目的：探讨药物重整在临床药师开展药学监护工作中的作用。方法：临床药师参与1 例高龄患者治疗的药学监护，就患

者的抗感染药物、心血管系统药物、电解质等治疗药物进行重整：停用非必需药物血必净注射液、康尔心胶囊、蛇胆川贝软胶囊、枸

橼酸莫沙必利片；调整氢氯噻嗪片、氯化钾缓释片剂量；停用非一线治疗药物利血平片，降低潜在的用药风险；根据病情转归及时

停用呋塞米片、乳果糖口服溶液和开塞露。结果与结论：临床药师通过药物重整，可避免重复用药，优化用药方案，减少用药品种

和药品费用，降低潜在的药品不良反应风险，保障患者用药安全、有效。

OBJECTIVE：To investigate the role of medication reconciliation in pharmaceutical care provided by clinical pharmacists.

METHODS：Clinical pharmacists participated in pharmaceutical care for a elderly patient，and reconciled drugs as anti-infective

drugs，cardiovascular drugs，electrolyte：stop taking unnecessary drugs：Xuebijing injection，Kang’erxin capsule，Shedan

chuanbei soft capsule，Mosapride citrate tablet；adjust the dose of Dihydrochlorothiazide tabet and Potassium chloride tablet；stop

taking Non first-line drug Reserpine tablet in order to decrease the risk of drug use； stop taking Furosemide tablet，Lactulose oral

solution and using Suppositories glycerol timely according to the disease outcome. RESULTS&CONCLUSIONS：The medication

reconciliation can avoid repeated drug use，optimize medication plan，reduce drug variety and cost and decrease the potential ADR

risk of drug use so as to guarantee safe and effective drug use.