我院2013年12月处方点评及不合理用药分析

Prescription Evaluation and Analysis of Irrational Drug Use in Our Hospital in Dec. 2013

目的:为进一步提高医师处方质量,促进临床合理用药提供参考。方法:从解放军第153医院临床药学管理系统中随机抽取2013年12月门诊处方100份、病区医嘱单30份,依据《处方管理办法》、病区医嘱点评要求进行点评分析。结果:门诊合理用药处方93张(占93.00%),用药不合理处方7张(占7.00%),其中无适应证用药、用法用量不合理、中西药联用不当、抗菌药物选用不当、禁忌用药各1张,分别占所审查门诊处方的1.00%,联合用药不当2张。病区医嘱单中合理用药医嘱25条(占83.33%),不合理用药医嘱5条(占16.67%),其中无适应证用药、无指征用药、重复用药、围术期用药不当和溶剂选择不当各1条,分别占点评医嘱的3.33%。结论:我院当月用药存在不合理现象。临床药学室已建立"不合理用药医师联系单"、"门诊不合理处方干预记录"、"病房不合理医嘱干预记录",以利及时发现并纠正临床潜在或已存在的不合理用药现象。

OBJECTIVE： To further improve the quality of prescription, to promote rational drug use. METHODS： 100 pieces of outpatient prescriptions and 30 copies of ward orders were randomly sampled from PASS.PharmAssist of No. 153 hospital of PLA, and then analyzed and evaluated according to ＂Prescription Administrative Policy＂ and ＂Ward Orders Evaluation Regulations＂. RESULTS： There were 93 outpatient prescriptions of rational drug use, accounting for 93.00% ; there were 7 prescriptions of irrational drug use, accounting for 7.00%, among which there was one prescription of no indication, unreasonable usage and dosage, improper drug combination, irrational selection of antibiotics or drug contraindications, accounting for 1.00%; there were 2 prescriptions of unsuitable drug combination, accounting for 2.00%. There were 25 medical orders of rational drug use, accounting for 83.33% ; there were 5 medical orders of irrational drug use, accounting for 16.67% ; among which there was one medical order of no indication medication, no evidence medication, repeated drug use, perioperative period improper medication and improper solvent selection, accounting for 3.33%, respectively. CONCLUSIONS： Irrational drug use exists in our hospital in Dec. 2013. ＂The doctor contact list on irrational drug use＂, ＂ the intervention records on irrational outpatient prescription＂ and ＂the intervention records on irrational medical orders in ward＂ have been established to detect and correct the potential or existent phenomenon of irrational drug use in clinical practice.