Dunn D C
Addenbrooke's Hospital, Cambridge.
Br Med J (Clin Res Ed). 1988 Mar 5;296(6623):687-91. doi: 10.1136/bmj.296.6623.687.
From 1982 to 1986 inclusive work of one surgical firm was audited with a microcomputer. Data were recorded on 4336 patients having 3355 operations, who were under the care of one consultant in a general surgical unit; fifty items of information were recorded on each patient, allowing a wide range of analyses to be performed--for example, the number of admissions and operations, grades of operation, diagnostic grouping, complications, and complication rates associated with individual surgeons. Data collected for the audit provided a valuable baseline for the unit, defining aspects of practice that could be reviewed and improved. During the audit the overall rate of complications as a percentage of admissions fell significantly from 13% to 9% and the rate of postoperative complications decreased significantly from 16% in 1982 to 11% in 1986. The incidence of chest and wound infections also decreased significantly. The system was improved by using the data to produce discharge summaries as well as audit; the microcomputer thus became an integral part of the office work of the unit.
1982年至1986年（含1982年和1986年），一家外科公司的工作用微机进行了审计。数据记录了在普通外科病房由一位顾问负责治疗的4336例患者，他们共接受了3355台手术；每位患者记录了50项信息，从而能够进行广泛的分析，例如入院和手术次数、手术分级、诊断分组、并发症以及与个别外科医生相关的并发症发生率。为审计收集的数据为该科室提供了宝贵的基线，明确了可以审查和改进的实践方面。在审计期间，并发症占入院人数的总体百分比从13%显著降至9%，术后并发症发生率从1982年的16%显著降至1986年的11%。胸部和伤口感染的发生率也显著下降。通过利用这些数据生成出院小结以及进行审计，该系统得到了改进；微机因此成为该科室办公室工作不可或缺的一部分。
