摘要
Abstract
Objective To summarize the common problems and their causes encountered by nurses when implementing elec-tronic medication orders in hospital practice,and to propose corresponding countermeasures.Methods A total of 2,092 dis-charged cases from the General Surgery and Urology departments of our hospital between January and October 2022 were randomly selected:1,413 General Surgery cases(averaging 56 standing and stat.orders per case,totaling 79,128 orders)and 679 Urology cases(averaging 56 standing and stat.orders per case,totaling 38,024 orders),for a combined total of 117,152 orders.Prior to case archiving,electronic order defects were examined and statistically analyzed.General nurse ex-ecution practices were reviewed.Results A total of 8,368 order defects were identified,yielding an overall defect rate of 7.14%.The breakdown of defects was as follows:omitted nurse signature after repeated printing(37.50%),unsigned execu-ted orders(15.12%),order entry errors(15.03%),administration of medication after order discontinuation(11.45%),administration timing not matching prescribed time(9.99%),discrepancy between executor and signer(8.28%),and missed or incorrect execution(2.63%).Nurses aged≤24 years had a significantly higher defect rate than older age groups(P<0.05).Nurses with lower professional titles had higher defect rates compared to senior nurses(P<0.05).Nurses with junior college education had higher defect rates than those with bachelor's degrees or above(P<0.05).Night-shift nurses exhibited higher defect rates than those on day or middle shifts(P<0.05).Conclusion The incidence of electronic order defects is negatively correlated with nurse age,professional title,and educational level:younger nurses and those with lower titles or educational attainment are more prone to errors.These defects not only impair work efficiency but also pose latent safety risks.Incorporating legal and regulatory training into routine management,strengthening policy and procedure education,raising nurses'awareness of the legal obligations of medication orders,and including order execution integrity in performance assessments are recommended to improve execution completeness,safeguard patient and institutional interests,and raise overall nursing quality.关键词
电子医嘱/执行问题/处理措施/医嘱缺陷Key words
Electronic medication orders/Execution errors/Countermeasures/Order defects分类
医药卫生
