Prescription: refers to the medical documents issued by registered medical practitioners and assistant medical practitioners for patients in their diagnosis and treatment activities, which are reviewed, prepared and checked by pharmaceutical professional and technical personnel who have obtained the qualifications for pharmaceutical professional and technical positions, and serve as the vouchers for drug deployment.
Prescriptions include medical institution ward medication orders.
Doctors should follow the principles of safety, effectiveness and economy when prescribing Yamatonokusushi.
Prescription is an important medical document with legal, technical and economic significance.
Prescription structure:
1, Preface of prescription
Including the name of the medical institution, outpatient or inpatient medical record number, prescription number, department or ward and bed number, cost, patient's name, gender, age, clinical diagnosis, date of issuance, etc. , you can add items required by your major.
2. Prescription text
Marked by prescription Rp or R, the drug name, dosage form, specification, quantity, usage and dosage are listed respectively.
3, prescription postscript
The signature and/or seal of the doctor, the amount of the drug and the signature of the pharmaceutical professional and technical personnel who examine, allocate, check and distribute the drug.
Prescription type:
Prescriptions are divided into narcotic drugs, psychotropic drugs of category I, psychotropic drugs of category II, emergency prescriptions, pediatric prescriptions and general prescriptions (prescriptions of medical insurance departments and at their own expense).
According to the prescribed format, print on light red, light yellow, light green and white paper respectively, and mark the text in the upper right corner of the prescription.
Prescription savings:
Medical, preventive and health care institutions or pharmaceutical retail enterprises that allocate and sell prescription drugs shall properly keep prescriptions.
General prescriptions, emergency prescriptions and pediatric prescriptions shall be kept for one year, toxic drugs for medical use, psychotropic drugs of category II and drug rehabilitation drugs for two years, and narcotic drugs and psychotropic drugs of category I for three years.
After the expiration of the shelf life of the prescription, it can be destroyed only after it is approved and registered by the competent leaders of medical, preventive and health care institutions or pharmaceutical retail enterprises.
Drug name:
Drug names include generic names, trade names, patent names and chemical names.
1, common name
It is the name that the new drug developer put forward to the competent government department when applying for a new drug. It is the name of the drug listed in the national standard, also known as the legal name of the drug.
Include international common name (INN) and China common name (CADN).
2. Trade name
It is a proprietary name given by the manufacturer for the circulation of drugs.
General procedure of prescription preparation:
Pharmaceutical professional and technical personnel should adjust the drug prescription according to the operating procedures, and the formulation procedures are as follows:
Recipient, inspector, pricing, deployment, packaging and labeling, inspection and distribution.
Prevention and treatment of prescription errors;
(1) Content of prescription error
1. The drug name is wrong.
2, drug dispensing or dosage error
3, drugs and indications do not match
4. Wrong dosage form or route of administration
5, dosing time error
6, treatment errors
7, drug compatibility taboo
8. Drug identification error
(2) Types of prescription errors
1. Error caused by objective environment/conditions (error did not occur)
2. An error occurs, but it will be sent to the patient.
3, sent to the patient but did not cause harm.
4. It is necessary to monitor the consequences of errors on patients and determine whether it is necessary to take preventive measures or reduce injuries according to the consequences.
5. The mistake caused temporary harm to the patient.
6. The harm of errors to patients can lead to hospitalization or prolong hospitalization time.
7. Mistakes can cause permanent harm to patients.
8. The patient's life is on the verge of death due to mistakes.
9, mistakes lead to the death of patients.
(3) the cause of the prescription error
1, inattention or inexperience during deployment.
2. Wrong drug choice
3. The prescription is unclear
4. Abbreviations are not standardized
5. The names of drugs are similar.
6. These drugs are similar in appearance.
(4) Preventive measures for prescription errors
1, put drugs correctly.
Basic standard requirements such as fixed-point positioning of varieties, drug name facing forward, and the period of validity being divided into several parts.
2. Formula
(1) Read the names, specifications and quantities of all drugs on the prescription before prescribing. Don't guess out of thin air if you have any questions. You can consult a superior pharmacist or contact a prescription doctor.
(2) Take the prescription after completing the prescription of a drug to avoid confusion.
(3) When labeling drugs, check them with prescriptions one by one.
(4) If the checker finds a dispensing error, the drug should be returned to the prescriber and the prescriber should be reminded.
3. Medicine
(1) Confirm the identity of patients and ensure that drugs are distributed to the corresponding patients.
(2) Explain the usage of each drug to patients one by one according to the prescription, which is helpful to find and correct the mistakes in prescription and dispensing.
(3) For patients or the elderly who have difficulty in understanding the drug label, they should patiently and meticulously explain the usage and supplement the drug label.
(4) In the consultation service, confirm that the patient/family members have understood the medication method.
(five) prescription error handling principles
1, set up the unit error handling plan.
2, when the patient or nurse reaction drug error, must immediately check the relevant prescriptions and drugs; If the wrong medicine or patient is sent, the pharmacist should immediately deal with it according to the error handling plan of the unit and report to the head of the department.
3, according to the severity of the consequences of the error, rescue measures were taken.
4, if you encounter improper medication, help patients, should actively provide rescue guidance, and provide medication education.
5, conscientiously sum up experience, improve the link that caused the error, and formulate measures to prevent recurrence.
6, with reference to the "China medication error management experts * * * knowledge" to classify errors, and encourage voluntary reporting.