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使用电子文档模块来提高外科诊断报告的有效性
Cristina J Crippen1, Tyler J Loftus2, Christine Simmons3
1Department of Surgery, University of Florida, Gainesville, FL. Electronic address: https://twitter.com/cris_crippen.
Surgery
|August 7, 2024
概括
在COVID-19大流行期间,实施结构化外科报告改善了手术室的沟通和患者的安全. 这项质量改进倡议通过电子健康记录的整合,提高了汇报的有效性和问题的解决.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 手术沟通策略 手术沟通策略
- 患者安全研究的研究.
背景情况:
- 有效的手术室沟通对于患者的安全和结果至关重要.
- 结构化的汇报工具提高了团队协调,并解决了安全问题.
- 随着COVID-19大流行,面对面培训和用于外科简报的资源分配面临挑战.
研究的目的:
- 评估一种基于电子健康记录的方法,用于记录外科报告和解决发现的问题.
- 评估这项干预措施对解答事件发生率,感知有效性和通信循环关闭的影响.
- 根据与流行病相关的限制,调整外科手术汇报实践.
主要方法:
- 一个纵向的,重复措施的质量改进研究,利用新的电子健康记录模块进行报告文档.
- 进行了调查,以评估人们对汇报过程的看法.
- 在3个医院的3个医院塔的56个手术室收集了3年的数据 (截至2023年12月),使用4个计划-做-研究-行动周期.
主要成果:
- 手术报告的发生率增加了111%,到最后一年达到88%.
- 干预后的调查显示,解答会的感知有效性增加了 (52%对38%,P=.02).
- 讨论设备问题 (87%与75%,P=.008) 和闭环问题 (46%与34%,P=.03) 的频率显著增加,领导层参与度更大.
结论:
- 电子健康记录集成的汇报系统成功地提高了汇报的发生率和感知效率.
- 干预改善了沟通循环的关闭,尽管面临大流行挑战,但对团队沟通产生了积极的影响.
- 这种方法证明了一种可持续的方法,可以在资源有限的环境中增强外科安全沟通.
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