摘要
目的对手术安全核查表及风险评估表的书写质量进行统计分析,以增加手术安全,提高医疗质量。方法以中国医院协会发布的手术安全核查表及风险评估表为指南,对454份手术安全核查表及风险评估表中的问题进行分析。结果 454份手术安全核查表中填写缺陷282项次,其中最主要的缺陷项目依次为患者过敏药物史错填83项次,占29.4%;术前备血漏填58项次,占20.6%。手术风险评估表存在填写缺陷244项次,其中最主要的缺陷项目为手术切口清洁度缺失143项次,占58.6%;手术持续时间缺失43项次,占17.6%;麻醉分级缺失40项次,占16.4%。结论手术安全核查和风险评估的正确实施对于提高医疗质量,减少医疗事故、避免医患纠纷有十分重要的意义,加强医师行业的规范化管理是亟待解决的重要问题。
Objective To make a statistical analysis on the writting quality of operation safety verification tables and risk assess- ment tables, so as to increase the safety of operations and improve the quality of medical treatment. Method According to the opera- tion safety verification tables and risk assessment tables announced by Chinese Hospital Association, we conducted an analysis on the problems existing in 454 cases of operation safety verification tables and risk assessment tables. Result There were 282 in 454 cases existing defects in operation safety verification tables, in which the most important defects were wrongly writting of history of drug allergy and lack of preoperative preparation of blood, the numbers were 83 and 58, and took 29.4% and 20.6%. There were 244 in 454 cases existing defects in operation risk assessment tables, in which the most important defects were lack of operation incision cleanliness, lack of operation last time and anesthesia classification, the numbers were respectively 143, 43 and 40, took 58.6%, 17. 6% and 16.4%. Conclusion The correct application of operation safety verification tables and risk assessment tables is of great impor- tance to improve medical treatment quality, decrease medical negligence and avoid medical disputes, and strengthen the standard man- agement of doctors is an important problem we need to solve urgently.
出处
《中国病案》
2013年第8期12-13,共2页
Chinese Medical Record
