scholarly journals Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment

2016 ◽  
Vol 22 (4) ◽  
pp. 1055-1062
Author(s):  
Elizabeth Rebello ◽  
Spencer Kee ◽  
Alicia Kowalski ◽  
Nusrat Harun ◽  
Michele Guindani ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Safety Issue ◽  
Electronic Record ◽  
Time Out ◽  
Patient Safety Issue ◽  
Anesthesia Time ◽  
Over Time

Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined ( p < 0.0001) and at the off-site locations ( p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.

scholarly journals Improvement of patient safety through implementation of electronic medical records

2017 ◽  
Vol 1 (4) ◽  
pp. 111-112
Author(s):  
Elahe Gozali ◽  
Marjan Ghazisaiedi ◽  
Malihe Sadeghi ◽  
Reza Safdari
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Access To Health Care ◽  
Clinical Care ◽  
Drug Management ◽  
Bar Code

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

scholarly journals Validity and reliability of a medical record review method identifying transitional patient safety incidents in merged primary and secondary care patients’ records

BMJ Open ◽  
2018 ◽  
Vol 8 (8) ◽  
pp. e018576 ◽  
Author(s):  
Marije A van Melle ◽  
Dorien L M Zwart ◽  
Judith M Poldervaart ◽  
Otto Jan Verkerk ◽  
Maaike Langelaan ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Medical Records ◽  
Secondary Care ◽  
Information Transfer ◽  
Safety Issue ◽  
Medical Center ◽  
Medical Record Review ◽  
Measurement Tool ◽  
Record Review

ObjectiveInadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify transitional safety incidents (TSIs) for use in a large intervention study and assess its reliability and validity.DesignA retrospective medical record review study.Settings and participantsCombined primary and secondary care medical records of 301 patients who had visited their general practitioner and the University Medical Center Utrecht, the Netherlands, in 2013 were randomly selected. Six trained reviewers assessed these medical records for presence of TSIs.OutcomesTo assess inter-rater reliability, 10% of medical records were independently reviewed twice. To assess validity, the identified TSIs were compared with a reference standard of three objectively identifiable TSIs.ResultsThe reviewers identified TSIs in 52 (17.3%) of all transitional medical records. Variation between reviewers was high (range: 3–28 per 50 medical records). Positive agreement for finding a TSI between reviewers was 0%, negative agreement 80% and the Cohen’s kappa −0.15. The reviewers identified 43 (22%) of 194 objectively identifiable TSIs.ConclusionThe reliability of our measurement tool for identifying TSIs in transitional medical record performed by clinicians was low. Although the TSIs that were identified by clinicians were valid, they missed 80% of them. Restructuring the record review procedure is necessary.

scholarly journals Use of Continuous Infusion Pumps During Radiation Treatment

2013 ◽  
Vol 9 (2) ◽  
pp. 107-111 ◽  
Author(s):  
Kate Bak ◽  
Eric Gutierrez ◽  
Elizabeth Lockhart ◽  
Michael Sharpe ◽  
Esther Green ◽  
...  
Keyword(s):  
Patient Safety ◽  
Radiation Exposure ◽  
Continuous Infusion ◽  
Radiation Treatment ◽  
Safety Issue ◽  
Infusion Pumps ◽  
Additional Testing ◽  
Infusion Devices ◽  
Patient Safety Issue

The varied results of radiation exposure on infusion devices suggest that additional testing should be carried out to determine the limits of dose exposure, and to raise awareness around this patient safety issue.

scholarly journals Trends in antiepileptic drug treatment and effectiveness in clinical practice in England from 2003 to 2016: a retrospective cohort study using electronic medical records

BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e032551 ◽  
Author(s):  
Graham Powell ◽  
John Logan ◽  
Victor Kiri ◽  
Simon Borghs
Keyword(s):  
Cohort Study ◽  
Clinical Practice ◽  
Electronic Medical Records ◽  
Retrospective Cohort Study ◽  
Medical Records ◽  
Retrospective Cohort ◽  
First Line ◽  
Nice Guideline ◽  
Treatment Trends ◽  
Over Time

ObjectiveTo assess the evolution of antiepileptic drug (AED) treatment patterns and seizure outcomes in England from 2003 to 2016.Design, setting and participantsRetrospective cohort study of electronic medical records from Clinical Practice Research Datalink and National Health Service Digital Hospital Episode Statistics databases. Patients newly diagnosed with epilepsy were identified and followed until end of data availability. Three eras were defined starting 1 April 2003 (first National Institute for Health and Care Excellence (NICE) guideline); 1 September 2007 (Standard and New Antiepileptic Drugs publication); and 1 January 2012 (second NICE guideline).Outcome measuresTime from diagnosis to first AED; AED sequence; time from first AED to first 1-year remission period (no new AED attempts and no seizure-related healthcare events); time from first AED to refractoriness (third AED attempt regardless of reason); Kaplan-Meier analysis of time-to-event variables.Results4388 patients were included (mean follow-up: 6.8, 4.2 and 1.7 years by era). 84.6% of adults (≥16 years), 75.5% of children (<16) and 89.1% of elderly subgroup (65+) received treatment within 1 year; rates were generally stable over time. Treatment trends included reduced use of carbamazepine (adult first line, era 1: 34.9%; era 3: 10.7%) and phenytoin, earlier line and increased use of levetiracetam (adult first line, era 1: 2.6%; era 3: 26.2%) and lamotrigine (particularly in adults and elderly subgroup), and a larger number of different AEDs used. Valproate use shifted somewhat to later lines. Rates of 1-year remission within 2 years of starting treatment increased in adults (era 1: 71.9%; era 3: 81.4%) and elderly (era 1: 76.1%; era 3: 81.7%). Overall, 55.5% of patients relapsed after achieving 1-year remission. Refractoriness rates remained stable over time (~26% of adults within 5 years).ConclusionTreatment trends often were not aligned with era-relevant guidance. However, our results suggest a slight improvement in epilepsy treatment outcomes over the 13-year period.

