Asgari Hedayatalah, Esfahani Sakineh Saghaeiannejad, Yaghoubi Maryam, Javadi Marzieh, Karimi Saeed
Health Management and Economics Research Center, Isfahan University of Medical Sciences, University of Isfahan, Isfahan, Iran.
Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
J Educ Health Promot. 2015 Aug 6;4:54. doi: 10.4103/2277-9531.162351. eCollection 2015.
Medical errors in hospitals kill more people every year than AIDS, breast cancer and auto accidents combined. Widespread consensus exists that health care organizations can reduce patient injuries by improving the environment for safety from implementing different alternatives from technical and managerial improvements to considering medical record data. Considering the preventability of medical errors, the Agency for Healthcare Quality and Research (AHRQ) developed patient safety indicators (PSIs). This study analyzes the PSIs calculated in Alzahra Hospital of Isfahan.
This study was conducted retrospectively using the inpatient medical record data of hospitalized patients in a six month period, from October 2010 to March 2011. An experienced team in the fields of medical record, health management and health information technology was involved in data reviewing. Based on a prior consultation and reviewing, some PSIs were selected. Indicators were calculated considering AHRQ guidelines. Excel software and hospital information system software were used.
Across all studied medical records of patients, out of 25,164 discharges, below measures were calculated. -8 Foreign Body cases (PSI 5) (0.31 per 1000). -30 Postoperative Hemorrhage or Hematoma cases (PS I9) (2.2 per 1000). -5 Accidental Puncture or Laceration cases (PSI 15) (0.3 per1000). -8 Complications of Anesthesia cases (PSI 1) (2.2 per 1000). -96 Selected Infections Due to Medical Care cases (PSI 7) (3.8 per1000). -17 cases of Postoperative Wound Dehiscence (PSI 14) (3.7per1000). -1 Birth Trauma - Injury to Neonate case, and (PSI 17) (1.7 per 1000). - 18 Obstetric Trauma - Cesarean Delivery cases (PSI 20) (40 per 1000) were flagged by studied PSIs developed by AHRQ.
Comparing with the reported rates by other studies and AHRQ study in 2006, all of calculated indicators have inadequate condition; i.e. these are far from empirical estimated rates. The hospital administrators should be more sensitive to this issue and perform some improvement programs.
医院里的医疗差错每年造成的死亡人数比艾滋病、乳腺癌和交通事故造成的死亡人数总和还要多。人们普遍认为，医疗保健机构可以通过改善安全环境来减少患者受伤，这包括实施从技术和管理改进到考虑医疗记录数据等不同的方法。考虑到医疗差错的可预防性，医疗保健质量与研究机构（AHRQ）制定了患者安全指标（PSI）。本研究分析了伊斯法罕的阿尔扎赫拉医院计算出的PSI。
本研究采用回顾性研究方法，使用了2010年10月至2011年3月这六个月期间住院患者的住院病历数据。一个由病历、健康管理和健康信息技术领域的经验丰富的团队参与了数据审查。在事先咨询和审查的基础上，选择了一些PSI。根据AHRQ指南计算指标。使用了Excel软件和医院信息系统软件。
在所有研究的患者病历中，在25164例出院病例中，计算出了以下指标。-8例异物病例（PSI 5）（每1000例中有0.31例）。-30例术后出血或血肿病例（PSI 9）（每1000例中有2.2例）。-5例意外穿刺或撕裂伤病例（PSI 15）（每1000例中有0.3例）。-8例麻醉并发症病例（PSI 1）（每1000例中有2.2例）。-96例因医疗护理导致的选定感染病例（PSI 7）（每1000例中有3.8例）。-17例术后伤口裂开病例（PSI 14）（每1000例中有3.7例）。-1例出生创伤 - 新生儿损伤病例，以及（PSI 17）（每1000例中有1.7例）。-18例产科创伤 - 剖宫产病例（PSI 20）（每1000例中有40例）被AHRQ制定的研究PSI标记出来。
与其他研究和AHRQ 2006年的研究报告率相比，所有计算出的指标情况都不理想；也就是说，这些指标与经验估计率相差甚远。医院管理人员应该对这个问题更加敏感，并实施一些改进计划。
