关键词:

术前讨论, 质量控制, 医疗安全

Abstract:

Objective To explore effective measures for target improvement，based on common questions in the implementation of preoperative discussion system. Methods Quality inspection and statistical analysis were performed in 200 cases of medical records. Results Many problems existed in the medical records，which were re⁃ lated with formalization of preoperative discussion，irregular writing of medical records and the weakened guidance role of senior doctors to junior doctors，etc. Conclusion The paper suggested to improve from five aspects to en⁃ hance the quality of preoperative discussion and to ensure medical safety，which include strict implementation of system for preoperative discussion to ensure surgery safety；enhancing training，standardization of medical re⁃ cords；strengthening quality control of process to ensure content quality；implementation of terminal quality inspec⁃ tion to improve the overall quality.

Key words: preoperative discussion,  , quality control,  , medical safety