我院2016年住院医嘱点评分析(1)
摘要：目的 通過对2016年1月～12月我院住院医嘱进行点评分析，查找不合理用药的主要原因、来源科室、涉及的药物类型，以便规范医师处方，保证患者合理安全用药。方法 通过HIS系统从2016年1月～12月我院31个科室26661份出院病历随机抽取共4352份进行点评，对每份病历中的临时医嘱和长期医嘱逐条审核并点评。汇总点评结果，采用帕累托分析法进行分析。结果 点评的4352份病历中，不合理用药医嘱病历366份，占病历总数的8.41%，全院合格91.59%；不合理医嘱的原因主要是适应证不适宜(44.34%)、用法用量不适宜(30.54%)、不符合特殊使用级抗菌药物管理规定(7.64%)，占全部不合理医嘱的82.51%；不合理医嘱的来源科室主要是肝胆外科(11.75%)、骨科(10.93%)、海扶肿瘤中心(8.20%)、血管外科(7.92%)等13个外科临床科室，占全部不合理医嘱的80.87%；不合理医嘱涉及的主要药物类型分别是抗生素类(25.62%)、活血化瘀类中药注射剂(18.72%)、肠外营养剂(11.33%)、脑代谢改善及益智药(8.13%)、质子泵抑制剂(6.16%)、免疫调节剂(5.42%)和肝病辅助药(4.93%)，占全部不合理医嘱的80.30%。结论 我院2016年住院医嘱合格率较高，但仍然存在一些问题，需要加强合理用药监控。
, 百拇医药
关键词：住院医嘱；医嘱点评；合理用药
An Analysis of the Hospital's Opinion in 2016
HE Yu-wei
(Department of Obstetrics，Second Affiliated Hospital，Chongqing Medical University，Chongqing 400010，China)
Abstract：Objective To analyze the hospital admissions from January to December in 2016，to find the main reason of unreasonable drug use，the source department，the type of drug involved，in order to regulate the prescription of doctors to ensure the rational use of drugs.Methods Through the HIS system from January to December 2016，our hospital 31 departments 26661 discharged medical records were randomly selected a total of 4352 comments，for each medical records in the temporary doctor's advice and long-term medical advice one by one review and comment.Summarize the results of the evaluation，using Pareto analysis method for analysis.Results A total of 4352 medical records of reviews，unreasonable medication orders of 366 medical records，medical records accounted for 8.41% of the total，the qualified 91.59%；is the main reason of unreasonable medical inappropriate indications (44.34%)，the amount of usage is not suitable (30.54%)，does not meet the special use level of antibacterial drug management regulations(7.64%)，the total the 82.51% source of irrational medical orders；unreasonable medical department is mainly Department of hepatobiliary surgery(11.75%)，Department of orthopedics(10.93%)，Haifu Cancer Center(8.20%)，vascular surgery(7.92%)and other 13 surgical clinical departments， accounting for all the unreasonable medical advice of the 80.87% major drugs； unreasonable medical types involved are antibiotics class(25.62%)， blood stasis Chinese herbal injections(18.72%)，parenteral nutrition agent(11.33%)，improvement of cerebral metabolism and nootropics(8.13%)，a proton pump inhibitor(6.16%)，immunomodulatory agent(5.42%)and liver(4.93%)，auxiliary medicine accounted for all the unreasonable orders 80.30%. Conclusion In our hospital in 2016，the qualified rate of the doctor's advice is higher，but there are still some problems，we need to strengthen the monitoring of rational drug use., 百拇医药(何雨蔚)
, 百拇医药
关键词：住院医嘱；医嘱点评；合理用药
An Analysis of the Hospital's Opinion in 2016
HE Yu-wei
(Department of Obstetrics，Second Affiliated Hospital，Chongqing Medical University，Chongqing 400010，China)
Abstract：Objective To analyze the hospital admissions from January to December in 2016，to find the main reason of unreasonable drug use，the source department，the type of drug involved，in order to regulate the prescription of doctors to ensure the rational use of drugs.Methods Through the HIS system from January to December 2016，our hospital 31 departments 26661 discharged medical records were randomly selected a total of 4352 comments，for each medical records in the temporary doctor's advice and long-term medical advice one by one review and comment.Summarize the results of the evaluation，using Pareto analysis method for analysis.Results A total of 4352 medical records of reviews，unreasonable medication orders of 366 medical records，medical records accounted for 8.41% of the total，the qualified 91.59%；is the main reason of unreasonable medical inappropriate indications (44.34%)，the amount of usage is not suitable (30.54%)，does not meet the special use level of antibacterial drug management regulations(7.64%)，the total the 82.51% source of irrational medical orders；unreasonable medical department is mainly Department of hepatobiliary surgery(11.75%)，Department of orthopedics(10.93%)，Haifu Cancer Center(8.20%)，vascular surgery(7.92%)and other 13 surgical clinical departments， accounting for all the unreasonable medical advice of the 80.87% major drugs； unreasonable medical types involved are antibiotics class(25.62%)， blood stasis Chinese herbal injections(18.72%)，parenteral nutrition agent(11.33%)，improvement of cerebral metabolism and nootropics(8.13%)，a proton pump inhibitor(6.16%)，immunomodulatory agent(5.42%)and liver(4.93%)，auxiliary medicine accounted for all the unreasonable orders 80.30%. Conclusion In our hospital in 2016，the qualified rate of the doctor's advice is higher，but there are still some problems，we need to strengthen the monitoring of rational drug use., 百拇医药(何雨蔚)