基于质控评审的住院患者围手术期死亡病例分析

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中图分类号：R197.323 文献标识码：A

Analysis of Perioperative Death Cases among Inpatients BasedonQuality Control Review/NIRuyang，WANG Jing，LIU Ninghong.// Chinese HealthQualityManagement，2026，33（1） ：33-38

Abstract Objective To conduct quality control review of perioperative death cases among inpatients and provide evidence for improving surgical qualityin hospitals.MethodsAretrospective analysis and qualitycontrolreview were performed on18 perioperative death cases identifiedatacertain hospital from December1，2023，toNovember 30，2024.

Results The perioperative mortality rate among inpatients at this hospital was 0.52% . In the quality evaluation of the front page of medical records，the most prominent issue was the omision of other surgeries and procedures （204号 （72.22% ）. In the evaluation of medical records documentation quality，the highest proportion of defects was the lack of analysis of examination and test results in the progress notes （94.44% ）.In the evaluation of the implementation of core systems， the primary problem was the failure to implement the preoperative discusson system （55.56% ）. In the evaluation of the standardization of key diagnostic and treatment processes before，during，and after surgery，the defects with the highest proportions were the absence of alternative surgical plans （27.78% ），severe complications directly resulting from improper surgical operations （22.22% ），and deficiencies in postoperative condition assessment （38.89% ），respectively.ConclusionDeficiencies were identified in the perioperative death cases among inpatients at this hospital in terms of medical records management，implementation ofcore systems，preoperative assessment and preparation，intraoperative operation and management，and postoperative condition assessment and treatment. Itis recommended to strengthen preoperative assessment，optimize anesthesia management，improve surgical technical skills，enhance postoperative management and monitoring，and establish a long-term mechanism for surgical quality management to reduce perioperative mortality and elevate the level of medical quality and safety.

Keywords Inpatients；Perioperative Period;Death Cases；Medical Quality;Medical Safety First-author'saddress BeijingGeriatric Hospital，Beijing，lOoo95，China

现代外科中围手术期管理的重要性已远远超过手术操作本身[1]。（剩余8760字）