住院电子病历用药合理性评价

Evaluation of the rationality of drug use in inpatient electronic medical records

目的:分析我院住院电子病历合理用药情况。方法:随机抽取我院2011年10月-2012年9月住院电子病历660份,对其中的用药情况进行统计、分析。结果:660份电子病历中涉及用药医嘱共6214条,其中合理用药医嘱数为6147条,不合理用药医嘱数为67条(占1.08%)。每个月不合理医嘱数占当月医嘱数的比例分别为1.37%,1.05%,2.09%,0.95%,1.39%,0.98%,0.78%,1.22%,1.14%,1.09%,0.37%和0.57%。不合理用药的医嘱中,未按抗菌药物临床应用管理规定使用抗菌药物的占19.40%;遴选药品不适宜的占8.96%;药品剂型或给药途径不适宜的占16.42%;用法用量不适宜的占50.75%;重复给药占1.49%;有配伍禁忌或不良相互作用的占2.99%。结论:医务人员应共同努力,积极采取措施,真正做到安全、有效、经济地使用药物。

Objective： To analyze the rationality of drug use of inpatient electronic medical records in our hospital. Methods： Six hundred and sixty inpatient electronic medical records were randomly selected from Oct. 2011 to Sept. 2012 for evaluation of the rationality of drug use. Results： There were 6 214 medication orders in 660 inpatient electronic medical records, in which 6 147 medication orders were rational and 67 medication orders were irrational. The ratio of monthly percentages in irrational medication orders accounted for 1.37%, 1.05%, 2.09%, 0.95%, 1.39%, 0.98 %, 0.78%, 1.22%, 1.14%, 1.09%, 0.37% and 0.57%, respectively. In 67 irrational medication orders, the use of antibacterials which are irregularly used in accordance with the regulations for clinical antibacterial application accounted for 19.40%, inappropriate selection of drugs 8.96%, inappropriate drug dosage form or route of administration 16.4%, inappropriate dosage 50.75%, the repeated administration 1.49% and selecting drugs with incompatibility or adverse drug interaction 2.99%. Conclusion：Medical staff should work together to ensure the safety, effectiveness and economy of drug use.