标准化作业流程在降低医嘱漏签字率中的应用  

Application of Standardized Workflow in Reducing the Missed Signature Rate of Medical Orders

作　　者：张诗恬 罗窅 朱俊娅 何妙妙 

机构地区：[1]贵州中医药大学护理学院,贵州 贵阳 [2]贵州中医药大学第二附属医院妇科,贵州 贵阳

出　　处：《护理学》2024年第2期217-221,共5页Nursing Science

摘　　要：目的:探讨标准化作业流程在降低医嘱漏签字率中的应用效果。方法:采用标准化作业流程针对医嘱漏签字问题进行干预,其中包括制定科室医嘱执行SOP及制度、加强培训、建立监督机制、完善流程、强化管理、提高患者参与度。结果:改善前2023年1月1日到4月30日的漏签字率为39%,通过标准化作业流程进行改善后,2023年7月1日至10月31日的漏签字率为16%。改善前后漏签字率相比已降低23%。结论:运用标准化作业流程能降低医嘱漏签字率,提升医嘱下达和实际执行的一致性,提高护理文书质量,更大程度保证临床医疗护理安全,降低医疗纠纷发生风险。Objective: To explore the effect of a standardized operation process in reducing the missed signature rate of medical orders. Methods: Standardized operation procedures were used to intervene in the problem of missed signature of medical orders, including the formulation of SOP and system for the implementation of medical orders, strengthening training, establishing a supervision mechanism, improving procedures, strengthening management and improving patient participation. Results: The missed signature rate was 39% from January 1 to April 30, 2023 before the improvement, and 16% from July 1 to October 31, 2023 after the improvement through standardized operating processes. The missed signature rate has been reduced by 23% compared to before and after the improvement. Conclusion: The application of standardized operation procedures can reduce the missed signature rate of medical orders, improve the consistency of medical orders issued and actual execution, improve the quality of nursing documents, ensure the safety of clinical medical care to a greater extent, and reduce the risk of medical disputes.

关 键 词：降低 医嘱 漏签 标准化作业流程 

分 类 号：R47[医药卫生—护理学]