口头医嘱记录本使用中存在的问题与管理对策

目的:分析口头医嘱记录本使用中存在的问题并提出改进措施,以减少或避免医疗不良事件的发生。方法:调查2011年5月至2012年3月我院所有科室口头医嘱记录本的使用情况。结果:全院56个科室中25个科室使用过口头医嘱记录本,共记录了1160条医嘱,包括现场口头医嘱1088条(93.79%)、电话口头医嘱72条(6.21%);其中152条医嘱项目记录不完整。结论:部分医护人员对口头医嘱的认识存在不足,频繁出现超范围下达和执行口头医嘱的现象;行政部门对口头医嘱的监管力度不够。因此加强医护人员的培训及定期监管是促进医护有效沟通和保障患者安全的有效途径。

Problems and countermeasures in Verbal Order Records

Objective： To analyze of the problems during the process of implementation of the verbal order records in order to reduce the occurrence of adverse events. Methods： Verbal order records from May 2011 to March 2012 in all departments were invertigated. Results： The verbal order records were used in 25 of 56 departments in the hospital. There were 1 160 medical orders, including 1088 （93.79%） on-site verbal orders and 72 （6.21%） telephone orders. Among them there were 152 incomplete verbal orders. Conclusion： Part of the medical staff did not pay enough attention to the verbal orders, and violation was frequently appeared in the verbal orders due to inadequate supervision of the administrative department. Therefore, training and regularly supervision could promote effective communication between doctors and nurses and protect the safety of patients.