使用定制的基于网络的患者发生报告实现无纸化

John F. Dixon MSN, RN
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引用次数: 31

摘要

背景:贝勒大学医学中心(达拉斯)将患者发病报告从纸质表格转换为使用医疗中心内部网的定制的基于web的系统。开发基于web的系统非药物患者的发生被手工记录在称为事件报告的纸质表格上,并且药物差异以电子方式输入。该医疗中心多年来一直使用相同的纸质表格,没有任何临时更新或修改。由于收到表格的时间延迟了一个多星期,这一过程既不高效也不及时。此外,纸质表格有时难以辨认或不完整。启动项目项目团队,代表质量和护理协调和信息服务中心,决定最好的方法是基于系统功能的开发和设施的转换准备的分阶段实施。报告将按照10个标准化的患者发生报告类别进行。结果和评估:对使用web表单之前和之后的季度数据进行比较显示,提交的数量增加了83.5%,从事件到提交的时间减少了79.5%。Web表单还消除了纸质表单在易读性、完整性和安全性方面的限制。报告并将收集到的数据转化为可用的信息仍然是个人的责任,这将推动过程改进。技术可以对这些努力做出重要的贡献,但是组织的文化必须有一个完整的规划策略。重点必须转移到报告,作为质量和安全的基石,远离错误和责任的传统观念。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Going Paperless with Custom-Built Web-Based Patient Occurrence Reporting

Background

Baylor University Medical Center (Dallas) converted patient occurrence reporting from a paper form to a custom-built Web-based system that used the medical center’s intranet.

Developing the Web-based system

Nonmedication patient occurrences were documented manually on paper forms known as incident reports, and medication variances were entered electronically. The medical center had used the same paper form for many years, without any interim updates or revisions. With a delay of more than a week in receiving forms, the process was not efficient or timely. In addition, paper forms were sometimes illegible or incomplete.

Launching the project

The project team, representing the Center for Quality and Care Coordination and information services, decided that the best approach would be a phased implementation based on development of system functionality and a facility’s readiness for conversion. Reporting was to be conducted in terms of 10 standardized patient occurrence reporting categories.

Results and evaluation

Comparison of quarterly data pre- and post-Web forms showed an 83.5% increase in number of submissions and a 79.5% reduction in event-to-submission time. Web forms also eliminated paper form limitations of legibility, completeness, and security.

Conclusion

It is still an individual responsibility to report and then transform collected data into usable information, which will drive process improvement. Technology can make an important contribution to these efforts, but the culture of the organization must have a complete program strategy. The focus must shift to reporting as a cornerstone to quality and safety and away from traditional notions of error and blame.

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