我院事前实时干预、事中互动审方和事后点评分析一体化用药决策系统的建设-中国药房

我院事前实时干预、事中互动审方和事后点评分析一体化用药决策系统的建设

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篇名：	我院事前实时干预、事中互动审方和事后点评分析一体化用药决策系统的建设
TITLE：
摘要：	目的：建设一体化用药决策系统，为临床安全、有效、经济和合理用药提供参考。方法：介绍我院一体化用药决策系统的建设情况。结果与结论：我院一体化用药决策系统包括事前实时干预、事中互动审方和事后点评分析3个方面的内容，是对住院医嘱和门诊处方执行前后的3个步骤。事前实时干预主要是从医嘱或处方的开具源头控制其合理性，对系统的实时性要求较高；事中互动审方要求药师在规定的时间内判定该医嘱或处方是否拒配，对数据结构化要求较高；事后点评分析规定药师在医嘱或处方执行完成后定期评价反馈。三者既存在差异，又具有协调性，是一个有机整体，尤其是事中互动审方过程需要与其他两个过程配合。通过实施一体化用药决策系统，我院不合理医嘱或处方比例由2016年上半年的6.07％下降到2017年同期的2.56％，用药剂量错误和存在配伍禁忌的情况大幅减少，禁忌证用药等现象更容易在点评分析中被发现。该系统可提高审方效率，提升合理用药水平，有效保证临床用药的安全、有效、经济和合理。
ABSTRACT：	OBJECTIVE： To construct integrated medication decision-making system， and to provide reference for safe， effective， economical and reasonable drug use in clinic. METHODS： The construction of integrated medication decision-making system was introduced in our hospital. RESULTS & CONCLUSIONS： The integrated medication decision-making system included three aspects as real-time intervention in advance， interactive review in the matter， afterward comment and analysis， as 3 steps before and after the implementation of inpatient medical order and outpatient prescription. The real-time intervention in advance was mainly to control the rationality of medical orders or prescriptions from their source， thus requiring the timely treatment. The interactive review in the matter required that pharmacists judged the medical order or prescription and made a decision of refusing prescribing within the fixed time. To make a decision accurately， the clinical information should be highly structured and correlated with drug signs. Afterward comment and analysis required that pharmacists evaluated the medical order or prescription regularly after the implementation. The three were not only different， but also coordinated， and they were an organic unity， especially interactive review in the matter needed to be coordinated with the other two processes. After the implementation of integrated medication decision-making system， the proportion of irrational medical orders or prescriptions in our hospital decreased from 6.07％ in the first half of 2016 to 2.56％ at corresponding period of 2017. Drug dose errors and incompatibility were greatly reduced， and medication against contraindications was more likely to be found in the review and analysis. The system can improve the efficiency of prescription review， improve rational drug use， and effectively ensure the safety， effectiveness， economy and rationality of clinical drug use.
期刊：	2017年第28卷第35期
作者：	杨全军，郭澄，徐嵘，郁静，干润，李婕，邱泉清，屠祎惺，张剑萍
AUTHORS：	YANG Quanjun，GUO Cheng，XU Rong，YU Jing，GAN Run，LI Jie，QIU Quanqing，TU Yixing，ZHANG Jianping
关键字：	事前实时干预；事中互动审方；事后点评分析；处方点评；合理用药；药师
KEYWORDS：	Real-time intervention in advance； Interactive review in the matter； Afterward comment and analysis； Prescription review； Rational drug use； Pharmacist
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