摘要
目的总结归纳我院护士执行电子医嘱过程中常见的缺陷类型,分析主要原因,提出管理对策。方法通过医院医嘱信息系统,抽查部分科室归档前出院病历1 840份,医嘱47 840条。主要检查记录医嘱缺陷类别及执行护士一般情况和班次。结果缺陷医嘱2 392条,其中已执行医嘱漏签名885条,占全部缺陷的37;医嘱执行者与签名不一致443条,占全部缺陷的18.52%;用药执行时间与医嘱要求不符371条,占全部缺陷的15.51%。3种缺陷合计1 699条,占全部缺陷医嘱的71%。结论护士执行医嘱存在的缺陷与年龄、工作年限、职称、学历成负相关,不同班次发生缺陷医嘱数量各不相同,尤以中班医嘱缺陷最高,占总缺陷的49.7%。这些缺陷已成为当前护患纠纷的隐患。应引起重视并探讨有效的措施,除科学合理安排人力外,将法律法规学习纳入管理常规工作,教育护理人员充分认识医嘱的法律性,把医嘱执行的完整性纳入考核等,提高医嘱执行的完整率,以保护护患双方的根本利益,全面提高护理质量。
Objective To summarize the common defect types in the process of executing electronic doctor＇s advice by nurses of our hospital, analyze the main reasons and then propose management countermeasures. Methods 1840 discharge records and 47480 doctor＇s advice from some departments in our hospital were chosen for spot check before they were filed through the hospital medical information system. Primary inspection was on the defect type of doctors＇ advice and the general execution of nurses. Results There were 2392 defect doctor＇s advice, of which 885 were executed with no doctors＇ signatures, accounting for 37 percent. 443 doctor＇s advice had different signatures, accounting for 18.52 percent. 371 executing time of administration drug was different from doctors＇ advice, accounting for 15.51 percent. The sum of three types added up to 1699, accounting for 71 percent. Conclusion The defect in the process of executing doctor＇s advice by nurses is negatively related to age, working experience, job title and qualifications. Occurrence of the defect doctor＇s advice at different shifts is different. The highest rate is with noon shift with 49.7 percent. These deficiencies have become the hidden trouble between nurses and patients. Therefore we should pay attention and explore effective measures to address those problems. In addition to sci- entific and reasonable arrangement of manpower, we should take the study of relevant laws and regulations into our routine job. The nursing staff should be taught to observe doctors＇ advice and their complete implementation of doctors＇ advice should be part of performance evaluation. Only by doing this, the interest of both the hospital and patients can be protected and the nursing quality can be improved.
出处
《实用临床医药杂志》
CAS
2011年第22期178-180,共3页
Journal of Clinical Medicine in Practice
关键词
执行医嘱
缺陷
对策
execute doctor＇s advice
defect
countermeasure
