PDCA循环理论在临床用药点评中的应用研究

发布时间：2018-09-01 16:03

【摘要】：目的：为加强对处方质量的管理,促进临床合理用药,保障医疗安全,卫生部于2007年颁布的《处方管理办法》,提出医疗机构应当建立处方点评制度,对不合理用药予以干预；2010年卫生部又印发了《医院处方点评管理规范(试行)》(卫医管发[2010]28号),以进一步规范医院处方点评工作。其中指出：处方点评是医院持续医疗质量改进和药品应用管理的重要组成部分,是提高临床药物治疗水平的重要手段。办法中提出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,从而发现存在或潜在的问题,制定并实施干预和改进措施,促进临床药物合理应用。该办法是落实《药品管理法》、《执业医师法》、《医疗机构药事管理条例》、《处方管理办法》等有关法律、法规、规章的重要保障措施,探索和提高有效的处方点评措施、方法、途径,是处方合格率持续改进提高的前提和保证。近年来,PDCA循环(戴明环)在质量控制方面的广泛应用,为我们提供了新思路。在医院药学工作中,对此进行了借鉴和引用,取得了满意效果。我们将PDCA循环运用于门诊处方点评、住院病历用药点评、抗菌药物动态监测评价和住院用药物专项点评,探索用药点评工作的新方法,促进临床药物的合理应用。方法：1.选择我院2013年1月—2014年6月的门诊处方进行点评,运用鱼骨图对引起处方不合理因素进行分析,运用柏拉图找出各项中最具影响力的因素,制定改进目标。在第一轮PDCA循环中(2013年1月-2013年12月),将完善电子处方系统,加强医师药物知识培训作为改进的主要目标。第二轮PDCA循环中(2014年1月—2014年6月),将处方不合格率降为5%以下为目标,对2013年1月—2013年6月与2013年7月—2014年6月的门诊处方合格率进行比较分析。2.选择我院2012年10月—2013年5月的住院病历,进行医嘱用药点评。分析造成用药不合理的主要因素,将完善电子病历系统作为PDCA改进的目标,对2012年10月—2012年12月与2013年3月—2013年5月的住院病历用药医嘱点评结果进行比较分析。 3.动态监测我院2013年4月—2013年12月抗菌药物的使用量、使用金额等,对限制使用级抗菌药物“注射用磺苄西林钠”的异常使用进行预警,采取干预措施,并从适应症、用法用量、药物经济学、联合用药等方面对注射用磺苄西林钠的应用合理性进行分析,降低其不合理使用。 4.选择我院2013年1月—2013年9月的住院病历,对肠外营养药物中的脂肪乳氨基酸(17)葡萄糖(11%)注射液(卡文)进行专项点评,运用鱼骨图分析影响卡文注射液合理应用的因素,对2013年1月—2013年3月与2013年7月—2013年9月的药物使用情况进行比较分析。结果：1.共分析门诊处方3550张,其中不合理处方558张,不合理项目656项。结果显示,实施PDCA循环前处方合格率为69.05%,实施后处方合格率上升为96.77%,提高了27.72%,统计学分析：两组率的比较使用T检验,两组合格率比较差异有统计学意义(P0.05),不合理用药情况得到很大改善。 2.共点评2012年10月—2013年5月的住院病历共478例,其中用药不合理病历131例。住院病历用药合格率由PDCA实施前的60.93%,上升为PDCA实施后的84.17%,提高了23.24%。 3.运用PDCA循环进行抗菌药物动态监测,快速准确的筛选出2013年4月—2013年6月异常使用的抗菌药物：注射用磺苄西林钠。对其预警并进行合理性评价,使其缩小了使用范围,减少了使用数量,避免耐药菌株的产生,降低由此产生的医院感染率。至2013年12月,该药物的应用已趋于合理。该研究为药师对抗菌药物合理应用的全面管理提供了方法。 4.对肠外营养药物中使用量较大的脂肪乳氨基酸(17)葡萄糖(11%)注射液(卡文)进行专项点评。实施PDCA循环后,医师在用药依据、病历记录、相关指标监测、药物配伍等方面的记录更加完整,卡文注射液的使用逐渐规范、合理。药师根据工作设计的“卡文注射液专项点评工作表”,能全面记录患者用药前后各项指标的变化,使药师由单纯的以药论药上升为根据患者情况实行个体化用药点评,提升了药师的素质与技能。结论：1.本课题为药物点评的管理工作提供了新思路。PDCA循环能有计划有步骤的解决药物点评中的问题,做到有的放矢,避免低效率的重复劳动,该方法操作简单,管理全面,可以作为药物点评工作持续改进的方法加以推广。 2.PDCA循环是上升式循环,每一循环都有新的目标和内容；每循环一周,质量就提高一步,未解决的问题落入下一循环,实现质量的持续改进。对存在问题的原因分析和制定对策是PDCA循环取得成效的前提。可以借助鱼骨图、柏拉图等工具,用头脑风暴等多种方法,集思广益,把导致问题产生的所有原因找出来,选择影响最大的因素作为改进的目标,可在短时间内快速提高工作效率。 3.用药点评是一项长期而且重要的工作,本文通过对门诊处方点评、住院病历点评、抗菌药物动态监测评价及药物专项点评的实践,建立了药物点评的新方法,并证明这种方法行之有效,对药物的安全合理应用起到显著的推动作用。
[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.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R95

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