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标准化最佳实践:一项倡议利用外科病房圆形检查清单来提高我们信任的患者安全和文档
Antonio Bozzi1, Heraa Islam1, Valentin Butnari1
1Department of General Surgery, Barking, Havering and Redbridge University Hospitals Trust, London, UK.
概括
实施标准化病房周围的形式显著改善了整体外科的住院病人的文档. 记录了静脉血栓塞栓症预防和液体平衡等关键安全要素,从而提高了患者的安全性.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 手术患者护理手术患者护理
- 医疗文档标准 医疗文档标准
背景情况:
- 综合的病房周围文档对于患者安全和有效的沟通至关重要.
- 标准化检查清单可以提高医疗保健机构的文档质量.
- 一个大量的外科病房发现了当前病房周围记录实践中的缺陷.
研究的目的:
- 为了评估标准化proforma对住院病房圆形文档在整体外科的影响.
- 审计和提高关键安全参数的文档完整性.
- 评估两个周期审计的有效性,并提供反以改进文档.
主要方法:
- 一项工作人员调查发现了文档缺陷,导致了标准化形式的开发.
- 基线审计 (循环1) 审查了45个病房的诊断,管理,评估,出院规划和物流.
- 第二次审计 (循环2) 审查了20条条目后的形式实施,以评估改进.
主要成果:
- 循环1揭示了重大遗漏:95.6%缺乏静脉血栓栓塞 (VTE) 预防,88.9%遗漏了当前问题,46.7%遗漏了疼痛评分.
- 流体平衡 (95.6%) 和肠道功能 (62.2%) 在基线文档中也经常缺失.
- 循环2显示了显著的改善,记录了大多数变量,并在95%的条目中记录了VTE预防和液体平衡.
结论:
- 一个标准化的病房周围的形式显著提高了一般外科病人的文档完整性.
- 改善安全参数的文档预计将对患者安全结果产生积极影响.
- 该研究强调了标准化工具在优化临床沟通和护理质量的价值.
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