提高对第一次做正确手术 (GIRFT) 的合规性 尾切除术文件准则:英国地区总医院的两周期审计
Lakshay Singla1, Neeraj V Bagade1
1General Surgery, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, GBR.
Cureus
|September 12, 2025
概括
实施结构化操作笔记模板和员工教育显著提高了英国腹腔镜尾切除术文档质量. 这提高了临床沟通和质量保证.
科学领域:
- 改善外科手术的质量
- 医疗信息学 医疗信息学
- 临床审计 临床审计
背景情况:
- 标准化操作文档对于有效的临床沟通,质量保证和医疗法律辩护至关重要.
- 英国 (UK) 的国家质量倡议强调了对腹腔镜尾切除术标准化文件的需求.
- 遵守文档标准可以确保患者的安全,并促进研究.
研究的目的:
- 为了评估对尾切除术的34个推标准的遵守.
- 评估干预措施对提高操作笔记质量的影响.
- 确定在外科手术记录实践中需要改进的领域.
主要方法:
- 在英国一家地区综合医院进行了两轮审计.
- 第一个周期涉及对75例腹腔镜尾切除病例 (2024年5月至7月) 的回顾性审查.
- 第二个周期涉及37个案件 (2024年9月至11月) 的前性审查,这些案件是在实施结构化操作笔记模板和员工教育后实施的.
主要成果:
- 干预后,在记录实践中观察到显著的改进.
- 电子系统的使用率从41.8%增加到76%.
- 中附的文档从78.1%提高到100%,血液损失报告从1.35%增加到13.6%.
结论:
- 简单,系统的变化,如结构化模板,可以大大提高外科手术文档的质量.
- 建议继续使用结构化模板和定期重新审计,以维持高标准.
- 改进的文档支持更好的临床沟通,质量保证和医疗法律保护.
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