摘要
目的对射阳县人民医院3600份住院病历进行用药点评,并对不合理用药情况进行分析。方法随机抽查射阳县人民医院2019年6月—2020年5月住院归档病历,每月随机抽取当月归档病历300份,共计3600份病历,对其住院用药医嘱的书写规范性、用药剂量、用药疗程、适应证和药物相互作用等进行全要素点评与分析。结果抽取的3600份住院病历中,不合理用药医嘱有40份,占1.11%。不合理医嘱类型重点涉及以下几个方面:无指征联合用药(抗生素、辅助用药)占23.91%;超疗程及超剂量用药占20.65%;重复用药占18.48%;无适应证占15.22%;禁忌用药、溶媒选择不当、药品使用方法不合理占比较小。不合理医嘱涉及药物种类中心血管药物占比较高,为30.43%,其次为抗生素药物、呼吸和消化药物等。非抗菌药物不合理率为2.00%,抗菌药物医嘱不合理率为0.56%。结论通过临床药师在临床合理用药中的药学服务,可提升临床合理用药水平,保证的患者用药安全,提高医院药事管理质量。
Objective To evaluate the medication of 3600 inpatient records from Sheyang County People’s Hospital,and to analyze the unreasonable medication use.Methods Randomly check the archived medical records of Sheyang County People’s Hospital from June 2019 to May 2020,and randomly select 300 archived medical records of the current month each month,a total of 3600 medical records,and the standardization,dosage,and dosage of hospitalized medications review and analyze all elements of medication treatment,indications,and drug interactions.Results Among the 3600 hospitalized medical records sampled,40 were irrational medication orders,accounting for 1.11%.Irrational medical order types focus on the following aspects:unindicated combination medications(antibiotics,adjuvant medications),accounting for 23.91%;overcourse and over-dose medications,accounting for 20.65%;repeated medications,accounting for 18.48%;no indications,accounting for 15.22%;contraindications,improper selection of solvents,and irrational use of drugs account for relatively small proportions.Cardiovascular drugs accounted for a relatively high proportion of the drugs involved in unreasonable medical orders,accounting for 30.43%,followed by antibiotic drugs,respiratory and digestive drugs.The unreasonable rate of nonantibacterial drugs was 2.00%,and the unreasonable rate of antibacterial drugs was 0.56%.Conclusion Through clinical pharmacists’pharmacy services in the clinical rational use of drugs,the level of clinical rational use of drugs can be improved,the safety of patient medication can be guaranteed,and the quality of hospital pharmacy management can be improved.
作者
刁姝姝
DIAO Shushu(Department of Pharmacy,Sheyang County People’s Hospital,Yancheng 224300,China)
出处
《临床合理用药杂志》
2021年第12期10-12,15,共4页
Chinese Journal of Clinical Rational Drug Use
关键词
住院病历
医嘱点评
临床药师
药学服务
合理用药
Inpatient medical record
Doctor’s order comment
Clinical pharmacist
Pharmaceutical care
Reasonable medication
