我院门诊中药处方点评的干预效果分析

Intervention effect analysis of comment on outpatient prescriptions of traditional Chinese medicine in our hospital

目的:了解我院门诊中药处方的书写质量情况,统计差错类型,提高处方质量,分析干预效果。方法:随机选取我院门诊于2017年10月-2018年3月开具的中药处方1600张,其中2017年10月-2017年12月中药处方点评实施前处方共计800张,以《医院处方点评管理规范(试行)》《中药处方格式及书写规范》及《处方管理办法》等相关标准为依据,找出存在的差错并进行统计和分类,探讨问题所在并开展防范。处方点评实施后,选取2018年1月-3月处方800张。统计处方点评前后的处方差错类型及不合格率。结果:点评前中药处方不合格率为8.50%(68/800),差错类型主要包括:未使用规定处方笺书写、未写临床诊断或字迹难以辨认、无中医诊断病名和证型以及超剂量使用未注明原因等问题。防范措施包括:规范处方书写、提升临床药师专业素养、多部门联合干预等。经过处方点评干预,处方不合格率为2.38%(19/800),与点评前相比,两者差异显著(P <0.05)。结论:开展中药处方点评,可提高处方质量、促进合理用药,是临床提高中药治疗水平的重要途径。点评后采取相应措施,可降低处方不合格率,保证临床疗效及用药安全,提升医院用药水平。

Objective: To understand the writing quality of outpatient prescriptions of traditional Chinese medicine in our hospital, to count the types of errors, to improve the quality of prescriptions, and to study the effect of intervention. Method: 1600 prescriptions of traditional Chinese medicine were randomly selected from October 2017 to March 2018 in our outpatient clinic. Among them, 800 prescriptions were prescribed before the implementation of the prescription review of traditional Chinese medicine from October 2017 to December 2017. Based on the relevant standards of "Hospital Prescription Review Management Standards(Trial Implementation)", "Format and Writing Standards of Traditional Chinese Medicine Prescription" and "Prescription Management Measures", the errors were found out and the statistics were made to classify, discuss the problems and take precautions. After the implementation of prescription review, 800 prescriptions were selected from January 2018 to March 2018. The types of errors in prescription variance and the rate of nonconformity before and after prescription review were counted. Result: The rate of unqualified prescriptions was 8.50%(68/800) before the comment. The main types of errors included: not using prescription notes, not writing clinical diagnosis or difficult to identify handwriting, not having the name and syndrome type of TCM diagnosis, and not specifying the cause of overdose use. Preventive measures include: standardizing prescription writing, improving professional literacy of clinical pharmacists, multi-sectoral joint intervention and so on. After intervention of prescription comment, the rate of unqualified prescription was 2.38%(19/800), which was significantly different from that before comment(P<0.05). Conclusion: Comments on Chinese herbal prescriptions can improve the quality of prescriptions and promote rational drug use, which is an important way to improve the level of clinical treatment of Chinese herbal medicine. Measures taken after the review can reduce the rate of unqualified prescriptions, ensure the clinical efficacy and safety of drug use, and improve the level of drug use in hospitals.