Murphy Alison R, Reddy Madhu C
College of Information Sciences and Technology, The Pennsylvania State University, University Park, PA 16802, USA.
Department of Communication Studies, Northwestern University, Evanston, IL 60208, USA.
Int J Med Inform. 2017 Jun;102:93-102. doi: 10.1016/j.ijmedinf.2017.03.010. Epub 2017 Mar 24.
This study identifies the types of patient-related information problems (PIPs) that patient-care teams encounter during morning rounds, and how those PIPs are identified and managed. PIPs are any issues related to patient information (e.g., wrong, missing, incomplete information) that affect the patient-care team's ability to perform their work. Not addressing PIPs can lead to workflow challenges, delayed patient-care decisions, and negative impacts to the patient.
We employed qualitative data collection methods by shadowing patient-care teams during 29 morning rounds resulting in 155h of observation. We observed the interactions between the rounding physicians and other patient-care team members, including: nurses, consulting physicians, care coordinators, pharmacists, social workers, and therapists.
This study resulted in identifying seven types of PIPs that occur during morning rounds. Additionally, the study presents the different ways that participants identified and managed the PIPs.
We discuss the potential negative effects of PIPs on the patient-care workflow. We also discuss socio-technical recommendations for organizational policies and training, as well as electronic health record (EHR) design improvements that could help patient-care teams more effectively identify and manage PIPs.
Hospital teams rely on accurate, available, and up-to-date information in order to make informed decisions on patient care. However, PIPs exist in EHR systems, paper documents, and verbal conversations. This study identifies a set of PIPs and how they are currently being identified and managed.
本研究确定患者护理团队在早查房期间遇到的与患者相关的信息问题（PIPs）类型，以及这些PIPs是如何被识别和管理的。PIPs是指与患者信息相关的任何问题（例如，错误、缺失、不完整的信息），这些问题会影响患者护理团队开展工作的能力。不解决PIPs可能会导致工作流程挑战、患者护理决策延迟以及对患者产生负面影响。
我们采用定性数据收集方法，在29次早查房期间跟踪患者护理团队，观察时长共计155小时。我们观察了查房医生与其他患者护理团队成员之间的互动，包括：护士、会诊医生、护理协调员、药剂师、社会工作者和治疗师。
本研究确定了早查房期间出现的七种PIPs类型。此外，该研究还介绍了参与者识别和管理PIPs的不同方式。
我们讨论了PIPs对患者护理工作流程的潜在负面影响。我们还讨论了针对组织政策和培训的社会技术建议，以及电子健康记录（EHR）设计改进措施，这些措施有助于患者护理团队更有效地识别和管理PIPs。
医院团队依靠准确、可用和最新的信息来做出关于患者护理的明智决策。然而，PIPs存在于电子健康记录系统、纸质文档和口头交流中。本研究确定了一组PIPs以及它们目前的识别和管理方式。
