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信息化临床决策提醒系统对VTE规范预防及发生的影响

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目的 通过建立院内静脉血栓栓塞症(venous thromboembolism,VTE)预防临床决策提醒信息系统,提高住院患者院内VTE的规范预防率,降低院内VTE发生率,减少潜在的院内非预期死亡及围手术期死亡,提高医疗质量、保障患者安全。方法 分别选取2023年6月与2023年10月某院住院的VTE高风险且无出血高风险的患者作为对照组与观察组,观察组采用医院VTE预防临床决策提醒系统,通过信息化警示、临床决策辅助、规范医嘱套组等方式提醒医师,将护理人员对患者的VTE罹患风险评估等级与医师应给予的规范预防之间进行信息化关联,结合培训、宣教等方式,比较两组VTE预防质量指标情况。结果 通过建立医院VTE预防临床决策提醒系统,药物预防执行率由18。01%提升至56。10%,医院相关性VTE发生率从2。42%下降至1。75%,差异均有统计学意义。结论 通过建立医院VTE预防临床决策提醒系统可有效提高院内VTE规范预防率,对医院的医疗质量和安全管理起促进作用。
Influence of information-based clinical decision reminding system on the standard prevention and oc-currence of VTE
Objective By establishing a clinical decision reminder information system for the prevention of venous thromboembolism in hospitals,the aim is to improve the standardized prevention rate of VTE in hospitalized patients,thereby re-ducing the incidence of VTE in hospitals,reducing potential unexpected and perioperative deaths,improving medical quality,and ensuring patient safety.Methods Select high-risk patients with venous VTE and no bleeding who were hospitalized in a certain hospital in June 2023 and October 2023 as the control group and observation group,respectively.The observation group uses the hospital's venous VTE prevention clinical decision reminder system,which reminds physicians through information warning,clin-ical decision assistance,and standardized medical order sets,Integrate information technology between the risk assessment level of VTE for patients by nursing staff and the standardized prevention measures that physicians should provide,and compare the quality indicators of VTE prevention between the two groups through training,education,and other methods.Results By estab-lishing a clinical decision reminder system for the prevention of venous VTE in hospitals,the drug prevention execution rate in-creased from 18.01%to 56.10%,and the hospital related VTE incidence rate decreased from 2.42%to 1.75%,with statisti-cally significant differences.Conclusion The establishment of a clinical decision reminder system for the prevention of venous thromboembolism in hospitals can effectively improve the standardized prevention rate of VTE in hospitals and promote the im-provement of medical quality and safety management.

Venous thromboembolismClinical decision reminder systemHospital informatization

王颖倩、张悦、王雨辰、吴巍巍

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清华大学附属北京清华长庚医院 北京 102218

南京大学中国医院改革发展研究院 江苏南京 210009

清华大学医院管理研究院 广东深圳 518055

清华大学临床医学院 北京 100084

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静脉血栓栓塞症 临床决策提醒系统 医院信息化

南京大学中国医院改革发展研究院课题项目

NDYG2023005

2024

现代医院
广东省医院协会

现代医院

影响因子:1.332
ISSN:1671-332X
年,卷(期):2024.24(6)