Jayakumar T K, Sikchi Rupesh, Rathod Kirtikumar J, Sinha Arvind
Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
J Indian Assoc Pediatr Surg. 2023 Jan-Feb;28(1):54-58. doi: 10.4103/jiaps.jiaps_169_21. Epub 2023 Jan 10.
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.
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.
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%).
Using checklists for daily ward rounds improves documentation. It reduces the gap in communication and potential errors in patient management.
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。
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。
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。
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。