床边给药双重身份核对落实情况调查分析

Investigation and Analysis of the Implementation of Bedside Double Identity Checking

目的调查人工及数据终端(PDA)相结合的双重核对方式在患者身份识别制度中的落实情况。方法根据《标准化床边给药身份核对流程》制订查检表,对4个护理单元124名护士床边操作身份识别情况进行观察。结果双重核对均到位69名(55.65%),人工核对执行率59.68%,PDA核对执行率83.06%,差异有统计学意义(P<0.01);主管护师在人工核对第一步中患者姓名执行率为83.33%,护师在人工核对第一步中患者姓名执行率为98.08%,护士在人工核对第一步中患者姓名执行率为100%,差异有统计学意义(P<0.05),护士使用PDA进行身份识别时存在手工操作及使用他人界面的现象。结论护理人员应严格执行患者身份识别制度,包括双向核对患者姓名,核对手腕带信息,遵循PDA身份识别操作流程,保证患者的用药安全。

Objective To investigate the implementation of double check system of manual and data terminal（PDA） in patient identification system. Methods According to the ＂standardized bedside administration identity verification procedure＂ for checklist, 4 nursing unit 124 nurses bedside operation identification were observed. Results Double check were in place 69（55.65%）, manual check execution rate was 59.68%, PDA check execution rate was 83.06%, the differences were statistically significant（P〈0.01）. The supervisor in the first step in the artificial check the name of the patient＇s implementation rate was 83.33%, nurse in the first step in the artificial check the patient＇s name implementation rate was 98.08%, nurses in the first step in the patient check the implementation rate was 100%. The difference was statistically significant（P〈0.05）, nurses used PDA to identify exited manual operation and the use of other people interface phenomenon. Conclusion Nursing staff should strictly implement the patient identification system, including two-way checking the patient name, checking the wrist band information, follow the PDA identification process, and ensure the safety of patient medication.