混合电子记录:用于各种医疗处方格式的错误减少策略
Carl-Heinz Kruse1, Michelle T D Smith, Damian L Clarke
1Department of Ophthalmology, School of Clinical Medicine, University of KwaZulu-Natal, Durban. ruraleye@gmail.com.
在眼科中实施电子健康记录 (EHR) 最初并没有减少处方错误,但减少了错误类型. 定期审计是减少错误的关键,尤其是在采用更高技术的情况下.
科学领域:
- 眼科医生 眼科 眼科
- 医疗信息学 医疗信息学
- 患者安全 患者安全
背景情况:
- 南非克瓦祖鲁纳塔尔州正在开发一个新的眼科电子注册表.
- 该注册表旨在整合一个临床决策支持系统,以尽量减少人为错误.
- 它必须能够适应各种医院系统,包括电子健康记录 (EHR) 和纸质记录.
研究的目的:
- 分析不同医院处方系统的白内障手术出院处方错误.
- 确定不同技术水平对处方错误率和类型的影响.
- 提出减少眼科处方错误的策略.
主要方法:
- 分析了2019-2020年白内障手术出院的处方.
- 数据来自KwaZulu-Natal的四家州立医院,使用不同的处方系统 (电子,标记纸,墨水盖章,手写).
- 错误被分类,在各个系统中进行比较,并确定了潜在的补救措施.
主要成果:
- 在1661份处方中,共发现1307个错误,分为20个类别.
- 技术水平的提高并没有降低整体错误率,但减少了错误的多样性.
- 电子健康记录 (EHR) 在删除容易纠正的错误后显示出最低的错误率,而手写记录显示出最高的错误率.
结论:
- 技术本身并不能显著减少处方错误,但可以减少错误的变化,简化纠正.
- 定期的审计有效地减少了处方错误,在更高的技术水平上影响更大.
- 混合电子注册表可以将审计的好处扩展到纸质系统.
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