三所三级甲等医院疾病诊断不符的情况分析  

Analysis of the misdiagnosis in the 3rd degree-,grade A hospitals

作　　者：傅万明[1] 胡毅华[2] 吴克俭[3] 邹俊卿[1] 张健玲[1] 石东[1] 谈洪波[1] 李风华[1] 程榕梅[4] 

机构地区：[1]南京军区南京总医院信息科,江苏南京210002 [2]南京市鼓楼医院信息科,江苏南京210008 [3]解放军第四五四医院信息科,江苏南京210002 [4]南京市医学研究所,江苏南京210008

出　　处：《医学研究生学报》2002年第4期346-348,共3页Journal of Medical Postgraduates

摘　　要：目的 :了解三所医院对疾病正确诊断水平和正确程度 ,期望从中总结出相关的经验教训 ,以引起医院领导和临床医师的重视 ,减少误诊 ,减轻患者的痛苦和经济负担。　方法 :用微机分别查出三所医院 3年中疾病诊断不符的病案号 ,再根据病案号调出全部病历 ,分类统计有关内容 ,回顾分析南京地区三所医院 3年中诊断不符情况。　结果和结论 :三所医院 3年中疾病诊断不符数占收容数的 1 45 % ,其中第一和第二诊断不符数分别占总收容数的 0 .94%和 0 5 1% ;内、外科系诊断不符数分别占总不符数的 5 4 47%和 45 5 3% ;并得出诊断不符高频发疾病群。Objectives:To understand the correct diagnosis levels in the three hospitals, and sum up the related experiences and lessons,in order to arouse the attention of the hospital leaders and the clinical doctors,to reduce the misdiagnosis rate and the expenses of the patients. Methods:To find out the case-record numbers of the misdiagnosed cases in three years in the three hospitals with computors. To classify and make statistical analysis about the contents,and to retrospectively analyze the misdiagnosed cases in three years in the three hospitals in Nanjing. Results and conclusions:For 3 years in the 3 hospitals,the total misdiagnosis rate for the in-patients was 1.45%,in which the misdiagnosis rates of the first and the second diagnosis were 0.94% and 0.51% respectively. The misdiagnosis rates in medical and surgical patients were 54.47% and 45.53% respectively. It also concluded the relationship among the misdiagnosis and the certern diseases, medical departments, advanced training doctors and the hospitals' own doctors.

关 键 词：三级甲等医院 疾病诊断 诊断不符 建议 

分 类 号：R44[医药卫生—诊断学]