一个多中心随机试验,以改善家庭临床笔记的访问和住院儿童的结果:床边笔记研究协议
Casey O'Hare1, Amanda K Gatewood1, Jennifer Baird2
1University of Wisconsin - Madison, Madison, Wisconsin, USA.
Journal of hospital medicine
|August 21, 2025
概括
床边笔记干预改善了护理人员对儿科医院笔记的访问,提高了患者安全和以家庭为中心的护理. 这项研究强调了在医院安全倡议中更好地参与护理人员的战略.
科学领域:
- 儿科医院的安全工作.
- 家庭为中心的护理.
- 医疗信息学 医疗信息学
背景情况:
- "2021年治疗法"使护理人员能够访问儿科医疗记录.
- 目前,不到10%的护理人员在住院期间访问笔记.
- 实时笔记审查可以识别安全问题并提高儿科患者的安全性.
研究的目的:
- 为了评估床边笔记干预对护理人员笔记访问的影响.
- 评估对护理人员激活,医院经验,安全问题报告和焦虑的影响.
- 识别实施护理人员笔记访问的障碍和促进者.
主要方法:
- 这是一项为期5年的多站点随机对照试验,涉及600名护理人员和30名医院工作人员.
- 11岁以下儿童的照顾者随机分配到通常的照顾或床边笔记干预.
- 干预包括通过平板电脑,指导视频和词汇表实时访问笔记;通过EHR审计,调查和采访衡量结果.
主要成果:
- 据假设,床边笔记干预可以显著增加护理人员的笔记访问.
- 预计在护理人员激活,医院经验和安全问题报告方面有所改善.
- 没有预期的护理人员焦虑的增加.
结论:
- 床边笔记的干预显示了改善儿童医院安全的护理人员参与的希望.
- 结果将为以家庭为中心的护理和减少错误的可扩展策略提供信息.
- 加强护理人员对医疗笔记的访问对于患者安全至关重要.
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