摘要
目的通过对门诊退回医生修改的处方进行统计和分析,提出预防和减少医师处方差错的对策。方法采用回顾性分析方法,对门诊西药房2011年《医生修改处方登记表》记录的修改项目及数量进行汇总分析,并对典型的个案进行点评。结果修改项目主要包括:药品名称、用法用量、规格、剂型、数量、合理用药、缺药、医生签名、皮试、其他等。全年修改处方共4896张,平均修改率0.34%。其中用法用量项目修改最多2529张、占51.65%;其后依次是医生漏签名1420张,占29.0%;缺药224张,占4.58%;其他项258张,占5.27%;其余为药品名称和剂型错误等。结论我院的处方差错主要是医生粗心大意造成,医生的重视及完善电子系统将有助于降低处方差错。
Objective In order to prevent and reduce physician prescription errors in outpatient, the outpatient pre- scriptions returned for revision were statistical analyzed. Methods The errors in items and quantity were analyzed retrospec- tively in prescriptions returned for revision registration forms in 2011, and some typical cases were put into discussion. Results The physician prescription errors included drug name, dosage, specification, dosage form, quantity, rational usage, shortages, doctor signatures, penicillin skin test, etc. Of prescriptions in 2011, there were 4896 prescriptions contained questions, accoun- ted for 0. 34%. During these prescriptions, the most common was drug dosage modification, of 2529 question prescriptions, ac- counted for 51.65%, and 1420 question prescriptions without doctor＇s signature, accounted for 29. 0%, and 224 errors pre- scriptions of drug shortage , accounted for 4. 58%, and 258 of other errors, accounted for 5.27%, and etc. Conclusion In our hospital, doctor＇s careless was the main reason for physician prescription errors, which will be reduced by doctor＇s attention and using electronic medical record system.
出处
《广州医药》
2013年第5期63-66,共4页
Guangzhou Medical Journal
关键词
门诊
处方修改
分析
Outpatient
Prescriptions Returned for Revision
Analysis
