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出院小结错误的前瞻性审计。

Prospective audit of discharge summary errors.

作者信息

Macaulay E M, Cooper G G, Engeset J, Naylor A R

机构信息

Department of Vascular Surgery, Aberdeen Royal Infirmary, UK.

出版信息

Br J Surg. 1996 Jun;83(6):788-90. doi: 10.1002/bjs.1800830619.

Abstract

During an 8-month interval of prospective audit, 63 of 637 (10 per cent) vascular discharge summaries were found to contain 94 errors. These comprised 11 (12 per cent) general errors, 21 (22 per cent) diagnostic errors, 19 (20 per cent) operative data errors, 19 (20 per cent) cases of incorrect clinical text information, 14 (15 per cent) missed complications and 10 (11 per cent) concerning follow-up arrangements. Overall, 2 per cent of consultant discharge summaries contained errors compared with 7 per cent for the senior registrar, 10 per cent for registrars and 17 per cent for senior house officers. Given that the majority of discharge summaries are currently prepared by junior staff, this study suggests that verification of the accuracy of clinical and management data should be an essential component of departmental audit meetings.

摘要

在为期8个月的前瞻性审计期间,637份血管科出院小结中有63份(10%)被发现存在94处错误。这些错误包括11处(12%)一般性错误、21处(22%)诊断错误、19处(20%)手术数据错误、19处(20%)临床文本信息错误、14处(15%)漏报的并发症以及10处(11%)有关随访安排的问题。总体而言,会诊医生的出院小结中有2%存在错误,相比之下,高级住院医师为7%,住院医师为10%,住院总医师为17%。鉴于目前大多数出院小结是由初级工作人员编写的,本研究表明,临床和管理数据准确性的核查应成为科室审计会议的重要组成部分

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