J. Cadwallader (1, 2), C. Asirwa (1, 2), X. Li (2), J. Kesterson (2), W. M. Tierney (1, 2), M. C. Were (1, 2)
(1) Indiana University School of Medicine, Indianapolis, IN; (2) Regenstrief Institute Inc, Indianapolis, IN
Documentation, medical errors, patient discharge, Medical order entry systems, Routine Diagnostic Tests
Background: Small numbers of tests with pending results are documented in hospital discharge summaries leading to breakdown in communication and medical errors due to inadequate followup.
Objective: Evaluate effect of using a computerized provider order entry (CPOE) system to enforce documentation of tests with pending results into hospital discharge summaries.
Methods: We assessed the percent of all tests with pending results and those with actionable results that were documented before (n = 182 discharges) and after (n = 203 discharges) implementing the CPOE-enforcement tool. We also surveyed providers (n = 52) about the enforcement functionality.
Results: Documentation of all tests with pending results improved from 12% (87/701 tests) before to 22% (178/812 tests) (p = 0.02) after implementation. Documentation of tests with eventual actionable results increased from 0% (0/24) to 50% (14/28)(p<0.001). Survey respondents felt the intervention improved quality of summaries, provider communication, and was not time-consuming.
Conclusions: A CPOE tool enforcing documentation of tests with pending results into discharge summaries significantly increased documentation rates, especially of actionable tests. However, gaps in documentation still exist.
M. Schoop, D. G. Wastell
Methods Inf Med 1999 38 4: 265-273
M. Maschke1*, E. Busch2*, C. Nitsch1, P. Dommes1, C. Weimar1, P. Berlit3, A. Rogozinski4, H. Gerhard4, V. Tenfelde5, H. C. Diener1
Nervenheilkunde 2007 26 4: 285-290
C. M. Couris1, C. Gutknecht2, R. Ecochard2, B. Gelas-Dore1, T. Hajri1, C. Colin1, A.-M. Schott1
Methods Inf Med 2006 45 5: 515-522