武文慧　崔静杰　刘淑娥辽宁省大连市妇幼保健院药剂科，辽宁大连　116033

某妇幼保健院门急诊处方点评及用药合理性分析

武文慧崔静杰刘淑娥
辽宁省大连市妇幼保健院药剂科，辽宁大连116033

目的 分析大连市妇幼保健院（以下简称“我院”）门急诊处方用药合理性，促进临床合理用药。方法 随机抽取我院2015年7～12月门急诊处方，包括每个月对门急诊25%具有抗菌药物处方权的医师所开具的处方，每名医师抽取的处方数不少于50份，每个月100张门急诊普通处方以及每个月指定一日的全部急诊处方，处方点评人员对抽取的处方进行点评。结果 共抽取门急诊处方4381张，不合理处方318张，不合理处方率为7.26%，其中不规范处方44张，占全部不合理处方的13.8%，主要表现为新生儿及婴幼儿未写明日/月龄、诊断书写不明确、单张门急诊处方超过5种药品，以及急诊处方超过3 d用量；用药不适宜处方224张，占全部不合理处方的70.4%，主要表现为用法用量不适宜、适应证不适宜和给药途径不适宜；此外还有无正当理由分解处方50张，占全部不合理处方的15.7%。结论 我院门急诊处方基本合理，但仍然存在一定的问题，建议继续加强对临床医师相关法律法规的培训，加强药师与医师的沟通，药师向临床医师提出用药合理化建议时提供更为充分的依据，以利于减少不合理用药的发生。

妇幼保健院；处方点评；门急诊；用药合理性

［Abstract］Objective To analyze the rationality of the outpatient and emergency department of in the Maternal and Child Health Hospital of Dalian（“our hospital”for short），promoting rational use of clinical drug therapy.Methods E-valuated prescriptions from the Department of Outpatient and Emergency of our hospital from July to December 2015 were selected randomly.The samples included prescriptions from 25%physician which have the right to prescribe antibiotics in outpatient and emergency with no less than 50 pieces every month for each doctor，100 pieces of general prescriptions each month，and all emergency prescriptions in one fixed day for each month.The prescriptions were eveluated by prescription comments personnel.Results Among the 4381 prescriptions，318 prescriptions were irrational，the irrational rate was 7.26%：44（13.8%）prescriptions were irregular，224（70.4%）prescriptions were inappropriate and 50（15.7%）prescriptions were unreasonable resolved.Common problems presented in irregular prescriptions were absence of age in day or month for baby，irregular diagnostic writing，more than 5 kinds of drugs on single prescription，and exceeding dosage of 3 days on single emergency prescription.Inappropriate prescriptions were mainly characterized by unsuitable usage and dosage，inappropriate indications and unreasonable route of administration. Conclusion The prescriptions are basically rational in our hospital，but still have some problems，strengthening clinicians training of related laws and regulations，as well as facilitating communication between pharmacists and physicians to provide vigorous support is needed to improve the rationality of drug-use.

［Key words］Department of Maternal and Child Health Hospital；Prescription review；Outpatient and emergency department；Rational drug usage

处方点评是根据相关法规、技术规范对处方书写的规范性及药物临床使用的适宜性 （用药适应证、药物选择、给药途径、用法用量、药物相互作用、配伍禁忌等）进行评价，发现存在或潜在的问题，制订并实施干预和改进措施，促进临床药物合理应用的过程［1］。……