北京市密云地区四家社区医院门诊处方点评工作情况介绍及结果分析

摘要

Objective:To review the regulatory compliance and drug suitability of the outpatient prescription of four community hospitals in Miyun area of Beijing from January to June in 2012, to find out quality control status of outpatient prescription in the four community hospitals, to remind pharmacists and physicians of the existing problems and to promote the clinical rational drug use. Methods:According to"Prescription Management"and"Hospital Prescription Review Management Practices (Trial)", we randomly inspected 100 pieces of prescription monthly and a total of 2400 copies were collected. Unreasonable prescriptions were reviewed and analyzed. Results:The unreasonable prescription rates in the four community hospitals were 32.17%、28.83%、36.67%and 22.67%respectively. Problems mainly involved drug usage and dosage and secondly empty clinical diagnosis. Conclusion:There were still certain problems in the prescription of the four community hospitals which needed efforts of hospitals, doctors and pharmacists to promote rational drug use and ensure patient safety by establishing training and supervision mechanisms, making full use of the hospital information system and improving prescription comment system.%目的：：通过对北京市密云地区四家社区医院2012年1-6月门诊处方的规范性、用药适宜性进行点评，了解四家社区医院门诊处方质控现状及存在问题，提醒药师、医师引起注意，促进临床合理用药。方法：以《处方管理办法》、《医院处方点评管理规范(试行)》为依据，随机抽查2012年1-6月份四家社区医院门诊处方，每月100张，共2400张，进行处方点评，对不合理处方进行分析。结果：四家社区医院门诊不合理处方百分率分别为32.17%、28.83%、36.67%、22.67%，不合理项目主要是用法用量不合理，其次是未写临床诊断等。结论：四家社区医院处方还存在一定的问题，需要医院、医师和药师共同努力，建立合理用药的培训监督机制，充分利用医院信息系统，建立健全处方点评制度，以促进医院合理用药水平，保障患者用药安全。