102份死亡病历医疗缺陷分析及应对措施

医疗缺陷是日常医疗工作中所发生的医疗事故、医疗护理差错、医疗问题及医疗护理缺点的统称。在当前医患关系比较紧张的形势下,住院死亡患者更容易引发医疗纠纷,加强死亡病历缺陷分析,提高医务人员自控自律意识,应摆在医院质量管理的突出位置。本文通过对军队某中心医院2013年度102份死亡病历质控扣分条目进行系统回顾,旨在从中找出病历书写中的普通缺陷及容易导致医患纠纷的敏感点,并提出应对措施。

M edical negligence,m edical nursing errors,m edical problem s and the m edical nursing defects that occur in the daily m edical w ork are collectively know n as m edical defects.U nder the current situation of the w orsening rela-tions betw een patients and doctors,the hospital death is m ore likely to give rise to m edical disputes.T herefore, strengthening the defect analysis of m edical death records and im proving consciousness of self-control and self-disci-pline of m edical staff should be placed in the outstanding position of hospital quality m anagem ent.T he paper system ati-cally review s the quality control point deduction item s of 102 m edical death records in an arm y central hospital in 2013 ,w hich aim s to figure out the com m on defects and the sensitive statem ents that can easily cause doctor-patient disputes in m edical records and put forw ard the corresponding m easures.