目的：通过临床药师对老年患者用药监护及用药干预，促进老年患者合理用药。方法：对吉林大学第一医院干部病房2015年5月-2016年11月一病区所有床位全部住院患者进行用药监护、教育，包括用药时间、服药方法、药品保存、药物相互作用等。结果：共监护1155例患者，发生用药5384次；累计发现用药差错677次，其中服药时间错误485次（占总差错71.6%），服药方法错误116次（占总差错17.2%），药品保存错误76次（占总差错11.2%）；临床药师干预后，患者对各项内容的知晓率分别由10.4%~70.6%提升至86.5%~100%。结论：临床药师深入临床指导患者用药，可以提高老年患者用药依从性，促进老年患者安全用药。

Objective: To promote rational drug use in elderly patients through medication monitoring and intervention by clinical pharmacists. Methods: All inpatients of cadre ward in the First Hospital of Jilin University from May 2015 to November 2016 were given medication monitoring and education, including medication time, medication method, drug preservation and drug interaction. Results: A total of 1155 patients were monitored and the number of medication was 5384. A total of 677 medication errors were found, including 485 medication time errors (accounting for 71.6%), 116 medication method errors (accounting for 17.2%) and 76 drug preservation errors (accounting for 11.2%). The awareness rate of the various contents after the intervention of clinical pharmacists has increased respectively from 10.4%~70.6% to 86.5%~100%. Conclusion: The guidance of medication by clinical pharmacists could improve medication compliance and promote safe medication in elderly patients.