基于信息化构建的静脉安全用药管理模式的应用研究  

Management Model for Intravenous Medication Safety Developed Based on Informatization

作　　者：周赛 马红丽[2] 阮文珍[1] ZHOU Sai;MA Hongli;RUAN Wenzhen(Department of Hematology,Shaoxing People's Hospital,Shaoxing 312000,China;Department of Nursing,Shaoxing People's Hospital,Shaoxing 312000,China)

机构地区：[1]浙江省绍兴市人民医院血液科,312000 [2]浙江省绍兴市人民医院护理部,312000

出　　处：《中国全科医学》2020年第24期3064-3069,共6页Chinese General Practice

基　　金：2018年浙江省医药卫生科技项目(2018KY821)。

摘　　要：背景静脉用药由于疗效明确、起效迅速等,已经成为临床治疗疾病的重要手段,而静脉用药过程中一个小失误就可能导致严重后果,因此确保患者用药安全是当今医疗安全的基础。目的利用信息化手段构建静脉安全用药管理模式,保障患者安全。方法2019年6月绍兴市人民医院全院开始实行静脉安全用药管理模式,采用随机数字表法选取2019年3—5月3个临床科室(肝胆胰二科、血液内科、胸心外科)住院患者为对照组(静脉用药共41537组),2019年7—9月3个临床科室(肝胆胰一科、呼吸内科一、消化内科)住院患者为观察组(静脉用药共39132组)。本院利用现代化信息技术,基于信息化构建静脉安全用药管理模式,即在医嘱系统中新增“警示”模块,对糖尿病患者使用葡萄糖或患者使用过敏类药物起到限制或提醒功能,同时增加输液结束扫描,实现静脉输液全程可追溯。比较两组静脉用药近似错误(糖尿病患者用葡萄糖、药物过敏干预近似错误)发生率、静脉输液追溯完整率。结果观察组糖尿病患者用葡萄糖近似错误发生率、药物过敏干预近似错误发生率低于对照组(0.02%与0.56%,0.03%与0.32%,P<0.05)。对照组静脉输液追溯完整率为0,而观察组静脉输液追溯完整率为97.34%。结论基于信息化构建的静脉安全用药管理模式可以减少静脉用药的潜在不安全危险因素,减少静脉用药近似错误的发生,有利于实现静脉输液全程可追溯,责任到人,持续质量改进,提高用药的科学性及合理性,保障患者安全,提升医疗质量。Background Intravenous medication has become an important administration means because of its clear and rapid effect.A small mistake in the process of intravenous administration may lead to serious consequences.So ensuring the safety of medication is the basis of today's medical safety.Objective To develop a management model for intravenous medication safety using information technology,safeguarding the medication safety of patients.Methods This study was carried out in Shaoxing People's Hospital during March to September 2019.Participants were randomly recruited from 3 clinical department(s No.2 Hepatobiliopancreatology,Hematology and Cardiothoracic Surgery)using the original intravenous medication management model during March to May(control group,consisting of 41537 subgroups),and from other clinical departments(No.1 Hepatobiliopancreatology,No.1 Respiratory Medicine and GI Medicine)using the new management model for intravenous medication safety(developed using the information technology,namely,adding a warning module in the computerized physician order entry system,limiting or reminding the amount of glucose to be used in diabetic patients or allergic drugs to be used in patients,and adding a scanning segment at the end of infusion,realizing the traceability of the whole process of infusion)during July to September(observation group,consisting of 39132 subgroups).The overall incidence of the possibilities of making intravenous medication errors(approximate errors in glucose use and drug allergy intervention)and the completion rates of intravenous infusion process based on traceability were compared between the two groups.Results The overall incidence of approximate errors in glucose use and drug allergy intervention in the observation group was lower than that in the control group(0.02%vs 0.56%,0.03%vs 0.32%,respectively,P<0.05).The completion rates of intravenous infusion process based on traceability in the control group and observation group were 0 and 97.34%,respectively.Conclusion Our management model f

关 键 词：静脉 药物疗法管理 给药系统 医院 信息化 静脉安全用药管理模式 近似错误 全程追溯 

分 类 号：R322.123[医药卫生—人体解剖和组织胚胎学] R95[医药卫生—基础医学]