【摘要】：目的：為加強(qiáng)對(duì)處方質(zhì)量的管理,促進(jìn)臨床合理用藥,保障醫(yī)療安全,衛(wèi)生部于2007年頒布的《處方管理辦法》,提出醫(yī)療機(jī)構(gòu)應(yīng)當(dāng)建立處方點(diǎn)評(píng)制度,對(duì)不合理用藥予以干預(yù)；2010年衛(wèi)生部又印發(fā)了《醫(yī)院處方點(diǎn)評(píng)管理規(guī)范(試行)》(衛(wèi)醫(yī)管發(fā)[2010]28號(hào)),以進(jìn)一步規(guī)范醫(yī)院處方點(diǎn)評(píng)工作。其中指出：處方點(diǎn)評(píng)是醫(yī)院持續(xù)醫(yī)療質(zhì)量改進(jìn)和藥品應(yīng)用管理的重要組成部分,是提高臨床藥物治療水平的重要手段。辦法中提出處方點(diǎn)評(píng)是根據(jù)相關(guān)法規(guī)、技術(shù)規(guī)范,對(duì)處方書寫的規(guī)范性及藥物臨床使用的適宜性(用藥適應(yīng)證、藥物選擇、給藥途徑、用法用量、藥物相互作用、配伍禁忌等)進(jìn)行評(píng)價(jià),從而發(fā)現(xiàn)存在或潛在的問(wèn)題,制定并實(shí)施干預(yù)和改進(jìn)措施,促進(jìn)臨床藥物合理應(yīng)用。該辦法是落實(shí)《藥品管理法》、《執(zhí)業(yè)醫(yī)師法》、《醫(yī)療機(jī)構(gòu)藥事管理?xiàng)l例》、《處方管理辦法》等有關(guān)法律、法規(guī)、規(guī)章的重要保障措施,探索和提高有效的處方點(diǎn)評(píng)措施、方法、途徑,是處方合格率持續(xù)改進(jìn)提高的前提和保證。近年來(lái),PDCA循環(huán)(戴明環(huán))在質(zhì)量控制方面的廣泛應(yīng)用,為我們提供了新思路。在醫(yī)院藥學(xué)工作中,對(duì)此進(jìn)行了借鑒和引用,取得了滿意效果。我們將PDCA循環(huán)運(yùn)用于門診處方點(diǎn)評(píng)、住院病歷用藥點(diǎn)評(píng)、抗菌藥物動(dòng)態(tài)監(jiān)測(cè)評(píng)價(jià)和住院用藥物專項(xiàng)點(diǎn)評(píng),探索用藥點(diǎn)評(píng)工作的新方法,促進(jìn)臨床藥物的合理應(yīng)用。 方法：1.選擇我院2013年1月—2014年6月的門診處方進(jìn)行點(diǎn)評(píng),運(yùn)用魚骨圖對(duì)引起處方不合理因素進(jìn)行分析,運(yùn)用柏拉圖找出各項(xiàng)中最具影響力的因素,制定改進(jìn)目標(biāo)。在第一輪PDCA循環(huán)中(2013年1月-2013年12月),將完善電子處方系統(tǒng),加強(qiáng)醫(yī)師藥物知識(shí)培訓(xùn)作為改進(jìn)的主要目標(biāo)。第二輪PDCA循環(huán)中(2014年1月—2014年6月),將處方不合格率降為5%以下為目標(biāo),對(duì)2013年1月—2013年6月與2013年7月—2014年6月的門診處方合格率進(jìn)行比較分析。2.選擇我院2012年10月—2013年5月的住院病歷,進(jìn)行醫(yī)囑用藥點(diǎn)評(píng)。分析造成用藥不合理的主要因素,將完善電子病歷系統(tǒng)作為PDCA改進(jìn)的目標(biāo),對(duì)2012年10月—2012年12月與2013年3月—2013年5月的住院病歷用藥醫(yī)囑點(diǎn)評(píng)結(jié)果進(jìn)行比較分析。 3.動(dòng)態(tài)監(jiān)測(cè)我院2013年4月—2013年12月抗菌藥物的使用量、使用金額等,對(duì)限制使用級(jí)抗菌藥物“注射用磺芐西林鈉”的異常使用進(jìn)行預(yù)警,采取干預(yù)措施,并從適應(yīng)癥、用法用量、藥物經(jīng)濟(jì)學(xué)、聯(lián)合用藥等方面對(duì)注射用磺芐西林鈉的應(yīng)用合理性進(jìn)行分析,降低其不合理使用。 4.選擇我院2013年1月—2013年9月的住院病歷,對(duì)腸外營(yíng)養(yǎng)藥物中的脂肪乳氨基酸(17)葡萄糖(11%)注射液(卡文)進(jìn)行專項(xiàng)點(diǎn)評(píng),運(yùn)用魚骨圖分析影響卡文注射液合理應(yīng)用的因素,對(duì)2013年1月—2013年3月與2013年7月—2013年9月的藥物使用情況進(jìn)行比較分析。 結(jié)果：1.共分析門診處方3550張,其中不合理處方558張,不合理項(xiàng)目656項(xiàng)。結(jié)果顯示,實(shí)施PDCA循環(huán)前處方合格率為69.05%,實(shí)施后處方合格率上升為96.77%,提高了27.72%,統(tǒng)計(jì)學(xué)分析：兩組率的比較使用T檢驗(yàn),兩組合格率比較差異有統(tǒng)計(jì)學(xué)意義(P0.05),不合理用藥情況得到很大改善。 2.共點(diǎn)評(píng)2012年10月—2013年5月的住院病歷共478例,其中用藥不合理病歷131例。住院病歷用藥合格率由PDCA實(shí)施前的60.93%,上升為PDCA實(shí)施后的84.17%,提高了23.24%。 3.運(yùn)用PDCA循環(huán)進(jìn)行抗菌藥物動(dòng)態(tài)監(jiān)測(cè),快速準(zhǔn)確的篩選出2013年4月—2013年6月異常使用的抗菌藥物：注射用磺芐西林鈉。對(duì)其預(yù)警并進(jìn)行合理性評(píng)價(jià),使其縮小了使用范圍,減少了使用數(shù)量,避免耐藥菌株的產(chǎn)生,降低由此產(chǎn)生的醫(yī)院感染率。至2013年12月,該藥物的應(yīng)用已趨于合理。該研究為藥師對(duì)抗菌藥物合理應(yīng)用的全面管理提供了方法。 4.對(duì)腸外營(yíng)養(yǎng)藥物中使用量較大的脂肪乳氨基酸(17)葡萄糖(11%)注射液(卡文)進(jìn)行專項(xiàng)點(diǎn)評(píng)。