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首页> 外文期刊>BMC Medical Informatics and Decision Making >Assessment of an electronic patient record system on discharge prescribing errors in a Tertiary University Hospital
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Assessment of an electronic patient record system on discharge prescribing errors in a Tertiary University Hospital

机译：第三大学医院排放规定误差的电子患者记录系统评估

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Prescribing error represent a significant source of preventable harm to patients. Prescribing errors at discharge, including omission of pre-admission medications (PAM), are particularly harmful as they frequently propagate following discharge. This study assesses the impact of an educational intervention and introduction of an electronic patient record (EPR) in the same centre on omission of PAM at discharge using a pragmatic design. A survey of newly qualified doctors is used to contextualise findings. Discharge prescriptions and discharge summaries were reviewed at discharge, and compared to admission medicine lists, using a paper-based chart system. Discrepancies were noted, using Health Information and Quality Authority guidelines for discharge prescribing. An educational intervention was conducted. Further review of discharge prescriptions and discharge summaries took place. Following introduction of an EPR, review of discharge summaries and discharge prescriptions was repeated. A survey was administered to recently qualified doctors (interns), and analysed using descriptive statistics and thematic analysis. Omission of PAM as prescribed or discontinued items at discharge occurs frequently. An educational intervention did not significantly change prescribing error rates (U?=?1255.5, p?=?0.206). EPR introduction did significantly reduce omission of PAM on discharge prescribing (U?=?694, p??0.001), however there was also a reduction in the rate of deliberate discontinuation of PAM at discharge (U?=?1237.5, p?=?0.007). Survey results demonstrated that multiple sources are required to develop a discharge prescription. Time pressure, access to documentation and lack of admission medicine reconciliation are frequently cited causes of discharge prescribing error. This study verified passive educational interventions alone do not improve discharge prescribing. Introduction of EPR improved discharge prescribing, but negatively impacted deliberate discontinuation of PAM at discharge. This is attributable to reduced access to key sources of information used in formulating discharge prescriptions, and separation of the discontinuation function from the prescribing function on the EPR discharge application.
机译：规定误差代表了对患者可预防损害的重要来源。放电时的规定误差，包括省略预处理预备药物（PAM），特别是常规在放电后经常繁殖。本研究评估了教育干预和引入电子患者记录（EPR）在同一中心使用务语设计时遗漏的申请。对新合格的医生的调查用于上下文的调查结果。使用纸张的图表系统，在放电时审查了放电处方和放电摘要，并与入院药物清单进行比较。注意到差异，使用健康信息和优质管理机构进行排放处方指南。进行了教育干预。进一步审查放弃处方和出院摘要。在引入EPR之后，重复审查放电摘要和放电处方。向最近合格的医生（实习生）进行调查，并使用描述性统计和主题分析进行分析。经常出院时的规定或已停止物品的遗漏。教育干预没有显着改变规定错误率（U？=？1255.5，P？= 0.206）。 EPR简介在放电处方（U？=α694，p≤x≤0.001）下显着减少了PAM遗漏的遗漏，但是在放电时审计停止率的速度也存在降低（U？= 1237.5，P ？=？0.007）。调查结果表明，需要多种来源来开发排放处方。时间压力，获取文档和缺乏入学医学和解是频繁的放电规定误差的原因。这项研究验证了被动教育干预单独改善排放处方。 EPR引入改善放电处方，但对拟PAM的故意停药进行负面影响。这是可归因的，以减少对配方中使用的信息的关键源的访问，以及从EPR放电应用中的处方功能的中断功能的分离。

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