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自动扩展软件提示减少了电子医院出院信中的缩写使用:一项介入前后观察性研究
Shamus Toomath1, Emily J Hibbert2,3
1Royal Prince Alfred Hospital, Camperdown, Sydney, Australia. stoo4541@uni.sydney.edu.au.
BMC medical informatics and decision making
|May 1, 2025
概括
实施自动扩展促使电子放电信 (eDL) 中的缩写使用大幅减少. 这种干预措施提高了在护理过渡期间的沟通清晰度和患者安全.
科学领域:
- 医疗信息学 医疗信息学
- 医疗保健通讯 医疗保健通讯
- 患者安全 患者安全
背景情况:
- 在医疗保健中滥用缩写导致错误的沟通和全球患者的不良结果.
- 电子放电信 (eDL) 容易出现与缩写有关的模两可.
- 减少缩写的使用对于改善患者护理过渡至关重要.
研究的目的:
- 评估自动扩展提示的有效性,以减少eDLs中的缩写使用.
- 评估技术辅助干预措施对临床文档清晰度的影响.
- 改善医院医生和社区医疗保健提供者之间的沟通准确度.
主要方法:
- 在第三级医院进行了干预前后的观察性研究.
- 初级医务人员 (JMO) 接受了关于缩写风险的教育,并接受了关于Cerner Powerchart中11个常见缩写的自动扩展提示的培训.
- 在干预前和后进行了200 eDL审计,以测量缩写频率.
主要成果:
- 在eDL中使用缩写的数量在干预后下降了34.4%.
- 11个目标缩写中的9个缩写的频率显著下降,这些特定缩写的总体下降率为43.6%.
- 在经过审计的eDL中,发现的唯一缩写的总数从350个下降到1093个.
结论:
- 自动扩展提示,加上教育,提供了一种具有成本效益的方法,以减少eDLs中的缩写使用.
- 这种干预措施提高了患者护理过渡期间的沟通清晰度.
- 减少缩写错误可能会最大限度地减少医疗错误,并提高患者的安全.
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