• 文献检索
  • 文档翻译
  • 深度研究
  • 学术资讯
  • Suppr Zotero 插件Zotero 插件
  • 邀请有礼
  • 套餐&价格
  • 历史记录
应用&插件
Suppr Zotero 插件Zotero 插件浏览器插件Mac 客户端Windows 客户端微信小程序
定价
高级版会员购买积分包购买API积分包
服务
文献检索文档翻译深度研究API 文档MCP 服务
关于我们
关于 Suppr公司介绍联系我们用户协议隐私条款
关注我们

Suppr 超能文献

核心技术专利:CN118964589B侵权必究
粤ICP备2023148730 号-1Suppr @ 2026

文献检索

告别复杂PubMed语法,用中文像聊天一样搜索,搜遍4000万医学文献。AI智能推荐,让科研检索更轻松。

立即免费搜索

文件翻译

保留排版,准确专业,支持PDF/Word/PPT等文件格式,支持 12+语言互译。

免费翻译文档

深度研究

AI帮你快速写综述,25分钟生成高质量综述,智能提取关键信息,辅助科研写作。

立即免费体验

实施检查表后儿科外科查房的质量改进

Quality Improvement in Pediatric Surgical Ward Rounds after Implementation of Checklist.

作者信息

Jayakumar T K, Sikchi Rupesh, Rathod Kirtikumar J, Sinha Arvind

机构信息

Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

出版信息

J Indian Assoc Pediatr Surg. 2023 Jan-Feb;28(1):54-58. doi: 10.4103/jiaps.jiaps_169_21. Epub 2023 Jan 10.

DOI:10.4103/jiaps.jiaps_169_21
PMID:36910290
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9997593/
Abstract

INTRODUCTION

Using checklists has been common in high-risk industries such as aviation, space, and maritime sectors. It is routinely being used in health care also. Daily ward rounds play an essential role in patient care. Missing key details in rounds are common. Sometimes, these medical errors can lead to adverse events or mismanagement of patients. A checklist was introduced for daily ward rounds in our newly established institution. This study aims to assess the improvement in the documentation.

MATERIALS AND METHODS

A checklist for ward rounds was introduced in September 2018. During the study period, between July 2017 and January 2020, 30 random case records for each of the two groups were taken. Group A (without checklist) and Group B (checklist) were compared to see the documentation of patient identification, diagnosis, operative status, fresh complaints, vitals, examination findings, charting treatment, catheters/drains/intravenous access, and urinary status/bowel movements.

RESULTS

Sixty case records were included in the study. Comparison of documentation between Group A and Group B showed a significant difference in patient identification (50% vs. 100%), diagnosis (47% vs. 100%), operative status (33% vs. 100%), fresh complaints (76% vs. 100%), vitals (63% vs. 100%), examination findings (43% vs. 100%), charting treatment (73% vs. 100%), catheters/drains/intravenous access (10% vs. 86%), and urinary status/bowel movements (30% vs. 100%).

CONCLUSION

Using checklists for daily ward rounds improves documentation. It reduces the gap in communication and potential errors in patient management.

摘要

引言

使用检查表在航空、航天和海事等高风险行业很常见。它在医疗保健领域也经常被使用。每日病房查房在患者护理中起着至关重要的作用。查房时遗漏关键细节很常见。有时,这些医疗差错会导致不良事件或患者管理不善。在我们新建的机构中,引入了一份用于每日病房查房的检查表。本研究旨在评估文档记录方面的改进情况。

材料与方法

2018年9月引入了一份病房查房检查表。在研究期间,即2017年7月至2020年1月,对两组中的每组随机抽取30份病例记录。比较A组(无检查表)和B组(有检查表)在患者识别、诊断、手术状态、新出现的主诉、生命体征、检查结果、治疗记录、导管/引流管/静脉通路以及尿液状态/排便情况的文档记录。

结果

该研究纳入了60份病例记录。A组和B组之间的文档记录比较显示,在患者识别(50%对100%)、诊断(47%对100%)、手术状态(33%对100%)、新出现的主诉(76%对100%)、生命体征(63%对100%)、检查结果(43%对100%)、治疗记录(73%对100%)、导管/引流管/静脉通路(10%对86%)以及尿液状态/排便情况(30%对100%)方面存在显著差异。

结论

在每日病房查房中使用检查表可改善文档记录。它缩小了沟通差距并减少了患者管理中的潜在差错。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8e5d/9997593/526062ea1bd5/JIAPS-28-54-g002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8e5d/9997593/aeaf8fce8e9e/JIAPS-28-54-g001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8e5d/9997593/526062ea1bd5/JIAPS-28-54-g002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8e5d/9997593/aeaf8fce8e9e/JIAPS-28-54-g001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8e5d/9997593/526062ea1bd5/JIAPS-28-54-g002.jpg

