围手术期麻醉记录单完整性评估：一项多中心观察性研究。
Assessment of perioperative anesthesia record sheet completeness: A multi-center observational study.
作者信息
Taye Moges Gelaw, Fenta Efrem, Tamire Tadese, Fentie Yewlsew
机构信息
Department of Anesthesia, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
出版信息
Ann Med Surg (Lond). 2022 Jul 2;79:104103. doi: 10.1016/j.amsu.2022.104103. eCollection 2022 Jul.
BACKGROUND
Anesthesia record is an essential part of perioperative patient management and, it is one of the global patient safety challenges. The aim of this study is to assess the completeness of perioperative anesthesia record sheets in Amhara regional state hospitals of Ethiopia.
METHODS
A retrospective review of anesthetic records was employed for patients who underwent surgery in Amhara Regional State Hospitals of Ethiopia from December 1, 2019, to February 29, 2020. All the intraoperative, preoperative, and postoperative data completeness of anesthesia record sheets was assessed using a structured checklist.
RESULTS
A total of 420 perioperative anesthetic records were included in this study. The basic preoperative history was documented in less than 80% of anesthesia record sheets. A physical examination was done and the results of the basic investigations were recorded in less than 75% of anesthesia record sheets. The name and dose of anesthetic medications were documented in 91% of the anesthesia records sheets. The completeness of parameters related to postoperative plans and orders was less than 70%.
CONCLUSION
The completeness of perioperative anesthesia record was poor in Amhara regional state hospitals of Ethiopia. Anesthesia professionals should document all the necessary perioperative parameters in the anesthesia record sheet.
背景
麻醉记录是围手术期患者管理的重要组成部分，也是全球患者安全面临的挑战之一。本研究旨在评估埃塞俄比亚阿姆哈拉地区医院围手术期麻醉记录单的完整性。
方法
对2019年12月1日至2020年2月29日在埃塞俄比亚阿姆哈拉地区医院接受手术的患者的麻醉记录进行回顾性研究。使用结构化检查表评估麻醉记录单的所有术中、术前和术后数据完整性。
结果
本研究共纳入420份围手术期麻醉记录。不到80%的麻醉记录单记录了基本术前病史。不到75%的麻醉记录单进行了体格检查并记录了基本检查结果。91%的麻醉记录单记录了麻醉药物的名称和剂量。与术后计划和医嘱相关的参数完整性不到70%。
结论
埃塞俄比亚阿姆哈拉地区医院围手术期麻醉记录的完整性较差。麻醉专业人员应在麻醉记录单中记录所有必要的围手术期参数。
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