住院医嘱点评及精准管控模式探讨与实践

Discussion and practicion of medical records review and precise control mode in hospital

目的:促进临床安全、有效、经济、合理用药,减轻患者经济负担,减少医疗纠纷。方法:通过临床用药的大数据,分析不合理用药情况,医嘱点评工作组根据合理用药原则,借助合理用药软件,以问题为导向寻找典型不合理用药情况,对不合理用药医疗组及药物进行精准管控。医嘱点评每月1次,执行PDCA循环。结果:执行医嘱点评及精准管控以来,临床不合理用药情况明显改善,特别是辅助用药、中药注射剂等使用金额显著减少,全院药占比明显降低。结论:以问题为导向住院医嘱点评及精准管控模式可有效降低药物不合理使用。

Objective:To promote clinical safety,effective,economic and rational use of drugs,reduce the economic burden of patients,and reduce medical disputes.Methods:Through the big data of clinical medication,the irrational medication was analyzed.The doctor's review working group looked for typical irrational medication cases according to the principle of rational medication,and used the rational medication software to control accurately the irrational medication group and drugs.The medical records review is conducted once a month,and the PDCA cycle is executed.Results:Since the implementation of medical records review and precise control,the situation of clinical irrational drug use has improved significantly,especially the amount of supplementary drug use and traditional Chinese medicine injection has decreased significantly,and the proportion of drugs in the whole hospital has decreased significantly.Conclusion:The problem-oriented medical records review and precise control can effectively reduce the irrational use of drugs.