住院患者口服用药医嘱点评与分析  

Review and analysis of oral medication orders for hospitalized patients

作　　者：陈福安[1] 姚晨蕊 张呈[1] 黄伟[1] 张亚同[1] 叶爱军[1] CHEN Fu′an;YAO Chenrui;ZHANG Cheng;HUANG Wei;ZHANG Yatong;YE Aijun(Department of Pharmacy,Beijing Hospital,National Center of Gerontology,Institute of Geriatric Medicine,Chinese Academy of Medical Sciences,Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application(Beijing Hospital),Beijing 100730,China)

机构地区：[1]北京医院药学部,国家老年医学研究中心,中国医学科学院老年医学研究院,北京市药物临床风险与个体化应用评价重点实验室(北京医院),北京100730

出　　处：《中国临床保健杂志》2024年第3期330-332,共3页Chinese Journal of Clinical Healthcare

基　　金：国家重点研发计划项目(2020YFC2009001)。

摘　　要：目的分析住院患者口服用药的医嘱点评结果。方法将2018年1月至2023年1月北京医院收治的9000例住院患者(9000张处方)作为研究对象,由临床药师对其口服用药处方进行医嘱点评,分析医嘱点评结果,包括不合理处方的发生率、时间分布、科室分布、不合理用药原因及医嘱书写不规范发生情况。结果9000张处方中,不合理处方张数为176张,不合理处方发生率为1.96%;住院患者口服用药不合理处方的时间分布,以2018年的不合理发生率最高(2.32%),2022—2023年的发生率最低(1.69%);住院患者口服用药不合理处方的科室分布中,以肿瘤科的不合理发生率最高(4.01%),外科的发生率最低(1.21%);住院患者口服用药不合理处方的原因中,未按药品临床应用管理规定用药最为常见,构成比为23.86%,超医嘱用药最为少见,构成比为3.98%;9000张处方中,医嘱书写不规范处方共849张,发生率为9.43%,其中包括药品名称387张、剂型规格273张、用法用量189张。结论住院患者口服用药不合理情况较为常见,应引起重视,加强用药管理。Objective To analyze the rationality of oral medication in hospitalized patients and provide feedback on medical advice.Methods Nine thousand hospitalized patients(9000 prescriptions)admitted to Beijing Hospital from January 2018 to January 2023 were selected as the research subjects.Clinical pharmacists evaluated their oral medication prescriptions and analyzed the results of the evaluation,including the incidence of unreasonable prescriptions,time distribution,department distribution,and the reasons for unreasonable medication,as well as the occurrence of non-standard medical instruction writing.Results Among the 9000 prescriptions,there were 176 unreasonable prescriptions,and the incidence of unreasonable prescriptions was 1.96%.In the time distribution of unreasonable oral medication prescriptions for hospitalized patients,the highest incidence rate was in 2018(2.32%),and the lowest incidence rate was in 2022—2023(1.69%).In the distribution of departments with unreasonable oral medication prescriptions for hospitalized patients,the incidence of unreasonable prescriptions was the highest in the oncology department(4.01%),and lowest in the surgery department(1.21%).Among the reasons for unreasonable oral medication prescriptions among hospitalized patients,failure to use drugs in accordance with the clinical application management regulations was the most common,with a constituent ratio of 23.86%,and medication beyond medical orders was the least common,with a constituent ratio of 3.98%.Out of 9000 prescriptions,there were 849 prescriptions with non-standard medical instructions,with an incidence rate of 9.43%,including 387 drug names,273 dosage forms,and 189 usage and dosage forms.Conclusions Unreasonable oral administration is common in inpatients,which should be paid more attention to,we should strengthen drug administration.

关 键 词：处方不当 投药 口服 住院病人 

分 类 号：R95[医药卫生—药学]