实施病例缺陷管理 提高医疗质量——对吉林省50家二、三级甲等医院1280例病例缺陷情况的分析

吉林省对各级各类医院实行了病例缺陷管理。主要是控制病人在住院期间的诊断、治疗、手术、抢救、医院感染、护理、营养、痛历书写等方面的缺陷。这个病例缺陷判定标准共分8个方面102条,我们近一年来先后对1280例现有的住院病人和出院病人进行了质量评价。结果验证用这种方法进行病例质量管理,是检衡医疗护理质量很好的控制手段,既评价了病例质量,又减少了医疗差错,保证了医疗安全,提高了医疗质量。

Assessment of Defects in Medical Services: Proposed Criteria

A series of medical defect assessment criteria, 102 items in eight categories, were used in 1, 280 in - patients treated by 50 A - level and B - level hospitals of Jilin Province, for examining defects in quality of medical services , such as diagnosis, treatment, operation, nosocomial infection control, nursing care, case notes; and were found to be useful in helping to reduce the incidence of medical negligence, ensure safety and improve quality in medical treatment.