某院妇科住院医嘱超药品说明书用药现状分析

Current Situation of Off-Label Drug Use of Medical Orders for Inpatients in the Department of Gynaecology in a Hospital

目的规范妇科临床合理用药。方法随机抽取某院2017年每月妇科出院病历25份,共300份,以相应药品说明书为依据,判断医嘱合理性。结果抽查300份病历,共6 725条医嘱,超说明书用药涉及病历234份(78. 00%),不合理医嘱数431条(6. 41%);主要包括4种用药类型,即超适应证用药医嘱245条(56. 84%),超用量用药医嘱125条(29. 00%),超用药途径用药医嘱58条(13. 46%);超溶剂用药医嘱3条(0. 70%)。结论该院妇科超药品说明书用药情况普遍,建议临床用药应尽量遵循药品说明书,以保障患者用药安全。

Objective To standardize the clinical medication in the Department of Gynaecology. Methods Totally 25 discharged medical records per month( totally 300 cases) from the Department of Gynecology in our hospital in 2017 were randomly selected. The rationality of medical orders was judged on the basis of corresponding drug instructions. Results Totally 300 medical records were selected,including 6 725 medical orders,of which 234( 78. 00%) medical records were involved in off-label drug use,431( 6. 41%) unreasonable medical orders. The main categories of off-label drug use were off-label indication( 245 medical orders,56. 84%),off-label dosage( 125 medical orders,29. 00%),off-label drug administration route( 58 medical orders,13. 46%),off-label drug solvent( 3 medical orders,0. 70%). Conclusion The off-label drug use is common in the Department of Gynaecology in our hospital. It is suggested that clinical medication should follow the drug instructions as far as possible in order to ensure the medication safety for patients.