我院儿童处方医嘱知识库建设与处方前置审核系统的运行实践  

The Construction of Pediatric Prescription Knowledge Database Facilitates Prescription Pre-audit Intelligent Decision

作　　者：吴丹[1] 徐颖[1] 张旭晖[1] 郑锋[1] 陈灏 李智平[1] WU Dan;XU Ying;ZHANG Xu-hui;ZHENG Feng;CHEN Hao;LI Zhi-ping(Department of Clinical Pharmacy,Children's Hospital of Fudan University,Shanghai 201102,China)

机构地区：[1]复旦大学附属儿科医院临床药学部,上海201102

出　　处：《中国药学杂志》2020年第12期1046-1050,共5页Chinese Pharmaceutical Journal

摘　　要：目的完善现有儿童合理用药知识库,用以降低儿童用药差错发生率,提高儿童药物治疗的安全性和有效性。方法通过查阅相关资料构建儿童处方医嘱知识库,以此为基础,在医生开具医嘱和处方时自动推荐用法用量,并对医嘱及处方进行前置审核,按不同安全等级予以拦截。结果2018年11月至2019年4月,前置审方系统共审核住院医嘱906945条,由于儿童合理用药知识库的使用,住院医嘱中慎用,相对禁用和绝对禁用医嘱占总医嘱的比例分别从71.71%,5.45%和0.12%下降至35.86%,3.51%和0.08%,开嘱医生对系统的适应性和用药的合理性逐月提高。结论儿童合理用药知识库的使用,显著降低了我院住院患儿用药差错的发生率,提高了医疗同质化水平,是值得考虑推广的医疗服务模式。OBJECTIVE To perfect China's pediatric knowledge database of rational medication use,to reduce the incidence of medication errors and to improve the safety and effectiveness of medication therapy in children.METHODS Construct the pediatric prescription knowledge database by accessing relevant handbooks,guidelines,online databases and researches,and embed it into the prescription pre-audit intelligent decision system.Based on this,the system could automatically recommend dosage and usage information to the physicians during prescribing,it could also pre-screen and intercept improper medical orders and prescriptions according to different security levels.RESULTS From November 2018 to April 2019,the prescription Pre-audit Intelligent Decision System reviewed a total of 906,945 inpatients orders.Due to the use of the Pediatric Prescription Knowledge Database,the inpatients'precaution,relative contraindication and absolute contraindications orders presented a remarkably decline,from 71.71%,5.45%and 0.12%respectively,to 35.86%,3.51%and 0.08%.The physician's fitness to the system and rationality of medication increased month by month.CONCLUSION The use of the Pediatric Prescription Knowledge Database significantly reduces the incidence of medication errors in hospitalized children and improves the level of medical homogenization.It is a medical service model worthy of consideration.

关 键 词：儿童 合理用药 知识库 前置审方 智能决策 

分 类 号：R969.3[医药卫生—药理学]