Moreland Patty J, Gallagher Sue, Bena James F, Morrison Shannon, Albert Nancy M
Nursing Informatics, Cleveland Clinic, OH 44195, USA.
Comput Inform Nurs. 2012 Feb;30(2):97-103. doi: 10.1097/NCN.0b013e318224b54e.
Nurses' perceptions of electronic medication administration record documentation versus medication administration record documentation over time in workload, teamwork, ease of documentation, drug information accuracy, patient safety, and overall satisfaction are not well understood. Using survey methods and a longitudinal design, nurses administering medications completed the Nursing Satisfaction with eMAR instrument anonymously after electronic medication administration record implementation and at 3 and 6 months. Data were analyzed using comparative and correlational statistics, and analysis-of-variance models used to complete multivariable regression. Participants were 719 nurses: baseline, n = 389; 3 months, n = 213; and 6 months, n = 117. Electronic medication administration record documentation was associated with perceived improvement in overall nurse satisfaction, workload, teamwork, ease of documentation, drug information accuracy, and patient safety across time periods (all P < .001) and in trends across time, (all P < .001). After regression, electronic medication administration record satisfaction improved across time periods (all P < .02), with the greatest improvement between baseline and 6-month follow-up (P < .001). An electronic medication administration record documentation system is associated with overall nurse satisfaction and perceptions of improvement in workload, teamwork, ease of documentation, drug information accuracy, and patient safety but not nurse/pharmacy communication. Since timeliness and accuracy of nurse/pharmacy communication remain key components to safe and timely medication administration and documentation, nurse and pharmacy personnel should develop alternate systems of communication.
护士对于电子给药记录文档与传统给药记录文档在工作量、团队协作、文档记录便捷性、药物信息准确性、患者安全以及总体满意度方面随时间变化的认知尚不清楚。采用调查方法和纵向设计，给药护士在电子给药记录实施后、3个月及6个月时匿名完成《电子给药记录护理满意度》问卷。使用比较和相关统计方法分析数据，并采用方差分析模型进行多变量回归分析。参与者为719名护士：基线期，n = 389；3个月时，n = 213；6个月时，n = 117。电子给药记录文档与各时间段内护士总体满意度、工作量、团队协作、文档记录便捷性、药物信息准确性及患者安全方面的感知改善相关（所有P <.001），且在各时间段的趋势上也相关（所有P <.001）。回归分析后，各时间段内电子给药记录满意度均有所提高（所有P <.02），基线期与6个月随访期之间改善最为显著（P <.001）。电子给药记录文档系统与护士总体满意度以及工作量、团队协作、文档记录便捷性、药物信息准确性和患者安全方面的改善感知相关，但与护士/药房沟通无关。由于护士/药房沟通的及时性和准确性仍然是安全及时给药及文档记录的关键要素，护士和药房人员应开发替代沟通系统。
