6000张门急诊处方点评与分析

Review and Analysis on 6 000 Outpatient and Emergency Prescriptions

目的:了解某三级甲等医院(以下简称"该院")门急诊处方情况,以提高处方质量,促进合理用药,保障患者用药安全。方法:通过该院计算机管理系统,2017年每月随机抽查门诊处方300张、急诊处方200张,进行点评分析。结果:2017年,该院门、急诊处方合理率分别为98.58%、99.22%;门、急诊处方平均用药品种数分别为2.40、2.64种;门、急诊处方平均用药金额分别为234.21、121.14元;门、急诊处方抗菌药物使用率分别为6.61%、44.19%;门、急诊处方注射剂使用率分别为26.11%、41.49%。不合理处方主要为诊断与用药不符、录入错误、用法与用量不适宜及抗菌药物使用不规范。结论:应不断规范医师处方行为,加强处方点评力度及干预措施,促进临床合理用药。

OBJECTIVE： To investigate the outpatient and emergency prescriptions in a three Grade A hospital（hereinafter referred to as ＂this hospital＂）, so as to improve the quality of prescriptions, promote the rational application of drugs and ensure the medication safety of patients. METHODS： Through the computer management system of this hospital, 300 outpatient prescriptions and 200 emergency prescriptions were randomly selected for review and analysis in each month of 2017. RESULTS： In 2017, the rational rate of outpatient and emergency prescriptions were 98.58% and 99.22%, respectively. The average number of drugs used in outpatient and emergency prescriptions were 2.40 and 2.64, respectively. The average medication amount for outpatient and emergency prescriptions were 234.21 and 121.14 yuan, respectively. The application rates of antibiotics for outpatient and emergency prescriptions were 6.61% and 44.19%, respectively. The application rate of injection for outpatient and emergency prescriptions were 26.11% and 41.49%, respectively. The unreasonable prescriptions mainly included inconsistency of diagnosis and medication, inaccuracy of input, inappropriateness of usage and dosage and nonstandard application of antibiotics. CONCLUSIONS： It is necessary to constantly standardize the prescription behavior of clinicians, strengthen the prescription review efforts and intervention measures and promote the clinical rational drug application.