【作者】 许苹；

【导师】 张鹭鹭；

【作者基本信息】 第二军医大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 国际公认“医疗风险无处不在”,它贯穿在门诊、住院、出院等环节和诊断、治疗、康复等诊疗行为的全过程中。医疗机构在目前的安全技术与管理下,完全杜绝医疗风险难以做到。但研究表明,尽管医疗风险难以杜绝,但大多数医疗不安全事件都可事先预防。本课题在国内外医疗风险管理现状研究员的基础上,分析医疗风险发生的背景、过程、规律、成因、分布领域等资料,进行医疗风险预警预控管理,就如何降低医疗风险提出相应政策性建议。研究分为五个部分。第一部分对我国医疗风险的概念、特点、种类和成因进行研究,探索医疗风险管理和医疗风险预警的理论框架,为实证研究奠定基础。第二部分对上海市某区2008年10月—2010年3月共计221例医疗纠纷投诉案例进行分析,得出高发科室为：普外科、妇产科、骨科、消化内科、心血管内科、神经内科等；高发原因为：手术不当、治疗不及时、漏诊误诊、用药不当、告知不到位、态度冷漠等；3、恶性闹访事件逐年增长；4、工作10年左右的医生为高发,经济相对困难、托熟人就医病人高发等。以上结果为实证研究干预科室和方法的确定提供依据。第三部分对东方肝胆外科医院医疗风险关键影响因素进行筛选,经单因素分析、多因素分析得出7项医疗风险预警指标和阈值,经专家咨询、将其中1、术中输血>2000ml;2、住院时间>1月；3、欠费>2万；4、病危；5、非计划再次手术5项指标制成软件并与医院信息系统链接,要求专人实时监控,发现预警患者要求专管人员深入临床一线调查,及时和患者沟通,及时安排各层次会诊等。研究结果发现该措施能有效降低了医疗风险。第四部分通过对上海市2007--2009年52起妇产科医疗事故进行回顾性研究,分析了妇产科医疗事故的成因、发生、转归和处理,形成产科单病种医疗风险预控管理路径表单,通过让患者参与风险管理的方法进行干预和监测,研究结果表明能有效提高患者住院满意度,缩短平均住院日。第五部分通过以上研究,从非惩罚性的上报系统上报内容、评估、反馈,加强根本原因分析等方法在医疗风险管理中的应用,加强医学生医疗风险防范教育,多点执业等提出相关政策性建议。更多还原

【Abstract】 It is nationally acknowledgeable that medical risks exist extensively, throughout ambulatory, hospitalization and discharge service, as well as the processes of diagnose, treatment and rehabilitation. However, despite the evitable medical risks, most medical safety issues could be prevented beforehand. The project based the research on present studies on medical risks management nationally and internationally, conducted analysis on background, process, discipline, cause, and distribution of the risks, and carried out early risk warning and pre-control management. Finally, the policy suggestions were proposed to decrease the risks in medical practice. The study is composed with four parts.Part I The study discussed concepts, characters, categories and causes of China’s medical risks, and exploring the theoretical framework of medical risk management and early warning, in order to provide the basis for empirical study.Part II The study analyzed221medical care related dispute cases in a certain district of Shanghai from October2008to March2010, which reflected that the disputes occurred more frequently in general surgery, obstetrics and gynecology, orthopedics, gastroenterology, cardiology and neurology departments due to causes such as impropriate surgery, treatment delay, misdiagnosis, irrational drug use, insufficient information, and indifferent attitude of physicians, etc; the fierce conflicts had kept increasing by years; and physicians with the practice experience of around10years, patients with economic difficulties and the visit recommended by familiar person were major factors of disputes. The findings above provided support to choose intervention objective and determine the method in empirical study.Part III The study investigated key factors related to the medical risks in Eastern Hepatobiliary Hospital, and selected7early warning indicators with thresholds through χ2test, logistic regression and expert interview. Among the indicators, over blood transfusion (with volume exceeds2000ml), long hospitalization (more than one month), arrearage over RMB20,000, terminal condition, and unplanned re-operation were included into hospital management information system in order to realize real-time monitoring. When a potential risk patient were find, Interventions were implemented including communication with arrearage patients to find out the reason, obtain the mutual understanding and organize experts consultations. The measure worked out successfully to decrease the medical risks. Part Ⅳ The research carried out retrospective study on52malpractice cases in obstetrics and gynecology department in Shanghai from2007to2009, analyzing the cause, development, outcome and management of the malpractice and forming pre-control check-list for obstetrics risks to involve patients into medical risk management. It turned out that the project improved inpatient satisfaction and shorten hospitalization stay.Part Ⅴ Based on the study above, policy suggestions were proposed to set up non-punishment oriented risk reporting system for monitoring, evaluation and feedback, promote the application of methods such as root analysis in medical risk management, enhance the education of risk prevention among medical students and encourage the multi-facility practice.更多还原