混合电子记录:针对不同医疗处方格式的减少错误策略

IF 1.2 Q2 MEDICINE, GENERAL & INTERNAL South African Family Practice Pub Date : 2024-06-07 DOI:10.4102/safp.v66i1.5845
Carl-Heinz Kruse, Michelle T. D. Smith, Damian L. Clarke
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引用次数: 0

摘要

背景:该项目是南非夸祖鲁-纳塔尔省(KZN)眼科新电子登记系统开发工作的一部分。该登记册应包括一个临床决策支持系统,以减少人为错误的可能性,并应适用于我们的各种医院,无论是电子健康记录(EHR)还是纸质记录:方法:纳入 2019 年和 2020 年连续白内障手术出院者的术后处方。所选的四家克州国立医院各有不同的药物处方系统,这为比较提供了便利:电子、勾选单、墨水印章和手写健康记录。将错误类型与医院系统进行比较,以确定容易纠正的错误。通过四个步骤寻找潜在的错误补救措施:结果:1661 份处方中共有 1307 个错误,分为 20 种错误类型。技术水平的提高并没有降低错误率,但却减少了错误类型的多样性。高技术处方的错误率最高,但如果剔除容易纠正的错误,电子病历的错误率最低,手写的错误率最高:结论:提高技术本身似乎并不能减少处方错误。然而,技术似乎确实降低了潜在错误类型的可变性,从而使许多错误更容易纠正:贡献:定期审核是大大减少处方错误的有效工具,技术水平越高,这些审核干预措施就越有效。利用混合电子登记系统打印正式医疗记录,可以将这一优势转移到纸质记录上。
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Hybrid electronic record: An error reduction strategy for diverse medical prescription formats
Background: This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based.Methods: Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process.Results: There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest.Conclusion: Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct.Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record.
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来源期刊
South African Family Practice
South African Family Practice MEDICINE, GENERAL & INTERNAL-
CiteScore
1.50
自引率
20.00%
发文量
79
审稿时长
25 weeks
期刊介绍: South African Family Practice (SAFP) is a peer-reviewed scientific journal, which strives to provide primary care physicians and researchers with a broad range of scholarly work in the disciplines of Family Medicine, Primary Health Care, Rural Medicine, District Health and other related fields. SAFP publishes original research, clinical reviews, and pertinent commentary that advance the knowledge base of these disciplines. The content of SAFP is designed to reflect and support further development of the broad basis of these disciplines through original research and critical review of evidence in important clinical areas; as well as to provide practitioners with continuing professional development material.
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