Ismat Mohd Sulaiman, Awang Bulgiba, Sameem Abdul Kareem
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引用次数: 2
摘要
医学缩略语可能会被误解,危及患者的生命。本研究首次调查了英语广泛使用的马来西亚电子放电摘要中缩略语的流行情况,并引出了与危险缩略语相关的风险因素。我们随机抽取并人工标注了1102份电子放电摘要的缩略语及其含义。三名医生根据歧义缩写如果被误解可能对患者造成伤害的程度,给它们指定了危险等级。使用二元逻辑回归确定危险缩略语的预测因子。缩略语占总字数的19%(33824个);歧义缩略语占22.6% (7640);52.3%(115个)的歧义缩略语被标记为危险。当缩略语有两个以上的意思时,危险的风险就会增加(OR = 2.991;95% CI 1.586, 5.641),与用药相关(OR = 6.240;95% CI 2.674, 14.558),它们是疾病(OR = 7.771;95% CI 2.054, 29.409)和程序(OR = 3.492;95% ci 1.376, 8.860)。当缩略语局限于单一学科时,危险风险降低(OR = 0.519;95% ci 0.278, 0.967)。通过意识管理缩写并实现自动缩写检测和扩展将提高临床文档的质量、患者安全以及为次要目的提取的信息。
Prevalence and Risk Factors for Dangerous Abbreviations in Malaysian Electronic Clinical Notes.
Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We randomly sampled and manually annotated 1102 electronic discharge summaries for abbreviations and their senses. Three medical doctors assigned a danger level to ambiguous abbreviations based on their potential to cause patient harm if misinterpreted. The predictors for dangerous abbreviations were determined using binary logistic regression. Abbreviations accounted for 19% (33,824) of total words; 22.6% (7640) of those abbreviations were ambiguous; and 52.3% (115) of the ambiguous abbreviations were labelled dangerous. Increased risk of danger occurs when abbreviations have more than two senses (OR = 2.991; 95% CI 1.586, 5.641), they are medication-related (OR = 6.240; 95% CI 2.674, 14.558), they are disorders (OR = 7.771; 95% CI 2.054, 29.409) and procedures (OR = 3.492; 95% CI 1.376, 8.860). Reduced risk of danger occurs when abbreviations are confined to a single discipline (OR = 0.519; 95% CI 0.278, 0.967). Managing abbreviations through awareness and implementing automated abbreviation detection and expansion would improve the quality of clinical documentation, patient safety, and the information extracted for secondary purposes.
期刊介绍:
Evaluation & the Health Professions is a peer-reviewed, quarterly journal that provides health-related professionals with state-of-the-art methodological, measurement, and statistical tools for conceptualizing the etiology of health promotion and problems, and developing, implementing, and evaluating health programs, teaching and training services, and products that pertain to a myriad of health dimensions. This journal is a member of the Committee on Publication Ethics (COPE). Average time from submission to first decision: 31 days