Nurses' perceptions of an electronic patient record from a patient safety perspective: a qualitative study

作者：Stevenson Jean E^*; Nilsson Gunilla

来源：Journal of Advanced Nursing, 2012, 68(3): 667-676.

DOI：10.1111/j.1365-2648.2011.05786.x

• acute hospital settings
• documentation
• electronic patient records
• focus group interviews
• patient safety
• record keeping
• supporting nursing practice

Aims. The overall aim of this study was to explore nurses perceptions of using an electronic patient record in everyday practice, in general ward settings. This paper reports on the patient safety aspects revealed in the study. Background. Electronic patient records are widely used and becoming the main method of nursing documentation. Emerging evidence suggests that they fail to capture the essence of clinical practice and support the most frequent end-users: nurses. The impact of using electronic patient records in general ward settings is under-explored. Method. In 2008, focus group interviews were conducted with 21 Registered Nurses. This was a qualitative study and the data were analysed by content analysis. At the time of data collection, the electronic patient record system had been in use for approximately 1 year. Findings. The findings related to patient safety were clustered in one main category: documentation in everyday practise. There were three sub-categories: vital signs, overview and medication module. Nurses reported that the electronic patient record did not support nursing practice when documenting crucial patient information, such as vital signs. Conclusions. Efforts should be made to include the views of nurses when designing an electronic patient record to ensure it suits the needs of nursing practice and supports patient safety. Essential patient information needs to be easily accessible and give support for decision-making.

• 出版日期2012-3