对计划外再次手术的监控与管理

Surveillance ＆ management of out-of-plan re-operations

对计划外再次手术采取一系列监控管理措施：①健全组织管理体系；②建立实时监控和上报制度；③加强手术科室的质量管理和持续改进；④加强医院质量管理部门对制度落实的督导工作；⑤加强病历质量控制；⑥建立监控结果的反馈机制；⑦建立奖惩机制。经过1年半的努力，对计划外再次手术的监控管理收到了显著效果。计划外再次手术发生率由措施实施之前的1．7％下降到实施之后的1．0％。

A series of surveillance and management actions was taken to minimize out-of-plan reoperations. These actions include： 1） Building and completing the surveillance and management mechanism against unplanned re-operations; 2） Building a real-time surveillance and reporting mechanism; 3） Enhancing quality control and continuous improvement at the operating departments; 4） Enhancing the supervision on regulations implementation by quality control departments of the hospital; 5） Enhancing quality control for medical records; 6） Building a feedback mechanism for surveillance results; 7） Building a penalty and reward mechanism. Efforts for one year and a half on such surveillance and management proved successful, as the incidence of out-of-plan re-operations fell from 1.7 % before these actions to 1.0% afterwards.