Accuracy in documentation - a study of peripheral venous catheters.

Area of Science:

• Medical Device Management
• Patient Safety
• Clinical Documentation

Background:

• Inadequate documentation of peripheral venous catheters (PVCs) poses risks to patient safety.
• Previous studies have not examined factors influencing PVC documentation or insertion site descriptions.

Purpose of the Study:

• To assess the completeness of postinsertion peripheral venous catheter (PVC) documentation in medical records.
• To identify the terminology used for PVC insertion sites and factors affecting documentation.

Main Methods:

• A cross-sectional study involving 933 adult inpatients with PVCs across university and general hospitals.
• Data collected included PVC insertion site, hand, lumen size, patient demographics, and medical record documentation.
• Logistic regression analysis was used to identify factors associated with documentation.

Main Results:

• Only 71.8% of PVCs had any documentation, with 46.2% including site, hand, and lumen size.
• Ten different descriptions were used for PVC insertion sites.
• Documentation was more likely in general hospital medical wards and for smaller (22 gauge) PVCs.

Conclusions:

• Peripheral venous catheter (PVC) documentation in medical records is notably low and lacks standardization.
• General hospital medical wards and smaller PVC lumen sizes are associated with more complete documentation.
• Standardized terminology and enhanced nurse education are recommended to improve PVC documentation.