基于信息化技术与多源证据的精细化医嘱审核实践

Practice of Information Technology and Multi-source Evidence Refined Medical Order Review

目的推进住院医嘱前置审核,提高医嘱合格率,保障临床用药安全。方法基于信息化技术构建医嘱前置审核系统,基于多源证据构建儿科药学规则库,按病区推进医嘱前置审核,实现对住院患儿用药医嘱的精细化审核。结果系统上线后医嘱合格率达99%,药师审核医嘱时间缩短至每次15 s,临床满意度达98.75%。结论利用医嘱前置审核系统开展医嘱审核,能规范医师开嘱行为,提高药师审核工作效率,提升临床合理用药水平。

OBJECTIVE To promote the pre-review of inpatient medical orders,improve the qualification rate of medical orders,and ensure the safety of clinical medication.METHODS The medical orders pre-review system was built based on information technology,the paediatric pharmacy rule library was built based on multi-source evidence,and the medical orders prereview was promoted according to the ward,so as to achieve the refined audit of medical orders of hospitalized children.RESULTS After the system went online,the qualified rate of medical orders reached 99%,the time for pharmacists to review medical orders was shortened to 15 s,and the clinical satisfaction was 98.75%.CONCLUSION Using the medical orders pre-review to carry out medical order audit can standardize the doctor’s ordering behavior,improve the pharmacist’s audit efficiency,and improve the level of clinical rational drug use.