我院处方点评工作的实践与分析

Practice and Analysis of Prescription Evaluation in Our Hospital

目的:介绍我院处方点评工作情况,为处方点评制度更好地实施提供参考。方法:以《处方管理办法》为依据,抽取2009年1月-2010年11月期间每月240张门/急诊处方(5520份)、30～40份住院病历(780份),每日静脉配置中心配制的3800～4000张长期静脉用药医嘱(271万张),以及2010年3-11月期间每日所有Ⅰ类切口手术出院病历(1677份),根据点评内容,填写处方指标点评表及不合理用药项目表,运用Excel软件处理数据,并对其中门/急诊处方基本指标、不合理处方比例、住院病历及长期静脉用药医嘱、Ⅰ类切口手术预防使用抗菌药物基本情况进行分类、统计。结果:我院门/急诊平均用药品种数均为1.7,平均不合理处方比例由2009年的22%下降为2010年的4.5%,不合理用药住院病历由2009年的25%降低至2010年的14%,长期静脉用药不合理医嘱由2009年的10%下降为2010年的1%,Ⅰ类切口手术预防使用抗菌药物合格率由2010年3月的27.3%升高为当年11月的73%。结论:我院的处方点评工作方法可行,能有效干预不合理用药,降低医疗纠纷的发生率,提高合理用药水平。

OBJECTIVE： To introduce the way of prescription evaluation in our hospital and share our experience on prescription evaluation. METHODS： According to Prescription Management Regulation, 240 out-patient and emergency prescriptions （5 520 pieces） and 30--40 in-patient clinical records （780 pieces）, 3 800--4 000 long-term intravenous medication orders （2 710 thousands） in PIVAS were collected each month from Jan. 2009 to Nov. 2010 as well as type Ⅰ incision medical records （a total of 1 677 pieces） during Mar--Nov. in 2010. According to the contents of evaluation, prescription evaluation table and irrational drug use sheet were filled and processed using Excel software. Basic index of out-patient and emergency descriptions, irrational prescription proportion, case history, medication orders of long-term intraveous administration, the phylactic application of antibacterial drugs in type I incision were classified statistically. RESULTS： 1.7 kinds of drugs were adopted in out-patient and emergency department of our hospital averagely. The percentage of irrational prescription decreased from 22% in 2009 to 4.5% in 2010. The percentage of irrational drug use in case history decreased from 25% in 2009 to 14% in 2010. The percentage of irrational medication orders of intravenous drug use in a long time decreased from 10% in 2009 to 1% in 2010. The percentage of the phylactic application of antibacterial drugs in type Ⅰ incision increased from 27.3% in Mar. 2010 to 73% in Nov. 2010. CONCLUSIONS： The prescription evaluation method of our hospital is feasible and can intervene in irrational drug use to reduce the incidence of medical disputes and improve rational drug use.