医院门诊处方点评及统计分析

摘要

Objective To assess prescription quality so as to understand the problems of unreasonable drug use in outpatient.Methods Totally 4 209 outpatient preseriptions from February 2013 to February 2014 were sampled,and the prescription quality was evaluated according to the prescription management regulations and hospital prescription evaluation management regulations (Trial).Results The average number of drugs was 2.21/per prescription;the number of antibiotics prescription was 557 (13.2％);the number of injection prescription was 428 (10.2％).There were 2 161 kinds of essential drugs,with percentage of 51.3％;there were 82.2％ (3 460/4 209) qualified prescriptions and 17.80％ (749/4 209) were unreasonable prescriptions including 664 irregular prescriptions,60 inappropriate medication prescriptions and 25 supernormal prescriptions.Conclusions There are problems of prescription writing,inappropriate and supernormal prescription in our hospital,which should be improved by effective interventions.%目的 了解医院门诊处方存在的问题.方法 采用人工随机抽样方法抽取第三军医大学第二属附属医院门诊2013年2月至2014年2月处方共计4 209张,按《处方管理办法》和《医院处方评价管理规范(试行)》评价处方质量.结果 平均每张处方用药品种数为2.21种.使用抗菌药物的处方数为557张,抗菌药使用率为13.2％;使用注射剂的处方数为428张,注射剂使用率为10.2％;处方中基本药物品种总数为2 161种,国家基本药物占处方用药的51.3％(2 161/4 209).不合理处方749张,处方不合格率为17.80％ (749/4 209),其中不规范处方664张,用药不适宜处方60张,超常(无适应证用药)处方25张.结论 本院门诊处方主要存在处方书写不规范、用药不适宜以及超常处方等问题.医院需完善处方统计制度并采取有效的干预措施,不断提高处方质量,提高门诊处方合理用药水平.