医院病区用药医嘱点评模式的探讨及应用评价

Discussion and implementation evaluation on mode of comments on inpatient prescriptions in hospital

目的:探索适合医院病区用药医嘱点评的模式,促进临床合理用药。方法:根据我院实际情况,制定医嘱点评工作指南、规范实施细则及实施干预措施,并对我院2011年1月-2012年12月住院病区用药医嘱进行分层等比例抽样点评。结果:共点评病区用药医嘱单1469份,涉及药品22 320品次,平均不合理医嘱率为20.08%,其中,不合理医嘱主要问题为用法用量不适宜(35.59%)、溶媒不适宜(26.78%)及未使用药品规范名称开具医嘱(25.76%);经过联络信沟通、目标考评相结合的干预措施,干预成功比例为38.22%,平均不合理医嘱率由2011年的24.21%下降到2012年的12.53%,并呈现逐月下降趋势。结论:该模式可有效评价及干预不合理医嘱,从而减少不合理医嘱的产生。

Objective： To explore the evaluation mode of inpatient prescriptions in hospital and promote the rational use of drugs.Methods： The evaluation mode of inpatient prescriptions were established by formulating operation guideline of evaluation,improving rules for the implementation and establishing intervention for rational drug use,and inpatient prescriptions stratified by equal-ratio sampling from January 2011 to December 2012 were evaluated.Results： Atotal of 1469 inpatient prescriptions involved in 22 320 drugs were evaluated,the unreasonable rate was 20.08%,the main problems of the unreasonable inpatient prescriptions were unreasonable usage and dosage（35.59%）,improper use of solvent（26.78%） and use of non-standard name of drugs（25.76%）.However,the interventional successful rate was 38.22%,and the unreasonable rate decreased from 24.21% in 2011 to 12.53% in 2012 and presented downtrend every month by communication and intervention.Conclusion： The unreasonable doctors＇ using of medicines can be evaluated and intervened by this mode,which can effectively reduce incidence of the unreasonable prescriptions.