The associations of information system’s support and nurses' documentation competence with the detection of documentation-related errors: Results from a nationwide survey

Abstract

The use of information systems and electronic documentation has become a central part of a nurse’s work, and it is expected to increase the quality of documentation and patient safety. However, errors related to documentation have been identified as a significant risk for the quality and safety of care. This study examined whether information system’s support for documentation and nurses' documentation competence are associated with how frequently nurses detect documentation-related errors that have caused an adverse event. A nationwide survey was conducted in 2020, and a total of 3610 nurses participated. Results from linear regression analyses showed that high documentation support from the information system and high documentation competence were associated with fewer detected documentation-related errors. Nurses with low documentation support from the system and low documentation competence detected the most errors. The results highlight the need to develop electronic health record functions in a way that they better support accurate documentation. Furthermore, organisations should invest in ensuring the documentation skills of nurses and providing appropriate training.

Type and Number of Errors of the Iranian Electronic Health Record (SEPAS) in Hospitals Affiliated with Mashhad University of Medical Sciences

“…The errors that occur in the SEPAS system are mostly due to the mistakes of the hospital information system users. Based on the World Health Organization, data entry is always associated with user-related errors; therefore, continuous prevention and correction of errors are emphasized [5]. The major supporting evidence of this study is the large sample size and the investigation of SEPAS system errors in 26 hospitals affiliated with MUMS that were connected to the SEPAS system.…”

Dampak Penggunaan Dokumentasi Keperawatan Elektronik terhadap Keselamatan Pasien: A Literature Review

“…Lima dari tujuh studi melaporkan, pendokumentasian berbasis elektronik berimplikasi terhadap peningkatan keselamatan pasien. Studi yang ada menunjukkan bahwa, dukungan sistem informasi, sarana prasarana serta kompetensi yang baik dari perawat dalam penggunaan dokumentasi keperawatan elektronik mampu meningkatkan keselamatan pasien, bermanfaat dalam menjamin perawatan dan pengobatan yang aman, mengurangi kesalahan pengobatan, meningkatkan kelengkapan data, meningkatkan keberlanjutan data, mengurangi kesalahan perawat dalam proses pendokumentasian, meningkatkan komunikasi dalam menyampaikan informasi yang diperlukan, serta efektif mencegah kesalahan dalam proses serah terima (Gita Wardani et al, 2022;Kaihlanen et al, 2021;Ausserhofer et al, 2021;Tubaishat, 2019;Pandya et al, 2019).…”

“…Studi yang ada menyoroti bahwa, sistem informasi dan kompetensi yang rendah dalam catatan berbasis elektronik meningkatkan kesalahan pendokumentasian, kesalahan entri data, serta terdapat kekhawatiran masalah privasi, kerahasiaan dan keamanan data pasien. Selain itu, sering terjadinya gangguan pada sistem pencatatan elektronik mengubah alur kerja dan pola komunikasi, meningkatkan beban kerja perawat, yang akhirnya meningkatkan potensi ancaman terhadap keselamatan pasien (Kaihlanen et al, 2021;Bani Issa et al, 2020;Tubaishat, 2019;Dudding et al, 2018). Penelitian sebelumnya telah menyoroti peningkatan insiden keselamatan terkait penggunaan catatan kesehatan elektronik (Palojoki et al, 2017).…”

Documenting Perioperative Care in the Electronic Health Record

“…31 Clinical support resources involving online information and software tools 23 (eg, links to relevant policies and procedures, informational messages, images) that are available at the point of care can help nurses avoid documentation errors. 12…”