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目的：通過將門診發(fā)生的藥品不良反應(yīng) 計入門診電子病歷，保證門診所發(fā)生藥品不良反應(yīng)的可追溯性，在加強臨床個體化用藥安全的同時促進對上市藥品的安全質(zhì)量監(jiān)控，保障廣大患者的用藥安全。方法：成立品管圈活動小組，遵循 PDCA程序，活用品管圈七大手法，分析門診藥品不良反應(yīng) 難以溯源的原因，探索對策，予以實施并評估活動效果。結(jié)果：比較活動前、后各項藥品不良反應(yīng) 可溯源指標均得到了明顯改善，門診藥品不良反應(yīng) 計入病歷率由改善前31%升至改善后 90.1%，活動后門診退藥登記表確認簽名率達87.2%，活動達標率為105.6%。結(jié)論：本次品管圈活動有效的提高了門診藥品不良反應(yīng) 計入病歷的質(zhì)量，患者承諾簽名一定程度的保證了門診藥品不良反應(yīng)的真實性，保證了門診藥品不良反應(yīng)的可溯源性，為藥品的臨床合理使用提供了依據(jù)。
Purpose: Guarantee the traceability of adverse drug reactions occurred during outpatient treatment by recording them into electronic medical record(EMR), and enhance monitoring the safety and quality of drugs
on current market in the meantime of strengthening individual medication safety, so as to secure the medication safety for massive patients. Method: Establish activity groups of quality control circle, follow PDCA procedures and flexibly use the QC 7 basic tools, analyze the reason why adverse drug reactions can hardly be traced, explore countermeasures, implement activity and evaluate activity effect. Results: Through comparing the traceability indexes of adverse drug reactions before and after the implementation of activity, it shows that the traceability indexes have been improved, and the rate of successfully recording adverse drug reactions into EMR has been increased from 31% before improvement to 90.1% after improvement, in addition, the signature rate on drug withdrawal list after implementation of activity can reach 87.2%, and the rate of reaching the standard in activity reached 105.6%. Conclusion: The QCC activity effectively improved the quality of recording adverse drug reactions into EMR. Patient's commitment to signature on drug withdrawal list guarantees the authenticity and traceability of adverse drug reactions, providing basis for clinical rational drug use.

關(guān)鍵詞：藥品不良反應(yīng)，品管圈，溯源
Keywords: Adverse Drug Reaction, Quality Control Circle; Traceability

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2樓2016-04-15 13:46:27