浙江省永康市妇幼保健院2016年1～6月临床药师医嘱点评及案例分析

Analysis and review of medication order in the Maternal and Child Health Hospital of Yongkang from January 2016 to June 2016 by clinical pharmacists

目的了解永康市妇幼保健院各病区住院患者的医嘱用药情况，分析不合理医嘱，促进合理用药。方法随机抽取永康市妇幼保健院2016年1-6月4个病区电子病历2691份，根据《医院处方点评管理办法（试行）》等相关规定，由临床药师对用药医嘱的合理性进行综合点评。结果2691份电子病历中，用药合理病历2386份（88．67％），不合理医嘱305份（11．33％）。不合理用药包括溶媒使用、用法用量、联合用药、抗菌药物预防使用、超说明书等。结论临床药师通过医嘱点评对临床用药实施监控，可以减少和避免不合理用药的发生，促进临床安全、合理用药。

Objective To investigate the situation of drug use in wards of the Maternal and Child Health Hospital of Yongkang, then analyzed the situation of irrational drug for facilitating the rational drug use. Methods 2 691 discharged inpatient medical records were randomly extracted in the Maternal and Child Health Hospital of Yongkang from January 2016 to June 2016 ,in which the irrational medication orders were analyzed statistically according to Hospital Prescription Review Management Regulations （Trial） and other relative provisions. Results Of the 2 691 medical records,2386（87.4% ） records were rational and 305 （ 12.6% ） records were non - rational. The irrational use of drugs manifested in the following aspects such as selection of the drug menstruum, usage, dosage, combination, antibacterial drug prevention and repeated drug use, etc. Conclusion Clinical pharmacists through the medical orders for clinical medication monitor, sequentially can reduce and avoid the happening of irrational drug use, and promote the clinical safety and rational drug use.