医护合作解决专科电子医嘱输入问题(1)
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[摘要] 目的：医护合作规范专科电子医嘱输入方法与技巧，减少轮转住院医生医嘱输入的错误，提高护士处理医嘱的工作效率，减少耦合性护理差错。方法：给新轮转进科的部分住院医生进行专科电子医嘱输入培训，与未培训组医生进行对比。结果：未培训医生发生医嘱错误占医嘱总数的29.12%。培训医生输入医嘱错误占医嘱总数的0.58%。培训后医嘱错误明显减少(χ2=1 449.07，P<0.001)。结论：培训后医嘱错误明显减少，护士处理和执行医嘱的工作效率提高，避免了医疗护理差错的发生。
[关键词] 医护合作；电子医嘱；培训
[中图分类号] R197.324 [文献标识码] B [文章编号] 1673-7210(2011)12(b)-170-02
Cooperation of doctor and nurse solving faculty electronic medical order input question
YANG Li, SUN Shuchun
Department of Gastroenterology, Xuanwu Hospital Affiliated to Capital Medical University, Beijing 100053, China
[Abstract] Objective: To investigate how to regulate the method and technique of input of faculty electronic medical order through cooperation of doctor and nurse, to reduce the errors of rotating resident physician′s medical order input and doctor-nurse coupling nursing mistakes and improve the efficiency of dealing with the medical order in nurse. Methods: The rotating resident physicians were divided into two groups, training group and no-training group. The training group was received training about how to input electronic medical order, the other group was not, then counted the errors of medical order input in each group. Results: The errors of medical order input of the no-training group accounted for 29.12% of total medical orders, and that of training group accounted for 0.58% after training, the errors of medical order input were decreased (P<0.001). Conclusion: Through the training, the errors of medical order input were decreased obviously. The efficiency of nurse handling and executing medical order is improved, and the occurrence of medical treatment and nurse errors is reduced.
[Key words] Cooperation of doctor and nurse; Electronic medical order; Training
医嘱为整个病历各组成要素最核心的部分，是医生根据患者病情需要，下达的书面医学指令，需由医护人员合作完成[1]。我院从2005年6月开始使用HIS系统进行医嘱网络管理。网络管理在我院已经运行了5年多，逐渐形成了正规化、规范化的模式。在实际运行过程中，虽然医院进行了电子医嘱统一培训，但缺乏专科性，处理医嘱时护士需要多次纠正医嘱错误。有人指出：护理差错与医疗差错有很强的不可分性，有些护理差错的发生正是以医疗差错为诱因的[2]。因此，医嘱错误是引起护理差错的危险因素之一。我院是三甲医院，住院医生每3个月轮转科室1次，进行专科学习，因此笔者发现轮转医生在进入一个新科室时，输入电子医嘱错误较多，影响了处理和执行医嘱的工作效率。为了使患者能够及时得到更安全、迅速、准确的治疗和护理，我科主治医师、护士长和主班护士对每次新轮转医生进行专科电子医嘱输入培训，使轮转住院医生尽快掌握专科医嘱输入方法与技巧，保证了病房医疗护理工作的正常运行。 ......
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