Darbyshire Daniel, Barrett Charlotte, Ross David, Shackley David
Health Education North West, Manchester, UK Accident and Emergency, The Royal Oldham Hospital, UK.
Department of Urology, Salford Royal Hospital, UK.
Int J Risk Saf Med. 2015;27(1):23-33. doi: 10.3233/JRS-150640.
Ward rounds are the traditional process by which clinical information is interpreted and management plans made in the inpatient setting and the only time during which patient-doctor interaction can reliably occur. Efforts to improve quality and safety have started looking at the ward round but this has mainly been in the acute medical setting.
To begin the quality improvement process for Urological ward rounds.
Twenty indicators thought to relate to quality were recorded for every weekday ward round by the Urology team for one month.
Twenty ward rounds, 93 patient encounters, were reviewed. A consultant was present for 37% of the patient encounters. 84% of observation charts were reviewed; drug charts 28% and antibiotics 70%. Plans were communicated to the doctors, patient and nursing staff. All notes were typed directly onto the electronic system, 20% of notes were checked by the lead clinician. Mean time per patient was 6 minutes.
By starting a discussion about ward rounds we aim to align the process with the broader values of the organisation. Ward rounds can be the cornerstone of delivering safe, clean and personal care and measuring this process is vital to understanding efforts to improve them.
查房是在住院环境中解读临床信息并制定管理计划的传统流程，也是医患互动能够切实发生的唯一时段。提高质量和安全性的工作已开始关注查房，但主要集中在急性医疗环境中。
启动泌尿外科查房的质量改进流程。
泌尿外科团队在一个月的每个工作日查房时记录20个被认为与质量相关的指标。
共审查了20次查房、93次患者诊疗情况。37%的患者诊疗时有顾问医生在场。84%的观察表得到审查；药物图表审查率为28%，抗生素审查率为70%。诊疗计划已传达给医生、患者和护理人员。所有记录均直接录入电子系统，20%的记录由主诊医生检查。每位患者的平均查房时间为6分钟。
通过开启关于查房的讨论，我们旨在使该流程与机构的更广泛价值观保持一致。查房可以成为提供安全、优质和个性化护理的基石，衡量这一流程对于了解改进措施的成效至关重要。
