Accuracy in documentation of peripheral venous catheters in paediatric care: An intervention study in electronic patient records

摘要

Aims. The aim of this study is to compare the accuracy and completeness in the recording of peripheral venous catheters before and after implementing a template in the electronic patient record in paediatric care. Background. As a basis for quality improvement and research purposes and to ensure patient safety, accurate clinical data need to be easily accessible in patient records. Several studies have concluded that the relation between performed care and what is documented in patient records is poor. Design. Before and after study. Method. The study took place at a large paediatric university hospital in Sweden. Inclusion criteria were patients who were admitted to one of the included wards, had one or several peripheral venous catheters and were available at the ward at the time for data collection. Data were collected by observations and record audits before and then four and 10months after the introduction of a template for recording peripheral venous catheters in a structured and standardised way. Results. A significant increase in peripheral venous catheters with complete recording was observed after as compared with before the intervention. The percentage of peripheral venous catheters with recording of any kind was relatively stable (85-93%). The overall recording of peripheral venous catheters insertion did not improve, but there was an increase in the recording of side and size after the intervention. One of the 22 complications observed before the intervention was documented and none of the complications (n=17 and n=9) after. Conclusion. The electronic patient record did not provide accurate data on peripheral venous catheters in paediatric care neither before nor after the intervention. Relevance to clinical practice. Further efforts to increase the documentation of catheter-related complications are needed. Integrated decision support systems in electronic patient records that remind nurses to inspect peripheral venous catheters regularly could be one solution.