Background

Reusing routinely recorded data from electronic hospital records (EHR) may offer a less-time consuming, and more real time alternative for monitoring compliance by nurses with a protocol for the safe preparation and administration of injectable medication. However, at present it is unknown if the data necessary to calculate the quality indicators (QIs) are recorded in EHRs, or if these data are suitable for automated QI calculation. Therefore, the aim of this study was to determine the feasibility of monitoring compliance by nurses with a protocol for the safe injectable medication preparation and administration by reusing routinely recorded EHR data for the automated calculation of QIs.

Methods

A cross-sectional study in 12 Dutch hospitals (October 2015–May 2016). The checks included in the currently prevailing national protocol for the safe preparation and administration of injectable medication were translated into 16 data elements required to calculate the QIs. At each hospital, one interview was conducted using a structured questionnaire to decide whether the data elements were available in EHRs. To present these results, descriptive statistics were used.

Results

In total, 20 health-care professionals were interviewed and four different EHR systems were evaluated. The availability of data elements was comparable between the four evaluated EHR systems. Nine of the 16 required data elements were recorded in EHRs, eight in a structured format. The seven missing data elements were mainly related to checks such as ‘gather all materials needed’ or ‘conduct hand hygiene’. Furthermore, changes were identified in the process for the preparation and administration of injectable medication. These changes are mostly related to the increased use of electronic medication administration registration and barcode medication administration systems.

Conclusions

Reusing EHR data to monitor compliance by nurses with the currently prevailing protocol for the safe preparation and administration of injectable medication is not entirely feasible. A decision should be made on which checks should be recorded in the EHRs and which checks should be audited in order to minimize the registration burden for nurses. Moreover, the currently prevailing protocol should be revised to bring it in line with work-as-done. Our results can be used as guidance for such a revision and also for designing new QIs that can be calculated by reusing routinely recorded EHR data.

中文翻译：

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重复使用常规记录的数据以监测可注射药物的安全制备和给药的可行性：一项多中心横断面研究。

背景

重用电子医院记录（EHR）中的常规记录数据可以为护士提供一种安全，可注射药物的管理方案，以减少监控系统的依从性，从而减少耗时，并提供更多实时性。但是，目前尚不清楚在EHR中是否记录了计算质量指标（QI）所需的数据，或者这些数据是否适合自动QI计算。因此，本研究的目的是通过重新使用常规记录的EHR数据来自动计算QIs，来确定用安全的可注射药物制备和给药方案监控护士依从性的可行性。

方法

在荷兰的12家医院进行的横断面研究（2015年10月至2016年5月）。当前流行的国家协议中关于安全制备和管理可注射药物的检查已转换为计算QI所需的16个数据元素。在每家医院，都使用结构化的问卷进行了一次访谈，以确定电子病历中是否有数据元素。为了呈现这些结果，使用了描述性统计数据。

结果

总共采访了20位医疗保健专业人员，并对四种不同的EHR系统进行了评估。四个评估的EHR系统之间的数据元素可用性相当。在EHR中记录了16个所需数据元素中的9个，以结构化格式记录了8个。缺少的七个数据元素主要与检查有关，例如“收集所有需要的材料”或“进行手卫生”。此外，在制备和给药药物的过程中发现了变化。这些变化主要与电子药物管理注册和条形码药物管理系统的使用增加有关。

结论

重复使用EHR数据来监视护士对当前流行的安全制备和注射药物治疗方案的依从性并不完全可行。为了减少护士的注册负担，应决定在电子病历中应记录哪些检查，并对哪些检查进行审核。此外，应修订当前流行的议定书，使其与完成的工作保持一致。我们的结果可以用作修订的指导，还可以用于设计可以通过重用常规记录的EHR数据来计算的新QI。