军队医院医疗安全(不良)事件信息标准及其应用研究

Information Standardization of Adverse Events in the Military Hospital and the Application

目的遵循WS 370-2012卫生信息基本数据集编制规范构建军队医疗安全不良事件主题数据集,建立信息系统,对其进行规范化管理。方法①医疗安全(不良)事件管理情况分析;②基于信息系统的医疗安全(不良)事件信息标准的研究。结果对军队医疗(安全)不良事件数据集的标准化描述,构建了包括医疗安全(不良)事件报告、处置、管理三个模块为内容的军队医疗(安全)不良事件数据集,研发医疗安全(不良)事件上报与管理系统。结论建立遵循卫生信息基本数据集编制规范的医疗安全(不良)事件数据集,为实现医疗安全(不良)事件信息的广泛交换和共享奠定基础。

Objective To construct the basic data set compiling specification of army medical（safety） adverse events follow the WS 370-2012 health information subject data set,establish an information system and realize its standardized management.Methods ①Analyze the medical safety（adverse） event management;②Study the information system based on the medical safety（adverse） event information standards.Results The standardization of the army medical（safety） adverse event data sets was described;the army medical adverse events（safety） data sets were set up which included three module as reporting,disposal and management;a medical safety（adverse） reporting and management system was developed.Conclusion The establishment of specifications medical safety（adverse） event data set will provide the foundation to realize the medical safety（adverse） extensive exchange and sharing of event information.