药物使用之标准、制度相关问题及参考答案

1、“药物使用”标准、测量要素、目的及相关制度、模拟问题编号标 准测 量 要 素目的相关制度11有效地管理医院用药以满足病人的需求。Medication use in the organization is efficiently organized to meet patient needs有效地管理全院用药以满足病人需求。Medication use is organized throughout the organization so that patient medication needs are metMedications are frequently used for treati

2、ng illness and moderating symptoms. As an important resource in patient care, medication use must be organized effectively and efficiently throughout a health care organization. Medication management is not only the responsibility of the pharmaceutical service but also of managers and clinical care

3、providers. How this responsibility is shared depends on the organizations structure and staffing. In those cases where a pharmacy is not present, medications may be managed on each clinical unit. In other cases, where a large central pharmacy is present, the pharmacy may organize and control medicat

4、ions throughout the organization. Applicable laws and regulations are incorporated into the organizational structure and the operations of the medication management system used in the organization.D-1D-20所有药物相关制度1 如何取得某药物之商品名、化学名或其他药品相关知识？编号标 准测 量 要 素目的相关制度医院药房或药剂服务和药物使用必须遵守相关的法律法规。The pharmacy or p

5、harmaceutical service and medication use in the organization comply with applicable laws and regulations药房或药剂服务和药物使用遵守相关的法律法规。The pharmacy or pharmaceutical service and medication use comply with applicable laws and regulations(see COP.11) HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-2处方和药物医嘱管理

6、规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-6 控制性药品管理制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-8药品贮存制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-18试验药物管理制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-19药物样品赠品管理制度 你认为你的工作合法吗？你怎么确定药剂科的各项工作是合法的？ 药剂科应备有基本用药目录单上的处方药，供临床使

7、用。医院基本处方用药的选择符合医院宗旨、病人需求及医院提供的服务。有医院基本用药目录或可及时从院外获得药品的清单。医院基本用药目录的选择是个协作的过程。每家医院应规定那些能在基本用药目录单上供临床使用的药物，该规定应根据医院宗旨，病人治疗需求和医院为病人提供的服务决定。医院应有基本用药目录单或可及时从院外获得的药物。在某些情况下，法律或法规可能会规定哪些药物必须包括在基本用药目录中。 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-1医院用药管理制度 HYPERLINK Hospital Policy2005.4.2802医院组织管理篇.do

8、c F-6委员会制度 HYPERLINK 目录.doc 院网首页3 医院的用药目录确定的原则是什么？4 药物采购计划如何制定并执行？医院如何修改药品目录：增加或减少药品目录中药物品种？6-1 如何得到医院药品目录？编号标 准测 量 要 素目的相关制度医院对基本用药目录和药物使用有监督机制。There is a method for overseeing the organizations medication list and medication use医院有监督用药目录的机制。医院有监督药物使用的机制。医院有防止药品失窃的机制。There is a method for overseein

9、g the medication listThere is a method for overseeing medication use in the organizationMedications are protected from loss or theft用药选择是个互相协作的过程，它必须考虑病人的需求和安全，同时还须考虑经济因素。医院应有一种方法如药事委员会来讨论和决定基本用药目录，并监控全院用药情况。偶尔，临床上会用基本用药目录单上所没有的药物。同样，有时夜间需要用某些药或药房已下班或药物被锁上，每家医院应对此类情况下药品的及时获得作出相应的规定，并教育员工 HYPERLINK 委

10、员会制度.doc F-6委员会制度 HYPERLINK PHR-G-4紧急情况.doc PHR-G-4药剂科安全和紧急事件的应对 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-6控制药品医院监督药物使用的流程是怎样的？你如何监控用药的准确性？你如何预防药物遗失或被盗？控制性药品失窃了，你怎么办？编号标 准测 量 要 素目的相关制度医院能及时获得某些需要但药房没有的药物。The organization can readily obtain medications not stocked or normally available to th

