加護病房評估疾病嚴重度之資料正確性

Accuracy of Data Used to Assess Severity of Illness in Intensive Care Patients

陶阿倫(Alan Ronald Talbot) ； 許天成(Tien-Cheng Hsui)

《醫療品質》 2卷1期 (2000/03) Pp. 13-18

摘要

自民國八十五年十月起，我們專注於APACHE資料的正確性。評分系統由早期完全人工登記轉換成電腦化的表格，再改進至由電腦程式直接讀取實驗室檢驗結果並評分。在三個月的過渡期中，人工及電腦化資料收集系統同步，所有的表格均查驗其正確性，全部表格只有46%無錯誤。發現的錯誤包括：由病歷抄錄資料錯誤（38%），表格評分錯誤（45%），及電腦鍵盤輸入錯誤（18%）。其中評分及加總的錯誤可由電腦化解決，多項檢驗值及含氧量計算的問題可在電腦聯線直接獲得檢驗結果後解決，餘下五個項目（心跳速率、體溫、呼吸速率、血壓及Glasgow Coma Scale）需人工記錄。未來經由病房監測器直接獲得前四項之資料，將只剩GCS需人工作業。

關鍵字

疾病嚴重度 ； 結果監測 ； 正確性

並列摘要

From October 1996, our department concentrated on the accuracy of data collected for the APACHE scoring systems. An earlier completely manual recording system was converted to computerized forms, then partially automated by reading and scoring laboratory data directly. During the change over period of three months, the two systems were maintained in parallel, and all data entry forms were checked for accuracy. The results included all possible types of error: incomplete retrieval of data from charts (especially for multiple laboratory values) 24%, transposition of digits 8%, keyboard mistakes 18%, incorrect scoring 44%, and incorrect summation of total score 2%. Only 46% of forms had no errors at all. The errors of incorrect scoring and summation were solved by computerization. The problem of multiple laboratory values and oxygen calculations were solved when the laboratory data became available on line. The remaining five items (heart rate, temperature, respiratory rate, blood pressure, and Glasgow Coma Score) remain as manually entered items with the problems of data entry. In the future, we hope to access the bedside monitors for the first four of these, leaving only the GCS data to be entered manually.

並列關鍵字

severity of illness ； outcomes monitoring ； APACHE II ； accuracy