我院电子处方存在的问题及改进建议

The problems and improving suggestion of the electronic prescriptions in our hospital

目的了解本院电子处方应用中存在的问题,探讨提高电子处方质量的对策。方法分析在电子处方审核过程中发现的问题处方。结果抽查2013年4月22～28日的门诊、住院处方,共2413张,其中问题处方340张,占抽查处方的14.09%;处方主要存在无诊断,用法、用量不正确,无适应证用药,诊断与适应证不相符,选用剂型和给药途径不合理等问题。结论本院电子处方系统尚存在许多不足,应通过增强处方医师的岗位责任心、医德医风,提高审方药师的综合素质等措施不断完善电子处方的质量,促进合理用药。

Objective To understand problems of electronic prescription applications in our hospital,and discuss coun- termeasures of improving the quality of electronic prescriptions. Methods Inappropriate prescriptions found in the checking process of the electronic prescriptions were analyzed. Results 2413 outpatient or inpatient prescriptions were sampled from April 22,2013 to April 28,2013,among those prescriptions,there were 340 inappropriate prescriptions and it accounted for 14.09%;the problems included mainly without diagnosis,incorrect usage and dosage,no indications of medication,discrepancy between the diagnosis and the selection of indications,discrepancy between dosage form and route. Conclusion Our electronic prescription system still exists many deficiencies,we should strengthen the post re- sponsibility,medical ethics of prescribers,enhance the comprehensive quality of prescription-checking pharmacists and other measures to continuously improve the quality of electronic prescription and promote the rational drug use.