基于SPO理论的医院不良事件管理体系应用与探讨  

Application and exploration of hospital adverse event management system based on SPO theory

作　　者：王文忠 李昕阳 曾瑜 魏彩云 潘婷 WANG Wenzhong;LI Xinyang;ZENG Yu;WEI Caiyun;PAN Ting(People’s Hospital of Xiangxiang City,Xiangxiang 411400,China)

机构地区：[1]湘乡市人民医院,湖南湘乡411400

出　　处：《现代医院》2025年第4期560-564,共5页Modern Hospitals

摘　　要：目的整合优化医院不良事件信息上报系统,运用PDCA循环管理方法来提升医疗安全不良事件的上报率。实现不良事件的闭环管理,提高医院不良事件管理工作效率,助力医院等级评审和高质量发展,降低医院低风险组死亡率。方法基于SPO理论,通过运用品管圈、PDCA循环管理、流程表和描述法,并结合以往的不良事件管理工作经验,简化了不良事件的上报及追踪处理流程,并对不良事件管理信息平台进行了优化重组,就2023年1-12月(对照组)和2024年1-12月(观察组)未实施和实施PDCA循环管理不良事件的这两个时间段,对每百名出院报告不良事件例次、医院低风险组死亡率进行对比分析。结果应用PDCA循环管理有效提高医疗安全不良事件上报率,降低医院低风险组死亡率。结论整合并设计的不良事件管理系统具有良好的适用性,可推广用于医院管理工作。Objective To integrate and optimize the hospital adverse event reporting system,and to enhance the reporting rate of medical safety adverse events by using PDCA cycle management method.Achieve closed-loop management of adverse events,improve the efficiency of adverse event management in the hospital,assist in hospital grading review and-quality development,and reduce the mortality rate of low-risk groups in the hospital.Methods Based on the SPO theory,the quality control circle,PDCA management,flow chart and description method were used,and combined with the previous adverse event management experience,the adverse event reporting and tracking process was simplified,and adverse event management information platform was optimized and restructured.The period from January to December 2023(control group)and the period from January to 2024(observation group)were compared and analyzed for the number of adverse event reports per 100 discharges and the mortality rate of the low-risk group before and after the implementation of PDCA cycle management.Results The application of PDCA cycle management effectively improved the reporting rate of medical safety adverse events and reduced the mortality rate of the hospital’s low-risk group.Conclusion The integrated and designed adverse event management system has good applicability and can be promoted for use in hospital management.

关 键 词：不良事件 上报率 信息系统 SPO理论 品管圈 PDCA循环 

分 类 号：R197[医药卫生—卫生事业管理]