實(shí)施PDCA循環(huán)后,醫(yī)師在用藥依據(jù)、病歷記錄、相關(guān)指標(biāo)監(jiān)測(cè)、藥物配伍等方面的記錄更加完整,卡文注射液的使用逐漸規(guī)范、合理。藥師根據(jù)工作設(shè)計(jì)的“卡文注射液專項(xiàng)點(diǎn)評(píng)工作表”,能全面記錄患者用藥前后各項(xiàng)指標(biāo)的變化,使藥師由單純的以藥論藥上升為根據(jù)患者情況實(shí)行個(gè)體化用藥點(diǎn)評(píng),提升了藥師的素質(zhì)與技能。 結(jié)論：1.本課題為藥物點(diǎn)評(píng)的管理工作提供了新思路。PDCA循環(huán)能有計(jì)劃有步驟的解決藥物點(diǎn)評(píng)中的問(wèn)題,做到有的放矢,避免低效率的重復(fù)勞動(dòng),該方法操作簡(jiǎn)單,管理全面,可以作為藥物點(diǎn)評(píng)工作持續(xù)改進(jìn)的方法加以推廣。 2.PDCA循環(huán)是上升式循環(huán),每一循環(huán)都有新的目標(biāo)和內(nèi)容；每循環(huán)一周,質(zhì)量就提高一步,未解決的問(wèn)題落入下一循環(huán),實(shí)現(xiàn)質(zhì)量的持續(xù)改進(jìn)。對(duì)存在問(wèn)題的原因分析和制定對(duì)策是PDCA循環(huán)取得成效的前提�？梢越柚~骨圖、柏拉圖等工具,用頭腦風(fēng)暴等多種方法,集思廣益,把導(dǎo)致問(wèn)題產(chǎn)生的所有原因找出來(lái),選擇影響最大的因素作為改進(jìn)的目標(biāo),可在短時(shí)間內(nèi)快速提高工作效率。 3.用藥點(diǎn)評(píng)是一項(xiàng)長(zhǎng)期而且重要的工作,本文通過(guò)對(duì)門診處方點(diǎn)評(píng)、住院病歷點(diǎn)評(píng)、抗菌藥物動(dòng)態(tài)監(jiān)測(cè)評(píng)價(jià)及藥物專項(xiàng)點(diǎn)評(píng)的實(shí)踐,建立了藥物點(diǎn)評(píng)的新方法,并證明這種方法行之有效,對(duì)藥物的安全合理應(yīng)用起到顯著的推動(dòng)作用。
[Abstract]:OBJECTIVE: To strengthen the management of prescription quality, promote rational clinical use of drugs and ensure medical safety, the Ministry of Health promulgated the "Regulations on Prescription Management" in 2007, and proposed that medical institutions should establish a prescription evaluation system to intervene in unreasonable drug use; in 2010, the Ministry of Health issued the "Hospital Prescription Evaluation Management Standards (Trial Implementation)" (Medical Administration and Distribution). [2010] 28) to further standardize the work of hospital prescription review. It is pointed out that prescription review is an important part of continuous medical quality improvement and drug application management and an important means to improve the level of clinical drug treatment. To evaluate the suitability of drugs for clinical use (indications, drug selection, route of administration, usage and dosage, drug interactions, incompatibility, etc.) so as to find out the existing or potential problems, formulate and implement intervention and improvement measures to promote the rational use of clinical drugs. In recent years, PDCA cycle has been widely used in quality control to provide us with effective measures, methods and approaches to evaluate prescriptions. In the work of hospital pharmacy, we used PDCA for reference and quotation, and achieved satisfactory results. We applied PDCA cycle in the evaluation of outpatient prescriptions, in-patient medical records, in-patient drug use, in-patient drug dynamic monitoring and evaluation of antibiotics, and in-patient drug specific evaluation to explore new methods of drug use evaluation and promote the rational use of clinical drugs.
