静脉用药医嘱自动审核模块的开发与应用

Development and application of automatic check module for medical order of intravenous medication

目的开发静脉用药医嘱自动审核模块,以提高静脉用药调配中心(PIVAS)医嘱审核效率,减少用药差错,提高患者用药安全性。方法基于PIVAS管理系统开发医嘱自动审核模块,从医院信息系统(HIS)、实验室信息管理系统(LIS)、电子病历系统(EMR)获取药品属性、患者信息、医嘱信息、实验室数据,创建医嘱审核规则及运算逻辑,从而实现医嘱自动审核功能。结果医嘱自动审核模块能基本完成医嘱的合理性审查,包括适应证、用法用量、溶媒选择、给药浓度、配伍禁忌、注意事项等问题。结论医嘱自动审核模块规则构建灵活,操作便捷,能自行更新维护,通过不断校准,有效警示率达到84%,提高药师审方效率,减少临床用药差错,提高患者用药安全。

Objective Develop automatic check module for medical order of intravenous medication,so as to enhance the check efficiency of pharmacy intravenous admixture service（PIVAS）,reduce medication errors and improve medication safety.Methods Automatic check module for medical order was developed based on the PIVAS management system.The drug attributes,patients＇ information,medical order information and laboratory datas were obtained from HIS,LIS and EMR.Check rules for medical order and arithmetic logic were found to achieve automatic check of medical order.Results Basically,automatic check module for medical order could check the rationality of medical order,included indications,usage,dosage,choice of the solvent,concentration,incompatibility,announcements and other problems.Conclusion The construction of automatic check module for medical order is flexible.It is easy to operate and can be updated and maintained automatically.Through continuous calibration,effective warning was 84%,which improves the efficiency of pharmacists＇ check of prescription,reduces the clinical medication errors and improves medication safety of patients.