医疗机构危重患者质量控制查房机制的构建研究

Research on the Construction of Quality Control Ward Inspection Mechanism for Critical Patients in Medical Institutions

目的探讨医疗机构危重患者质量控制查房机制实施效果并分析存在的问题,提出对策建议。方法选择2016年1月—2020年12月厦门市海沧医院2177份危重患者病案为研究对象,通过文献调查法、问卷调查法、专家访谈法对医院危重患者质控专家组查房机制开展研究。结果梳理危重患者质控专家组查房机制实施流程。2016年1月—2020年12月完成2177份危重患者病历质量检查,其中2016年250份,2017年373份,2018年488份,2019年589份,2020年477份,每季度完成1次危重患者专家组质量控制小结,5年合计20次。将2016年质量控制查房机制实施第一年的250份危重患者病案作为对照组,2020年质量控制查房机制实施最后一年的477份危重患者病案作为观察组。病案甲级率、病历书写及时率,病历打印及时率有效提升,输血病历不合格率明显下降。结论针对医院危重患者质量控制查房机制的构建过程中存在的问题提出完善临床危重患者处置与反馈机制,加强全院医生病历规范书写培训和建立有效的病历检查与奖惩机制的对策建议,以期提高医院危重患者的治疗效果,提高医务人员的医疗质量安全意识和医疗质量,为医疗机构完善质量控制体系提供一定的参考。

Objective Discuss the implementation effect of the quality control ward round mechanism for critically ill patients in medical institutions,analyze the existing problems and put forward countermeasures and suggestions.Methods A total of 2177 critically ill patients from Xiamen Haicang Hospital from January 2016 to December 2020 were selected as the study objects,and conduct research on the ward round mechanism of the hospital's critical patient quality control expert group through literature survey,questionnaire survey,and expert interview methods.Results Sort out the implementation process of the ward round mechanism of the quality control expert group for critically ill patients.From January 2016 to December 2020,2177 critical patient medical records quality checks were completed,including 250 in 2016,373 in 2017,488 in 2018,589 in 2019,and 477 in 2020.The critical patient expert group quality control summary was completed once a quarter,a total of 20 times in 5 years.250 critically ill patients'medical records implemented by the quality control ward round mechanism in 2016 were taken as the control group,and 477 critically ill patients'medical records implemented by the quality control ward round mechanism in 2020 were taken as the observation group.The Grade A rate of medical records,the timely writing rate of medical records,the timely printing rate of medical records were effectively improved,and the unqualified rate of blood transfusion medical records was significantly reduced.Conclusion In response to the problems in the construction of the quality control ward round mechanism for critically ill patients in hospitals,suggestions are proposed to improve the handling and feedback mechanism for clinical critically ill patients,strengthen the training of standardized medical record writing for all doctors in the hospital,and establish effective medical record inspection and reward and punishment mechanisms,in order to improve the treatment effect of critically ill patients in the hospital,enhance the awareness of medical quality,safety,and medical quality of medical staff,Provide certain reference for improving the quality control system of medical institutions.