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[JAMA最新发表]:限制电子病历记录同时打开记录数对错误医嘱的影响:一项随机临床试验
2019年05月17日 时讯速递, 进展交流 暂无评论

Original Investigation May 14, 2019

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial

Jason S. Adelman, Jo R. Applebaum, Clyde B. Schechter, et al

JAMA. 2019;321(18):1780-1787. doi:10.1001/jama.2019.3698

Abstract

Importance 背景

Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation.

美国的推荐意见建议将电子病历记录(EHR)一次显示的患者记录数目限制为1,尽管仅有很少的证据支持这一推荐意见

Objective 目的

To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently.

评估EHR配置中限制医生同时打开的患者记录数目为1和4时错误医嘱的风险

Design, Setting, and Participants 试验设计,场景和研究对象

This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings.

这项随机临床试验于2015年10月至2017年4月,在纽约州的一家大型医疗中心的急诊科、住院部及门诊部进行,3356名临床医生参加。

Interventions 干预措施

Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687).

临床医生按照1:1的比例接受随机分组,分别为EHR配置限制同时打开1名患者记录(限制组;n = 1669)或允许同时打开4名患者记录(非限制组;n = 1687)。

Main Outcomes and Measures 主要预后指标

The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient).

分析单元为医嘱组,即医生为一名患者开具的一系列医嘱。主要预后指标为错误医嘱撤销重开系统(发现医生为某位患者开具医嘱,随后撤销,然后很快为另外一名患者开具同样医嘱)发现的包括1个或以上错误医嘱的医嘱组。

Results 结果

Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions.

接受随机分组的3356名临床医生(平均[SD]年龄,43.1 [12.5]岁;在研究中心平均工作年限,6.5 [6.0]岁;1894名女性[56.4%])均提供了医嘱数据,并纳入分析。研究纳入对543490名患者开具的4486631个医嘱组,共包括12140298个医嘱。限制组和非限制组每100000个医嘱组中错误医嘱并无显著差异(90.7 vs 88.0; 比数比 [OR], 1.03 [95% CI, 0.90-1.20]; P = .60), 在不同场所中错误医嘱也无显著拆(ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; 住院部: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; 或门诊部: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71)。上述效果在不同场所中并无差异(交互作用P = .99)。在非限制组,66.2%的医嘱组在打开1名患者记录的情况下开具,包括ED 34.5%,住院部53.7%,及门诊部83.4%。

Conclusions and Relevance 结论与意义

A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors.

与允许同时打开4名患者记录的策略相比,限制临床医生仅能打开1名EHR患者记录的策略不能减少错误医嘱比例。然而,非限制组的临床医生在打开一名患者记录的情况下开具了很多医嘱,从而影响了本研究的效力,即确定减少开具医嘱时开放记录数能否减少错误医嘱的风险。

Trial Registration 试验注册

clinicaltrials.gov Identifier: NCT02876588

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