Security interventions are frequently undocumented in emergency department clinical notes

Area of Science:

• Emergency Medicine
• Healthcare Security
• Patient Safety

Background:

• Security interventions are vital in emergency departments (ED) for managing patient behavior.
• Effective documentation of these interventions is crucial for patient safety and interdisciplinary communication.
• Previous studies have not comprehensively compared documentation across clinical notes and security records.

Purpose of the Study:

• To compare the documentation of security interventions in emergency department (ED) presentations between clinical notes and security records.
• To assess the completeness of security intervention documentation in electronic health records.

Main Methods:

• A retrospective study analyzed 680 alcohol-related ED presentations at a tertiary hospital in Queensland, Australia (April 2016 - August 2017).
• Data on security interventions (observation, de-escalation, physical restraint) were manually extracted from clinical notes and the security service database.
• Manual extraction and comparison of documented security interventions between the two data sources.

Main Results:

• Security interventions were documented in the security database for 41 presentations.
• Of these, only 20 (48.8%) had corresponding documentation in the clinical notes.
• Patients requiring security interventions had significantly higher hospital admission rates (73.2%) compared to those who did not (26.8%).

Conclusions:

• Less than half of security interventions in ED presentations were documented in clinical notes.
• Improving the documentation of security interventions in clinical notes is essential for optimizing risk management and ensuring the safety of patients, staff, and visitors.
• Enhanced documentation strategies are needed to support multidisciplinary team communication and patient safety throughout the care continuum.