11、e organization1 能及时获得某些需要但药房没有的药品。2 员工知道该流程。There is a process to obtain required medications not stocked or normally available to the organization 行542Staff understands the process如何按规定的程序获得所需的药品。当病人出现紧急情况时，快速获得某些急救药品很重要。每家医院规定药品的放置位置和管理，急救药品可以考虑放于急救药柜、急救车、袋子或箱子等，为了确保紧急情况下急救药品的获得，医院应建立一个机制来防止急救药物的滥

12、用、被窃或丢失，并确保急救药物在使用后或在过期/损坏时，及时更换。 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-1 医院用药管理制度你如何得到临床需要使用但药房没有的药品？描述该流程。在药房正常工作时间之外，有取药途径。There is a process to obtain medications when the pharmacy or pharmaceutical service is closed在药房正常工作时间之外，有取药流程。员工知道该流程。There is a process to obtain medications w

13、hen the pharmacy is closedStaff understands the process(see ) HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-14病区药房送药制度11 夜间急诊/住院病人如何得到药物？编号标 准测 量 要 素目的相关制度能及时获得急救药品，并对储存在药房外的急救药进行监控，确保安全。在规定时间内获得急救药品。妥善保管急救药品以防丢失或失窃。监控急救药品，并在使用后或在过期/损坏时，及时更换。12-1 急救车药物是如何管理的？医院制度和程序指导开药，给药和用药监测。Prescribing, orde

14、ring, administration, and monitoring of medications are guided by policies and procedures制度和程序指导开药、给药和用药监测。根据规定书写医嘱。规定口头药物医嘱的使用。相关人员接受开药、给药和用药监测培训。Policies and procedures guide the safe prescribing, ordering, administration, and monitoring of medications in the organizationDocumentation requirements

15、 are statedThe use of verbal medication orders is statedRelevant staff is trained in correct prescribing, ordering, administration, and monitoring practicesSafe prescribing, ordering, administration, and monitoring of medications and their effects are guided by organization policies and procedures.

16、Medical, nursing, pharmacy, and administrative staff collaborate to develop and monitor the policies and procedures. Requirements for documenting medications ordered or prescribed and using verbal medication orders are defined in policy. Relevant staff is trained in correct prescribing, ordering, an

17、d administration practices. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-2处方和药物医嘱管理规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-7化疗药物管理制度12是否有书面的制度和规定来指导开药、给药、用药监测？所有使用药物的部门是否执行这些制度？口头医嘱怎么执行？编号标 准测 量 要 素目的相关制度 医院规定开药、给药人员的资格。只有有相应执照、符合法律法规要求并得到医院认可的人员才有处方权。医院对某些特殊药物的处方权限制有相应的规定。药房有全院拥有处

18、方权的医生的名字。4 有相应执照、符合法律法规要求并得到医院认可的人员才有权给药。 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-20药品处方权资格认定制度 谁有资格开处方/药物医嘱？你怎么确定开处方/药物医嘱的医生具有相应的权限？谁可以给病人用药？编号标 准测 量 要 素目的相关制度医院制度和操作规程规定病人自我用药管理、药物样品的控制、病人/家属自带药物的使用和出院带药。Policies and procedures govern any patient self-administration of medications, the c

19、ontrol of medication samples, the use of any medications brought into the organization by the patient or his or her family, and the dispensing of medications at discharge制度和操作规程管理病人的自我用药。制度和操作规程控制药物样品的获得和使用。制度和操作规程控制病人的自带药品。制度和操作规程控制病人的出院带药。制度和操作规程得到实施。Policies and procedures govern patient self-adm

20、inistration of medications 护12Policies and procedures control the availability and use of medication samplesPolicies and procedures govern the documentation and management of any medications brought into the organization for or by the patient 护 12Policies and procedures govern the dispensing of medi

21、cations at the time of the patients discharge Policies and procedures are implementedOverseeing medication use in an organization requires an understanding of the sources and uses of medications that are not prescribed or ordered in the organization. Medications brought into the organization by the

