网上医嘱处理质量实时控制分析

目的：通过对医院近2年网上医嘱处理质量的分析，探索网上医嘱处理质量的管理方法，促进护理文书的规范化，以适应现代医院的发展和社会的需要。方法：调用与医院信息网实现无缝连接的、医院自行设计的“医嘱处理实时监控系统”网上数据库，对2000年10月—2002年9月，98万余条医嘱中报错医嘱及出错人员，分4个时间段进行对比分析。结果：网上医嘱处理存在的主要问题集中在临时医嘱上，其次是控制时间段内未转抄校对医嘱。对医嘱分类出错频次进行分类分析，2年中报错率呈明显减少趋势；对出错人员工作年限进行分析结果表明：报错率与工作年限呈正相关。结论：在网上运用“医嘱处理实时监控系统”，为及时发现和纠正医嘱处理过程中的错误提供了可能；监控数据库的自动生成也为管理者能正确分析和统计医嘱处理过程中存在的问题，有针对性地解决问题提供了可靠的依据和管理方法。

An analysis on the online real- time control of doctor''s advice disposition

Objective To explore a way that can control the quality of doctor's advice disposition online.Method An analysis was conducted in those who had made come mistakes during Oct.2000 to Sept.2002 in about 980,000 pieces of doctor's advice.The author divided this period of time into 4 phases and compared with each other.Results Temporary doctor's advice was the one that most of the mistakes existed,the second was failing to collate the doctor's adivce in time.They also analyzed the frequency of the mistakes and the results indicated that during recent two years the mistake making rate was decreasing significantly.The analysis on the working years of the personnel who made mistakes suggested that there was a positive correlation between the mistake making rate and working years.Conclusion Using online doctor's advice disposition real time control system makes it possible to find out and correct the mistake in time during the doctor's advice disposition.At the same time,the quality control database can be created automatically.It can provide a reliable basis and management method for the administrators to analyze the problems that exist in the doctor's advice disposition and solve the problem correctly.