山西省某三甲医院处方点评分析  

Analysis of the prescription comments of a Grade A tertiary hospital in Shanxi province

作　　者：马医杰 闫若弘 任清兰 Ma Yijie;Yan Ruohong;Ren Qinglan(Department of Pharmacy,Taiyuan Central Hospital,Taiyuan 030001,China)

机构地区：[1]太原市中心医院药剂科,山西太原030001

出　　处：《实用药物与临床》2023年第4期357-361,共5页Practical Pharmacy and Clinical Remedies

摘　　要：目的通过对该院门诊处方进行规范性点评,分析不合理处方原因,并提出改进建议,为提高处方质量,促进合理用药,保障患者用药安全提供依据。方法采用回顾性分析方法,随机抽取太原市中心医院2021年1-12月门诊处方,以《医院处方点评管理规范(试行)》、《处方管理办法》、药品说明书等为依据,进行处方规范性点评,分析不合理处方的类型并结合帕累托图进行讨论。结果分析随机抽取的47557张处方,其中合理处方46689张,处方合理率为98.17%,不合理处方868张,处方不合理率为1.83%。在868张不合理处方中,不规范处方681张,用药不适宜处方55张,超常处方132张。开具抗菌药物的处方3353张,抗菌药物使用率7.05%。结论该院处方合理率未达三甲医院评审的要求,其中处方超量、书写不规范等是当前影响处方不合理的主要原因,其次超说明书用药备案流程未完善是超常处方主要原因。建议加强医师培训,优化管理流程,不断完善处方点评制度,以提高处方质量,保证患者用药安全。Objective To analyze the reasons for unreasonable prescriptions and put forward suggestions for improvement through normative comments on the outpatient prescriptions of the hospital,and provide a certain basis for improving the quality of prescriptions,promoting rational drug use,and ensuring the safety of drug use in patients.Methods The outpatient prescriptions of Taiyuan Central Hospital from January to December 2021 were randomly selected by using the retrospective analysis method.On the basis of the Hospital Prescription Review Management Norms(Trial),Prescription Management Measures,drug instructions,etc.,the prescriptions were reviewed in a standardized manner,the types of unreasonable prescriptions were analyzed and discussed by using the Pareto Chart.Results Totally 47557 prescriptions were randomly selected through analysis,including 46689 reasonable prescriptions,the prescription reasonable rate was 98.17%.There were 868 unreasonable prescriptions,unreasonable prescription rate being 1.83%.Among the 868 irrational prescriptions,681 were nonstandard prescriptions,55 were inappropriate use of drugs,and 132 were abnormal prescriptions.There were 3353 prescriptions with antibiotics,and the utilization rate of antibiotics was 7.05%.Conclusion The rational rate of prescriptions in our hospital does not meet the requirements of the Grade A tertiary hospital evaluation.Among them,excessive prescriptions and nonstandard writing are the main reasons for the irrational prescriptions at present.Secondly,the imperfect record process of off-label drug use is the main reason for abnormal prescriptions.It is suggested to strengthen the training of physicians,optimize the management process,and constantly improve the prescription review system to improve the quality of prescriptions and ensure the safety of durg use in patients.

关 键 词：门诊处方 处方点评 合理用药 超说明书用药 

分 类 号：R95[医药卫生—药学]