药物医嘱闭环执行系统的设计及应用

通过设计药物医嘱闭环执行系统,将执行医嘱的全过程及对药物疗效观察的所有数据写入医院信息系统中,进行全流程数据跟踪及医嘱闭环管理。临床应用后,提高了医嘱录入和药物配置的准确性,护士医嘱执行正确率和药物宣教记录的符合率均>99%,给药错误发生率由0.51次/千床日降至0.42次/千床日,护理质量和患者安全明显提高。

Development and application of a closed-loop medication orders executive system

This paper introduces a closed-loop medication orders executive system.The whole process and data of medication administration and observation of drug reactions were inputted into the hospital information system and achieved closed-loop management of data to track the whole process and the doctor’s orders.This practice improved the accuracy of physician orders entry and pharmacy admixture.The accuracy rate of orders execution and the qualification rate of drug education records was over 99%.The incidence of medication errors decreased from 0.51 to 0.42 cases per thousand beds per day.The quality of nursing and patient safety were improved significantly.