Analysis of the agreement on fall records between electronic health records and notifications: cohort study
DOI:
https://doi.org/10.33448/rsd-v9i12.10773Keywords:
Patient Safety; Electronic Health Records; Accidental Falls; Communication; Risk management.Abstract
Objective: To analyze the agreement on fall records between patient progress data in electronic health records and notifications by the Incident Reporting System. Method: Retrospective cohort study conducted at a public hospital in Porto Alegre, Rio Grande do Sul, Brazil. The sample consisted of 367 patients, 441 self-reported notifications and 441 patient progress notes. Data were collected from the online annotation system WebAnno between September and December 2018. A collection instrument was developed. Data analysis was performed through descriptive statistics. Data were analyzed using the Statistical Package for the Social Sciences, SPSS Inc., Chicago, version 17.0 for Windows. Results: Among the patients, 316 had one fall and 51 had two falls or more. The study included 441 fall notifications. Of these, 43.9% were not recorded in the electronic medical records on the day of their occurrence. Regarding the record of risk assessment for falls, only three (0.7%) progress notes contained it. More complete records were identified in the notifications as compared to the electronic health records. The results related to fall location, recorded in all notifications and in 13.8% of the progress notes, and damage degree, recorded in all notifications and in only 1.6% of the progress notes, are noteworthy. Conclusion: A gap of records for falls in electronic health records was identified. The results point to an aspect of extreme relevance in terms of communication via patients’ electronic health records, which can directly influence the planning and implementation of effective care.
References
Agency for Healthcare Research and Quality [AHRQ], Patient Safety Network [PSNet]. (2019). Reporting Patient Safety Events, PSNet;. Retrieved from: https://psnet.ahrq.gov/primer/reporting-patient-safety-events
Banakhar, M. A., Tambosi, A. I., Asiri, S. A.-A., Banjar, Y. B., Essa, Y. A. (2017). Barriers of Reporting Errors among Nurses in a Tertiary Hospital. Int. Journ. of Nurs. & Clin. Practices, 4:245-51. DOI: 10.15344/2394-4978/2017/245
Brasaite, I., Kaunonen. M., Martinkenas, A., Mockiene, V., Suominen, T. (2017). Health Care Professionals’ Knowledge Regarding Patient Safety. Clin Nurs Res, 26(3):285-300. DOI: 10.1177/1054773816628796
Brasil. Agência Nacional de Vigilância Sanitária [ANVISA]. (2015). Orientações gerais para a notificação de eventos adversos relacionados à assistência à saúde ANVISA; Retrieved from: http://portal.anvisa.gov.br/documents/33852/271858/Nota+t%C3%A9cnica+N%C2%BA+01+de+2015+-GVIMS-GGTES-ANVISA/b98ec033-1676-4443-9603-24a4edae1505
Brasil. Agência Nacional de Vigilância Sanitária [ANVISA]. (2014). Documento de referência para o Programa Nacional de Segurança do Paciente. Brasília (DF). Retrieved from: https://bvsms.saude.gov.br/bvs/publicacoes/documento_referencia_programa_nacional_seguranca.pdf
Carlfjord, S., Öhrn, A., & Gunnarsson, A. (2018) Experiences from ten years of incident reporting in health care: a qualitative study among department managers and coordinators. BMC Health Serv Res, 18(113). DOI: 10.1186/s12913-018-2876-5
dos Santos, H. D. P., Silva, A. P., Maciel, M. C. O., Burin,H. M.M V., Urbanetto, J. S., Vieira, R. (2019). Fall Detection in EHR using Word Embeddings and Deep Learning. In 2019 IEEE 19th International Conference on Bioinformatics and Bioengineering (BIBE), 265-268. Retrieved from: https://ieeexplore.ieee.org/document/8941806
Hauer, K., Lamb, S. E., Jorstad, E. C., Todd, C., Becker, C. (2006). Systematic review of definitions and methods of measuring falls in randomised controlled fall prevention trials. Age Ageing, 35:5-10. DOI: 10.1093/ageing/afi218
Lee, W., Kim, S. Y., Lee, S., Lee, S. G., Kim, H. C., Kim, I. (2018). Barriers to reporting of patient safety incidents in tertiary hospitals: A qualitative study of nurses and resident physicians in South Korea. Int J Health Plann Manage, 33(4):36–43. DOI: 10.1002/hpm.2616
Lemos, G. F., Ferreira, J. B., Santos, K. T., Reis, L. A., Morais, K. C. S. (2017). Fatores Associados a Quedas em Idosos de uma Unidade Básica de Saúde. Id on Line Rev. Mult. Psic, 11(38):150-165. DOI: https://doi.org/10.14295/idonline.v11i38.884
Morse, J. M. (2009). Preventing patient falls: establishing a falls intervention program. 2nd ed. New York: Springer; 172 p.
