游翠芳 陈娟

[摘要] 目的 了解本院门诊西药处方使用合理性情况，寻找处方不合理的主要因素，为持续改进工作提供依据。 方法 收集、整理本院2014年1～ 12月的10 328张处方，将不合理处方归纳为11类，利用Excel软件对数据进行处理，采用描述性分析方法计算构成比与累计构成比，并绘制管理学上的帕累托图，据图分析影响处方合理性的主要、次要和一般因素。 结果 门诊不合理处方中诊断不全、无适应证用药、违反抗菌药物使用原则、用法不适宜、遴选药品不适宜累计构成比为78.41%，为主要因素；用量不适宜构成比为7.31%，为次要因素；其余为一般因素。 结论 应针对性进行有效干预和药学服务，结合医、药、护之力共同为患者的安全用药保驾护航。

[关键词] 处方点评；回顾性分析；帕累托图；配伍禁忌

[中图分类号] R95 [文献标识码] A [文章编号] 1674-4721（2016）03（c）-0140-04

[Abstract] Objective To understand the reasonable statas of western medicine prescription in outpatient of our hospital to find the main factors of irrational prescription to provide the basis for continuous improvement. Methods 10 328 prescriptions from January to December 2014 of our hospital were collected and arranged.The irrational prescriptions were classified into 11 classes.The data were conducted by using Excel software.The descriptive analysis method was used to count constituent ratio and cumulative constituent ratio.Pareto chart of management science was drawn.The mainly，minor and general factor impacting the prescription rationality was analyzed respectively according to the chart. Results The cumulative constituent ratio of diagnosis was not complete，no indications for drug use，violation the principle of antimicrobial agents use，not appropriate usage and not appropriate selected drugs in outpatient irrational prescriptions was 78.41%，which were the mainly reason.The constituent ratio of not appropriate dose was 7.31%，which was the minor reason.The others were general factor. Conclusion Effective intervention and pharmaceutical care should be targetedly conducted，and combined with the strength including doctors，pharmacy staff and nurses to take care of the patients′ safety medication.

[Key words] Prescription comment；Retrospective analysis；Pareto chart；Incompatibility

处方是指由注册在院取得相应处方权的执业医师在诊疗活动中为患者开具的，由取得药学专业技术职务任职资格的药学专业技术人员审核、调配、核对，并作为患者用药凭证的医疗文书[1]。处方合理与否关系到临床用药的安全、有效、经济、适当，反映医疗机构的用药水平与医疗质量。处方点评是药事和药物使用管理与持续改进的重要基础与组成部分，为进一步提高处方合理水平、持续改进工作重点提供数据依据。本文通过对常态化的处方点评进行回顾性分析，知晓该院门诊西药处方合理格率，寻找影响处方合理率的主要因素，为进一步提高处方合理率指明了方向，也是医、药、护人员共同奋斗的目标。……