网上医嘱处理质量实时控制分析

Real-time Control Analysis on Quality of Handling the Internet Medical Orders

目的 :探索网上医嘱处理质量的管理方法 ,促进护理文书的规范化。方法 :采用我院自行设计的“医嘱处理实时监控系统” ,对网上数据库内 2 0 0 0年 10月— 2 0 0 2年 9月 98万条医嘱中报错医嘱、出错人员分 4个时间段进行对比分析。结果 :网上医嘱处理存在的主要问题在临时医嘱上 ,其次是控制时间段内未转抄校对医嘱 ,出错人员报错率与工作年限呈正相关。结论 :在网上运用“医嘱处理实时监控系统” 。

Objective: to explore the administrative method on handling medical orders on the internet, to make nursing document more standardized. Methods: self-designed the 'Medical Order Handling Real-time Monitoring System' was adopted. A total of 980 thousand of medical orders dated from Oct. 2000 to Sep. 2002 on the internet data base were analyzed. Among which, mistakes in reporting the orders, who made these mistakes were comparatively analyzed in 4 different time period. Results: main problem existed in the internet order handling was those temporary orders. Nursing staff did not transcribe and proofread the orders in time was in the second place. The amounts of mistakes nursing staffs made had the positive relation with the time period of their working experience. Conclusion: to use the 'Medical Order Handling Real-time Monitoring System' on the internet may find out and correct the mistakes made by nurses in the course of orders handling.