我院门诊处方点评工作中发现的问题与建议  

Problems and Suggestions of Outpatient Prescription Comment in Our Hospital

作　　者：刘日升[1] 张雯[1] 

机构地区：[1]海南医学院附属医院,海口市570102

出　　处：《中国药房》2011年第33期3164-3166,共3页China Pharmacy

摘　　要：目的:介绍我院门诊处方点评工作情况,为处方点评制度更好地实施提供参考。方法:以《医院处方点评管理规范(试行)》为依据,从我院2010年1-12月门诊处方中每月随机抽取1周的处方进行点评,从不合理处方分类、不合理处方类型及发生频次统计、开具不合理处方的科室排序等方面进行统计、分析,并提出建议。结果与结论:共抽取处方36793张,其中不合理处方包括不规范处方、用药不适宜处方、超常处方;不合理处方类型包括处方内容缺项(1052次),剂量、规格等书写不规范(935次),门诊处方超过7日量且未注明理由(1731次)等;便民门诊、妇产科、儿科分别位居开具不合理处方的科室前3位。建议可通过组建处方点评工作小组,制定相应的规章制度,加强合理用药知识培训,制定医院处方集,加快医院电子处方的建设等方面来加强处方点评工作。OBJECTIVE： To introduce outpatient prescription comment in our hospital, and to provide reference for the implementation of prescription comment system. METHODS： According to Hospital Prescription Comment Management Practice （trial）, outpatient prescriptions within a week were randomly collected every month from Jan. to Dec. in 2010, and these prescriptions were analyzed statistically in respect of irrational prescription＇s category, frequency and department. RESULTS ＆ CONCLUSION： A total of 36 793 prescriptions were collected, among which irrational prescription included non-standard prescription, inappropriate medication prescription and abnormal prescription; category of irrational prescriptions were item missing （1052 times）, non-standard writing of dosage and specification （935 times）, dosage of outpatient prescription beyond dosage within 7 days without masons noted （1 731 times）, etc. Most of these irrational prescriptions were from convenience outpatient department, obstetrics and gynecology department and pediatric department. It is suggested to strengthen prescription comment by establishing prescription comment group, formulating relevant regulations and system, enhancing rational drug use training, setting hospital formulary, speeding up the construction of hospital electronic prescription and so on.

关 键 词：处方 点评 分析 问题 建议 

分 类 号：R95[医药卫生—药学]