摘要
目的 分析门急诊处方点评中不合理处方点评结果,为提升医院合理用药水平提供参考。方法 通过医院信息系统(HIS),随机抽取本院2022年1—12月门急诊处方共3600张进行点评,并对不合理处方进行讨论分析。结果 3600张处方中,不合理处方共276张,不合理处方率为7.67%(276/3600)。其中,不规范处方有179张,占(179/276)64.86%。主要不合理问题为门诊处方超7 d用量但未标注理由和不写临床诊断或临床诊断不全面。用药不适宜处方共88张,占(88/276)31.88%,主要不合理问题为药品的用法用量不适宜和适应证不适宜,其次为遴选的药品不适宜。超长处方有9张,占(9/276)3.26%,主要不合理问题为无适应证用药。结论 门急诊患者普遍存在不合理用药问题,而处方点评可有效分析不合理用药情况及发生原因,为医院不合理处方整改与预防措施提供依据。医院应逐步加大处方点评力度和广度,加强对临床医师、药师的专业培训,优化升级合理用药监测系统(PASS),以提高处方合格率,进而提升临床合理用药水平。
Objective To analyze the results of irrational prescription evaluations in outpatient and emergency departments to provide a reference for improving the level of rational drug use in hospitals.Methods Randomly select 3600 outpatient and emergency prescriptions from our hospital from January to December 2022 through the Hospital Information System(HIS)for evaluation,discuss and analyze unreasonable prescriptions.Results Among the 3600 prescriptions,there were 276 irrational prescriptions,with an irrational prescription rate of(276/3600)7.67%,including 179 non-standard prescriptions,accounting for(179/276)64.86%,with the main irrational issues being outpatient prescriptions exceeding 7 days of dosage without indicating reasons and incomplete or absent clinical diagnoses;88 prescriptions with inappropriate medication usage,accounting for(88/276)31.88%,mainly due to inappropriate dosage and indications of drugs,followed by inappropriate selection of drugs.There were 9 overly long prescriptions,accounting for(9/276)3.26%,with the main issue being the use of medications without appropriate indications.Conclusion Patients in outpatient and emergency departments commonly have problems with irrational medication use,and prescription evaluation can effectively analyze the situation and causes of irrational medication use,providing a basis for the rectification and preventive measures of irrational prescriptions in hospitals.Hospitals should gradually strengthen the intensity and breadth of prescription evaluation,enhance professional training for clinicians and pharmacists,optimize and upgrade the rational drug use monitoring system(PASS),improve the prescription qualification rate,and enhance the level of clinical rational drug use.
作者
张晓琴
ZHANG Xiaoqin(Minle County Maternal and Child Health Hospital,Zhangye,Gansu 734500)
出处
《智慧健康》
2025年第14期185-187,191,共4页
Smart Healthcare
关键词
门急诊
处方点评
不合理用药
点评结果
Outpatient and emergency care
Prescription review
Irrational drug use
Review result
