我院不合格处方类型研究及对策.doc

我院不合格处方类型研究及对策摘要：目的：通过不合格处方分析，找出不合格处方的存在原因，提醒医师正确开具处方和加强药师对处方的审核，提高处方质量，防止医疗差错的发生。方法： 抽取我院门诊西药房2011年第二季度电子处方158011张（除精麻处方外），找出不合格处方，以《处方管理法》、药品说明书和临床药理学知识为标准进行分析。结果：大多数处方合格、用药合理，不合格为3.56%，主要表现在：处方类型与处分颜色不符、用药与临床诊断不符、处方医生未签名、用法用量不正确等方面。结论：我院门诊电子处方存在一定程度的不合格，因此要加强医师与药师的交流，不断提高药师审核处方能力，把好处方关“四查十对”制度，减少不合格处方出现，从而杜绝医疗事故的发生，确保患者用药安全有效。 关键词：不合格处方；处方分析；对策Abstract:Target：We analyze unqualified recipes to identify the reasons for the existence of unqualified recipes, prescribing the right to remind physicians and pharmacists on the recipe of strengthening the audit and improve the quality of recipes, to prevent the occurrence of medical errors.Method：We have collected 158,011 electronic recipes (except for recipes outside the fine linen) in our hospital pharmacy two quarter of 2011 to identify unqualified recipes to “Recipe Management Act,” description of the drug and knowledge of clinical pharmacology as a standard for analysis.Result：Most of recipes are qualified, using drug reasonable, the failure is 3.56% which is mainly display in the color does not match the prescribed type and disposition, medication does not match with the clinical diagnosis, prescribing physicians are not signed, the incorrect dosage and so on.Conclusion：Electronic prescribing in our hospital has a certain degree of failure, so doctors and pharmacists should strengthen exchanges, and constantly improve the ability of pharmacists review recipes, recipe of the good relations “four examinations ten pairs of” system, reduce the emergence of unqualified recipes, so as to prevent medical malpractice occurrence, to ensure safe and effective drug in patients. Key words:unqualified recipe； recipes analyze；countermeasure【中图分类号】R197.3【文献标识码】A【文章编号】1672-3783(2012)02-0021-02 处方是执业医师在诊疗活动之中为患者开具的、由取得药学专业技术职务资格的药学专业技术人员审核、调配、核对、并作为患者用药凭证的医疗文书，具有法律、技术、经济责任。处方质量是医疗质量的体现，直接反映医疗质量水平的高低，不合格处方给患者带来不合理用药的结果，同时易酿成医患纠纷的发生。 1资料与方法 抽取我院门诊西药房2011年第二季度电子处方158011张（除精麻处方外），找出不合格处方，以《处方管理法》、药品说明书和临床药理学知识为标准进行统计分析。