Neves, K.C.; Fassarella, B.P.A.; Ribeiro, W.A.; Faillace, G.B.D.; Fassarella, M.B.; Silva, A.C.S.; Silva, F.J.D.; Felicio, F.C.; Oliveira, K.G.M.; Oliveira, S.L.; Silva, A.S.; Farias, B.S. (2020). Benefits and disadvantages of implementing the electronic patient record for the health service. Research, Society and Development,9(7):1-16. DOI: http://dx.doi.org/10.33448/rsd-v9i7.4630
Palojoki, S., Mäkelä, M., Lehtonen, L., Saranto, Kaija. (2016). An analysis of electronic health record–related patient safety incidents. Health Informatics J, 23(2):134-145. DOI: 10.1177/1460458216631072
Pereira, A. S.; Shitsuka, D. M.; Parreira, F. J.; Shitsuka, R. (2020). Metodologia da pesquisa científica. Santa Maria: NTE. Retrieved from: https://repositorio.ufsm.br/bitstream/handle/1/15824/Lic_Computacao_Metodologia-Pesquisa-Cientifica.pdf?sequence=1
Sendlhofer, G., Schweppe, P., Sprincnik, U., Gombotz, V., Leitgeb, K., Tiefenbacher, P., Kamolz, L.-P, Brunner, G. (2019). Deployment of Critical Incident Reporting System (CIRS) in public Styrian hospitals: a five year perspective. BMC Health Serv Res, 19(412):8 p. DOI: https://doi.org/10.1186/s12913-019-4265-0
Severo, I. M., Kuchenbecker, R. S., Vieira, D. F. V. B., Lucena, A. F., Almeida, M. A. (2018). Risk factors for fall occurrence in hospitalized adult patients: a case-control study. Rev. Latino-Am. Enfermagem, 26:1-9. DOI: 10.1590/1518-8345.2460.3016
Smits, M., Zegers, M., Groenewegen P. P., Timmermans, D. R. M., Zwaan, L., Van der Wal, G., Wagner, C. (2010). Exploring the causes of adverse events in hospitals and potential prevention strategies. Qual Saf Health Care,19(5):1-7. DOI: 10.1136/qshc.2008.030726
Sociedade Brasileira de Geriatria e Gerontologia [SBGG]. (2008). Quedas em idosos: prevenção. Retrieved from: www.projetodiretrizes. org.br/projeto_diretrizes/082.pdf
Souza, P. A. F., Dal Sasso, T. M., Barra, D. C. C. (2012). Contributions of the electronic health records to the safety of intensive care unit patients: an integrative review. Text Context Nursing, 21(4):971-9. DOI: 10.1590/S0104-07072012000400030.
SPSS Inc. SPSS Statistics for Windows. Version 17.0. Chicago: SPSS Inc. Released 2008.
Stavroupolou, C., Doerthy, C., Tosey, Paul. (2015). How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review. Milbank Q, 93(4):826-866. DOI: 10.1111/1468-0009.12166
Umberfield, E., Ghaferi, A. A., Krein, S. L., Manojlovich, M. (2019). Using Incident Reports to Assess Communication Failures and Patient Outcomes. Jt Comm J Qual Patient Saf, 45(6):1-8. DOI: 10.1016/j.jcjq.2019.02.006
Urbanetto, J. S., Creutzberg, M., Franz, F., Ojeda, B. S., Gustavo, A. S., Bittencourt, H. R., Steinmetz, Q. L., Farina, V. A. (2013). Morse Fall Scale: translation and transcultural adaptation for the Portuguese language. Rev. Esc. Enferm. USP, 47(3):569-575. DOI: 10.1590/S0080-623420130000300007
Urbanetto, J. S., Pasa, T. S., Bittencout, H. R., Franz, F., Rosa, V. P. P.; Magnago, T. S. B. S. (2016). Analysis of risk prediction capability and validity of Morse Fall Scale Brazilian version. Rev. Gaúcha Enferm, 47(4):569-575. DOI: 10.1590/1983-1447.2016.04.62200
Vrbnjak, D., Denieffe, S., O’Gorman, Claire., Pajnkihar, M. (2016). Barriers to reporting medication errors and near misses among nurses: A systematic review. Int J Nurs Stud, 63:162–78. DOI: 10.1016/j.ijnurstu.2016.08.019
Weissman, J. S., Schneider, E. C., Weingart, S. N., Epstein, A. M., David-Kasdan, J., Feibelmann, S., Annas, C. L., Ridley, N., Kirle, L., Gatsonis, C. (2008). Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? Ann Intern Med, 149(2):100-8. DOI: 10.7326/0003-4819-149-2-200807150-00006.
World Health Organization [WHO]. (2019). Global action on patient safety. Seventy-second World Health Assembly, 5 p. Retrieved from: https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_R6-en.pdf?ua=1
World Health Organization [WHO]. (2007). Global report on falls prevention in older. Retrieved from: http://www.who.int/ageing/publications/Falls_prevention7March.pdf.
World Health Organization [WHO]. (2009). Conceptual framework for the international classification for patient safety version 1.1: final technical report. Retrieved from: http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
World Health Organization [WHO]. (2016). Minimal Information Model for Patient Safety Incident Reporting and Learning Systems, WHO. Retrieved from: https://www.who.int/patientsafety/implementation/information_model/en/
World Health Organization [WHO]. (2018). Falls: key facts. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/falls
Yimam, S. M., Gurevych, I., Castilho, R. E., Biemann, C. (2013). WebAnno: A Flexible, Web-based and Visually Supported System for Distributed Annotations. Proceedings of the 51st Annual Meeting of the Association for Computational Linguistics, 1-6. Retrieved from: https://pdfs.semanticscholar.org/aa24/9f0ec2cce968f37ee6d368375317561ddd7d.pdf
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Copyright (c) 2020 Maria Carolina Oliveira Maciel; Haline Maria Velho Burin; Amanda Pestana da Silva; Henrique Dias Pereira dos Santos; Renata Vieira; Janete de Souza Urbanetto
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