基于用药安全的计算机辅助人工前置审方模式的构建  

Ensuring the Safety of Medication for Inpatients by the Mode of Computer-aided Order Audit

作　　者：彭婕[1] 张海霞[1] 吴晓燕[1] 葛卫红[1] 秦旺强 PENG Jie;ZHANG Haixia;WU Xiaoyan;GE Weihong;QIN Wangqiang(Department of Pharmacy,Nanjing Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School,Nanjing 210008,China;Ipharmacare Information Technology Co.Ltd,Hangzhou 311112,China)

机构地区：[1]南京大学医学院附属鼓楼医院药学部,南京210008 [2]杭州逸曜信息技术有限公司,杭州311112

出　　处：《药学与临床研究》2020年第4期313-316,共4页Pharmaceutical and Clinical Research

摘　　要：目的:利用计算机辅助人工处方前置审核软件,建立系统审核规则,构建住院医嘱审核模式,实现住院医嘱100%前置审核。方法:依托软件自带的规则,建立系统审查体系并不断优化,实现前置处方审核和拦截。结果:本院计算机辅助人工处方前置审核流程运行后,住院医嘱合理率上升到99.2%。部分在多专科不规范使用的药品用量降低4%~50%。该审方模式既可以实现7×24 h禁忌医嘱拦截,同时药师在患者个体化用药审查、药物交互审查、肠外营养医嘱审查等方面发挥专业优势。结论:本院在计算机辅助人工前置审方的模式下,通过系统规则优化提高人工审核效率,进一步保障患者用药安全。Objective: To realize all inpatients medical order audit in our hospital, we established the mode of computer-aided pharmacists’ prescription audit. Methods: Basing on the "octopus" rule design route, we optimized the system audit rules, so as to reduce software audit errors. Results: After the mode of computer-aided pharmacists’ prescription audit was ran, the reasonable rate of inpatient orders rose to 99.2%. Some drugs’ improper usages were reduced by 4% to 50%. Our mode not only intercepted contraindicant orders for 7×24 hours, but also gave the pharmacists opportunities to realize technical expertise on patients’ individualized medication, drug interaction review, parenteral nutrition order review and so on.Conclusion: The efficiency of our audit mode is improved after rule optimization. Rational drug use management is more efficient and effective.

关 键 词：住院医嘱 前置审核 模式 成效 用药安全 

分 类 号：R95[医药卫生—药学]