将待办实验室列表自动化为出院总结
Khanh T Nguyen1, Chukwunedum Aniemeka2, Nia Feaster3
1Section of Hospital Medicine, University of Chicago Department of Medicine, Chicago, Illinois, USA knguyen@bsd.uchicago.edu.
BMJ open quality
|December 12, 2025
概括
自动化待处理的实验室结果排放总结显著改善了文档. 这项质量改进倡议通过确保关键测试结果得到有效沟通,提高了急性护理过渡后的患者安全.
科学领域:
- 医疗信息学 医疗信息学
- 患者安全 患者安全
- 提高质量 提高质量
背景情况:
- 在急性护理后的过渡期间,未完成的测试结果的不完整沟通可能会导致患者受伤和诊断错误.
- 启动了一项质量改进倡议,以评估待处理的实验室结果自动化成排放总结的影响.
研究的目的:
- 评估一个自动化系统的有效性,以传达待处理的实验室和病理学结果.
- 改善患者出院期间待办的测试的文档和后续工作.
主要方法:
- 一个"SmartLink"工具被集成到EpicCare电子健康记录中,以自动将悬而未决的研究填充到出院摘要中.
- 进行了对2个月排放遭遇的前后审查,以比较实施前后的文档化率.
主要成果:
- 出院摘要中提到所有待办实验室的比例显著增加,从干预前的26.9%增加到干预后的90.4% (p<0.01).
- 虽然后续说明中报告异常结果的频率显示出显著的趋势,但在总体报告率上没有观察到任何差异.
结论:
- 自动化将待办的研究纳入下放总结,大大提高了这些关键结果的文档.
- 需要进一步努力,以应对急症后护理过渡的复杂性,并确保收到和跟进待定测试通讯.
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