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预先填写的特定程序同意表在紧急一般外科手术中的作用:质量改进研究
Claudia Zizzo1, Maria Henriques2, James Wooding2
1Emergency, Great Western Hospital, Swindon, GBR.
Cureus
|August 27, 2025
概括
预先填写的特定程序的同意表格显著改善了紧急程序中手术风险的记录. 这项质量改善举措提高了患者的理解,并减少了知情同意过程中的错误.
科学领域:
- 改善外科手术的质量
- 患者安全
- 医疗文件
背景情况:
- 为了让患者了解手术的风险和好处,
- 手写的同意书通常不完整,难以阅读和不一致.
- 现有的紧急腹腔镜胆囊切除和尾切除程序缺乏标准化的风险文件.
研究的目的:
- 审查和加强紧急腹腔镜胆囊切除和尾切除的知情同意程序.
- 引入预先填写的,具体程序的同意表,以改善风险沟通.
- 评估这些新形式对已记录的手术风险的质量的影响.
主要方法:
- 一个回顾性审查将手写的同意表与标准化的风险组进行了比较.
- 制定了两个预先填写的,具体程序的同意表,包括非专业人士的解释和额外风险的空间.
- 第二次回顾性分析评估了干预后的同意表.
主要成果:
- 在干预前,记录的风险平均为尾切除术的64%和胆囊切除术的56%,遗漏了诸如不孕症之类的关键信息.
- 干预后的风险记录增加到尾切除术的82%和胆囊切除术的80%.
- 新的表格改善了结构化的讨论,减少了文档错误.
结论:
- 预先填写的特定程序的同意表是改善手术知情同意过程的有效工具.
- 这些表格提高了风险记录,促进了患者和外科医生的沟通,并最大限度地减少了人为错误.
- 提出了关于未来同意表格开发和数字化整合的建议,以及关于知情同意的培训.
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