FMEA质控管理在住院病案终末质量控制中的应用价值  

The Application Value of FMEA Quality Control Management in the Final Quality Control of Inpatient Medical Records

作　　者：孙晓娟 陈烨 李翠琼 SUN Xiaojuan;CHEN Ye;LI Cuiqiong(Nursing Department,FAW General Hospital,Jilin Province,Changchun,Jilin Province,130011 China;Department of Hand and Foot Surgery,FAW General Hospital of Jilin Province,Changchun,Jilin Province,130011 China;Department of Neurology,FAW General Hospital,Jilin Province,Changchun,Jilin Province,130011 China)

机构地区：[1]吉林省一汽总医院护理部,吉林长春130011 [2]吉林省一汽总医院手足外科,吉林长春130011 [3]吉林省一汽总医院神经内科,吉林长春130011

出　　处：《中国卫生产业》2022年第4期25-28,共4页China Health Industry

摘　　要：目的探究FMEA质控管理在住院病案终末质量控制中的可行性。方法选取2019年1月—2021年2月该院在职护理人员57名,并由质量控制部抽查归档病案1000份作为研究对象,根据时间不同记为管理前(2019年1月—2020年2月)和管理后(2020年3月—2021年2月),管理前进行传统护理管理模式,管理后进行FMEA质控管理模式,对比管理前后护理人员护理文书书写质量和归档病案书写问题发生率。结果管理后护理人员客观、真实、准确、及时、完整等护理文书书写质量评分显著高于对照组,差异有统计学意义(P<0.05);管理后护理人员病历首页、评估单、病重病危护理记录单、交接记录单、体温单、医嘱单、护理病历缺陷等护理文书书写问题发生率显著低于管理前,差异有统计学意义(P<0.05)。结论运行病历质控是护理文书质量提升的重要一环,对其实施FMEA质控管理模式可显著提升护理人员书写质量,有效减少病案书写问题发生率,全面强化护理工作内容,为患者提供更加优质的护理服务。Objective To explore the feasibility of FMEA quality control management in the final quality control of inpatient medical records.Methods From January 2019 to February 2021,57 in-service nursing staff in the hospital were selected,and 1000 medical records were randomly checked and archived by the quality control department as the research objects,and recorded as before management according to the time(from January 2019 to February 2020)and after management(from March 2020 to February 2021),the traditional nursing management mode is carried out before management,and the FMEA quality control management mode is carried out after management,and the quality of nursing documents written by nursing staff before and after management and the incidence of problems in filing medical records are compared.Results After management,the nursing staff's objective,true,accurate,timely and complete nursing document writing quality scores were significantly higher than those of the control group,and the difference was statistically significant(P<0.05);after management,the incidence of nursing document writing problems such as case homepage,assessment sheet,critically ill nursing record sheet,handover record sheet,temperature sheet,doctor's order sheet,and nursing case defects were significantly lower than those before management,and the difference was statistically significant(P<0.05).Conclusion The operation of medical record quality control is an important part of improving the quality of nursing documents.Implementing the FMEA quality control management model can significantly improve the quality of nursing staff's writing,effectively reduce the incidence of medical record writing problems,comprehensively strengthen the content of nursing work,and provide patients with better quality care.

关 键 词：FMEA质控管理 护理文书 书写质量 书写问题 

分 类 号：R47[医药卫生—护理学]