Khan M Noah H, Shafiq Hassan, Ilyas Muhammad Waqas, Jamshed Muhammad Hamzah, Qureshi Ammal Imran, Khan Basharat Ghafoor, Anjum Neshat
Royal Victoria Hospital, Belfast, Flat 3 Blenheim Court 56-58 Westwood Road, Southampton SO17 1ES, UK.
SHO T&O Royal London Hospital, UK.
Ann Med Surg (Lond). 2021 Oct 15;71:102949. doi: 10.1016/j.amsu.2021.102949. eCollection 2021 Nov.
Consent is a process of communication and the consent form is an important legal document of the evidence of discussion between doctor and patients. We observed frequent use of abbreviations in the consent forms in our department that can result in misunderstanding and miscommunication when consenting patients for orthopaedic procedures.
We completed an audit cycle starting by reviewing a total of 350 consent forms retrospectively in level one trauma centres in October-November of 2019 for different orthopaedic trauma procedures. The standards for the project were guidelines published by the general medical council (GMC), The royal college of surgeons (RCS) Glasgow, and the British orthopaedic association (BOA).The results were presented at our mortality and morbidity meeting. Written Feedback was obtained from the attending members on how a change can be implemented to increase ccompliance in filling consent forms. A generic email was sent to all medical professionals to avoid the use of abbreviations on the document and encourage colleagues to point out errors if they spot them. The use of full medical terms and to avoid abbreviations in consent form was well advertised, The re-audit was performed for the period of January & February 2020 that included 400 consent forms. The results were analysed and compared with our original audit results.
The use of abbreviations declined from 54% in first audit to 22% in the re-audit. DVT and PE were the most common abbreviations.
This audit cycle has shown the importance of education and reminders to the health professionals in achieving better adherence to the guidelines and improves patient care.
同意是一个沟通的过程,同意书是医生与患者讨论证据的重要法律文件。我们观察到,在我们科室的同意书中经常使用缩写,这在为骨科手术患者进行同意时可能会导致误解和沟通不畅。
我们完成了一个审核周期,首先回顾了2019年10月至11月一级创伤中心共350份不同骨科创伤手术的同意书。该项目的标准是由普通医学委员会(GMC)、格拉斯哥皇家外科医学院(RCS)和英国骨科协会(BOA)发布的指南。结果在我们的死亡率和发病率会议上进行了汇报。从与会成员那里获得了书面反馈,内容是关于如何实施变革以提高同意书填写的合规性。向所有医学专业人员发送了一封通用电子邮件,以避免在文件中使用缩写,并鼓励同事如果发现错误指出。在同意书中使用完整医学术语并避免缩写的做法得到了广泛宣传。在2020年1月和2月期间进行了重新审核,其中包括400份同意书。对结果进行了分析并与我们原来的审核结果进行了比较。
缩写的使用从首次审核时的54%下降到重新审核时的22%。深静脉血栓形成(DVT)和肺栓塞(PE)是最常见的缩写。
这个审核周期表明了对卫生专业人员进行教育和提醒在更好地遵守指南及改善患者护理方面的重要性。