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Prevention of wrong-site tooth extraction: Clinical guidelines

JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY 2007年第9期65卷 1793-1799页

作者： Lee, Janice S. Curley, Arthur W. Smith, Richard A. Univ Calif San Francisco Dept Oral & Maxillofacial Surg San Francisco CA 94143 USA

Wrong-site tooth extraction can be defined as the extraction of a tooth other than the one intended by the referring dentist. This adverse event continues to be one of the major reasons for filing malpractice claims against oral and maxillofacial surgeons. Most cases of wrong-site tooth extractions are preventable and can be minimized by the development of an educational program, an informative, unambiguous referral form, a pre-operative check list, and incorporation of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery into daily clinical practice. (C) 2007 American Association of Oral and Maxillofacial Surgeons.

关键词： Forms and Records Control Humans Medical Errors Practice Guidelines as Topic 表格和记录管理医疗差错转诊和会诊外科口腔拔牙牙再植术真相揭露 Medical Errors Tooth Extraction Patient Safety Forms and Records Control good clinical practice clinical practice

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Validation of death certificate diagnosis of out-of-hospital coronary heart disease deaths in Olmsted County, Minnesota

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MAYO CLINIC PROCEEDINGS 2000年第7期75卷 681-687页

作者： Goraya, TY Jacobsen, SJ Belau, PG Weston, SA Kottke, TE Roger, VL Mayo Clin & Mayo Fdn Div Cardiovasc Dis & Internal Med Rochester MN 55905 USA Mayo Clin & Mayo Fdn Clin Epidemiol Sect Rochester MN 55905 USA Mayo Clin & Mayo Fdn Dept Lab Med & Pathol Rochester MN 55905 USA Mayo Clin & Mayo Fdn Biostat Sect Rochester MN 55905 USA Olmsted Cty Coroners Off Rochester MN USA

Objective: To evaluate the validity of death certificate diagnosis of out-of-hospital (OOH) coronary heart disease (CHD) and sudden cardiac death (SCD) in Olmsted County, Minnesota, between 1981 and 1994. Methods: In this review of the medical records, autopsy reports, and coroner's files, OOH deaths with heart disease as the underlying cause of death on the death certificate were classified into CHD (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 410-414) and non-CHD (other ICD-9-CM heart disease codes) deaths. A 10% random sample (n=174) of these death certificates was reviewed by physicians, and published validation criteria were applied to classify these deaths into validated CHD or non-CHD categories. Sudden cardiac death was defined as validated CHI) that occurred at an OOH location with less than 24 hours between symptom onset and death. Results: The death certificate definition of OOH CHD death (ICD-9-CM codes 410-414) had high sensitivity and positive predictive value of 91% and 96%, respectively. The specificity and the negative predictive value were slightly lower at 86% and 72%, respectively. The sensitivity of death certificate diagnosis of CHD for validated SCD was 89%, and the positive predictive value was 77%, Using a more restrictive definition of SCD, that is, less than 1 hour between the onset of symptoms and death, the positive predictive value of CHD codes for SCD was lower at 52%, Conclusions: In Olmsted County, the positive predictive values of death certificate diagnosis for OOH CHD and SCD are high. Relying on death certificate diagnoses results in about 5% underestimation of the true CHD rates, whereas their use as a surrogate for SCD yields a 16% overestimation of the true SCD rates.

关键词：尸体解剖死亡原因置信区间冠心病/分类法冠心病/死亡率死亡证猝死心脏/流行病学表格和记录管理心脏病/分类法心脏病/死亡率高血压/死亡率明尼苏达/流行病学试验预期值结果可重复性回顾性研究风湿性心脏病/死亡率敏感性与特异性时间因素人类

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Neonatal discharge and follow up

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TROPICAL DOCTOR 1999年第4期29卷 201-204页

作者： Manzar, S Sultan Qaboos Univ Hosp Dept Child Hlth Div Neonatol Muscat Oman

Increased intensive care for low birth weight and premature infants has made it essential to establish a well-organized plan for neonatal discharge and follow up. The preventive medical goal is improved care and outco... 详细信息

