我院医嘱智能审方系统的建立与实践结果分析

Establishment of an intelligent pre-order prescription review system in our hospital and analysis of its practical results

目的:建立医嘱智能审方系统,保障临床用药安全、有效、合理。方法:以广州市天恒信息科技公司药慧士智能互动审方为平台,科学制订审方规则和流程及规则重置,设置问题医嘱分级。调取门诊和住院部智能审方系统应用前2018年10-12月总医嘱数199 895例作为对照组,2019年10-12月实施智能审方系统后的总医嘱数203 480例为分析组,对2组问题医嘱数进行分析比较,统计2组问题医嘱及干预情况。结果:在对照组发现问题医嘱数15 212例,占总医嘱7.62%。其中西药问题医嘱10 189例,中药5 023例;分析组发现问题医嘱数5 086例,占总医嘱2.50%。其中西药问题医嘱3 383例,中药1 703例,2组对比差异有统计学意义(P<0.05)。结论:医嘱智能审方系统具有显著的优越性,能明显降低问题医嘱或处方的发生,并且能对其进行有效的干预与拦截,从合理用药水平得到显著提升,能够给患者提供更简单、便捷和安全的药学服务。

OBJECTIVE To establish an intelligent pre-order prescription review system to ensure the safety, effectiveness and reasonableness of clinical medications.METHODS Yaohuishi intelligent prescription review platform of Guangzhou Tianheng Information Technology Inc was employed for formulating the rules and procedures of reviewing prescription and process of reset rules and identifying unreasonable physicians’ s order sheets.The total number of 199 895 medical orders from October to December 2018 before applying outpatient/inpatient department intelligent review system as control group and 203,480 medical order from October to December 2019 after implementing intelligent review system as experimental group.Two groups of unreasonable physician orders were analyzed.RESULTS In control group, 15 212 physician orders were unreasonable and accounted for 7.61% of total orders.Among them, 10,189 medical orders were for western medicine and 5 023 for traditional Chinese medicine.There were 5 086 unreasonable orders in experimental group and accounted for 2.50% of total orders.And 3 383 medical orders were for western medicine and 1,703 for traditional Chinese medicine.Significant inter-group difference existed(P<0.05).CONCLUSION The pre-order intelligent prescription review system offers significant advantages.It greatly reduces the occurrence of unreasonable medical orders or prescriptions and enables accurate and effective interventions.More rational drug use allow for providing safer and more simple, convenient pharmaceutical services for patients.