抗菌药物应用病历质量缺陷分析及对策

目的了解抗菌药物应用病历质量缺陷，为加强抗菌药物管理提供依据。方法根据《抗菌药物临床应用指导原则》等相关规定，制定抗菌药物应用病历质量检查标准，对675份抗菌药物应用归档病历进行检查。结果抗菌药物应用病历质量缺陷前5项为：用药时间过长，占22．05％；无指征用药，占13．89％；未做细菌培养和药敏试验，占13．77％；预防性用药抗菌药物等级过高，占12．61％；用药时机不合理，占10．62％等。结论医院可通过建立健全抗菌药物合理使用制度、强化合理使用抗菌药物经常性培训、加强抗菌药物应用病历质量监控以及强化考核、奖惩兑现等，提高临床医师抗菌药物应用水平，促进抗菌药物应用病历质量持续改进。

Analysis and Countermeasure on Quality of Medical Records with Antimicrobial Agents

Objective To investigate the quality defects of medical records with application of antimicrobial agents,provide evidence to strengthen the management of antimicrobial agents.Method According to the relevant rules of the "guiding principles on clinical use of antibiotics",the antimicrobial agents medical quality inspection standard was developed to check the archive medical records of 675 antimicrobial agents.Result The first five quality defects in antimicrobial agents medical records were:medication for too long,accounting for 22.05%;no indications of drug use,accounting for 13.89%;without making a bacterial culture and sensitivity test,accounting for 13.77%;prophylaxis of antimicrobial agents levels over high,accounting for 12.61%;irrational medication timing,accounting for 10.62%.Conclusion Through the establishment of a sound anti-bacterial drugs rational use of the system,strengthening the rational use of antibiotics recurrent training,strengthening the application of antimicrobial agents medical quality control,and strengthening the assessment,cash rewards and punishments,etc.,hospital can improve the clinicians skill level on application of antimicrobial agents,promote the continuous improvement and enhancement of the medical records quality involving antimicrobial agents.