急诊科每日记录审查：教学医院的质量保证体系

Emergency department daily record review: a quality assurance system in a teaching hospital.

作者信息

Harchelroad F P, Martin M L, Kremen R M, Murray K W

机构信息

Division of Emergency Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212-9986.

出版信息

QRB Qual Rev Bull. 1988 Feb;14(2):45-9. doi: 10.1016/s0097-5990(16)30187-7.

DOI:10.1016/s0097-5990(16)30187-7

PMID:3127773

Abstract

A system of daily patient chart review of 11 categories of physician documentation and patient care was implemented over a 36-month period at Allegheny General Hospital in Pittsburgh. A total of 108,317 charts of emergency patients were reviewed. Feedback on errors in all categories were given to the physicians responsible, and necessary corrective actions were taken as soon as possible. All new resident physicians rotated in two-month blocks and received orientation to patient care and chart documentation expectations prior to starting the service. All physicians' charts underwent the same thorough chart review. Not only did the percentage of errors decrease from the first months to the second months of the residents' rotations, but the yearly percentage of total errors decreased as the study progressed, from 5.47% to 3.57%.

摘要

匹兹堡的阿勒格尼综合医院在36个月的时间里实施了一个对11类医生文件记录和患者护理进行每日病历审查的系统。总共审查了108317份急诊患者的病历。向负责的医生反馈了所有类别中的错误，并尽快采取了必要的纠正措施。所有新住院医生以两个月为一个周期轮岗，并在开始服务前接受患者护理和病历记录要求方面的培训。所有医生的病历都接受了同样全面的病历审查。不仅住院医生轮岗的第一个月到第二个月错误百分比有所下降，而且随着研究的进行，每年的总错误百分比也从5.47%下降到了3.57%。