我院门诊不合格处方分析与建议

Comments and Analysis of Outpatient Prescriptions in Our Hospital

目的:了解我院门诊处方书写质量及合理用药基本情况,提高临床合理用药水平。方法:以《处方管理办法》、《抗菌药物临床应用指导原则》、《医院处方点评管理规范(试行)》为依据,随机抽取我院2010年3-8月门诊处方共1800张,对处方基本指标进行分析,并对书写规范情况、用药适宜性及超常处方进行评价(其中1项不合格即判定为不合格处方),同时提出建议。结果与结论:我院平均每张处方用药品种数2.1种,抗菌药物使用百分率为18.7%;不合格处方471张,其中书写不规范处方415张,表现为临床诊断、药品的剂量书写不规范等;用药不适宜处方49张,表现为遴选药品不适宜、重复给药等;超常处方7张,表现为开具2种以上药理作用相同的药物、无适应证用药等。可见我院处方合格率较低,抗菌药物过度应用现象普遍。建议通过加强医师处方规范书写意识、加强药师与医师之间的沟通、建立处方质量管理制度来提高门诊处方质量。

OBJECTIVE： To analyze the quality of outpatient prescription writing and rational drug use in our hospital, and to promote the clinical use of drugs. METHODS： According to Prescription Management Methods, Guidance and Principle for Clinical Use of Antibiotics and Management Criteria of Hospital Prescription Comment （trial）, 1 800 outpatient prescriptions were ran- domly collected from our hospital during Mar.--Aug. 2010. Basic index of prescription were analyzed. The prescription writing, reasonability of drug use and extraordinary prescription were evaluated （if there was one unqualified item in prescription, the prescription was considered as unqualified）, and some suggestions were put forward. RESULTS ＆ CONCLUSIONS： 2.1 kinds of drugs are used every prescription in our hospital averagely, antibiotics account for 18.7%. There are 471 irrational prescriptions, among which 415 prescriptions are unqualified in writing, such as no clinical diagnosis, non-standard writing of drug dose; 49 prescriptions are unqualified in reasonability of drug use, such as irrational drug selection, repeated drug use; there are 7 extraordinary pre- scriptions, such as prescribing 2 drugs which have same pharmacological effect, drug use without indications. The pass rate of prescription is relatively low, over-application of antibiotics is widespread. It is suggested to strengthen the awareness of physicians on standard prescription writing, communication of pharmacist and physicians, and establish prescription quality management system to improve the quality of outpatient prescription.