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Charting errors in a teaching hospital
Savithiri Ratnapalan1, Kristen Brown, Peter Cieslak
1Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. savithiri.ratnapalan@sickkids.ca
Pediatric Emergency Care
|February 21, 2012
Summary
New medical trainees make more charting errors in July. Audits and reminders significantly reduced these errors, improving documentation quality.
Area of Science:
- Medical Education
- Healthcare Quality Improvement
Background:
- Junior trainees often exhibit higher charting error rates at the start of the academic year.
- Incomplete medical documentation poses risks to patient care and hospital efficiency.
Purpose of the Study:
- To assess charting errors made by junior medical trainees in the emergency department.
- To evaluate the effectiveness of audits and reminders in reducing these charting errors.
Main Methods:
- Retrospective review of medical records from June and July 2006 to identify charting errors.
- Implementation of an intervention (audits and reminders) in July 2007 and subsequent record review.
Main Results:
- The mean charting error rate was significantly higher in July (24%) compared to June (17%).
- Following the intervention in July 2007, the mean charting error rate decreased to 14%.
Conclusions:
- A notable increase in charting errors occurs with new trainees starting in July.
- Simple interventions like reminders and alerts can effectively reduce charting errors in medical documentation.
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