手术医嘱信息化闭环管理系统的开发和应用  

Development and Application of an Informationized Closed-loop Management System for Surgical Orders

作　　者：杨杰[1] 肖璇 傅诚 卜智斌[1] 宋柏杉[1] YANG Jie;XIAO Xuan;FU Cheng;BU Zhi-bin;SONG Bai-shan(Zhejiang Hospital,Hangzhou 310012,China)

机构地区：[1]浙江医院,杭州市310012

出　　处：《现代医院管理》2025年第1期92-94,共3页Modern Hospital Management

基　　金：浙江省康恩贝医院管理软科学研究项目(2021ZHA-KEB102);浙江省医学会临床医学科研专项资金项目(2022ZYC-A125)。

摘　　要：目的通过自主开发信息化平台实现手术医嘱全流程闭环管理,研究该系统在提升围手术期患者安全中的应用价值。方法自主开发信息化业务平台,整合多个信息系统,实现手术医嘱全流程信息化闭环管理;比较系统应用前后围手术期患者安全相关指标的变化情况。结果手术医嘱全流程闭环设置28个节点。系统应用后,不良事件系统报告入准备室时医疗文书未完成比例从5.06%下降到0.28%;因医疗文书未完成导致手术延迟或取消的发生率从1.63%降低到0.28%。手术相关并发症发生率、非计划重返手术室比例、围手术期死亡率、手术流程相关投诉发生率都有所下降,手术患者满意度从85.60%提升到了91.11%。结论手术医嘱全流程实现信息化闭环管理,手术相关不良事件发生率较前下降,围手术期安全相关指标较前改善,患者满意度明显提升。Objective:In order to independently develop an informationized platform,achieve the closed-loop management of the entire process of surgical orders,and study the application value of this system in improving patient safety during the perioperative period.Method:An information-based business platform was independently developed,multiple information systems integrated,and the closed-loop information-based management of the entire surgical order process achieved;Then the changes in safety related indicators of perioperative patients before and after the application of the system were compared.Result:28 nodes are set up in the closed-loop process of surgical orders.After the application of the system,the proportion of the incomplete medical documents reported by the adverse event system in the preparation room decreased from 5.06%to 0.28%;The incidence of surgical delays or cancellations due to incomplete medical documents has decreased from 1.63%to 0.28%.The incidence of surgical complications,unplanned return to the operating room,perioperative mortality rate,and complaint rate related to surgical procedures have all decreased,and patient satisfaction with surgery has increased from 85.60%to 91.11%.Conclusion:The entire process of surgical orders has achieved information-based closed-loop management,resulting in a decrease in the incidence of surgical related adverse events,improvement in perioperative safety indicators,and a significant increase in patient satisfaction.

关 键 词：信息化 闭环管理 患者安全 满意度 

分 类 号：R197[医药卫生—卫生事业管理]