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术后查房是否标准化?

Is the post-take ward round standardised?

作者信息

Mansell Alexandra, Uttley Jessica, Player Paul, Nolan Oscar, Jackson Steve

机构信息

Medical School, University of Leicester, UK.

出版信息

Clin Teach. 2012 Oct;9(5):334-7. doi: 10.1111/j.1743-498X.2012.00566.x.

Abstract

BACKGROUND

The importance of the post-take ward round to both patient safety and medical education cannot be overemphasised. Despite this, significant variation exists between consultants and senior doctors in the conduct and content of ward rounds. This discrepancy prompted the idea of using a checklist to audit whether essential components were being consistently addressed during post-take ward rounds. This would allow an exploration of whether introducing a checklist would benefit both patient safety and medical education.

METHODS

The post-take ward round was audited by a small group of medical students over a few months using a checklist. This checklist contained 17 evidence-based items that had been identified as important for patient safety. A number of different consultants were included in the audit.

RESULTS

Results of the audit analysis confirmed that there was significant variability between consultants in both the approach and the content of the post-take ward round. Although some areas were completed most of the time, there were other areas in which inconsistent approaches were demonstrated.

DISCUSSION

As such variability was demonstrated between consultants in their conduct of the ward rounds, it was concluded that the introduction of this checklist would provide a standardised approach that junior doctors could learn from. Therefore, the introduction of this checklist into clinical practice was identified as a worthwhile teaching resource for juniors in order to enhance patient safety and foundation doctor learning.

摘要

背景

接收患者后查房对患者安全和医学教育的重要性怎么强调都不为过。尽管如此,顾问医生和资深医生在查房的实施方式和内容上仍存在显著差异。这种差异促使人们想到使用一份检查表来审核接收患者后查房期间是否始终涵盖了基本要素。这将有助于探究引入检查表是否对患者安全和医学教育都有益处。

方法

一小群医学生在几个月的时间里使用一份检查表对接收患者后查房进行审核。该检查表包含17项基于证据的项目,这些项目已被确定对患者安全很重要。审核纳入了多位不同的顾问医生。

结果

审核分析结果证实,顾问医生在接收患者后查房的方式和内容上存在显著差异。虽然有些方面大部分时间都能完成,但也有其他方面存在不一致的做法。

讨论

鉴于顾问医生在查房过程中表现出这种差异,得出的结论是,引入这份检查表将提供一种初级医生可以借鉴的标准化方法。因此,将这份检查表引入临床实践被确定为对初级医生而言有价值的教学资源,以提高患者安全并促进住院医生的学习。

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