尽量减少电子健康记录中患者医嘱不匹配的情况。
Minimizing electronic health record patient-note mismatches.
机构信息
Department of Biomedical Informatics, Columbia University Medical Center, New York, New York 10032, USA.
出版信息
J Am Med Inform Assoc. 2011 Jul-Aug;18(4):511-4. doi: 10.1136/amiajnl-2010-000068. Epub 2011 Apr 12.
Abstract
We measured the prevalence (or rate) of patient-note mismatches (clinical notes judged to pertain to another patient) in the electronic medical record. The rate ranged from 0.5% (95% CI 0.2% to 1.7%) before a pop-up window intervention to 0.3% (95% CI 0.1% to 1.1%) after the intervention. Clinicians discovered patient-note mismatches in 0.05-0.03% of notes, or about 10% of actual mismatches. The reduction in rates after the intervention was statistically significant. Therefore, while the patient-note mismatch rate is low compared to published rates of other documentation errors, it can be further reduced by the design of the user interface.
摘要
我们测量了电子病历中患者记录不匹配（被判断为涉及其他患者的临床记录）的发生率（或比率）。在弹出窗口干预之前，该比率范围为 0.5%（95%CI 0.2%至 1.7%），干预后降至 0.3%（95%CI 0.1%至 1.1%）。临床医生在 0.05%至 0.03%的记录中发现了患者记录不匹配，或者说大约发现了实际不匹配的 10%。干预后比率的下降具有统计学意义。因此，虽然与已发表的其他文档错误率相比，患者记录不匹配率较低，但通过用户界面的设计可以进一步降低该比率。
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