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电子健康记录中的错误发生率及类型:一项混合系统评价方案

Prevalence and types of errors in the electronic health record: protocol for a mixed systematic review.

作者信息

Kharko Anna, Hägglund Maria, Angelova Dafina, Scott Duncan Therese, Hagström Josefin, Hansford Kirralise, Hunt Joanne, Trolle Lagerros Ylva, Locher Cosima, McMillan Brian, Nivins Asha-Judy, Rosch Sophie Anna, Schwarz Julian, Simola Saija, Blease Charlotte

机构信息

Department of Women and Children's Health, Uppsala University, Uppsala, Sweden

Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK.

出版信息

BMJ Open. 2025 Jun 9;15(6):e098241. doi: 10.1136/bmjopen-2024-098241.

Abstract

INTRODUCTION

In countries with access to the electronic health record (EHR), both patients and healthcare professionals have reported finding errors in the EHR, so-called EHRrors. These can range from simple typos to more serious cases of missing or incorrect health information. Despite their potential detrimental effect, the evidence on EHRrors has not been systematically analysed. It is unknown how common EHRrors are or how they impact patients and healthcare professionals.

METHODS AND ANALYSIS

A mixed systematic review will be carried out to address the research gap. We will search PubMed, Web of Science and CINAHL for studies published since 2000, which report original research data on patient-identified and healthcare professional-identified EHRrors. We will analyse (1) the prevalence of EHRrors, (2) the types of EHRrors and (3) their impact on care. Quantitative and qualitative findings will be synthesised following the Joanna Briggs Institute Framework for Mixed Systematic Reviews. Identified studies will be critically appraised for meta-biases and risk of bias in individual studies. The confidence in the emerging evidence will be further assessed through the Grading of Recommendations Assessment, Development and Evaluation approach. Findings will be contextualised and interpreted involving an international team of patient representatives and practising healthcare professionals.

ETHICS AND DISSEMINATION

The study will not involve collection or analysis of individual patient data; thus, ethical approval is not required. Results will be published in a peer-reviewed publication and further disseminated through scientific events and educational materials.

PROSPERO REGISTRATION NUMBER

CRD42024622849.

摘要

引言

在可获取电子健康记录(EHR)的国家,患者和医疗保健专业人员都报告称在EHR中发现了错误,即所谓的电子健康记录错误(EHRrors)。这些错误范围从简单的拼写错误到更严重的健康信息缺失或错误情况。尽管它们可能产生有害影响,但关于电子健康记录错误的证据尚未得到系统分析。目前尚不清楚电子健康记录错误有多常见,以及它们如何影响患者和医疗保健专业人员。

方法与分析

将进行一项混合系统评价以填补这一研究空白。我们将在PubMed、科学网和护理学与健康领域数据库(CINAHL)中检索自2000年以来发表的研究,这些研究报告了关于患者识别和医疗保健专业人员识别的电子健康记录错误的原始研究数据。我们将分析(1)电子健康记录错误的发生率,(2)电子健康记录错误的类型,以及(3)它们对医疗护理的影响。将按照乔安娜·布里格斯研究所混合系统评价框架对定量和定性研究结果进行综合分析。对纳入的研究将针对元偏差和个别研究中的偏倚风险进行严格评估。将通过推荐分级评估、制定和评价方法进一步评估新出现证据的可信度。研究结果将结合国际患者代表和执业医疗保健专业人员团队进行背景化和解读。

伦理与传播

本研究不涉及收集或分析个体患者数据;因此,无需伦理批准。研究结果将发表在同行评审的出版物上,并通过科学活动和教育材料进一步传播。

PROSPERO注册号:CRD42024622849。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/94d6/12161391/329c3bf6fd55/bmjopen-15-6-g001.jpg

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