某三级甲等综合医院儿科门诊基于用药日志的抗菌药物合理使用精细化管理实践

Fine management practice of rational use of antimicrobial agents in pediatric outpatient clinics based on medication log in a tertiary grade A general hospital

某院基于抗菌药物临床应用指导原则设计了用药日志,日志填报项目包含患儿症状、体征以及检查结果等,以综合体现医生处方依据。考虑影响医生处方的非医学因素,在日志中增设了疾病所需、经验用药以及家属要求等处方原因。日志由医生自主填报,由专人定期统计结果,在科室例会上汇总、分析用药情况,提出整改建议。使用日志后,某院首次获得了儿科门诊不同原因的不合理用药数据,明确了改进方向;医生合理用药意识提升、自律性增强;用药管理效能提升。某院未来将继续推行用药日志,并推广至其他科室门诊,加快电子病案建设,将电子日志嵌入医生工作站,优化用药考核。

A hospital designed a medication log based on the guiding principles of clinical application of antibiotics.The items filled in the log included symptoms, signs and examination results of children, so as to comprehensively reflect the basis of doctors’ prescriptions. Taking into account the non-medical factors affecting doctors’ prescriptions, the reasons for prescribing were added in the log, such as the need for illness, the experience of medication, and the request of family members. The logs were filled in by physicians independently, and the results were counted regularly by speciallyassigned personnel, and the medication situation was summarized and analyzed at the regular meeting of the department,and rectification suggestions were put forward. After the using the log, the hospital obtained the data of irrational drug use for different reasons in pediatric outpatient department for the first time, which clarified the direction of improvement.Doctors’ awareness of rational drug use was improved and their self-discipline was strengthened. Medication management efficiency improved. In the future, the hospital will continue to implement medication log and promote it to other outpatient departments, accelerate the construction of electronic medical records, embed the electronic log into the doctor’s workstation,and optimize medication assessment.