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目的通过对手术患者死亡病案缺陷及死亡原因分析,提升病历内涵质量,加强围手术期安全管理。方法选择2008年1-12月具备手术指征的外科住院死亡病案,分为择期手术、急诊手术和未手术死亡三类,分别由本专业专家审阅,重点为围手术期处理和死亡原因分析,找出重点问题,提出解决问题的建议。结果择期手术要加强术前脏器功能评估和术后并发症管理,急诊手术要加强绿色通道建设,未获得手术机会者应加强慢病管理。结论围手术期处理是外科患者治疗成功的关键,外科医生应加强全科及交叉学科的知识培训,提高急、危、重症的处理能力。
OBJECTIVE To improve the connotation and quality of medical records and enhance perioperative safety management through analysis of the death cases and death causes of surgical patients. Methods Surgical inpatient death cases with surgical indications from January to December in 2008 were divided into three categories: elective surgery, emergency surgery and non-operative death, which were reviewed by the experts respectively. The focus was on perioperative management and the cause of death, Out of focus, put forward proposals to solve the problem. Results Elective surgery to strengthen the assessment of preoperative function of organs and postoperative complications management, emergency surgery to strengthen the construction of green channel, without access to surgery should strengthen the management of chronic disease. Conclusion Perioperative management is the key to the success of surgical patients. Surgeons should strengthen knowledge training of general and interdisciplinary subjects to improve their ability to deal with acute, critical and severe diseases.