Anderson Jaclyn, Shroff Divya, Curtis Ann, Eldridge Noel, Cannon Katrina, Karnani Rajil, Abrams Thad, Kaboli Peter
Department of Veterans Affairs, VA Medical Center, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City, Iowa, USA.
Jt Comm J Qual Patient Saf. 2010 Feb;36(2):62-71. doi: 10.1016/s1553-7250(10)36012-0.
Few studies on the safety or efficacy of current patient handoff systems exist, and few standardized electronic medical record (EMR)-based handoff tools are available. An EMR handoff tool was designed to provide a standardized approach to handoff communications and improve on previous handoff methods.
In Phase I, existing handoff methods were analyzed through abstraction of printed handoff sheets and questionnaires of internal medicine residents at Department of Veterans Affairs medical centers (VAMCs). In Phase II, the handoff tool was designed, and the software was tested and revised through user feedback and regular conference calls. Phase III involved postimplementation systematic abstraction of printed handoff sheets and questionnaires of internal medicine residents. Two VAMCs participated in abstraction of printed handoff sheets, with four VAMCs responding to the questionnaires.
Handoffs were abstracted for 550 patients at baseline and 413 postimplementation. Improvements were found in consistency of information transfer for all handoff content, including code status, floor location, room number, two types of identifying information, typed format, medication, and allergy lists (p = .01). The 63 and 51 questionnaires completed pre- and postimplementation, respectively, showed improvement in perceptions of ease of use, efficiency, and readability (p < .05) and in perceptions of patient safety and quality (p < .01) without causing omission (p < .01) or commission of information (p = .02).
This standardized EMR-based handoff software improved data accuracy and content consistency, was well-received by users, and improved perceptions of handoff-related patient safety, quality, and efficiency. A final version of the software was incorporated into the national EMR software program and made available to all VAMCs.
目前关于患者交接班系统安全性或有效性的研究较少，且几乎没有基于标准化电子病历（EMR）的交接班工具。设计了一种EMR交接班工具，以提供标准化的交接班沟通方法，并改进以往的交接班方式。
在第一阶段，通过对退伍军人事务部医疗中心（VAMC）内科住院医师的打印版交接班记录单进行摘要分析以及问卷调查，分析现有的交接班方法。在第二阶段，设计交接班工具，并通过用户反馈和定期电话会议对软件进行测试和修订。第三阶段涉及对打印版交接班记录单进行实施后系统摘要分析以及对内科住院医师进行问卷调查。两个VAMC参与了打印版交接班记录单的摘要分析，四个VAMC对问卷进行了回复。
在基线时对550例患者的交接班情况进行了摘要分析，实施后为413例。在所有交接班内容的信息传递一致性方面均有改善，包括代码状态、楼层位置、房间号、两种识别信息、打印格式、用药和过敏清单（p = 0.01）。实施前和实施后分别完成的63份和51份问卷显示，在易用性、效率和可读性方面的认知有所改善（p < 0.05），在患者安全和质量方面的认知也有所改善（p < 0.01），且未导致信息遗漏（p < 0.01）或信息错误（p = 0.02）。
这种基于标准化EMR的交接班软件提高了数据准确性和内容一致性，受到用户好评，并改善了对与交接班相关的患者安全、质量和效率的认知。该软件的最终版本已纳入国家EMR软件程序，并提供给所有VAMC使用。
