临床药师对院内900份病历用药情况的点评与分析

Comments and Analysis by Clinical Pharmacists of Medication of 900 Pieces of Medical Records in Our Hospital

目的:了解我院各病区住院患者的用药情况,以促进临床合理用药。方法:随机抽取南宁市中医医院连续12个月各病区出院病历共计900份,根据《医院处方点评管理办法(试行)》等相关规定,对住院医嘱用药的合理性进行分析、点评。结果:所查的900份出院病历中,用药合理病历787份(87.4%),用药不合理病历113份(12.6%)。不合理用药的问题包括围手术期预防用药不合理、配伍禁忌或不良的相互作用、重复用药等。结论:通过对900份病历用药的点评与分析,发现临床不合理用药在一定程度上存在,我院应进一步加强对临床不合理用药的反馈与干预。

Objective： To investigate the situation of drug use in wards of our hospital so as to promote the rational drug use. Methods： A total of 900 pieces of medical records were collected randomly from the medical records of the patients discharged from Nanning Traditional Chinese Medicine Hospital in 12 consecutive months, and according to Hospital Prescription Review Management Regulations （Triol） and other relative provisions, the rationality of medication in hospitalization was analyzed and commented. Results： Of the 900 medical records, 787 （87.4%） of medication was rational and 113 （12.6%） was non-rational. The irrational use of drugs manifested in the following aspects such as inconformity of perioperative preventive medication, incompatibility or adverse drug interactions, and repeated drug use, etc. Conclusion：Through the review and analysis of 900 medical records , it was found that the irrational drug use still existed in a certain extent, and the hospital should further strengthen the intervention and feedback of the clinical irrational drug use.