PDCA循环在提高危重症护理记录书写质量中的应用

Application of PDCA cycle in quality management on writing of nursing records of critically ill patients

目的探讨PDCA循环在提高危重症护理记录书写质量管理中的应用效果。方法科室采用PDCA循环对危重症护理记录书写低质量的主要原因进行分析,制定并实施相应整改措施,不断检查和反馈,持续质量改进。采取便利抽样法抽取2015年1月—12月28份危重症护理记录作为对照组,抽取PDCA循环实施后2016年3月—2017年2月33份危重症护理记录作为观察组。对比2组危重护理记录书写缺陷率。结果观察组护理记录书写缺陷率低于对照组(P<0.05)。结论运用PDCA循环对危重症护理记录书写进行质量管理,减少了护理病历书写存在的缺陷,促进了护理记录持续质量改进。

Objective To investigate the effect of PDCA cycle in quality management on writing of nursing records of critically ill patients. Methods To tally 28 critically ill patients were selected as the control group before implementation of PDCA cycle（ between January,2015 and December,2015）. Their nursing records were retrospectively analyzed by PDCA cycle methods.The potential reasons of lowquality in writing of nursing records were analyzed,and corresponding measures were carried out to continuously improve the quality management in writing of nursing records. Another 28 critically ill patients were selected as the observation group between March,2016 and February,2017,and the defect rate of nursing records writing was compared with that of controls. Results The defect rate of nursing records writing was lower in the observation group than that of controls（ P〈0. 05）. Conclusion The PDCA cycle is an effective to ol in reducing the risk of defects in nursing records writing,soas to continuously improve the nursing quality of critically ill patients.