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通过改进出院文件提高患者安全:苏丹哈萨赫萨教学医院的质量改进审计
Mustafa Mohamed1, Abdelrahman Elfatih Elsheikh Abdelrahim2, Elaf Abdelrahman3
1General Surgery, Prince Othman Digna Teaching Hospital, Port Sudan, SDN.
Cureus
|December 8, 2025
概括
一张标准化的出院卡显著提高了资源有限的医院的文档质量. 这种简单的干预措施通过确保完整的出院摘要,提高了患者的安全性和护理连续性.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 临床文档标准 临床文档标准
- 患者安全倡议 患者安全倡议
背景情况:
- 在资源有限的环境中,不完整的排放摘要会导致沟通缺口,错误和再录取.
- 有效的出院文件对于患者的安全和护理的连续性至关重要.
- 苏丹的哈萨赫萨教学医院面临出院文件质量方面的挑战.
研究的目的:
- 评估标准化排放卡对排放文件质量的影响.
- 评估低成本干预措施在改善医疗保健沟通方面的有效性.
- 为了提高患者的安全和护理的连续性在一个资源有限的医院.
主要方法:
- 在内部医学中进行了两轮临床审计.
- 一个基线评估 (循环1) 审查了50张放电卡.
- 一次干预涉及新放电卡,员工培训和视觉辅助工具,随后对50张卡进行了重新审计 (循环2).
主要成果:
- 干预后,所有领域的文档质量都显著改善.
- 关键信息的记录从22-56%增加到94-100%.
- 改进在统计学上显著 (p < 0.001),工作人员对实用性的反是积极的.
结论:
- 标准化放电卡是一种简单,有效的干预措施,用于改进文档.
- 这种干预措施提高了在资源有限的环境中患者的安全和护理的连续性.
- 建议对可持续性进行更广泛的实施和长期评估.
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