Objective:To analyze the research hotspots and development trends in the field of clinical decision support in China,retrace the development pattern,and suggest the future research direction,with a view to improving the level of clinical decision support.Methods:Based on the CNKI database,relevant literature from 2012 to 2022 was searched,and CiteSpace software was used to conduct a scientific quantitative analysis of the literature and draw a knowledge graph.Results:A total of 950 CNKI articles were included,and the overall number of studies showed an increasing trend.The main research materials for clinical decision support came from electronic medical records,and the main technical means were data mining and data warehousing.The construction of knowledge bases showed a new development trend.Conclusion:Under the guidance of national policies and the support of new technologies,the knowledge base construction of clinical decision support systems shows an evolutionary trend from the traditional static knowledge base to the knowledge middleware,and from the generalization of general medicine to the specialization of single diseases.

目的:评价医院对医疗诉讼案件采取一系列质量控制措施后的效果.方法:利用中国裁判文书网以及2010年1月1日至2021年11月30日中国医学科学院北京协和医院作为被告或上诉人、关于医疗损害责任案由的生效判决文书,统计分析案卷中医院承担的赔偿责任比例、结案标的数额等要素.结果:2015年以来,医院承担无责或轻微责任案件数目比例逐步增加,尤其是从2019年开始,无责结果的案件数量比例以超过10％的幅度显著提升,案件数量和赔偿总额大幅度下降.结论:医院采取一系列加强诉讼过程质量控制措施确实能提高医院医疗损害赔偿责任中无责或轻微责任案件数目比例;通过聘用驻院律师团队,构建医法深度融合体系,能进一步降低医疗诉讼案件数量和赔偿总额,值得借鉴.

我国在推行医保支付方式改革的过程中,为驱动医疗机构主动进行精细化管理,建立与医保的激励约束机制,相关部门纷纷出台结余资金由医疗机构留用的有关政策.本文通过系统梳理相关规定并结合对部分地区的调研,提出完善结余留用政策的若干建议,旨在推动结余资金管理的合法合规和科学高效.

Peking Union Medical College Hospital has carried out the practical exploration of a new system of medical risk prevention and control based on the integration of medical and law, broken the traditional practice of legal counsel only handling medical disputes after the event, explored the pre-management and control mode of medical risks. The hospital established a whole process medical risk management mode in which legal counsel, medical administrators and clinical medical staff cooperated and participated, further standardized the medical behavior, legal concept and legal practice awareness of medical personnel, realized standardized management and formed a long-term mechanism. It could not only effectively integrate the fragmented clinical legal service needs and extensively enhance the sense of occupational security of clinical medical staff, but also effectively improve the operation quality of medical safety indicators and promote the high-quality development of the hospital.

目的 基于CiteSpace知识图谱对国内外非计划再手术研究主体、热点进行可视化分析.方法 以PubMed和中国知网数据库中2000—2020年非计划再手术文献为研究对象,运用CiteSpace 5.7软件对非计划再手术文献进行关键词共现分析、突现词分析、发文作者和研究机构分析.结果 共检索到有效的非计划再手术中文文献205篇,英文文献476篇.中文文献作者以三大研究团体为主,研究机构以医院为主;英文文献作者以两大研究团体为主,研究机构以高校和医院为主.中文和英文文献关键词共现分析分别得到5大聚类群,中文文献分别为原因分析、PDCA循环、产后出血、手术并发症和临床分析,英文文献分别为morbidity、fusion、administrative data、NSQIP、laparoscopy.中文和英文文献分别得到7个突现词,中文文献分别为手术并发症、腹部损伤、预防、分析、负性事件、再次手术、影响因素,英文文献分别为adverse event、management、quality、cardiac surgery、NSQIP、pediatric、surgical site infection.结论 相比于国外,国内非计划再手术研究作者和机构更为分散,合作更少,缺少跨区域研究.国内外非计划再手术研究热点主要从临床视角出发,管理学视角和经济学视角研究较少;研究前沿主要为从科室、手术原因角度对非计划再手术进行深入探讨.

