住院患者糖皮质激素类药物专项点评分析与评价

Analysis and evaluation of special comments on glucocorticoid drugs in inpatients

目的分析评价本院住院患者糖皮质激素类药物临床用药情况,使用趋势以及合理性趋势,并且对不合理用药情况进行总结分析,为临床合理用药及持续改进提供参考,提出2018年度工作重点及持续改进措施。方法 2017年度出院病历3382份每月全部抽取100%使用糖皮质激素类药物病历进行点评,共计点评153份,统计临床用药情况,并进行评价分析。结果2017年度第一季度医嘱合理率为94.44%,第二季度医嘱合理率为73.68%,第三季度医嘱合理率为90.63%,第四季度医嘱合理率为96.43%;不合理医嘱主要为医生开具医嘱在病程中无记录或用药分析和无适应症用药。结论住院患者糖皮质激素类药物医嘱合理率总体呈上升趋势,不合理用药的现象有所下降,体现持续改进。

Objective To analyze and evaluate of clinical drug use, using trend and the trend of rationality of glucocorticoid drugs in our hospital, and to provide a reference for clinical rational drug use and continuous improvement, and to put forward the emphasis of work and continuous improvement measures in 2018. Methods 3382 medical records of discharge in 2017 were collected from the medical records of 100% glucocorticoid drugs use per month for review, a total of 153 medical records were reviewed. The clinical drug use was evaluated and analyzed. Results The reasonable rate of doctors’ prescription was 94.44% in the first quarter of 2017, 73.68% in the second quarter, 90.63% in the third quarter and 96.43% in the fourth quarter of 2017. Unreasonable doctors’ prescription were mainly those without any record by doctors or analysis of medication and unindications in the course of the disease. Conclusion The rational rate of glucocorticoid medicine orders in inpatients is on the whole rising, and the phenomenon of irrational use is decreasing, which reflects continuous improvement in rational drug use.