Lichtner Valentina, Wilson Stephanie, Galliers Julia R
Centre for Human Computer Interaction Design, City University, Northampton Square, London, UK.
Health Informatics J. 2008 Jun;14(2):141-50. doi: 10.1177/1081180X08089321.
The correct identification of a patient's health record is the foundation of any safe patient record system. There is no building of a ;patient history', no sharing or integration of a patient's data without the retrieval and matching of existing records. Yet there can often be errors in this process and these may remain invisible until a safety incident occurs. This article presents the findings of an ethnographic study of patient identification at a walk-in centre in the UK. We offer a view of patient identifiers as used in practice and show how seemingly simple data, such as a person's name or date of birth, are more complex than they may at first appear and how they potentially pose problems for the use of integrated health records. We further report and discuss a dichotomy between the identifiers needed to access health records and the identifiers used by practitioners in their everyday work.
正确识别患者的健康记录是任何安全的患者记录系统的基础。如果没有检索和匹配现有记录，就无法建立“患者病史”，也无法共享或整合患者数据。然而，这一过程中经常会出现错误，这些错误可能在安全事件发生之前都不为人所知。本文介绍了在英国一家无需预约的医疗中心对患者身份识别进行的人种学研究结果。我们展示了实际使用中的患者标识符，并说明看似简单的数据，如姓名或出生日期，实际上比初看起来更为复杂，以及它们如何可能给综合健康记录的使用带来问题。我们还进一步报告并讨论了访问健康记录所需的标识符与从业者日常工作中使用的标识符之间的二分法。
