某院2021年门诊中药饮片处方点评与合理用药分析

Prescription review and rational drug use analysis of traditional Chinese medicine decoction pieces in outpatient department of a hospital in 2021

目的通过点评中药饮片处方,找出不合理处方产生的原因并提出规范化建议,以减少不合理处方数量,保障临床用药安全。方法2021年1月~12月,每月从吉林省中医药科学院第一临床医院门诊中药房随机抽取中药饮片处方300张,以《中国药典》(2015年版)、《处方管理办法》、《中药处方格式及书写规范》和《医院处方点评管理规范》为依据对处方进行回顾性点评分析。结果2021年共抽查中药饮片处方3600张,不合理处方308张,处方不合理率8.56%;其中不规范处方180张(占不合理处方的58.44%),包括电子处方修改后未二次签名、未注明特殊煎煮要求、临床诊断书写不规范和无理由疗程超过7 d;用药不适宜处方128张(占不合理处方的41.56%),包括适应证不适宜、用法用量不适宜和存在配伍禁忌。结论某院门诊中药饮片处方仍存在不合理应用情况,医师应重视处方开具的合理性,药师应认真履行处方审核的职责,确保用药安全。

Objective By commenting on the prescription of traditional Chinese medicine(TCM)decoction pieces,this paper finds out the causes of unreasonable prescription,and puts forward standardized suggestions,so as to reduce the number of irrational prescription and ensure the safety of clinical medication.Methods From January to December in 2021,300 TCM decoction pieces were randomly selected every month from the outpatient pharmacy of the First Clinical Hospital of Jilin Academy of Traditional Chinese Medicine,and retrospectively reviewed the prescriptions according to Chinese Pharmacopoeia(2015Editon),Prescription Management Measures,Format and Writing Specifications of TCM Prescriptions,and Hospital Prescription Comment Management Specifications.Results In 2021,a total of 3,600 prescriptions of TCM decoction pieces were randomly selected,of which 308 were irrational,with an irrational rate of 8.56%.Among them,there were 180 non-standard prescriptions(accounting for 58.44%of the irrational prescriptions),including the electronic prescriptions that were not signed twice after modification.The special decocting requirements were not indicated,the clinical diagnosis writing was not standardized and there was no reason for the course of treatment to exceed 7 days.There were 128 inappropriate prescriptions(accounting for 41.56%of irrational prescriptions),including inappropriate indications,inappropriate usage and dosage,and incompatibility.Conclusion There is still irrational application of prescriptions for TCM decoction pieces in outpatient department in hospital.Doctors should pay attention to the rationality of prescriptions and pharmacists should carefully perform the responsibility of prescription review to jointly ensure the safety of clinical medication.