通过中等护理教学医院的闭环质量改进审计,提高外科同意文件的完整性
Hashim Homaida1, Zubaida Kamal Abdalkhaliq Ahmed2, Ahmed Abdelal2
1Urology, Hamad Medical Corporation, Doha, QAT.
Cureus
|March 16, 2026
概括
改善手术同意文件对于患者安全和知情决策至关重要. 质量改进审计和干预措施显著提高了这些基本医疗记录的完整性.
科学领域:
- 改善医疗质量 改善医疗质量
- 患者安全 患者安全
- 进行手术的同意.
背景情况:
- 不完整的外科同意文件对知情决策,患者安全和法律保护构成风险.
- 缺陷很普遍,特别是在资源有限的医疗保健机构.
- 关于同意的标准化伦理和专业指导方针往往没有得到满足.
研究的目的:
- 评估手术同意文件的完整性.
- 实施有针对性的质量改善 (QI) 干预措施.
- 通过闭环临床审计来评估QI干预措施的影响.
主要方法:
- 在苏丹Almanagil教学医院进行了闭环QI审计.
- 两个审计周期审查了44个手术同意表,建立了基线和干预后的合规性.
- 干预措施包括员工教育,反和修订的同意表.
主要成果:
- 基线文件的完整性在诸如手术指示 (5.4%) 和风险解释 (1.8%) 等关键领域非常低.
- 干预后,同意的遵守,麻醉类型和医生细节达到了100%.
- 麻醉和手术风险的解释分别提高到97.7%和93.2%,尽管额外的手术和失能细节仍然不够理想.
结论:
- 结构化,以审计为导向的QI干预措施有效地提高了手术同意文件的完整性.
- 持续的审计和加强是保持改进和解决持久差距的必要条件.
- 这种方法提供了一个可复制的模型,用于在类似的环境中提高患者护理标准.
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