我院急诊药房处方干预记录分析.pdfVIP

Case Analysis 案例分析 我院急诊药房处方干预记录分析 田德蔷，陆茵，赵志刚* 首都医科大学附属北京天坛医院药剂科，北京 100050 [摘要] 目的：提高急诊处方质量，保障患者安全、合理用药。方法：随机抽取我院2012年10月至2013年3月急诊处方9044张， 依据《处方管理办法》等相关内容进行干预记录并进行统计分析。结果：查出不合格处方616张，平均干预率6.81% ；诊断与 用药不符项占不合格构成比62.01% 、医师无签字18.18%、其他(合理性不确定)11.69% ；抗菌药物用药指证不明确占诊断与用药 不符总数的29.32% 。结论：我院急诊处方开立仍存在不够规范现象，还应加强对处方书写及合理用药的管理，保障患者用药 安全。 [关键词] 急诊处方；干预；分析 [中图分类号] R969.3　　[文献标识码]　A　　[文章编号]　1672-2809(2014)12-0043-04 Analysis of the Records of Prescription Intervention at Emergency Pharmacyin Our Hospital * TIAN De-qiang, Lu Yin, ZHAO Zhi-gang Department of pharmacy,Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing 100050, China [Abstract] Objective: To improve prescription quality at emergency department and to ensure patients rational drug use. Methods: 9044 prescriptions were randomly selected from the prescriptions at emergencypharmacy between October 2012 and March 2013. Records of pharmacists intervention were analyzed. Interventions were made according to “Prescription Administrative Policy”. Results: Totally616 prescriptions did not meet the normal requirements. The interventionratewas6.81%. 62.01%of the interventionswere for diagnosis and medication discrepancy, 18.18% were because of absence of physicians signature and 11.69% were irrational for other reasons. As for diagnosis and medication discrepancy, 29.32% were antibiotic presc riptions with no clinical indication. Conclusion: There were still problems in prescription writing and rational drug use in emergency department, which need further improvement in order to ensure the patients safety. [Key words] Emergency Prescription; Intervention; Analysis 规范处方管理、促进合理用药，卫生部 全、经济、高效的药学服务，促进临床合理用药。 为颁布了《处方管理办法》[1]和《医院处 方点评管理规范(试行)》[2]等文件，规定医疗机构 1 资料与方法 需建立处方点评机构，对处方实施监测，采取干预 资料来源于2012年1