我院451065张门、急诊电子处方审核的情况分析

451065 electronic prescriptions in outpatient department in our hospital

目的调查我院门、急诊电子处方质量,总结贯彻新的《处方管理办法》过程中出现的问题,提高门、急诊电子处方质量。方法对我院2008年5月-2009年5月门、急诊电子处方审核过程中发现的问题处方进行统计、分析。结果在审核451 065张电子处方中,缺陷处方5 624张,占处方总数的1.25%。包括一般项目错误、诊断与用药不符、药名输入错误、剂量单位错误、用法用量错误、不适当联用等。结论电子处方提高了工作效率,但存在的问题不可忽视,可通过完善电子处方的审核系统,加强医务人员综合素质等措施来提高电子处方的质量。

Objective To investigate electronic prescriptions in the outpatient department in our hospital and seek solutions to improve the quality of prescriptions.Methods Prescriptions were screened by examining and verifying from May 2008 to May 2009 and analyzed.Results Among all the 451 065 prescriptions,5 624 were problematic prescriptions（1.25%）,involving common errors,improper dosage,wrong drugs,errors of dosage and usage,and so on.Conclusion It is necessary to improve the quality of electronic prescriptions in outpatient clinic to complete the electronic prescription subsystem.