缺陷病案分析对于减少神经内科护理不良事件发生率的应用效果  

Application Effect of Defect Medical Record Analysis in Reducing the Incidence of Adverse Events in Neurology Nursing

作　　者：郭润蓉[1] 黄凡[1] 傅丽伟 Guo Runrong;Huang Fan;Fu Liwei(Department of Neurology,Qingdao Municipal Hospital,Qingdao 266071,Shandong Province,China;不详)

机构地区：[1]青岛市市立医院神经内科,山东省青岛市266071

出　　处：《中国病案》2022年第2期102-105,共4页Chinese Medical Record

摘　　要：目的 通过缺陷病案分析,查找神经内科护理问题,以期提高护理质量,减少神经内科不良事件发生率。方法 随机选取2020年3月1日-2020年5月31日住院患者对照组180人,随机选取某医院神经内科2020年6月1日-2020年9月30日住院患者为观察组180人。对照组采用常规护理,观察组采用缺陷病案分析,查找不良事件发生的原因改进护理措施。比较两组患者护理质量评分、不良事件发生率。结果 观察组患者护理质量评分和病案质量评分(95.63±9.42、94.17±9.25)明显高于对照组(87.52±8.93、87.09±8.72),差异有统计学意义(t=8.383、7.472,P=0.000)。观察组患者不良事件发生率(0.56%)明显低于对照组(3.89%),差异有统计学意义(χ^(2)=4.602,P=0.032)。观察组护理操作、辅助合作、护患沟通、服务态度、应急能力和总分均明显高于对照组,差异有统计学意义(t=7.535、9.875、6.362、11.388、5.298、14.015,P<0.05)。结论 缺陷病案分析可以帮助护理人员查找护理措施漏洞,提高护理质量,降低神经内科不良事件发生率。Objective To find out the nursing problems of neurology through the analysis of defective medical records,in order to improve the quality of nursing and reduce the incidence of adverse events in neurology.Methods A total of 180 patients admitted to the Department of Neurology of a hospital from June 1,2020 to September 30,2020 were randomly selected as the observation group,and 180 patients admitted to the Department of Neurology of a hospital from March 1,2020 to May 31,2020 were randomly selected as the control group.The observation group used conventional nursing care,and the control group used defective medical record analysis to find out the causes of adverse events and improve nursing measures.The care quality score and the incidence of adverse events were compared between the two groups.Results The nursing quality score and medical record quality score in the observation group(95.63±9.42,94.17±9.25) were significantly higher than those in the control group(87.52±8.93,87.09±8.72),the difference was statistically significant(t=8.383,7.472,P=0.000).The incidence of adverse events in observation group(0.56%) was significantly lower than that in control group(3.89%),and the difference was statistically significant(χ~2=4.602,P=0.032).The observation group was significantly higher than the control group in nursing operation,auxiliary cooperation,nurse-patient communication,service attitude,emergency capability and total scores,with statistical significance(t=7.535,9.875,6.362,11.388,5.298,14.015,P<0.05).Conclusion Defect medical record analysis can help nurses find loopholes in nursing measures,improve nursing quality,and reduce the incidence of neurological adverse events.

关 键 词：缺陷病案分析 神经内科 护理病案 不良事件发生率 应用效果 

分 类 号：R473.74[医药卫生—护理学]