应用PDCA循环法对医疗安全不良事件持续改进的效果

罗金梅　黄洁　彭清艳　朱凌燕　李瑞八　宋洁　高华斌

摘要：目的  分析我院醫疗安全不良事件的上报情况，为制定有针对性的持续改进措施提供可靠依据。方法  收集我院2016～2018年在院内信息系统主动上报的1796例医疗安全不良事件，对上报等级、类别、科室分布进行回顾性分析。结果  近三年我院医疗安全不良事件的上报例数呈逐年上升趋势;医疗安全不良事件上报等级的频数分布比较，差异有统计学意义（P<0.05）;医疗安全不良事件上报类别的频数分布比较，差异有统计学意义（P<0.05）;医疗安全不良事件上报科室的频数分布比较，差异有统计学意义（P<0.05）。结论  通过建立非惩罚性、主动上报的医疗安全不良事件院内信息直报系统，运用PDCA循环定期对获取的医疗安全信息、不良事件进行分类汇总分析，有利于发现存在的不足，提出改进措施，建立绩效激励机制，有助于提高医疗安全不良事件上报率，降低漏报率，促进医疗质量持续改进，有效避免医疗差错与纠纷，保障病人安全。

关键词：PDCA;医疗安全不良事件;持续改进

中图分类号：R197.323                               文献标识码：A                                DOI：10.3969/j.issn.1006-1959.2020.14.042

文章编号：1006-1959（2020）14-0137-03

Application of PDCA Cycle Method to the Continuous Improvement

of Medical Safety Adverse Events

LUO Jin-mei，HUANG Jie，PENG Qing-yan，ZHU Ling-yan，LI Rui-ba，SONG Jie，GAO Hua-bin

（Medical Department，the First Affiliated Hospital of Kunming Medical University，Kunming 650032，Yunnan，China）

Abstract：Objective  To analyze the report of medical safety adverse events in our hospital， and provide a reliable basis for the develop continuous improvement measures in a targeted manner.Methods  A total of 1796 medical safety adverse events voluntarily reported by the information system of our hospital from 2016 to 2018 were collected， and a retrospective analysis was conducted on the grades， classifications and departments.Results  The number of reported cases of medical safety adverse events in our hospital has increased year by year in the past three years; the frequency distribution of medical safety adverse event reporting levels has been compared， and the difference is statistically significant（P<0.05）; categories of medical safety adverse event reporting Compared with the frequency distribution， the difference was statistically significant （P<0.05）; compared with the frequency distribution of medical safety adverse events reported to the department， the difference was statistically significant （P<0.05）.Conclusion  Through the establishment of a non-punitive， proactive reporting of medical safety adverse events in-hospital information direct reporting system， the PDCA cycle is used to periodically classify and summarize the obtained medical safety information and adverse events， which is helpful to find the existing deficiencies， propose improvement measures， and establish performance The incentive mechanism helps to increase the reporting rate of medical safety adverse events， reduce the rate of missed reports， promote continuous improvement of medical quality， effectively avoid medical errors and disputes， and ensure patient safety.

Key words：PDCA;Medical safety adverse events;Continuous improvement

医疗安全不良事件（medical safety adverse events）是临床诊疗活动及医院运行过程中，任何可能影响病人的诊疗结果、增加病人的痛苦和负担并可能引发医疗纠纷或医疗事故，以及影响医疗工作的正常运行和医务人员人身安全的因素和事件[1-3]。医疗安全不良事件报告是发现医疗过程中存在的安全隐患、防范医疗事故、提高医疗质量、保障患者安全、促进医学发展和保护患者利益的重要措施。本研究回顾性分析了我院2016～2018年在院内信息系统主动上报的1796例医疗安全不良事件，以期了解我院实施PDCA循环法后医疗安全不良事件发生的等级、类别、科室分布，规范医疗安全不良事件的主动、全面报告流程，增强全院职工风险防范意识，及时发现医疗安全不良事件和安全隐患，有效避免医疗差错与纠纷，保障患者安全，现将结果报道如下。

1对象与方法

1.1研究对象  通过院内信息直报系统收集2016～2018年在院内信息系统主动上报的1796例医疗安全不良事件为研究对象，医疗安全不良事件三甲评审标准：C级标准（每百张床位年报告≥10例），B级标准（每百张床位年报告≥15例），A级标准（每百张床位年报告≥20例）。……