Alongside the social and economic development in China, medical risks, economic risks, and legal risks rise as well in the management of public hospitals. However, the capabilities of these hospitals in prevention and control of medical risks and disposal of legal affairs fall far behind the increasingly complex legal affairs. In this consideration, the authors introduced their innovative practice in taking legal actions for prevention and control of medical risks in the hospital, analyzed the problems found in medical legal affairs, and put forward specific suggestions to promote the standardization and modernization of hospital legal affairs.

Objective To summarize the research trend with numerous publications on patient safety during the past 10 years and find out recent hot spot in this field. Methods Four thousands publications for the past 10 years focusing on patient safety were selected in the citation database of Web of Science. Bibliometric and visualization software named Citespace was utilized for co-existence analysis and burstness detection in analyzing key words and cited references. Results Organizations distributed in developed countries such as the United States, the United Kingdom accounts for the majority of publications. The most frequent key words in the research field of patient safety were care, adverse event, health care, error, quality etc. Newly emerged burstness turned to attitude question naire, experience, knowledge and patient safety culture etc. Conclusions A wide and in-depth series of studies in patient safety has been carried out from 2009 to 2019 especially in developed countries with a hot spot on patient safety culture. More studies from Chinese researchers on patient safety are warranted to form China's own experience.

医疗质量与患者安全是医院管理的永恒主题,通过绩效激励、引导临床科室的工作方向是医院管理的重要手段.北京协和医院建立的医疗绩效考核方案覆盖管理全程,包括医疗效率、医疗质控、患者安全管理、院感管理、医保管理和患者满意度等考核内容,实行按季度考核-反馈的绩效管理模式.经过几年的运行,起到了显著地管理效果,实现精细化管理.质量与安全管理考核方案的实施,既起到了对医院和科室管理效果的评价作用,也起到了管理风向标和指挥棒的引导作用.在全院范围内形成了人人有主动的安全意识,处处有量化目标的管理文化.

医疗质量管理是医院管理的核心问题,而医疗质量评价是其先导.在医疗质量管理的过程中,该研究者首先提出了医疗质量评价指标池(Medical Quality Indicator Pool,MQIP)的概念.MQIP的建设需注意普适性、个体化和不断改进的原则,并需与信息化的采集和分析方法.MQIP概念的提出、建设和改进能更全面、实时地反映医疗质量,促进医院健康持续发展.

医疗风险防控是医疗安全管理工作的重要内容之一.北京协和医院通过构建点面结合的风险防控体系,包括医疗风险哨点预警、风险评估和识别、风险的院科两级主动干预、以及风险的分担和转移等多种防控措施的综合应用,取得了良好效果,对于医疗纠纷的预防和患者安全的保障有积极作用.

知情告知不充分或医患沟通不足已成为引起医疗纠纷的重要原因之一.对于病情复杂的疑难病例或高风险手术等可能引发医疗纠纷的情况下,医疗机构可引导患者在律师见证下完成知情告知工作.由律师见证的知情告知,能够促进医务工作者充分地履行告知义务,保障了患者的知情同意权,加强了医患沟通的有效性,对于纠纷的预防有积极作用.北京协和医院近十年来共有2003例由律师见证的知情告知,均未出现重大医疗纠纷.因此,律师见证能够帮助患方充分了解各项医疗风险,同时也能够帮助医院提前进行风险防范,是对医患双方的一项有效预防保护措施.

目的 探索DRGs在医院医疗质量管理中的作用,为医院管理提供实证参考.方法 选取北京市某大型三甲医院,将DRGs组数、CMI、时间消耗指数、费用消耗指数4个DRGs相关指标纳入科室绩效考核,对医院近3年的统计数据进行分析描述.结果 医院疾病种类、疑难疾病占比增长明显,病案首页正确率明显提升.结论 将DRGs纳入医院绩效管理有助于促进医疗质量的提升与学科建设,但应持续关注病案首页质量,对罕见病应根据医院实际情况来调整.

Medical liability and technology screening mechanism are innovatively used.82 cases of medical disputes or adverse events in the past 5 years are retrospectively and systematically analyzed.The paper not only anlyzed the medical system defects,proposed improvement strategies,but also gives internal correction of different judicial identification case,to ensure sustainable development of medical technology.

