手术不良事件文档的自动化:提高完整性和准确性
Francis D Graziano1, Charles Z Jiang1, Bracha L Pollack1
1Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
概括
自动化外科二次事件 (SSE) 报告显著提高了不良事件 (AE) 文档的完整性和准确性. 该系统可以改善手术质量数据收集,特别是在轻微的AEs.
科学领域:
- 医疗信息学 医疗信息学
- 改善外科手术的质量
- 健康数据管理 管理健康数据
背景情况:
- 手动记录手术不良事件 (AE) 容易不完整和不一致.
- 准确的AE数据对于手术质量评估和患者安全至关重要.
研究的目的:
- 为了比较手术AE文档的完整性和准确性,手动报告和与手术次要事件 (SSE) 数据库连接的自动化系统之间的手术AE文档.
- 评估SSE自动报告对捕捉轻微和重大不良事件的影响.
主要方法:
- 对AE报告方法的回顾性比较.
- 手动报告队列 (2021年10月 - 2022年4月) 与自动报告队列 (2023年1月 - 2023年7月).
- 自动化队列中的AE通过结构化的注释链接的SSE数据库捕获;评估的结果是完整性和准确性.
主要成果:
- 随着自动报告,AE记录的完整性从20%大幅提高到94% (P < 0.001).
- 捕获小AE的数量从7%增加到96% (P < 0.001),主要AE的数量从29%增加到92% (P < 0.001).
- 自动化SSE报告显示,手术AE文档的完整性和准确性都得到了显著改善.
结论:
- 自动化SSE报告显著提高了外科手术不良事件记录的完整性和准确性.
- 该系统在改善捕获轻微不良事件方面特别有效.
- 这种方法支持更可靠的外科质量数据收集和患者安全倡议.
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