2018版医院短缺药品管理制度.pdf

南安市海都医院短缺药品管理制度为标准我院短缺药品管理、促进短缺药品供给，保障临床诊疗需求，制定本制度。一、短缺药品的分类：短缺药品是指临床必需且不可替代或者不可完全替代，因生产、流通、使用环节及其他因素导致的，在一定区域内不能满足临床当前或者预期用量需求，存在短缺风险的药品。根据短缺药品的供给情况，将其分成三类：一类短缺药品是指连续6 个月及以上不能正常供给的药品类短缺药品；二类短缺药品指连续3 个月及以上不能正常供给的药品；三类短缺药品是指连续1 个月及以上不能正常供给的药品。二、成立短缺药品管理工作小组：1.成员名单：组长：xxx 副组长：xxx 成员：xxx 工作组办公室设在药剂科，日常工作由药剂科负责。我院统一负责辖区内村卫生室、社区卫生服务站短缺药品相关管理工作。三、短缺药品管理组织的职责：短缺药品管理工作组负责制订我院短缺药品管理的相关管理制度与工作流程，组织我院短缺药品识别、确认与处置，包括：收集与确认、分析与评估、上报与内部通报短缺药品信息，遴选替代药品，预防药品短缺发生及处理伦理学相关问题等。四、短缺药品管理组织的成员职责：xxx 负责短缺药品相关工作的沟通和协调；xxx 负责收集、上报短缺药品信息，内部通报短缺药品和替代药品相关信息；xxx 及各临床科室主任共同负责分析评估短缺药品信息、遴选替代药品；叶峰负责提供信息相关技术支持。五、短缺药品信息收集1、短缺药品信息来源短缺药品的信息来源包括但不限于我院、药品流通企业、药品生产企业或进口代理商、省级药品集中采购平台、国家药品供给保障相关业务系统、有关行业学协会和患者等。2、短缺药品信息收集内容应当详细收集短缺药品相关信息，包括但不限于以下主要内容：药品基本信息：包括通用名、商品名、剂型、规格、给药途径、批准文号、价格；药品流通企业名称；药品生产企业或进口代理商名称；药品分类信息：按适应证、药品价格、是否为处方药、是否属于国家基本药品、是否为抢救药品、是否属于特殊管理药品等进行分类；短缺信息：短缺原因和预计短缺时间、短缺影响的地理范围和相关临床科室，以及我院内该药品目前剩余库存、有效期、历史用量和预计可以维持使用的时间。3、短缺药品信息收集方法可通过但不限于告知、电子邮件、纸质表单、在线数据查询和业内、同行信息资源共享等方式收集短缺药品信息。六、短缺药品信息确认与分析评估1、短缺药品信息确认与分析评估人员在收集到短缺药品信息后，短缺药品管理工作组应当指定药剂科人员及时组织确认与分析评估。2、短缺药品信息确实认短缺药品信息确认与分析评估人员对我院药品短缺相关信息进行确认，包括但不限于：短缺原因，受影响的主要患者群体，该药品现有库存、采购历史和实文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6际使用情况，估计受影响的持续时间，拟用替代药品及供给情况等。3、短缺药品信息的分析评估短缺药品信息确认与分析评估人员对药品短缺的真实性，短缺药品的需求量、可替代性、临床必需性和对患者治疗的影响等进行分析评估。七、短缺药品信息的上报与内部通报1、短缺药品信息上报流程及方式分析评估后的短缺药品信息经药剂科长审核、组长审批通过后，由信息上报人员登录“全国短缺药品信息直报系统”上报，并报药事管理委员会备案。2、短缺药品信息的内部通报流程及方式：在完成短缺药品信息分析评估的基础上，信息上报人员填写“短缺药品信息内部通报表”附件 1，由组长审核签字后报送医务科、信息科，由医务科将短缺药品信息发布在科主任及医生微信群，信息科将信息发布到院内网，及时更新信息。八、短缺药品替代策略：1、替代药品遴选策略：工作组组织药学、临床医学、护理等相关专业人员基于循证原则及相关技术标准遴选替代药品。2、替代药品的获取短缺药品管理工作组将替代药品遴选结果上报药事管理委员会，假设替代药品不在本机构供给目录内，药事管理委员会应当启动应急采购，并及时在院内通报替代药品信息。在替代药品使用过程中应当加强医患沟通，对患者做好必要的监护。3、短缺药品恢复供给后替代药品的处置短缺药品恢复正常供给后，由短缺药品管理工作组提出替代药品处置方案，文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6并上报药事管理委员会备案。短缺药品恢复供给后的相关信息应当进行内部通报并按规定上报。4、无替代药品时的处置假设无可替代药品，应当积极采取其他治疗措施，及时进行内部通报并按规定上报。九、短缺药品预防策略：以福建省药械采购集中平台为依据，建立我院药品短缺监测预警系统，实行院科二级预警、分级负责、联动保障的监测预警和供给保障工作机制，优化采购管理，强化用药监管，完善报告系统，增强应对药品短缺的能力。附件 1 短缺药品信息内部通报表文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 ZT8H9W1O6C6文档编码:CZ9I8X6A6F9 HC9I9E7J2F7 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