYHLOLJKHLGYDQGH SDWLs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wPSOHPHQWHHUGRSGHDIGHOLQJLQWHUQHJHQHHVNXQGH'LW ODDWVWHSURMHFWZRUGWQXQRJEHWDDOGXLW]RUJYHUQLHXZLQJVJHOGHQ2RNGLWSURMHFW]DO XLWHLQGHOLMNYDQXLWGHPDDWVFKDSJHILQDQFLHUGPRHWHQZRUGHQ 0HGLFDWLHYHULILFDWLHLVHHQYDQGHWLHQWKHPD¶VYDQKHWYHLOLJKHLGVPDQDJHPHQWV\VWHHPZDDU KHW]LHNHQKXLVVLQGVPHHZHUNW 0DUNHWLQJ +HW]LHNHQKXLVSHUVRQHHOZRUGWJHwQIRUPHHUGYLD SUHVHQWDWLHVRSGHDIGHOLQJ SUHVHQWDWLHVDDQGHPHGLVFKHVWDIHQ5DDGYDQ%HVWXXU PDDQGEODGYDQKHW]LHNHQKXLVZDDUZHDOPHHUGHUHPDOHQLQKHEEHQJHVWDDQ 3DWLsQWHQHQRIPDQWHO]RUJHUVZRUGHQJHwQIRUPHHUGYLD GLUHFWHEHWURNNHQKHLGELQQHQKHWSURMHFWPLGGHOVKHWFRQVXOWELMRSQDPHHQRIRQWVODJ PDDQGEODGYDQKHW]LHNHQKXLVZDDUGLYHUVHSDWLsQWHQKXQZDDUGHULQJRYHUKHWSURMHFWKHEEHQ XLWJHVSURNHQ +XLVDUWVHQYLD HQTXrWHVPHWWHYHQVXLWOHJRYHUKHWSURMHFW PDDQGEODGYDQKHW]LHNHQKXLVZDDUPHHUGHUHPDOHQKHWSURMHFWLVJHQRHPG =LHNHQKXLVHQRSHQEDUHDSRWKHNHQYLD HQTXrWHVPHWWHYHQVXLWOHJRYHUKHWSURMHFW GLYHUVHSUHVHQWDWLHVLQGHUHJLRHQRSODQGHOLMNHELMHHQNRPVWHQ =RUJYHU]HNHUDDU$JLVYLD KHWVFKULMYHQYDQHHQXLWJHEUHLGUDSSRUWRYHUKHWSURMHFWHQDOOHXLWNRPVWHQWRWQRJWRH0HGHGRRU GLWUDSSRUWKHEEHQZLMYHUGHUH]RUJYHUQLHXZLQJVJHOGHQRQWYDQJHQRPKHWSURMHFWRSGHDIGHOLQJ LQWHUQHJHQHHVNXQGHXLWWHNXQQHQUROOHQ $PVWHUGDPMDQXDUL)DWPD.DUDSLQDUSURPRYHQGXVHQ0DUMR-DQVVHQ ]LHNHQKXLVDSRWKHNHU
%LMODJHQ %LMODJH 3SSPHWKLHULQFKHFNOLVWPHGLFDWLRQUHFRQFLOLDWLRQELMRQWVODJFKHFNOLVWRQWVODJJHVSUHNPHW GHSDWLsQWPHGLFLMQNDDUWHQRQWVODJUHFHSWPHGLFDWLHRYHU]LFKW %LMODJH VWURRPVFKHPDV %LMODJH SDWLsQWLQIRUPDWLHEULHI %LMODJH 'HUHVXOWDWHQYDQKHWRQGHU]RHNRSGHORQJDIGHOLQJ MXQL
3DJLQDYDQ
