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护士对某国家三级医院电子病历中“复制粘贴”功能安全使用的认知与建议

Nurses' Perceptions and Recommendations on the Safe Use of "Copy and Paste" Function in an Electronic Medical Record of a National Tertiary Hospital.

作者信息

Rosales Neil Roy B, Reyes Clemarl Salvador M, Lugay Marie May F

机构信息

Philippine General Hospital, University of the Philippines Manila.

出版信息

Acta Med Philipp. 2025 Jun 13;59(7):13-26. doi: 10.47895/amp.vi0.9685. eCollection 2025.

Abstract

BACKGROUND AND OBJECTIVES

This study at a national tertiary hospital in Manila, Philippines investigated the use of the "Copy and Paste" Function (CPF) within their Electronic Medical Record (EMR). While CPF has benefits and risks, little is known about its usage patterns and impact on patient safety at the institution. This study explores nurses' perceptions and recommendations on CPF use in this hospital's EMR, assessing its prevalence, impact on patient safety, associations between prevalence and impact, and providing usage recommendations.

METHODS

A sequential explanatory research design was employed using surveys and semi-structured interviews. Ethical clearance was obtained before data collection. Instruments were adapted from similar studies and have undergone expert validation. Content validity was confirmed, and internal consistency was acceptable (Cronbach's Alpha = 0.77). Stratified random sampling determined the respondents per area. Data analysis included descriptive statistics, Spearman's rho, and thematic analysis.

RESULTS

The survey (n = 256) showed CPF use by nurses and doctors, and was confirmed by semi-structured interviews (n = 9). Nurses generally perceived CPF's impact on documentation as neutral (40.17%), leaning towards positive impact. Interviews supported this, revealing both "challenges" and "benefits" of CPF use as themes after thematic analysis. There was no statistically significant association between perceived CPF prevalence and its perceived impact on patient safety (p = 0.164). The theme "considerations for safe CPF use" also emerged from the analysis.

CONCLUSION

This study found mixed perceptions on CPF's impact in healthcare. There is a call to continue its use, but safety measures must be implemented first. Recommendations include order verification, caution, practice standardization, selective CPF usage, additional technological features, and alternative documentation methods. A governance structure to manage EMR-related issues, such as unsafe CPF practices, is also recommended to ensure proper monitoring and response.

摘要

背景与目的

本研究在菲律宾马尼拉的一家国立三级医院开展,调查了电子病历(EMR)中“复制粘贴”功能(CPF)的使用情况。虽然CPF有其益处和风险,但对于该机构中其使用模式以及对患者安全的影响却知之甚少。本研究探讨了护士对该医院EMR中CPF使用的看法和建议,评估其使用 prevalence、对患者安全的影响、使用 prevalence 与影响之间的关联,并提供使用建议。

方法

采用了顺序解释性研究设计,运用问卷调查和半结构化访谈。在数据收集前获得了伦理批准。研究工具借鉴了类似研究并经过专家验证。内容效度得到确认,内部一致性可接受(克朗巴哈系数=0.77)。分层随机抽样确定了每个区域的受访者。数据分析包括描述性统计、斯皮尔曼等级相关系数和主题分析。

结果

调查(n = 256)显示护士和医生都使用CPF,半结构化访谈(n = 9)也证实了这一点。护士普遍认为CPF对文档记录的影响为中性(40.17%),倾向于积极影响。访谈支持了这一点,主题分析后揭示了CPF使用的“挑战”和“益处”这两个主题。CPF使用 prevalence 与对患者安全的感知影响之间没有统计学上的显著关联(p = 0.164)。分析还出现了“安全使用CPF的注意事项”这一主题。

结论

本研究发现对CPF在医疗保健中的影响存在不同看法。有人呼吁继续使用,但必须首先实施安全措施。建议包括医嘱核实、谨慎使用、实践标准化、选择性使用CPF、增加技术功能以及替代文档记录方法。还建议建立一个管理与EMR相关问题(如不安全的CPF操作)的治理结构,以确保进行适当的监测和应对。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/d648/12257558/e2f8a8367416/AMP-59-7-9685-g001.jpg

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