目的 分析北京市某三级甲等医院住院超30天患者分布情况及其影响因素.方法 调取医院2017年1月1日-2017年12月31日期间住院天数超过30天患者的病案首页信息共2415例,进行回归分析.结果 超30天患者人数占全院总出院人数2.43％,中位数为55天,平均年龄为50岁;出院科室前五位依次是风湿免疫科、基本外科、感染内科、血液科、神经科;疾病类别前五位分别是肿瘤、骨胳肌肉系统和结缔组织疾病、循环系统疾病、消化系统疾病、某些传染和寄生虫病.住院次数、转归、ICD疾病分类、转科、手术及操作、医院感染是住院超30天的重要影响因素.结论 医院应对重点科室、重点病种加强管理,把握质控环节,有效控制术后并发症,避免发生医院感染,多渠道减少超长期住院患者,缩短平均住院日.

Informed consent is the embodiment of the patient's health and life right and personality right. Informed consent right based operation signature system in China has carried out since the 1980s and the main body of the signed has changed from family member to the patients himself. In recent years, with the introduction of the Tort Liability Act and the General Principles of Civil Law, some difficulties of operation signature in legal has been regulated but it still some troubles in practice needs to be further discussed to regulate this system.

目的 分析北京某三甲医院2016年度不良事件与患者安全隐患上报数据,发现不良事件管理的薄弱环节,并针对性提出改进建议.方法 采取回顾性分析法,搜集北京某三甲医院2016年度不良事件与安全隐患数据678例,分别从性别、年龄、科室、等级、类别、上报区域等角度进行分析.结果 患源性不良事件占比73.3％,远高于医源性不良事件,急诊科和麻醉科上报数量最多,病房和手术室发生不良事件较多,不同区域发生的不良事件等级有差异,病房和手术室发生不良事件级别较高,不同科室类别在医疗投诉和不良事件上报方面有差异.结论 加强医源性不良事件的上报意识,加强患者期望值管理和依从性管理,并关注手术室等不良事件高发科室.

Objective To explore the effective method to reduce the incidence of unplanned reoperation.Methods Patients who were hospitalized from January,2012 to December,2016 and underwent the surgery were actively monitored.Meanwhile,they had to be managed.The reports of unplanned reoperation were found,and statistical incidence and cause were obtained.Results There were 914 cases of unplanned reoperation in 225 944 cases.The average incidence rate was 0.40％,and there was a significant decreasing trend in the five years.Causes of unplanned reoperation were mainly infection of surgical site,dehiscence of the incision,incisional hernia or poor healing,postoperative bleeding,leakage or fistula,which accounted for 73.9％.Conclusion To improve the active surveillance and reporting system,to strengthen the management of two levels,including the hospital and the department,and to draw attention to reason analysis and the improvement that could effectively reduce the incidence of unplanned reoperation are needed.

To further enhance the connotative quality of medical records and inherit the traditional culture in Pecking Union Medical College Hospital on medical records writing with high standards and strict requirement,senior clinical experts were invited to participate in the expert team for medical record quality control.The evaluation criteria of the connotative quality of medical records were innovatively set,and the single veto for the plagiarism behavior of writing medical record was also involved.Using the connotative quality control of medical records as the core,a three levels framework of quality control had built with the full range of medical records quality management system between faculties and hospital.The excellent rate of connotative quality of medical records was improved from 64.95％ in the early stage of quality control by experts to 88.98％,which made the connotative quality control of medical records become a significant measure for medical quality.

广义的医疗纠纷是指患者及其家属在因伤病就医过程中与医疗机构及其医务人员之间产生矛盾而发生的分歧和纠纷，而狭义的医疗纠纷指局限于患者在就医过程中因为医务人员的治疗、护理等医疗行为而引发的分歧和纠纷［1］。目前，我国医疗纠纷呈现数量多、增长快、影响大的特点，医患矛盾突出，甚至有些医疗纠纷演变为恶性暴力事件，致使医患关系更为紧张，不利于医疗卫生行业的健康发展。

北京协和医院已开展近10年医疗责任险,其在分散和转移医疗风险方面取得了一定成效.然而结合医院运行数据,医疗责任险仍然存在投保额高、赔偿少、回款慢、限制多、程序繁琐、保险抗风险能力与医院投保初衷相分离等问题.基于此,提出建立医疗机构与医务人员分别投保医责险的制约机制、推动建立强制性医疗责任保险、建立医疗纠纷“保险—调解—评估—理赔”四位一体快速解决机制等建议.