scholarly journals NFC Based Electronic Medical Record

2019 ◽  
Vol 13 (03) ◽  
pp. 4
Author(s):  
Noor Cholis Basjaruddin ◽  
Edi Rakhman ◽  
Kuspriyanto Kuspriyanto ◽  
Mikhael Bagus Renardi
Keyword(s):  
Medical Record ◽  
Electronic Medical Records ◽  
Mobile Phones ◽  
Medical Records ◽  
Near Field ◽  
Near Field Communication ◽  
Important Data ◽  
Record System ◽  
Medical Record System ◽  
Beta Testing

Near Field Communication (NFC) technology enables mobile phones to store important data safely and reliably. The data can be sent to another phone equipped with NFC or read by NFC reader. Through special applications the data can also be added, subtracted, or modified. This NFC capability allows the phone to be developed into a device that can store important data such as e-money or electronic medical records. In this research has been developed medical record system based on Near Field Communication (NFC). The results of alpha and beta testing show that the developed application has good performance.

Use of first names among medical staff… a patient safety issue?

Heart ◽  
2020 ◽  
Vol 107 (2) ◽  
pp. 168-169
Author(s):  
Jonathan Hinton ◽  
Mark Signy
Keyword(s):  
Patient Safety ◽  
Medical Staff ◽  
Safety Issue ◽  
Patient Safety Issue

scholarly journals Mixed-methods feasibility study of blood pressure self-screening for hypertension detection

BMJ Open ◽  
2019 ◽  
Vol 9 (5) ◽  
pp. e027986 ◽  
Author(s):  
Alice Tompson ◽  
Susannah Fleming ◽  
Mei-Man Lee ◽  
Mark Monahan ◽  
Sue Jowett ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Mixed Methods ◽  
Medical Record ◽  
Electronic Medical Records ◽  
Feasibility Study ◽  
Medical Records ◽  
Alternative Methods ◽  
Hypertension Detection ◽  
Technical Problems ◽  
The Cost

ObjectiveTo assess the feasibility of using a blood pressure (BP) self-measurement kiosk—a solid-cuff sphygmomanometer combined with technology to integrate the BP readings into patient electronic medical records— to improve hypertension detection.DesignA concurrent mixed-methods feasibility study incorporating observational and qualitative interview components.SettingTwo English general practitioner (GP) surgeries.ParticipantsAdult patients registered at participating surgeries. Staff working at these sites.InterventionsBP self-measurement kiosks were placed in the waiting rooms for a 12-month period between 2015 and 2016 and compared with a 12-month control period prior to installation.Outcome measures(1) The number of patients using the kiosk and agreeing to transfer of their data into their electronic medical records; (2) the cost of using a kiosk compared with GP/practice nurse BP screening; (3) qualitative themes regarding use of the equipment.ResultsOut of 15 624 eligible patients, only 186 (1.2%, 95% CI 1.0% to 1.4%) successfully used the kiosk to directly transfer a BP reading into their medical record. For a considerable portion of the intervention period, no readings were transferred, possibly indicating technical problems with the transfer link. A comparison of costs suggests that at least 52.6% of eligible patients would need to self-screen in order to bring costs below that of screening by GPs and practice nurses. Qualitative interviews confirmed that both patients and staff experienced technical difficulties, and used alternative methods to enter BP results into the medical record.ConclusionsWhile interviewees were generally positive about checking BP in the waiting room, the electronic transfer system as tested was neither robust, effective nor likely to be a cost-effective approach, thus may not be appropriate for a primary care environment. Since most of the cost of a kiosk system lies in the transfer mechanism, a solid-cuff sphygmomanometer and manual entry of results may be a suitable alternative.

scholarly journals IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety

2016 ◽  
Vol 24 (2) ◽  
pp. 323-330 ◽  
Author(s):  
Alexandre Caron ◽  
Emmanuel Chazard ◽  
Joris Muller ◽  
Renaud Perichon ◽  
Laurie Ferret ◽  
...  
Keyword(s):  
Patient Safety ◽  
User Interface ◽  
Adverse Events ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Medical Procedures ◽  
Odds Ratios ◽  
Hand Column ◽  
Case Crossover ◽  
Interactive Tool

Background: The significant risk of adverse events following medical procedures supports a clinical epidemiological approach based on the analyses of collections of electronic medical records. Data analytical tools might help clinical epidemiologists develop more appropriate case-crossover designs for monitoring patient safety. Objective: To develop and assess the methodological quality of an interactive tool for use by clinical epidemiologists to systematically design case-crossover analyses of large electronic medical records databases. Material and Methods: We developed IT-CARES, an analytical tool implementing case-crossover design, to explore the association between exposures and outcomes. The exposures and outcomes are defined by clinical epidemiologists via lists of codes entered via a user interface screen. We tested IT-CARES on data from the French national inpatient stay database, which documents diagnoses and medical procedures for 170 million inpatient stays between 2007 and 2013. We compared the results of our analysis with reference data from the literature on thromboembolic risk after delivery and bleeding risk after total hip replacement. Results: IT-CARES provides a user interface with 3 columns: (i) the outcome criteria in the left-hand column, (ii) the exposure criteria in the right-hand column, and (iii) the estimated risk (odds ratios, presented in both graphical and tabular formats) in the middle column. The estimated odds ratios were consistent with the reference literature data. Discussion: IT-CARES may enhance patient safety by facilitating clinical epidemiological studies of adverse events following medical procedures. The tool’s usability must be evaluated and improved in further research.

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