妇产科专科特色处方前置审核系统的建设与应用

Construction and Application of Prescription Pre-Audit System with Features of Obstetrics and Gynecology

目的建立适应妇产科专科特色的处方前置审核系统。方法引进处方前置审核软件,经后台运行收集基于商业知识库规则的审方数据,建立妇产科用药规则维护分级依据,进行规则优化并形成妇产科合理用药知识库,疏通处方前置审核流程并加以实施。结果通过抽样数据对比发现,药师审方上线后,系统预审问题数及比例、医师提交问题数及比例明显下降、医师主动返回修改问题数及比例相应上升,人员疏忽所致的严重用药错误可被拦截,药师干预处方/医嘱成功率达93.81%。结论建立妇产科专科特色处方前置审核系统,能有效保证审方准确性,能减少临床医师和审方药师不必要的工作量,有利于处方前置审核工作的推进,进一步保障患者用药的安全性和合理性。

OBJECTIVE To construct a prescription pre-audit system to accommodate the features of obstetrics and gynecology. METHODS With the introduction of a prescription pre-audit software, clinical pharmacists collected the prescription review data based on the commercial knowledge base rules through the background operation. By establishing the classification basis of the maintenance of obstetrics and gynecology medication rules, the rules were optimized, the obstetrics and gynecology rational medication knowledge base was formed, the prescription pre-audit process was sorted out and finally implemented. RESULTS Through the comparison of sample data collected before and after the prescription pre-audit work by pharmacists, the number and proportion of problems in system pre-examination and submitted by doctors significantly decreased, while the number and proportion of the problems voluntarily revised by doctors increased. Serious medication errors caused by personnel negligence could be intercepted, and the rate of pharmacists′ successful interventions to prescriptions and doctor′s orders reached 93.81%. CONCLUSION The establishment of a prescription pre-audit system in obstetrics and gynecology can effectively ensure the accuracy of prescription examination, reduce the unnecessary workload of clinicians and prescription-checking pharmacists, facilitate the promotion of prescription pre-audit work, and further ensure the safety and rationality of patients′ medication.