某医院62份封存病历医疗过错分析

Medical Errors Analysis in 62 Sealed Medical Records of A Hospital

目的对封存病历中存在的过错进行分析,探讨封存病历合理、合法的管理举措。方法整理某三甲医院病案室自2006年9月至2016年9月所有封存病历62份,对发生年份、涉及科室进行分类统计汇总,结合纠纷处理结果分析纠纷病历质量及存在问题。结果协商解决病历30份,占48.4%;经司法和医学会鉴定判决病历15份,占24.2%;存在医疗过错纠纷病历38份,占61.3%;医院全责病历8份,占12.9%,以骨科、妇产科、普外科手术病历居多。结论医务人员在医疗记录书写和医患沟通能力方面的提高是减少或避免医疗纠纷的重要保证。

Objective To analyze the errors in the sealed medical records,and to explore the reasonable and legal management measures for the medical records. Methods 62 sealed medical records from September 2006 to September 2016 were statistically analyzed and classified for the year of occurrence,involving departments and so on,combined with the results of medical disputes to analyze the qualities and problems in medical records. Results Disputes records with negotiated settlement were 30 cases,accounted for 48. 4%;disputes records with judicial and medical identification judgment were 15 cases,accounted for 24. 2%;disputes records with medical mistakes were 38 cases,accounted for 61. 3%;records with hospital full responsibility were 8 cases,accounted for 12. 9%,the majority of thesemedical records were in depatments of orthopedics,obstetrics and gynecology,general surgery.Conclusion Medical staffs need to strengthen the ability of medical record writing and communication between doctors and patients,in order to reduce or avoid the occurrence of medical disputes.