我院住院部750份医嘱质量统计与分析

The quality statistics and analysis of 750 in-patient department medical order

目的:了解新的《处方管理办法》实施以来新疆八一钢铁集团公司医院的贯彻执行情况,以提高医嘱质量,保障医疗安全,为今后医院临床药师合理参与用药提供参考。方法:回顾性分析2010年11月—2011年11月750份住院病历中的长期和临时医嘱单,结合病历中医生书写的病程记录、有关疾病治疗标准等诊断依据以及对应的医嘱,判定用药的合理性,对不合理的医嘱进行统计分析。结果:在抽查的750份病历中不合理医嘱为141份,占总抽查病历的18.8%。不合理医嘱中表现为:医嘱书写不规范占46.8%;药品选择不合理占19.1%;重复给药、药品使用不当占21.3%;溶媒选用不当以及无药敏试验分别占6.4%。结论:医嘱用药基本合理,但仍存在一定问题,不合理医嘱中存在的问题应引起医师的注意,同时临床医师与药师需共同加强药学知识的学习。

Objective：To understand the implement situation of new ＂prescription management method＂ in Xin- jiang Bayi Iron Steel Group Corp Hospital,to improve the quality of medical order and ensure medical safety. In order to supply reference for clinical doctor rational using medicines. Methods ：Seven hundreds and fifty patients extended and interim medical order was examined retrospective. Combined with clinical doctors writing course records,related disease diagnosis and treatment standard of the corresponding orders ,judge the rationality of drug use ,the unreason- able medical statistical was analyzed. Results ：In 750 cases,141 cases was unreasonable orders,accounted for the total sample of 18.8%. The unreasonable orders showed ：non-standard writing accounted for 46.80//00 ,drug selection unrea- sonable accounted for 19. 1% ,repeated dosing,drug misuse accounted for 21.2% ,solvent improper selection and no drug sensitivity test accounted for 6. 3%. Conclusion： In hospital, ward prescription drugs is reasonable, but some problems still exist ,unreasonable medical problems should cause the attention of physicians ,while clinicians and phar- macists need to learn the pharmacy knowledge.