Rebello Elizabeth, Kee Spencer, Kowalski Alicia, Harun Nusrat, Guindani Michele, Goravanchi Farzin
The University of Texas MD Anderson Cancer Center, USA
The University of Texas MD Anderson Cancer Center, USA.
Health Informatics J. 2016 Dec;22(4):1055-1062. doi: 10.1177/1460458215608901. Epub 2015 Oct 14.
Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined (p < 0.0001) and at the off-site locations (p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.
在错误的患者电子记录中进行开启和记录操作存在患者安全问题。作者调查了所报告错误的发生率，以及利用麻醉暂停和条形码技术的措施是否降低了围手术期环境中患者电子病历开启和记录错误的发生率。作者查询了2009年1月至2012年9月期间所有需要麻醉的手术和操作的数据库。在识别出的115,760份麻醉程序记录中，研究期间有57例记录开启和记录错误的情况。所有地点合并来看呈现下降趋势（p＜0.0001），非现场地点也是如此（p = 0.0032）。所有地点和非现场地点随着时间推移均呈现出具有统计学意义的错误下降模式。条形码技术和麻醉暂停在降低围手术期环境中患者记录错误开启的错误方面可能发挥重要作用。
