手术麻醉信息管理系统中风险预警的构建及应用

Establishment and evaluation of early risk warning in electronic nursing information system for operating room

目的探讨手术室护理信息管理系统中风险预警的构建以及其对手术室护理安全的重要影响。方法构建手术室护理信息管理系统中的手术患者安全核查、手术器械追溯、手术耗材管理和收费、术中输血和用药管理、病理标本管理、术中压力性损伤防护等6个风险预警提示模块,并评估其在手术室护理安全管理中的作用。结果患者安全核查执行率、器械追溯执行率、标本信息准确率、手术压力性损伤上报率、医护人员和患者满意度明显上升;过期物品使用率、手术收费漏费和差错率、手术压力性损伤发生率明显降低。结论手术室护理信息管理系统中的各种风险预警提示,可强化手术室护士的风险意识,提高其风险识别和管理能力,实现手术全程安全监管和无缝对接,保障手术患者的医疗安全。

Objective To explore the establishment of early warning in electronic nursing information system for operating room （OR） and to examine its effects on nursing safety in OR. Methods We used six models in OR electronic nursing information system as the risk warning models, and we assessed their effects on surgical safety management. Six models included verification of patient＇s identification; follow-up of surgical equipment; management and charging of surgical commodities; management of blood transfusion and drug usage in surgery; management of pathological specimen; and pressure injury prevention. Results The implementation rate of patient safety check,the retroactive rate of equipment,the accuracy rate of specimen information, the reported rate of surgical stress injury,the medical personnel and patient satisfaction were significantly increased;the rate of use of expired items,leakage and error rate of surgical charges,and surgical pressure injury were significantly reduced. Conclusion Appropriate establishment of early warning OR electronic nursing information system can enhance risk awareness of OR nurses, make better safe control of the whole process for patients undergoing surgeries.