运用点评软件辅助构建处方点评标准与体系的实践

Practice on using software to establish prescription evaluation criteria

目的探索软件辅助下新型处方点评模式的评价标准,构建创新的三级处方点评体系,增加处方点评结果的准确性,降低用药风险。方法利用软件抽取北京积水潭医院2017年2-7月的门诊处方并对处方进行初步判断,药师以《中国国家处方集》、《临床用药须知》及最新的临床指南作为判断标准,利用三级点评制度进行复核,以药学专家组意见作为处方点评结果的最终依据。结果软件6个月共计抽取28 770张处方。处方点评的不合理率从2017年2月的3.75%下降至7月的2.39%。软件点评和最终处方点评结果的差异率不断下降,从5.77%下降至1.81%。结论药师利用循证医学证据,完善处方点评软件判断标准与依据,构建创新型三级处方点评体系,有效降低了处方不合理率,使处方点评软件更加实用化,从而保障临床用药的安全性,更好地为临床工作服务。

Objective To optimize the prescription evaluation criteria,build innovation system of three-level prescription comment, improve the accuracy of prescription＇ result, and reduce risk of medication by using software. Methods Pharmacists use software to extract and initially judge the outpatient prescription in Beijing Jishuitan Hospi- tal from February to July 2017 ; with＂ China National Formulary＂,＂ Clinical Medication Notice＂ and the latest clinical guidelines as a criterion,the pharmacists use the three-level evaluation system to recheck the result;take the opinion of the pharmacy expert group as the final basis for the results of the prescription review. Results The software extracts a total of 28 770 prescriptions in six months. The unreasonable rate of prescription decreased from 3.75% in February to 2. 39% in July. The rate of difference in the evaluation by software and by the final result also decreased from 5.77% to 1.81%. Conclusion By using evidence-based medicine,improving the criteria of software and building innovation system of three-level prescription, the unreasonable rate of prescription has been decreased, prescription evaluation software becomes more practical and ensure the safety of clinical medication is ensured, which is better for clinical work.