22、patient or his or her family are known to the patients physician and noted in the patients record. The organization controls the availability and use of medication samples. The self-administration of medications, either those brought into the organization or those prescribed or ordered within the or

23、ganization, is known to the patients physician and noted in the patients record. Each organization also needs to determine its role in providing medications to patients at discharge. Those who prescribe or order medication and patients and their families know what medications, if any, are available,

24、 how to obtain them, and if there are any limits or costs. These medication use practices are guided by organization policies and procedures to ensure patient safety and therapeutic effectiveness. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-12 病人自备注射药物和自我给药规定 HYPERLINK Hospital Policy2005.4.28

25、01病人服务管理篇.doc D-19 药物样品赠品管理制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D13病人出院带药规定病人是否可以使用所有自备的口服药物或者注射剂？药物样品可以给病人使用吗？病人有出院带药吗？怎么控制出院带药？编号标 准测 量 要 素目的相关制度制度和操作规程指导肠内/外营养治疗的准备、配制、贮存和发放。制度和操作规程指导肠内外营养品的贮藏、准备和发放。制度和操作规程得到实施。 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-2处方和药物医嘱管理规定五 住院病人TPN

26、的管理21 医院肠内/肠外营养是怎么准备、配置、贮存和发放的？制度和操作规程指导放射性药物、科研用药和其它药物的保管、发放和处理。Policies and procedures govern the storage, distribution, handling, and dispensing of radioactive, investigational, and other medications制度和操作规程指导放射性药物的保管、发放和处理。制度和操作规程指导科研用药的保管、发放和处理。Policies and procedures govern the storage, handlin

27、g, distribution, and dispensing of radioactive medications Policies and procedures govern the storage, handling,distribution, and dispensing of investigational medicationsThe organization ensures that radioactive, investigational, and other such medications are safe and used appropriately. The stora

28、ge, handling, distribution, and dispensing are governed by policies and procedures. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D6 控制性药品管理制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-7化疗药物管理制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-18试验药物管理制度22 放射性药品是怎么保管、发放和处理的？23 科研用药的定义是什么？

29、科研用药是怎么保管、发放、处理的？编号标 准测 量 要 素目的相关制度药物应在安全和清洁的环境中储存、准备和发放。Medications are stored, prepared, and dispensed in a safe and clean environment药物标签清晰。储存恰当。在清洁和安全的环境中准备和分发药物。药物准备和发放符合相关的法律法规和专业实践标准。Medications are labeled properlyMedications are stored properlyMedications are prepared and dispensed in clean

30、 and safe areas 护15Medications preparation and dispensing adhere to law, regulation, and professional standards of practiceThe pharmacy or pharmaceutical service prepares and dispenses medications in a clean and safe environment that complies with law, regulation, and professional practice standards

31、. In particular, medications are clearly labeled, stored properly, and protected from heat and light when necessary. Medications stored and dispensed from areas outside the pharmacy, for example patient care units, comply with the same safety measures. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc

32、 D3 药物使用规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-8 药品的储存制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-10多剂量注射药品（西林瓶）的使用 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-14病区药房送药制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-15退药制度 HYPERLINK PHR-G-11药品效期管理.doc PHR-G-11效期 HYP

33、ERLINK PHR-G-3设施管理.doc PHR-G-3设施24 药物按照什么原则存放？定位吗？新增加的药物品种如何摆放？25 散片、小针剂没有效期标示时，你怎么确定有效期？26 配置完成的输液有效期（稳定时间）如何确定？27 贮存药品的效期、品质如何保证？28 你多久进行一次药架或冰箱的清洁？29 有些药品需冷藏或冷冻贮存，你如何确定温度是否符合要求？30 化疗药物是如何准备、分发、使用的？31 药物补充时，怎么确保正确？编号标 准测 量 要 素目的相关制度由执业药师、技术员或其他受过专业训练的人员负责监督药物的储存、准备和发放。An appropriately licensed pha

