2016年医院门诊成人处方合理性分析

摘要

目的 促进临床合理用药.方法 抽取2016年门诊成人处方72366张进行合理性点评.结果 每张处方平均用药2.72种,平均用药金额188.94元,注射剂处方比例10.89%,抗菌药物处方比例18.42%,雌孕激素处方比例57.10%,处方合理率98.30%.不合理处方1230张,主要分布在生殖医学门诊(27.72%)、妇科门诊(19.02%)、宫颈疾病门诊(14.55%);其中不规范处方845张(68.70%),主要表现为用药药品超过规定量未注明原因、诊断不规范或不全、处方医师未签名或未盖章、处方医师签名与留样不一致;用药不适宜处方372张(30.24%),主要表现为用法与用量不适宜、适应证不适宜、遴选的药品不适宜;超常处方13张(1.05%),主要表现为超说明书用药.结论 该院2016年门诊成人处方合理率高,但仍存在少量问题,建议加强医师对处方书写及药品相关知识培训;提升药师专业知识及技能水平,加强处方审核;加强与门诊医生地沟通,及时准确地传达最新药品信息;完善处方点评系统,提高门诊处方质量,促进安全、合理用药.%Objective To promote rational drug use. Methods Totally 72366 adult prescriptions in outpatient service in 2016 were collected for rational review. Results The average kinds of drugs of each prescription was 2. 72,the average sum of medication was 188. 94 yuan,the proportion of injection prescription was 10. 89%,the proportion of antibacterial prescription was 18. 42%,the proportion of estrogen and progestin was 57. 10% ,and the rate of prescription was 98. 30%. There were 1230 irrational prescriptions,mainly distributed in reproductive medicine clinic(27. 72%),gynecology clinic(19. 02%) and cervical disease clinic(14. 55%),in which,845 prescriptions(68. 70%)were not standardized,mainly for the drug dosage exceeded the prescribed amount and the reason didn't indicated, the diagnosis wasn't standard or incomplete,the doctor's signature wasn't signed or sealed,and the doctor's signature was inconsistent with the sample;372 prescriptions(30. 24%) were unsuitable for medication,mainly for inappropriate use and dosage,unsuitable indications, and unsuitable drugs;13 prescriptions(1. 05%)were supernormal,mainly for the use of over instruction. Conclusion The rational rate of outpatient prescriptions for adults in the hospital in 2016 was high,but there are still a few problems,the training for physician's prescrip-tion writing and drug related knowledge should be strengthened;the pharmacist ' s professional knowledge and skills should be im-proved and the prescription examination should be strengthened;communication with the outpatient doctor should be strengthened to de-liver the latest drug information timely and accurately;the prescription review system should be improved and prefected in order to improve the quality of outpatient prescriptions,and promote safe and rational use of drugs.