通过改进升级规划和文档来提高患者护理:一个地区总医院的质量改进项目
Rana Maqsood1, Mudasar Aziz2, Katherine Hartley2
1Internal Medicine, Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, GBR.
Cureus
|July 16, 2025
概括
实施标准化的预制形式显著改善了患者安全文件,包括不尝试心肺复苏 (DNAR) 决策和升级规划,加强临床交付和患者护理.
科学领域:
- 医疗信息学 医疗信息学
- 患者安全 患者安全
- 临床文档 临床文档
背景情况:
- 清晰的升级计划对于患者的安全至关重要,特别是在工作时间外的工作时,正如皇家医学院建议的那样.
- 对关键决策的不一致记录,如不尝试心肺复苏 (DNAR) 和升级计划,对患者护理和交付效率构成风险.
研究的目的:
- 评估标准化形式对患者文档质量的影响,特别是DNAR决策,升级计划和周末交付.
- 改善医院环境中的患者安全和临床交接流程.
主要方法:
- 利用计划-做-研究-行动 (PDSA) 循环方法来进行代改进.
- 审查了30个患者笔记,以确定基线文档质量.
- 在胃肠道病房实施了标准化的proforma,并进行了随后的PDSA循环.
主要成果:
- 在引入proforma之后,在文档质量方面观察到显著的改进.
- DNAR 文档从 47% 增加到 90%.
- 升级计划文件从23%提高到81%,周末交付文件达到100%.
结论:
- 一个标准化的形式有效地提高了胃肠道病房患者文档和交付的质量.
- 结构化格式对临床信息的记录产生了积极的影响,有助于更安全的患者护理.
- 预型的成功导致其被其他医院病房采用.
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