关键词：出院后医疗发育障碍/预防和控制表格和记录管理婴儿出生时低体重婴儿早产病人出院人类婴儿新生

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Telemedical record documentation: a preliminary survey

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JOURNAL OF TELEMEDICINE AND TELECARE 1999年第Sup1期5卷 6-8页

作者： Huston, JL Artz Pathol D-65197 Wiesbaden Germany

Telemedical records are the weak link in telemedicine. With a number of medicolegal and reimbursement issues still unresolved, telemedical record documentation will be a critical piece of the puzzle when the patient's original legal medical record must be produced. A questionnaire was distributed to active telemedicine programmes in the USA to determine how interactive teleconsultations were being documented. Forty programmes completed the questionnaire. The responses indicated a lack of consistency and a need for documentation guidelines for telemedical records.

关键词：文献工作表格和记录管理病案/标准远程医学/组织和管理美国人类

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Ordering blood for the wrong patient - Getting inside the minds of ordering physicians

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MAYO CLINIC PROCEEDINGS 2003年第11期78卷 1337-1339页

作者： Moore, SB Foss, ML Mayo Clin & Mayo Fdn Div Transfus Med Rochester MN 55905 USA

Objective: To assess the impact on ordering errors when physicians stopped handwriting patient identifiers on requests for blood transfusion. Material and Methods: Physicians, frustrated by the amount of time required to complete paper forms to order blood, asked if the requirement for handwritten patient identifiers, which were in addition to such information "stamped" on blood requests, could be eliminated. We acquiesced to the request, modified the blood ordering forms accordingly, and continued to monitor ordering errors. Results: After elimination of the handwritten identifiers in 1997, ordering errors increased from an annual rate of 1 in 10,000 to 6 in 10,000 blood requests by late 1999. We alerted the clinicians by newsletter, and the rate decreased somewhat (3 in 10,000 requests). However, the error rate did not decrease to its previous level of 1 in 10,000 requests until mid-2001, about 2 1/2 years after reinstitution of the requirement for handwritten patient identifiers. Conclusion: An obligatory second entry of demographic identifiers on a blood order requires ordering physicians to carefully consider the identity of the patient receiving a transfusion and reduces the likelihood of transfusion of. an unintended recipient. Error management tools, such as a predetermined method for planning, reviewing, and documenting all changes, facilitate detection of trends and responses to corrective actions.

关键词： Academic Medical Centers Blood Transfusion Forms and Records Control Handwriting 医学科学研究中心输血表格和记录管理书写给药错误

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消化内科见习医学生临床思维及沟通能力的培养与探索

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现代医药卫生 2019年第3期35卷 462-464页

作者：梁凯孔维宗王迎春大连大学附属中山医院消化内科辽宁大连116001

目的探索培养见习医学生临床思维和医患沟通能力的方法,提高医学生分析和解决复杂问题的能力。方法将2016年3月至2017年11月在该科进行临床见习的124名本科生随机分成对照组和试验组,每组62名。对照组进行传统床旁教学,试验组除床旁教学... 详细信息

目的探索培养见习医学生临床思维和医患沟通能力的方法,提高医学生分析和解决复杂问题的能力。方法将2016年3月至2017年11月在该科进行临床见习的124名本科生随机分成对照组和试验组,每组62名。对照组进行传统床旁教学,试验组除床旁教学外,每次见习均进行1次病例讨论。通过病史采集与病例分析,评价见习学生临床思维能力,通过医患沟通技能评价(SEGUE)量表评价见习医学生医患沟通能力。结果试验组学生在课堂氛围活跃、师生关系、理论知识理解与应用实际结合、分析与解决问题方面认可度方面明显高于对照组,差异均有统计学意义(P<0.05)。试验组病史采集与病例分析评分的优良比例明显高于对照组,差异均有统计学意义(P<0.01)。2组学生SEGUE量表得分比较,差异有统计学意义(P<0.01)。结论床旁教学与启发式、讨论式的病例讨论相结合的教学模式是培养见习医学生临床思维与沟通能力的有效方法。

