基于高可靠性组织理论的护理病历无纸化质量控制系统应用效果评价  

Application effect of the paperless quality control system for nursing medical records based on the Highly Reliable Organization Theory

作　　者：唐方芳[1] 崔璀[1] 魏晓琼[2] 申雪兰 郑显兰[1] TANG Fangfang;CUI Cui;WEI Xiaoqiong;SHEN Xuelan;ZHENG Xianlan(Nursing Department,Children's Hospital of Chongqing Medical University,Chongqing,400014,China)

机构地区：[1]重庆医科大学附属儿童医院护理部,重庆市400014 [2]重庆医科大学附属儿童医院风湿免疫科,重庆市400014 [3]重庆医科大学附属儿童医院血液肿瘤科,重庆市400014

出　　处：《中国护理管理》2024年第11期1651-1654,共4页Chinese Nursing Management

基　　金：2022年重庆市科卫联合医学中青年高端人才科研项目(2022GDRC007)。

摘　　要：目的:构建基于高可靠性组织理论的护理病历无纸化质量控制系统,并评价其应用效果,以提升护理病历质量与质量控制效率。方法:2023年2月,我院护理部开始实施护理病历全流程无纸化质量控制及归档系统,开展护理病历生成、质量控制、提交及归档环节信息化建设,分别比较系统应用前后各6个月的病历质量、质量控制时间、护士满意度、打印机维护费及耗材消耗费。结果:系统应用后,护理病历整体质量、护士应用满意度较前显著提升(P<0.05),病历质量控制时间、打印机维护费及耗材消耗费低于系统应用前。结论:基于高可靠性组织理论的护理病历无纸化质量控制系统聚焦实时监控及事前预警,加快数据利用及流转,可提高终末护理病历质量,保障护理质量与护理安全。Objective:To establish a paperless quality control system for nursing records based on High Reliability Organization Theory and evaluate its usability.Methods:Since February 2023,a paperless quality control system for nursing records was implemented.Information technology was employed for nursing record generation,quality control,submission,and archiving processes.The quality of nursing records,time consumed for quality control,nurse satisfaction,printer maintenance,and consumable expenditure rates were compared before and after system implementation over a period of six months.Results:The overall quality of nursing records and nurse satisfaction improved(P<0.05),while the time consumed for quality control,printer maintenance,and consumable expenditure rates decreased.Conclusion:The paperless quality control system for nursing records,based on the High Reliability Organization Theory,focuses on process control and data flow,enhance nursing work efficiency and improve the quality of final nursing records.This system can promote the scientific,standardized,and efficient management of clinical nursing records.

关 键 词：高可靠性组织 病历质量控制 无纸化 护理信息化 

分 类 号：R47[医药卫生—护理学] R197[医药卫生—临床医学]