摘要
目的探讨急诊信息化管理系统建立后,实施医嘱闭环管理,对规范急诊用药及医疗护理管理质量的影响及效果。方法随机抽取2014年8月至2015年2月应用急诊信息化管理系统就诊患者中500例病历资料,作为观察组;2014年2月至2014年8月应用传统流程就诊患者中500例病历资料,作为对照组。比较2组在医嘱执行时间、医嘱信息错误率、医嘱信息遗漏率及合理用药等方面的差异,探讨急诊信息化实施前后医嘱管理的变化。结果观察组医嘱执行时间[(9.383±2.118)min]明显较对照组[(15.568±2.533)min]短,差异有统计学意义(P<0.05);观察组医嘱信息错误率(1.7%)较对照组(10.2%)低,差异有统计学意义(P<0.05);观察组医嘱信息遗漏率(0.1%)较对照组(4.4%)低,差异有统计学意义(P<0.05);观察组合理用药率(95%)较对照组(70%)高,差异有统计学意义(P<0.05)。结论应用急诊信息化管理系统后医嘱实现了闭环管理,不仅提高工作效率,减少医疗差错,而且对规范急诊用药及持续改进医疗护理管理质量有很大帮助。
Objective To investigate the influence and effect of application of medical order closed-loop management to standardizing management of the emergency medicine and medical care quality after the construction of the emergency department and information management system. Methods We randomly chose 500 cases of medical records between August 2014 and February 2014 who hospitalized through emergency information management system as experimental group and 500 cases with traditional process from February to August of 2014 as control group. These medical records of patients from both groups were taken randomly from the emergency medical department of our hospital. We compared the execution time,infor- mation error rate, information missing rate of medical order, as well as proper application rate of medicine in order to investi- gate the variation of the medical order management before and after the application of emergency information management. Results During the execution time of medical order, the information error rate, information missing rate of medical order, and proper application rate of medicine were all significantly declined in experimental group than those in control group （ P 〈 0.05 ）. Conclusion The application of emergency information management system makes the medical order achieved the closed loop management, which not only improves the work efficiency, declines the medical mistakes, but also greatly benefits specifying the application of emergency medicine as well as continuously improving the quality of medical nursing management.
出处
《创伤与急危重病医学》
2015年第5期272-274,共3页
Trauma and Critical Care Medicine
关键词
信息化管理系统
医嘱闭环管理
医疗护理
危重症
information management system
medical order closed-loop management
medical care
critical disease
作者简介
通讯作者：高燕，E—mail：gaoyan1515@163．com
