J Am Med Inform Assoc - Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

Tópicos

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Resumo

JECTIVE: To examine information flow, a vital component of a patient's care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement.DESIGN: This was a qualitative study of a sample of eight medical-surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staff's communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices.RESULTS: Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patient's electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication.CONCLUSION: The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patient's plan.

Resumo Limpo

jectiv examin inform flow vital compon patient care outcom sampl multipl hospit nurs unit uncov potenti sourc error opportun systemat improvementdesign qualit studi sampl eight medicalsurg nurs unit four divers hospit one us state conduct direct work observ nurs staff communic pattern entir shift h total h gather relat document artifact analys data code use qualit content analysi procedur synthes organ themat character current practicesresult three major theme emerg analys repres serious vulner flow patient care inform nurs handoff entir interdisciplinari team across time set three theme variat nurs document communic absenc central care overview patient electron health record ie easili access entir care team rariti interdisciplinari communicationconclus care inform flow vulner catalyst multipl type serious undetect clinic error two major recommend address gap standard format content word use document core inform plan care make easili access team member conduct extens usabl test ensur tool electron health record help disconnect interdisciplinari team member maintain share understand patient plan

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