Discussion on establishing a surgical complications recording system using homepage of medical records / 中华医院管理杂志

ABSTRACT

Objective To establish an adverse event monitoring system in the course of encoding medical record homepages, using the internationally accepted Clavien-Dindo surgical complications grading standard, for the purpose of hospital′s medical safety management. Methods The surgical complications record system was established based on encoded medical record homepages. Data of three types of medical therapies of the discharge cases of a tertiary hospital in 2017 were studied and the incidence, type and grading of the surgical complications were analyzed, to identify doctors′missed diagnoses. Results A total of 588 surgical complications were detected from the discharge cases throughout the year. The incidence of surgical complications was 1.1% (588/52 319). The highest proportions of all surgical complications were infection and surgical incision problems. Grade Ⅱ complications accounted for the highest incidence rate (41.5% , 244/588); the proportion of missed surgical complications at the initial homepage was 62.2% (366/588), most of which being as grade Ⅱ complications ( 42.1% , 154/366). Conclusions The hospital adverse event monitoring system established based on the encoded medical record homepages features unified standard, making it feasible and universal, which serves an important role of the medical adverse event reporting system.