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临床信息系统:即时可用的普遍临床数据,用于减少差错并改善临床结局。

Clinical information systems: instant ubiquitous clinical data for error reduction and improved clinical outcomes.

作者信息

Feied Craig F, Handler Jonathan A, Smith Mark S, Gillam Michael, Kanhouwa Meera, Rothenhaus Todd, Conover Keith, Shannon Tony

机构信息

Institute for Medical Informatics, 110 Irving Street, NW, Washington, DC 20010, USA.

出版信息

Acad Emerg Med. 2004 Nov;11(11):1162-9. doi: 10.1197/j.aem.2004.08.010.

Abstract

Immediate access to existing clinical information is inadequate in current medical practice; lack of existing information causes or contributes to many classes of medical error, including diagnostic and treatment error. A review of the literature finds ample evidence to support a description of the problems caused by data that are missing or unavailable but little evidence to support one proposed solution over another. A primary recommendation of the Consensus Committee is that hospitals and departments should adopt systems that provide fast, ubiquitous, and unified access to all types of existing data. Additional recommendations cover a variety of related functions and operational concepts, from backups and biosurveillance to speed, training, and usability.

摘要

在当前医疗实践中,即时获取现有临床信息的能力不足;现有信息的缺失导致或促成了许多类别的医疗差错,包括诊断和治疗差错。对文献的回顾发现,有充分证据支持对因数据缺失或无法获取而导致的问题的描述,但几乎没有证据支持某一种提议的解决方案优于另一种。共识委员会的一项主要建议是,医院和科室应采用能够提供对所有类型现有数据的快速、普遍和统一访问的系统。其他建议涵盖了从备份和生物监测到速度、培训和可用性等各种相关功能和操作概念。

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