基于病案首页加强对医院获得性问题的管理  

Enhanced management of hospital acquired conditions using homepage of medical records

作　　者：焦建军[1] 王妍艳[1] 

机构地区：[1]中日友好医院医务处,北京100029

出　　处：《中华医院管理杂志》2017年第10期761-763,共3页Chinese Journal of Hospital Administration

摘　　要：目的对医院获得性问题（HACs）进行分析，以减少医源性HACs发生。方法利用病案首页中的“入院病情”，收集2014年的医源性HACs数据。通过医师自查，分析产生医源性HACs的原因，并提出相应的改进措施。将改进后（2015年）的HACs数据与改进前（2014年）进行比较。结果通过自查，医生认识到应加强患者入院前宣教、医患沟通、科室间的合作等各医疗过程，从而减少医源性HACs的发生。2015年HACs发生数量和发生率均较2014年明显降低，差异有统计学意义（P〈0．05）。结论加强对HACs的分析与管理，特别是对医源性HACs的分析与管理是减少医院内并发症发生的重要手段。Objective To analyze and minimize iatrogenic hospital acquired conditions （HACs）. Methods ＂ Admission conditions＂ in homepage of medical records was studied to collect iatrogenic problems between 2014 and 2015. Self-inspection of physicians was made to identify causes of iatrogenic HACs for improvement measures. The post-improvement HACs data （2015） were compared with that of before （2014）. Results Physicians came to learn following the self-examination the importance of preadmission communications, doctor-patient communications and cooperation between the departments in less HACs. Occurrence of HACs in 2015 was significantly lower than 2014. Conclusions Enhanced analysis and management of HACs, especially for iatrogenic problems, significantly contribute to less HACs.

关 键 词：病案首页 入院病情 医院获得性问题 医源性问题 分析与管理 

分 类 号：R197.323[医药卫生—卫生事业管理]