特需门诊处方实时审核及点评结果分析

Real-time Review of Prescriptions for Special Needs and Analysis of Review Results

目的 探讨某院特需门诊药房窗口药师发药时的实时处方审核及事后处方二次抽查点评工作,分析不合理处方原因,促进临床合理用药。方法 2021年6月1日-2021年11月30日门诊药房窗口药师发药时,实时审核门诊处方6392张,将不合理处方以联络信的形式告知病区。同时责任药师每月25日随机抽取当月前2个整周的40张处方进行二次抽查点评。应用Excel2013对不合理处方进行统计分析。结果实时审核处方6392张,不合理处方24张,不合理率为0.38%,处方不合理类型构成比较高有处方用药与临床诊断不符(20.83%)、剂量及用法不正确(16.67%)、用法用量不明确(16.67%)、未注明过敏试验及结果的判断(16.67%);二次抽查点评240张处方中,不合理处方45张,不合理率为18.75%。结论 处方实时审核是改善和维持处方合理性的有效手段,处方二次抽查点评具有查缺补漏与提高处方合理性的作用。药师、医师及医院管理部门通力协作可促进临床合理用药,降低不合理处方发生,保障患者用药安全,提高医疗服务水平。

Objectives This study aims to discuss the real-time prescription review when the pharmacist in the outpatient pharmacy window of a hospital dispenses medicines and post-event prescription second spot check review work, analyze the reasons for irrational prescriptions, and promote clinical rational drug use. Methods From June 1,2021 to November 30, 2021, when the pharmacist at the window of the outpatient pharmacy dispenses the medicine, 6,392 outpatient prescriptions were reviewed in real-time. The ward was informed of the unreasonable prescriptions in the form of contact letters. At the same time, on the 25th of each month, the responsible pharmacist randomly selected 40 prescriptions from the first two full weeks of the month for a second spot check and comment.Statistical analysis of unreasonable prescriptions was carried out by using Excel 2013 statistical tables. Results 6392prescriptions were reviewed in real-time, containing 24 unreasonable prescriptions, with an unreasonable rate of 0.38%. The composition of irrational types of prescriptions was relatively high, including prescription medications inconsistent with clinical diagnosis(20.83%), incorrect dosage and usage(16.67%), unclear usage and dosage(16.67%), unspecified allergy tests and judgment of results(16.67%). Among the 240 prescriptions reviewed in the second spot check, 45 prescriptions were unreasonable, with an unreasonable rate of 18.75%. Conclusions The real-time review of prescriptions is an effective means to improve and maintain the rationality of prescriptions, and the second random inspection and review of prescriptions can check for gaps and further improve the rationality of prescriptions. At the same time, pharmacists, physicians, and hospital management departments should work together to promote clinically rational drug use, effectively reduce the occurrence of unreasonable prescriptions,ensure drug safety for patients, and improve the level of medical services.