住院医嘱点评中抗菌药物不合理使用常见问题析评

The appraisal of irrational use of antimicrobials in chart order review

目的分析住院患者抗菌药物不合理使用情况,促进抗菌药物合理使用。方法按比例随机抽取2015年4月—2016年6月出院病历进行住院医嘱点评,收集不合理使用抗菌药物的医嘱及问题进行汇总分析。结果 2015年4月—2016年6月共抽查并点评出院病历2430份,其中有372份病历的抗菌药物存在不合理使用,共计医嘱数601条,常见问题类型16项。结论通过住院医嘱点评,能够发现抗菌药物不合理使用问题,将不合理使用抗菌药物情况通过整改单及沟通单的书面形式反馈给临床科室,有利于促进抗菌药物合理使用。

Objective To appraise the irrational use ofantimicrobials in hospitalized patients, in order to promote the rational use of antimicrobials. Methods Medical records from April 2015 to June 2016 were sample dmonthly at certain percentage for retrospective chart order review. Orders containing irrational use of antimicrobials were collected and analyzed. Results A total of 2430 medical records were sampled and appraised, among which 372 contained in appropriate use of antimicrobials, involving 601 orders with 16 categories of problems. Conclusion Irrational use of antimicrobials can be spotted by retrospective chart order review. Written feedback is an effective way to make the physicians aware of the problems, and to promote the rational use of antimicrobials.