关键词：表格和记录管理病案数据收集病史采集病例讨论临床思维沟通能力

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Using a pharmacist's progress-note form to manage HIV pharmacotherapy

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AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY 1999年第5期56卷 420-421页

作者： Geletko, S Small, FJ Piñón, M Univ Rhode Isl Providence RI 02908 USA Vet Affairs Med Ctr Dept Pharm Providence RI 02908 USA Brigham & Womens Hosp Invest Drug Serv Boston MA 02115 USA Univ Texas Cooperat Pharm Program El Paso TX 79902 USA

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Circulating microRNAs: Novel biomarkers for esophageal cancer

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World Journal of Gastroenterology 2010年第19期 2348-2354页

作者： Sheng-Li Zhou Li-Dong Wang Cancer Research Center Xinxiang Medical UniversityXinxiang 453003Henan ProvinceChina Henan Key Laboratory for Esophageal Cancer Research Basic Medical CollegeZhengzhou UniversityZhengzhou 450052Henan ProvinceChina

Esophageal carcinogenesis is a multi-stage process, involving a variety of changes in gene expression and physiological structure change. MicroRNAs (miRNAs) are a class of small non-coding endogenous RNA molecules. Recent innovation in miRNAs profiling technology have shed new light on the pathology of esophageal carcinoma (EC), and also heralded great potential for exploring novel biomarkers for both EC diagnosis and treatment. Frequent dysregulation of miRNA in malignancy highlights the study of molecular...[第一段]

关键词： RNA 癌表格和记录管理工艺学食管肿瘤微RNAs 胰岛素肿瘤干细胞

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患者姓名差错2341例原因分析

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中国误诊学杂志 2009年第27期9卷 6689-6690页

作者：袁瑞良邓琼刘祖华郧阳医学院附属十堰市太和医院医务处湖北十堰442000

目的:通过对十堰市某"三甲"医院最近3 a《患者姓名更名登记簿》进行统计,分析患者姓名差错的原因,并总结出减少此类差错的对策,以减少此类差错带给患者、医院及社会的不利影响。方法:通过分析将差错归纳为六大类,运用频数统... 详细信息

目的:通过对十堰市某"三甲"医院最近3 a《患者姓名更名登记簿》进行统计,分析患者姓名差错的原因,并总结出减少此类差错的对策,以减少此类差错带给患者、医院及社会的不利影响。方法:通过分析将差错归纳为六大类,运用频数统计法进行统计,用Exe l计算分析。结果:前四项为医院可控因素,占94.53%,后二项为医院不可控因素,占5.46%。结论:既然可控因素近95%,那么医院通过加强管理,可以将绝大部分此类差错克服掉,为此可挽回大量的损失和浪费。

关键词：表格和记录管理

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癌症患者电子疼痛护理记录单的设计与应用

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临床医药文献电子杂志 2016年第48期3卷 9675-9676页

作者：蒋波黄美红成雄中国人民解放军第113医院

为了进一步规范癌痛患者的疼痛护理记录,全面体现疼痛治疗与护理过程,设计了癌症患者电子疼痛护理记录单。经过1年多的临床应用,取得了良好的效果。该记录单设计采用表格与文字书写相结合,全面记录疼痛评估、动态评分、阿片类药物与非... 详细信息

为了进一步规范癌痛患者的疼痛护理记录,全面体现疼痛治疗与护理过程,设计了癌症患者电子疼痛护理记录单。经过1年多的临床应用,取得了良好的效果。该记录单设计采用表格与文字书写相结合,全面记录疼痛评估、动态评分、阿片类药物与非药物镇痛措施、用药信息、药物不良反应观察与记录、健康教育要点等信息,多单合一,既简化护士记录、减轻护士工作量,又能够直观、动态、简明、全面反映疼痛治疗和护理过程及控制效果,值得临床推广应用。

关键词：肿瘤疼痛护理记录表格和记录管理

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