34、rmacist, technician, or other trained professional supervises the storage, preparation, and dispensing of medications1 有资格的人员监督药房的工作。2 药品发放准确。控制性药品帐目清楚。A qualified individual supervises all activitiesMedications are accurately dispensedControlled substances are accurately accounted forA qualified in

35、dividual directly supervises the activities of the pharmacy or pharmaceutical service. The individual is appropriately licensed, certified, and trained. Supervision includes controlling all medications and safely and accurately dispensing medication. There is a registry, log, or other mechanism to m

36、onitor and account for controlled substances. HYPERLINK PHR-G-2员工资格和教育.doc PHR-G-2员工资格和教育 HYPERLINK Hospital Policy2005.4.2802医院组织管理篇.doc F-6委员会制度 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-6控制性药品管理制度32 药房有非专业人员从事药学服务吗？你如何确保药品发放的准确性？你如何预防听似、看似的药物发放错误？35 你如何保证控制性药品（精、麻、毒、放）之帐物相符？编号标 准测 量 要 素目的

37、相关制度医嘱核对。Medication prescriptions or orders are verified用药前核对医嘱/处方。有疑问时联系开医嘱的医生。Each prescription or order is reviewed before administration 医544There is a process to contact the individual who prescribed or ordered the medication when questions arise 医544The licensed pharmacist, technician, or trai

38、ned professional reviews each prescription or order for medication before administration. When questions arise, the individual who prescribed or ordered the medication is contacted. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-2处方和药物医嘱管理规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D3 药物使用

39、规定36 调配处方/医嘱时，你核对哪些内容？有疑问时，你如何联系医生？目的是什么？38-1 HYPERLINK 过敏实验.doc 如何确认病人对所用药物不过敏？编号标 准测 量 要 素目的相关制度11.4.3 医院有药物召回系统。The organization has a medication recall system医院有药物召回系统。医院制度和操作规程规定即将过期或已过期药品的使用。医院制度和操作规程规定即将过期或已过期药品的销毁。制度和操作规程得到实施。There is a medication recall system in placePolicies and procedure

40、s address any use of medications known to be expired or outdated.Policies and procedures address the destruction of medications known to be expired or outdatedPolicies and procedures are implementedThe organization has a process for identifying, retrieving, and returning or destroying medications re

41、called by the manufacturer or supplier. There is a policy or procedure that addresses any use of or the destruction of medications known to be expired or outdated. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-8药品贮存制度D HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc 16 药物召回制度什么情况下药物被召回？请描述召回系统。已

42、过期的药物是怎么处理的？（报损制度）近效期药品是怎么管理的？（效期管理制度）（请将记录作为证据。）编号标 准测 量 要 素目的相关制度医院给药系统确保在正确的时间把正确的剂量发放给正确的病人。A system is used to dispense medications in the right dose to the right patient at the right time HYPERLINK 给药系统.doc 医院有统一的给药系统。发药程序尽量简便。3 发药准确。发药及时。There is a uniform medication dispensing and distributi

43、on system in the organization Medications are dispensed in a form requiring minimal manipulationThe system supports accurate dispensingThe system supports timely dispensingThe organization dispenses medications in the most ready-to-administer form possible to minimize opportunities for error during

44、distribution and administration. The central pharmacy and other medication-distribution points throughout the organization use the same system. The system supports accurate dispensing of medications in a timely manner. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-4给药错误处理制度如何保证病人用药时间的一致？怎么确保药品调配

45、和使用的正确？怎么保证病人及时用药？编号标 准测 量 要 素目的相关制度给药前核对病人。Patients are identified before medications are administered有病人身份确认机制。给药前核对病人姓名。There is a system in place to ensure the identification of patientsPatients are identified before medications are administered The safe administration of medications includes ve

46、rifying theMedication with the prescription or order;Time and frequency of administration with the prescription or order;Dosage amount with the prescription or order;Route of administration with the prescription or order; andIdentity of the patient HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-2

