Background

Omissions in nursing care can compromise patient safety. To date, this phenomenon has been investigated almost exclusively via nurse surveys. However, such surveys restrict the range of activities which can be assessed for omissions, and patient level analysis. As an alternative, retrospective chart review methodology has been used successfully in other research fields, but not yet for omitted nursing care.

Objectives

To describe characteristics and frequency of omitted nursing care using a retrospective chart review methodology.

Design, setting and participants

Observational single center study in two German neurological inpatient units. A random sample of 100 patient admissions was used.

Methods

A structured chart review protocol to detect nursing omissions was developed and applied. The full range of expected nursing care activities were assessed regarding the importance of documenting them and whether they had been fully or partially omitted. Vital sign measurements were assessed regarding both the measurement target number and the number of measurements recorded.

Results

In total, 1885 activities—a mean of 19 per patient—were identified. Of the reviewed activities, 52% (n = 971) were fully or partially omitted. Patients experienced between one and 22 omitted nursing care activities during their hospital stay (8–84% of expected care activities). Ranging from 6% to 100% some activities were more commonly omitted than others during admission. The most frequently omitted nursing activity was giving emotional care (88%, n = 66); the least frequently omitted was teaching (10%, n = 29). Vital signs were recorded only 50% (n = 141) of the targeted number of times.

Conclusions

Using a retrospective chart review protocol to identify omissions in nursing care allows the assessment of a broad range of nursing activities. Additionally, this is the first-time patient-level data on a broad range of activities have been analyzed. The newly developed chart review methodology can complement established survey methods and provide a new perspective on the phenomenon of omitted nursing care.

中文翻译：

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使用回顾性图表审查探索护理中的遗漏：一项观察性研究

背景

护理中的疏忽会危及患者的安全。迄今为止，几乎完全通过护士调查对这种现象进行了调查。然而，此类调查限制了可评估遗漏和患者水平分析的活动范围。作为替代方案，回顾性图表审查方法已成功用于其他研究领域，但尚未用于省略的护理。

目标

使用回顾性图表审查方法描述遗漏护理的特征和频率。

设计、设置和参与者

在两个德国神经病学住院病房进行的观察性单中心研究。使用了 100 名入院患者的随机样本。

方法

开发并应用了一种用于检测护理遗漏的结构化图表审查协议。根据记录它们的重要性以及它们是否被完全或部分省略，对所有预期的护理活动进行了评估。根据测量目标数量和记录的测量数量评估生命体征测量。

结果

总共确定了 1885 项活动——平均每位患者 19 项——被确定。在审查的活动中，52% ( n  = 971) 被完全或部分省略。患者在住院期间经历了 1 到 22 次忽略的护理活动（预期护理活动的 8-84%）。从 6% 到 100%，一些活动在入院期间比其他活动更常被遗漏。最常被忽略的护理活动是给予情感关怀（88%，n  = 66）；最不常被遗漏的是教学（10%，n  = 29）。生命体征仅记录 目标次数的50% ( n = 141)。

结论

使用回顾性图表审查协议来确定护理中的遗漏，可以对广泛的护理活动进行评估。此外，这是首次对广泛活动的患者级别数据进行分析。新开发的图表审查方法可以补充现有的调查方法，并为遗漏护理现象提供新的视角。