产房ISBAR信息化护理交接班系统的构建及应用  

Construction and application of a computerized nursing shift handover system based on ISBAR handoff format in the delivery room

作　　者：王瑶[1] 李六兰 汤颖[1] 张婷婷[1] 孟楠兰 Wang Yao;Li Liulan;Tang Ying;Zhang Tingting;Meng Nanlan(Delivery Room,Women′s Hospital of Nanjing Medical University(Nanjing Maternity and Child Health Care Hospital),Nanjing 210004,China)

机构地区：[1]南京医科大学附属妇产医院(南京市妇幼保健院)产房,江苏南京210004

出　　处：《护理学杂志》2023年第18期68-71,共4页Journal of Nursing Science

摘　　要：目的构建产房特色护理交接班系统,提高交接班质量。方法以ISBAR结构化沟通模式为依据,构建产房ISBAR信息化交接班系统;选取南京市某三级甲等妇产专科医院产房的62名助产士为研究对象,比较ISBAR信息化护理交接班系统应用前后,交接班报告书写时间、错误数与遗漏数及助产士对交接班的质量评价、一般自我效能感。结果产房ISBAR信息化护理交接班系统应用后,交接班报告书写时间缩短(P<0.05),交接班报告书写错误、遗漏数减少;助产士对交接班的质量评价及其一般自我效能感显著提升(均P<0.05)。结论产房ISBAR信息化护理交接班系统可规范助产士交接班行为,有利于减少书写耗时和书写错误、遗漏,提高交接班质量及助产士的一般自我效能感。Objective To develop a specific nursing shift handover system for the delivery room and to improve the quality of nurse shift handover.Methods Based on ISBAR handoff format,a computerized nursing handover system was constructed for the delivery room.Time to documenting handover report,the number of errors and omissions in the handover report,midwives′evaluation of the handover quality and their general self-efficacy were compared before and after application of the system by investigating 62 midwives who used the handover system.Results After application of the handover system,time to documenting handover report was significantly reduced(P<0.05),and the number of errors and omissions in the handover report decreased.Midwives′evaluation of the handover quality and their general self-efficacy were significantly improved(both P<0.05).Conclusion The computerized nursing shift handover system based on ISBAR handoff format for the delivery room can standardize midwives′shift handover behavior,reduce documentation time and errors in the report,and improve the quality of handover and midwives′general self-efficacy.

关 键 词：产房 交接班 信息系统 护理交接班系统 ISBAR沟通模式 一般自我效能感 

分 类 号：R473.71[医药卫生—护理学] TP317.1[医药卫生—临床医学]