Journal article
Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information
Journal of the American Medical Informatics Association : JAMIA, Vol.20(2), pp.245-251
03/01/2013
DOI: 10.1136/amiajnl-2012-000894
PMCID: PMC3638178
PMID: 22822042
Abstract
Objective 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.
Details
- Title: Subtitle
- Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information
- Creators
- Gail Keenan - University of Illinois at ChicagoElizabeth Yakel - University of Michigan–Ann ArborKaren Dunn Lopez - University of Illinois at ChicagoDana Tschannen - University of Michigan–Ann ArborYvonne B. Ford - Western Michigan University
- Resource Type
- Journal article
- Publication Details
- Journal of the American Medical Informatics Association : JAMIA, Vol.20(2), pp.245-251
- Publisher
- Oxford Univ Press
- DOI
- 10.1136/amiajnl-2012-000894
- PMID
- 22822042
- PMCID
- PMC3638178
- ISSN
- 1067-5027
- eISSN
- 1527-974X
- Number of pages
- 7
- Grant note
- R01 HS01 5054 02 / Agency for Healthcare Research and Quality; United States Department of Health & Human Services; Agency for Healthcare Research & Quality R01NR012949 / NATIONAL INSTITUTE OF NURSING RESEARCH; United States Department of Health & Human Services; National Institutes of Health (NIH) - USA; NIH National Institute of Nursing Research (NINR) R01HS015054 / AGENCY FOR HEALTHCARE RESEARCH AND QUALITY; United States Department of Health & Human Services; Agency for Healthcare Research & Quality
- Language
- English
- Date published
- 03/01/2013
- Academic Unit
- Nursing
- Record Identifier
- 9984370658102771
Metrics
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