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目的了解我院门诊处方书写质量及合理用药基本情况,提高临床合理用药水平。方法利用处方点评系统随机从电脑中抽取2015年上半年门急诊处方每月共1000张,共计6000张,根据《处方管理办法》、《抗菌药物临床应用管理中法》及《医院处方点评管理规范(试行)》和药品说明书的规定开展处方点评工作,对不合理处方进行分类统计及评价分析。结果 2015年1~6月份抽查不合理处方84份,其中未写临床诊断12例次,诊断书写不全9例次,无特殊情况下的超量处方2例次,遴选的药品不适宜7例次,给药途径不适宜14例次,用法用量不适宜17例次,重复给药8例次,无适应证用药26例次。结论应加强门急诊医师在合理用药方面的培训,加强药师的干预,以进一步提高门诊处方的安全性及合理性,确保患者用药的安全有效。
Objective To understand the quality of outpatient prescriptions in our hospital and the basic situation of rational drug use and improve the clinical reasonable medication level. Methods A total of 6,000 prescriptions per month were randomly collected from computers using a prescription review system. According to the “Regulations on the Management of Prescriptions,” “Application of Antibiotics in Clinical Practice” and “Regulations on Management of Hospital Prescriptions (Trial) ”and the provisions of the drug specification to carry out prescription reviews, classification of unreasonable prescriptions and evaluation analysis. Results From January to June of 2015, 84 samples of unreasonable prescriptions were randomly selected. Among them, 12 were not clinically diagnosed, 9 were incompletely diagnosed, 2 were over-prescribed without special circumstances, and 7 were unsuitable for selected drugs , Route of administration is not suitable for 14 times, dosage is not suitable for 17 cases, repeated administration of 8 cases, no indications of medication for 26 cases. Conclusions The outpatient and emergency department physicians should be trained on the rational use of drugs and pharmacists should be strengthened to further improve the safety and rationality of outpatient prescriptions and ensure the safety and effectiveness of the medication for patients.