相似文献

1
Quality Improvement in Pediatric Surgical Ward Rounds after Implementation of Checklist.实施检查表后儿科外科查房的质量改进
J Indian Assoc Pediatr Surg. 2023 Jan-Feb;28(1):54-58. doi: 10.4103/jiaps.jiaps_169_21. Epub 2023 Jan 10.
2
Using a Structured Checklist to Improve the Orthopedic Ward Round: A Prospective Cohort Study.使用结构化检查表改善骨科病房查房:一项前瞻性队列研究。
Orthopedics. 2017 Jul 1;40(4):e663-e667. doi: 10.3928/01477447-20170509-01. Epub 2017 May 15.
3
Implementation and evaluation of a checklist to improve patient care on surgical ward rounds.用于改善外科病房查房中患者护理的检查表的实施与评估。
ANZ J Surg. 2016 May;86(5):356-60. doi: 10.1111/ans.13151. Epub 2015 May 12.
4
Randomized clinical trial of the impact of surgical ward-care checklists on postoperative care in a simulated environment.随机临床试验研究手术病房护理清单对模拟环境下术后护理的影响。
Br J Surg. 2014 Dec;101(13):1666-73. doi: 10.1002/bjs.9654. Epub 2014 Oct 28.
5
The surgical ward round checklist: improving patient safety and clinical documentation.外科病房查房检查表:提高患者安全与临床记录质量
J Multidiscip Healthc. 2019 Sep 16;12:789-794. doi: 10.2147/JMDH.S178896. eCollection 2019.
6
Intelligent checklists improve checklist compliance in the intensive care unit: a prospective before-and-after mixed-method study.智能检查表可提高重症监护病房检查表的依从性:一项前瞻性前后混合方法研究。
Br J Anaesth. 2021 Feb;126(2):404-414. doi: 10.1016/j.bja.2020.09.044. Epub 2020 Nov 17.
7
'Take Ten' improving the surgical post-take ward round: a quality improvement project.“十分钟查房”改善术后查房:一项质量改进项目。
BMJ Open Qual. 2018 Mar 1;7(1):e000045. doi: 10.1136/bmjoq-2017-000045. eCollection 2018.
8
Can Checklists Solve Our Ward Round Woes? A Systematic Review.清单能否解决我们的病房查房难题?系统评价。
World J Surg. 2022 Oct;46(10):2355-2364. doi: 10.1007/s00268-022-06635-5. Epub 2022 Jul 3.
9
Ward round checklist improves patient perception of care.查房清单可提高患者对护理的满意度。
ANZ J Surg. 2021 May;91(5):854-859. doi: 10.1111/ans.16543. Epub 2021 Jan 18.
10
Introduction of a new ward round approach in a cardiothoracic critical care unit.心胸重症监护病房引入新的查房方法
Nurs Crit Care. 2015 Jul;20(4):210-8. doi: 10.1111/nicc.12149. Epub 2015 Jan 16.

本文引用的文献

1
Developing a ward round checklist to improve patient safety.制定查房检查表以提高患者安全。
BMJ Qual Improv Rep. 2015 Feb 11;4(1). doi: 10.1136/bmjquality.u204775.w2440. eCollection 2015.
2
Current issues in patient safety in surgery: a review.手术患者安全的当前问题:综述
Patient Saf Surg. 2015 Jun 5;9:26. doi: 10.1186/s13037-015-0067-4. eCollection 2015.
3
Introduction of a new ward round approach in a cardiothoracic critical care unit.心胸重症监护病房引入新的查房方法
Nurs Crit Care. 2015 Jul;20(4):210-8. doi: 10.1111/nicc.12149. Epub 2015 Jan 16.
4
Is the post-take ward round standardised?术后查房是否标准化?
Clin Teach. 2012 Oct;9(5):334-7. doi: 10.1111/j.1743-498X.2012.00566.x.
5
Why patients need leaders: introducing a ward safety checklist.患者为何需要领导者:引入病房安全清单。
J R Soc Med. 2012 Sep;105(9):377-83. doi: 10.1258/jrsm.2012.120098.
6
Perspectives in quality: designing the WHO Surgical Safety Checklist.质量视角:世卫组织手术安全核对表的设计。
Int J Qual Health Care. 2010 Oct;22(5):365-70. doi: 10.1093/intqhc/mzq039. Epub 2010 Aug 11.
7
Medical records and issues in negligence.医疗记录与过失问题。
Indian J Urol. 2009 Jul;25(3):384-8. doi: 10.4103/0970-1591.56208.
8
Reducing medical errors through better documentation.通过更好的文档记录减少医疗差错。
Health Care Manag (Frederick). 2004 Oct-Dec;23(4):329-33. doi: 10.1097/00126450-200410000-00007.