基于精准管控模式的医嘱专项点评在住院患者用药质量管理中的应用

Application of special comments on medical advice based on precise control mode in medication quality management for inpatients

目的探讨精准管控模式的医嘱专项点评在住院患者用药质量管理中的应用情况,为临床合理用药提供参考。方法根据《霍山县医院合理用药检查抽取病历、门诊处方方案和实施细则》抽取某院2018年9月~2018年12月住院患者病历293份,按照《医院处方点评管理规范(试行)》等规定的标准分析住院患者用药的合理性,并提供改进措施。结果在抽取的293份病历中,不合理病历占10.92%(32份);不合理病历按科室划分以疼痛科占比最大(100.00%);不合理用药的情况有如下8种:遴选药品不适宜、用法用量不适宜、无指征用药、抗菌药使用不规范、疗程不适宜、围手术期用药不适宜、联合用药不适宜、辅助药物占比超标。结论通过对住院患者用药进行精准管控模式的医嘱专项点评,能够加强患者用药质量的管理,为临床合理用药提供改进依据。

Objective To explore the application of special comments on medical advice based on precise control mode in medication quality management for inpatients and provide reference for clinical rational drug use.Methods 293 medical records of patients hospitalized in the hospital from September to December 2018 were collected according to The Extracted Records,Outpatient Prescription Schemes and Implementation Details of Reasonable Medication Inspection in Huoshan County.According to the standards stipulated by Hospital Prescription Comments Management Practices(Trial),medication rationality of inpatients was analyzed,and improvement measures were provided.Results Among the 293 medical records,10.92%(32)of them were unreasonable.The proportion of unreasonable medical records was the highest in the pain department(100.00%).There were 8 situations where unreasonable medication occurred,which were inappropriate drugs selection,inappropriate usage and dosage,non-indicative medication,improper usage of antibacterial drugs,inappropriate treatment course,inappropriate perioperative medication,inappropriate combination medication and excessive proportion of auxiliary drugs.Conclusion The application of special comments on medical advice based on precise control mode in medication of inpatients can strengthen the management of medication quality,and provide an improved basis for clinical rational drug use.