Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Australia.
Int J Nurs Stud. 2011 Aug;48(8):1024-38. doi: 10.1016/j.ijnurstu.2011.05.009. Epub 2011 Jun 12.
Communication practices of healthcare professionals have been strongly implicated in the cascade of events that unfold into poor outcomes for surgical patients. The purpose of this paper is to explore the role of documents and documentation in communication failure among healthcare professionals across the perioperative pathway. The perioperative pathway consists of 3 interconnecting, but geographically distinct domains: preoperative, intraoperative and postoperative.
A comprehensive search of the literature was undertaken to provide a focused analysis and appraisal of past research.
Electronic databases searched included the Cochrane Database of Systematic Reviews, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline and PsycINFO from 1990 to end February 2011. Additionally, references of retrieved articles were manually examined for papers not revealed via electronic searches.
Content analysis was used to draw out major themes and summarise the information.
Fifty-nine papers were selected based on their relevance to the topic. The results highlight that documentation such as surgeons' operation notes, anaesthetists' records and nurses' perioperative notes, deficient in the areas of design, quality, accuracy and function, contributed to the development of communication failure among healthcare professionals across the perioperative pathway. The consequences of communication failure attributable to documentation ranged from inefficiency, delays and increased workload, through to serious adverse patient events such as wrong site surgery. Documents that involve the coordination of verbal communication of multidisciplinary surgical teams, such as preoperative checklists, also influenced communication and surgical patient outcomes.
Effective communication among healthcare professionals is vital to the delivery of safe patient care. Multiple documents utilised across the perioperative pathway have a critical role in the communication of information essential to the immediate and ongoing care of surgical patients. Failure in the communicative function of documents and documentation impedes the transfer of information and contributes to the cascade of events that results in compromised patient safety and potentially adverse patient outcomes.
医疗保健专业人员的沟通实践已被强烈暗示与手术患者结果不佳的事件链有关。本文旨在探讨文件和文档在手术患者围手术期路径中医疗保健专业人员沟通失败中的作用。围手术期路径由三个相互连接但地理位置不同的领域组成：术前、术中、术后。
对文献进行了全面搜索，以对过去的研究进行重点分析和评估。
电子数据库搜索包括 Cochrane 系统评价数据库、护理学和联合健康文献累积索引（CINAHL）、Medline 和 PsycINFO，检索时间从 1990 年到 2011 年 2 月底。此外，还手动检查了检索到的文章的参考文献，以查找电子搜索未显示的文章。
使用内容分析法提取主要主题并总结信息。
根据与主题的相关性，选择了 59 篇论文。结果表明，在设计、质量、准确性和功能方面存在缺陷的文档，如外科医生的手术记录、麻醉师的记录和护士的围手术期记录，导致了围手术期路径中医疗保健专业人员之间的沟通失败。由于文档导致的沟通失败的后果从效率低下、延迟和工作量增加，到严重的不良患者事件，如错误的手术部位，不一而足。涉及多学科手术团队口头沟通协调的文档，如术前检查表，也会影响沟通和手术患者的结果。
医疗保健专业人员之间的有效沟通对安全患者护理的提供至关重要。围手术期路径中使用的多种文档在沟通对手术患者即时和持续护理至关重要的信息方面发挥着关键作用。文档和文档在沟通功能方面的失败会阻碍信息的传递，并导致事件链的发生，从而危及患者安全并可能导致不良的患者结果。
