实施电子护理记录对护理质量和安全指标的影响
Manel Chouchene Douma1,2, Mohamed Ben Rejeb2,3, Najet Zardoub4
1Department of Care, Sahloul University Hospital, Sousse, Tunisia.
The Libyan journal of medicine
|November 21, 2024
概括
在突尼斯,电子护理记录 (ENR) 改善了生命体征和输液管理的可追溯性. 然而,纸质文档显示了更好的团队间交付可追溯性,表明在医疗保健质量和安全方面需要加强ENR的领域.
科学领域:
- 医疗信息学 医疗信息学
- 护理信息学 护理信息学
- 提高医疗保健的质量 改善医疗保健的质量
背景情况:
- 电子健康记录 (EHR) 旨在提高护理质量,但护理文档仍然是一个挑战.
- 突尼斯正在采用电子医疗记录 (EMR) 系统,但护理文档在很大程度上是纸质的.
- 在突尼斯,之前还没有研究过电子护理文档对护理质量的影响.
研究的目的:
- 评估电子护理记录 (ENR) 对护理质量和安全指标 (QSCI) 的影响.
- 评估ENR实施在突尼斯大学医院环境中的影响.
主要方法:
- 一项使用准实验设计的干预研究,遵循StaRI原则.
- 通过文献审查和Delphi共识定义和验证了17个QSCI.
- 在ENR实施之前测量QSCI,一个月后,在干预和控制组中测量QSCI,并在干预和控制组中测量QSCI.
主要成果:
- 在ENR组观察到生命体征可追溯性 (p < 10−3) 和输液管理 (p = 0.027) 的显著改善.
- 纸质文档组显示了团队间交付的优越可追溯性 (ENR组的95.1%与71.9%相比).
- ENR的实施对特定的护理质量方面产生了积极的影响,但揭示了团队间沟通的差距.
结论:
- 电子护理文档对于患者安全至关重要,并代表了医疗保健的重大转变.
- 在突尼斯的一家医院环境中,ENR的实施在特定的QSCI,特别是可追溯性方面显示出好处.
- 需要对ENR系统进行进一步的改进,以应对诸如团队间交付文件等挑战.
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