手术患者交接单在围术期安全管理中的应用

Application of Patient Check Sheet in the Perioperation Safety Management

目的探讨手术患者交接单对手术患者围术期安全管理质量的影响。方法针对外科病房至手术室、手术间至恢复室或病房以及恢复室至病房等手术患者转运过程的三个关键交接环节容易疏忽和遗漏的细节设计核查项目,形成手术患者交接单,比较应用交接单前后2012年和2013年围术期各交接环节的缺陷率、手术患者和手术科室医护人员对麻醉科/手术室的服务质量满意度。结果 2013年临床应用交接单后,影像资料遗漏/遗失、手术部位安全标识不全、病情交接不清和交接前后病情变化责任不明等交接缺陷病例数显著下降,2013年手术患者和手术相关科室对麻醉科/手术室的服务质量满意度显著提升。结论应用手术患者交接单可以有效减少围术期交接环节差错的发生率,提升围术期安全管理质量。

Objective To investigate the effect of patient check sheet on safety management efficacy in surgery patients .Methods The items in patient check sheet were designed aim directly at the details often neglec -ted and omitted on three key links in the transport process of surgery patients that includes from surgical ward to op -erating room, from operating room to post -anesthetic ICU（PACU） or patient＇s ward, form PACU to patient＇s ward or ICU and so on.The check sheet was applied at 1st, January 2013, and it was retrospective analyzed that the is-sues of communication on the three key links in perioperation patients from 2012 to 2013 , and degrees of satisfac-tion of both surgery patients and surgeons on quality of service of medical personnel in department of anesthesiolo -gy.Results The frequency of both forget or loss of patients＇imaging documents and hand over patient＇s condition with confusing in 2013 were less than in 2012 , the number of absence of making on patient＇s operative site reduced in 2013.In addition , it was decreased apparently in 2013 that the incidence rate of a condition that neither anes -thesiologist nor surgeon to take his responsibility for the changes of state of a post -operation illness .The degrees of satisfaction of both surgery patients and surgeons on quality of service of medical personnel in department of anes -thesiology were raised also in 2013.Conclusion The application decreased effectively the occurrence of mistake in the key links of patient＇s transportation, and improved the safety management of perioperation patient .