Finnish Institute for Health and Welfare, Helsinki, Finland.
Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland.
Health Informatics J. 2021 Oct-Dec;27(4):14604582211054026. doi: 10.1177/14604582211054026.
The use of information systems and electronic documentation has become a central part of a nurse's work, and it is expected to increase the quality of documentation and patient safety. However, errors related to documentation have been identified as a significant risk for the quality and safety of care. This study examined whether information system's support for documentation and nurses' documentation competence are associated with how frequently nurses detect documentation-related errors that have caused an adverse event. A nationwide survey was conducted in 2020, and a total of 3610 nurses participated. Results from linear regression analyses showed that high documentation support from the information system and high documentation competence were associated with fewer detected documentation-related errors. Nurses with low documentation support from the system and low documentation competence detected the most errors. The results highlight the need to develop electronic health record functions in a way that they better support accurate documentation. Furthermore, organisations should invest in ensuring the documentation skills of nurses and providing appropriate training.
信息系统和电子文档的使用已经成为护士工作的核心部分,预计这将提高文档的质量和患者的安全性。然而,与文档相关的错误已被确定为护理质量和安全的重大风险。本研究考察了信息系统对文档的支持以及护士的文档编写能力是否与护士发现导致不良事件的文档相关错误的频率有关。2020 年进行了一项全国性调查,共有 3610 名护士参与。线性回归分析的结果表明,信息系统的高文档支持和高文档编写能力与检测到的文档相关错误较少有关。系统文档支持度低且文档编写能力低的护士检测到的错误最多。研究结果强调了需要以更好地支持准确文档的方式开发电子健康记录功能。此外,组织应投资于确保护士的文档技能并提供适当的培训。