住院医嘱前置审核+人工审核药学服务模式的实践与探讨

目的:通过对住院医嘱实行前置审核+人工审核的结果汇总分析,促进临床规范用药,保障患者用药安全。方法:采取回 顾性分析方法,利用Excel 软件对我院住院电子病历系统和临床合理用药智能管理系统(前置审核系统)中2020 年的医嘱审核 数据进行汇总,分别对医嘱前置审核和人工审核数据进行分析,并将分析结果进行归纳总结、讨论。结果:住院医嘱前置审核系 统预审医嘱913 742 份,干预不合理医嘱总数22 014 份,不合理医嘱占比2. 41%,其中不合理医嘱类型排名前3 位的是给药剂 量不适宜、药品剂型或给药途径不适宜、重复用药等;人工审核医嘱数量455 676 份,提供用药建议6 875 份,医师响应率达 82. 05%。其中不合理医嘱类型排名前3 位的是用法用量不适宜、遴选药品不适宜、适应证不适宜。结论:前置审核和人工审核 医嘱模式相辅相成,二者结合能够及时发现住院医嘱中存在的不合理用药,有效保障患者用药安全,提升药学服务能力水平。

Practice and Discussion on Pharmaceutical Care Mode of Inpatient Medical Orders Pre-Review +Manual Review

Objective: To summarize and analyze the results of pre-review + manual review of inpatient medical orders, so as to promote clinical standard drug use and ensure medication safety of patients. Methods: Retrospective analysis method and Excel software were used to summarize the medical order review data in the inpatient electronic medical record system and clinical rational drug use intelligent management system (pre-review system) in 2020. Data of medical orders pre-review + manual review were analyzed, and the analysis results were summarized and discussed. Results: There were 913,742 medical orders pre-reviewed by the inpatient medical order pre-review system, and the total number of irrational medical orders was 22,014, accounting for 2. 41%. The top three types of irrational medical orders were the inappropriate dosage, improper dosage form or inappropriate administration route, and repeated medication. A total of 455,676 medical orders were manually reviewed and 6,875 medication recommendations were provided, with response rate of 82. 05%. The top three types of irrational medical orders were inappropriate usage and dosage, improper selection and inappropriate indication. Conclusion: The mode of pre-review + manual review of inpatient medical orders complement each other, which can timely find the irrational drug use phenomenon in inpatient medical orders, effectively guarantee the safe drug use of patients, and improve the level of pharmaceutical care.