Department of Laboratory Medicine, UW Medicine, Seattle, Washington, USA.
J Am Med Inform Assoc. 2019 Mar 1;26(3):269-272. doi: 10.1093/jamia/ocy170.
Many point-of-care laboratory tests are manually entered into the electronic health record by ambulatory clinic staff, but the rate of manual transcription error for this testing is poorly characterized. Using a dataset arising from a duplicated workflow that created a set of paired interfaced and manually entered point-of-care glucose measurements, we found that 260 of 6930 (3.7%) manual entries were discrepant from their interfaced result. Thirty-seven of the 260 (14.2%) errors were discrepant by more than 20% and included potentially dangerous mistranscriptions. An additional 37 (14.2%) errors were due to inclusion of non-numeric characters. Staff-entered result flags deviated from the result flag generated in the laboratory information system in 5121 of 6930 (73.9%) pairs. These data demonstrate that clinically significant discrepancies for clinic-entered point of care results occurred at a rate of approximately 5 per 1000 results and they underline the importance of interfacing instruments when feasible.
许多即时检测实验室测试由门诊诊所工作人员手动输入到电子健康记录中，但这种测试的手动转录错误率描述得很差。使用源自复制工作流程的数据集中的一组配对接口和手动输入的即时检测葡萄糖测量值，我们发现 6930 个手动条目中有 260 个（3.7%）与接口结果不一致。260 个错误中有 37 个（14.2%）相差超过 20%，包括潜在危险的误传。另有 37 个（14.2%）错误是由于包含非数字字符。在 6930 对中的 5121 对（73.9%）中，工作人员输入的结果标志与实验室信息系统中生成的结果标志不同。这些数据表明，临床显著的诊所输入即时护理结果差异率约为每 1000 个结果中有 5 个，这突显了在可行的情况下接口仪器的重要性。
