某三甲医院住院药房医嘱审核探讨及体会

Analysis of Prescription Checking in Inpatient Dispensary from the Grade A Class 3 Hospital

目的了解某三甲医院临床科室用药医嘱的不合格类型及其发生原因,为促进临床用药医嘱规范提供循证依据。方法收集2013年9月至2014年2月某三甲医院综合内科(肾内科与呼吸内科)、消化内科与内分泌科医嘱,对58 194组数据分析采用描述性统计方法。结果不合格医嘱为538组(0.92%),主要存在问题包括医嘱录入错误,配伍禁忌,溶剂选择、剂量、用法、用药频次与用药浓度不当。病区用药医嘱经干预后,不合理医嘱比例明显降低,达到预期目的。结论临床药师需要积极开展药学临床服务,积极纠正临床不合理用药医嘱,保障病区患者用药安全。

Objective To investigate the types and causes of irrational prescription administrationin clinical department, and provide evidence for the promotion of clinical rational prescription. Methods Prescription information in departments of General Internal Medicine（ Nephrology and respiratory medicine）, Gastroenterology and Endocrinology prescription were collected from September 2013 to February2014, data were analyzed by using descriptive statistical method. Results Totally 58 194 group of prescription information in 3 clinical departments were collected within 6 months, 538 group（ 0. 92%） were irrational. The main problems including： Prescription entrying errors, incompatibility, improper solvent, dosage, usage, frequency and concentration. After prescription intervention, the proportion of irrational prescription was reduced as expected. Conclusion The clinical pharmacists need to provide clinical pharmacy services actively, so as to correct clinical irrational prescription and guarantee medication safety of patients.