住院患者用药医嘱审核系统优化与自定义规则库建设  

Optimization of the Medical Order Audit System for Inpatients and the Construction of Custom Rules

作　　者：陈晓旭 李洪盟 张辉[2] 荆自伟 张旭锋 聂春杰[1] 杜书章[1] CHEN Xiaoxu;LI Hongmeng;ZHANG Hui;JING Ziwei;ZHANG Xufeng;NIE Chunjie;DU Shuzhang(Department of Pharmacy,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450000,China;Pediatric Surgery,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450000,China)

机构地区：[1]郑州大学第一附属医院药学部,郑州450000 [2]郑州大学第一附属医院小儿外科,郑州450000

出　　处：《医药导报》2023年第5期653-660,共8页Herald of Medicine

基　　金：国家自然科学基金资助项目(82003956);河南省医学科技攻关计划项目(LHGJ20190277)。

摘　　要：目的 总结医嘱审核系统优化与自定义规则库建设的成效。方法 引进医嘱审核系统后,对比人工与系统点评医嘱的结果,评估系统功能,进而优化系统功能、修改医嘱审核规则,开发超说明书用药线上审批功能、建立规则维护制度,形成动态的自定义规则库。结果 系统功能优化后,规则维护的逻辑性更强,药师查询、修改规则更简便,完善审核项的同时,规则数量由约30.9万大幅降至约2.8万。自定义规则库建立后,医嘱审核进入稳定期,与上线初期比较,系统预审不合理医嘱占比由16.16%升高至17.92%(P<0.01);刚性拦截医嘱占比由0.33%提升至2.34%(P<0.01);医师自主返回修改率由45.29%提升至60.83%(P<0.01);药师干预成功占比总体上大于60%。与医嘱审核系统上线前比较,上线初期全院医嘱合格率由88.03%提升至92.50%(P<0.01),稳定期进一步提升至95.60%(P<0.01)。结论 借助医嘱审核软件,建立动态自定义规则库可提高医嘱审核的准确性,降低医师、药师工作量,进一步提升医嘱合格率,保障住院患者安全合理用药。Objective To explore the effectiveness of the medical order audit system optimization and the construction of a custom rule base.Methods After the medical order audit system was induced,the results of manual comments and software comments on medical orders were compared to evaluate the system's function.Then,the software functions were optimized,the rules were modified,the online application process of off-label drug use and the routine rules maintenance operation procedure was established,and the dynamic custom rule base of our hospital was formed.Results After the optimization of software functions,rules maintenance was more logical,and it was easier for pharmacists to query and modify rules.The number of rules was decreased significantly from about 309000 to 28000.After the establishment of the custom rule base,the medical order audit entered the stable period,compared with the initial stage,the proportion of unreasonable medical orders in system prereview was increased from 16.16%to 17.92%(P<0.01),the proportion of rigid blocking orders increased from 0.33%to 2.34%(P<0.01),avoiding serious medication errors,the rate of doctors'self-returned modification was increased from 45.29%to 60.83%(P<0.01),the proportion of successful intervention by pharmacists was greater than 60%.Compared with the stage before adopting medical order pre-audit system,the qualified rate of the medical orders increased from 88.03%to 92.50%(P<0.01),and further increased to 95.60%(P<0.01)after the completion of the custom-defined rule base.Conclusion With the help of a prescription audit system,the establishment of a hospital custom rule base can significantly improve the accuracy of prescription audits,reduce the workload of pharmacists,improve the qualified rate of prescriptions,and ensure the safe and rational drug use of inpatients.

关 键 词：医嘱审核 动态自定义规则库 成效分析 医嘱合格率 

分 类 号：R95[医药卫生—药学]