Methods: 1. Choose the outpatient prescriptions of our hospital from January 2013 to June 2014 for comment, use fish bone diagram to analyze the unreasonable factors causing the prescription, use Plato to find out the most influential factors, and set the improvement goals. In the first round of PDCA cycle (January 2013 - December 2013), we will improve the electronic prescription system and strengthen the doctor. In the second round of PDCA cycle (January 2014 - June 2014), the prescription failure rate was reduced to less than 5%. The outpatient prescription eligibility rates from January 2013 to June 2013 and from July 2013 to June 2014 were compared and analyzed. 2. The hospital medical records from October 2012 to May 2013 were selected. The main factors causing unreasonable drug use were analyzed. The improvement of electronic medical record system was taken as the goal of PDCA improvement. The results of inpatient medical record medication order evaluation from October 2012 to December 2012 and from March 2013 to May 2013 were compared and analyzed.
3. Dynamic monitoring of the use of antimicrobial agents in our hospital from April 2013 to December 2013, the amount of money used to limit the use of antimicrobial drugs "Sulfampicillin Sodium for Injection" for early warning, intervention measures, and from the indications, usage and dosage, pharmacoeconomics, combination of drugs and other aspects of the application of Sulfampicillin Sodium for Injection. Rational analysis, to reduce its unreasonable use.
4. Selecting the medical records of our hospital from January 2013 to September 2013, special comments were made on fat emulsion amino acid (17) glucose (11%) injection (Cavin) in parenteral nutrition drugs. The factors influencing the rational use of Cavin injection were analyzed by fish bone diagram. The drug use from January 2013 to March 2013 and July 2013 to September 2013 was improved. Row comparative analysis.
Results: 1. A total of 3550 outpatient prescriptions were analyzed, including 558 unreasonable prescriptions and 656 unreasonable items. P0.05) the situation of irrational drug use has been greatly improved.
2. A total of 478 inpatient medical records from October 2012 to May 2013 were reviewed, including 131 unreasonable medical records. The qualified rate of drug use in inpatient medical records rose from 60.93% before the implementation of PDCA to 84.17% and 23.24% after the implementation of PDCA.
3. Using PDCA cycle for dynamic monitoring of antimicrobial agents, quickly and accurately screened out the abnormal use of antimicrobial agents: sulfobenzillin sodium for injection from April 2013 to June 2013. Infection rates. By December 2013, the use of the drug has become reasonable. This study provides a method for pharmacists to comprehensively manage the rational use of antimicrobial drugs.
4. Special comments were made on fat emulsion amino acid (17) glucose (11%) injection (Calvin) which was used more frequently in parenteral nutrition drugs. After PDCA cycle, physicians'records on the basis of drug use, medical records, monitoring of related indicators, drug compatibility and other aspects were more complete. The use of Calvin injection was gradually standardized and reasonable. The "Carvin Injection Special Evaluation Worksheet" can fully record the changes of the indexes before and after the use of drugs, so that the pharmacists can carry out individualized drug evaluation according to the patient's situation instead of simply taking drugs as the basis, thus improving the quality and skills of pharmacists.
CONCLUSIONS: 1. This project provides a new idea for the management of drug evaluation. PDCA cycle energy can systematically and systematically solve the problems in drug evaluation, so as to be targeted and avoid inefficient repeated labor. This method is simple to operate, comprehensive management, and can be promoted as a method for continuous improvement of drug evaluation.
2. PDCA cycle is an ascending cycle, each cycle has new goals and contents; every cycle, the quality is improved one step, unresolved problems fall into the next cycle, to achieve continuous improvement of quality. Brainstorming and other methods, brainstorming, all the causes of the problem to find out, choose the most influential factors as the goal of improvement, can quickly improve work efficiency in a short period of time.
3. Drug evaluation is a long-term and important work. Through the practice of out-patient prescription evaluation, inpatient medical record evaluation, dynamic monitoring and evaluation of antibiotics and special evaluation of drugs, a new method of drug evaluation has been established, which has been proved to be effective and has played a significant role in promoting the safe and rational use of drugs.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R95

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