47、处方和药物医嘱管理规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-13病人出院带药规定44 你如何确定药物给了正确的病人？（门诊病人发药、住院病人给药）编号标 准测 量 要 素目的相关制度在正确的时间给病人正确的剂量。The right dose of medication is administered at the right time核对药物。核对剂量。核对给药途径。在规定时间内给药。根据医嘱要求给药。Medications are verified with the prescription or order The dosag

48、e amounts of the medication are verified with the prescription or order The routes of administration are verified with the prescription or order Medications are administered on a timely basisMedications are administered as prescribed(see ) HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-2处方和药物医嘱管理

49、规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D3 药物使用规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-10多剂量注射药品（西林瓶）的使用 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-11氯化钾的使用和管理46 你怎么保证药物调配和使用完全正确？（住院指住院病人，不排除门诊病人）编号标 准测 量 要 素目的相关制度监测病人药物疗效。Medication effects on patients are monitored监测

50、病人药物疗效。2 协同监测。Medication effects on patients are monitoredThe monitoring process is collaborativeThe patient, his or her physician, nurse, and other care providers work together to monitor patients on medications. The purposes of monitoring are to evaluate the medications effect on the patients symp

51、toms or illness, adjust the dosage or type of medication when needed, and evaluate the patient for adverse effects. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D3 药物使用规定47 病人的药物疗效是怎么监测的？编号标 准测 量 要 素目的相关制度药物医嘱及用药情况记录于病历中。Medications prescribed and administered are written in the patients record1

52、药物医嘱记录于病历中。2 记录每次给药。3 用药信息保存在病历中或在出院/转院时放入 病人病历中。Medications prescribed or ordered are recorded for each patientMedication administration is recorded for each doseMedication information is kept in the patients record or inserted into his or her record at discharge or transferThe record of each patie

53、nt who receives a medication contains a list of the medications prescribed or ordered for the patient and the dosage and times the medication was administered. Included are medications administered “as needed.” If this information is recorded on a separate medication form, the form is inserted in th

54、e patients record at discharge or transfer. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-2处方和药物医嘱管理规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D3 药物使用规定编号标 准测 量 要 素目的相关制度在病历中记录任何药物不良反应。Adverse medication effects are noted in the patients record疗效观察包括观察药物不良反应。医院规定哪些不良反应必须记录，哪些必须上报。不良反应记录于

55、病历中。根据要求报告不良反应。Monitoring includes observing adverse medication effectsThe organization has identified those adverse effects that are to be recorded in the patients record and those that must be reported to the organizationAdverse effects are documented in the patients recordAdverse effects are repo

56、rted as requiredMonitoring medication effects includes observing and documenting any adverse effects. The organization identifies all adverse effects that are to be recorded and those that must be reported. The organization establishes a mechanism for reporting adverse events when required and the t

57、ime frame for reporting. HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D3 药物使用规定 HYPERLINK Hospital Policy2005.4.2801病人服务管理篇.doc D-5 药物不良反应处理制度48 哪些药物不良反应必须记录，哪些必须上报？接到药物不良反应的信息时，你怎么做？请药物不良反应报告程序。编号标 准测 量 要 素目的相关制度医院规定给药差错的报告程序及时间框架。Medication errors are reported through a process and time frame d

58、efined by the organization定义给药差错。在规定时间内报告给药差错。 利用给药差错报告提供的信息来改进给药流程。A medication error is definedMedication errors are reported in a timely manner using an established processThe organization uses medication error reporting information to improve medication use processesThe organization has a proces

59、s to identify and report medication errors. The process includes defining a medication error, using a standardized format for reporting, and educating staff on the process and importance of reporting. The reporting process is part of the organizations performance improvement program. The program foc

60、uses on preventing medication errors through understanding the types of errors that occur in the organization and in other organizations. Improvements in medication processes and staff training are used to prevent errors in the future. The pharmacy participates in such staff training. HYPERLINK Hosp