医疗不良事件管理系统的构建与应用

Establishment and application of management system of medical adverse events

目的:构建科学、合理、高效的医疗不良事件管理系统,提升医疗质量。方法:在医院现有电子病历质控程序基础上,嵌入不良事件管理模块,以不良事件结构式选项或简要文字描述为报告内容,重点关注不良事件关键词筛查出的和高危特殊患者等病例,预警疑似不良事件,提高报告率。结果:系统试运行期间效果显著,报告例数与上年度同比增加139.68%,医务人员报告积极性增强,报告效率和报告准确度也得到了相应的提高。结论:该系统能够有效监控医疗环节,预警医疗风险,持续改进医疗质量,保障患者安全,具有实际应用价值。

Objective To establish a medical adverse events management system to enhance medical quality.Methods An adverse events management module was embedded into the existing electronic medical record quality control program.Structural options and short text on medical adverse events constituted the medical adverse events report, which posed emphases on the cases determined by keyword screening or with high-risk conditions.The report contributed to early warning against suspected medical adverse events, and thus the report rate could be increased.Results The trials showed that the reported cases were increased by 139.68% when compared with that in last year, and enhancement also occurred in medical staff enthusiasm as well as the efficiency and accuracy of the report.Conclusion The system behaves well in medical links supervision, medical risk warning, medical service enhancement and patient safety improvement, and thus is worthy promoting practically.