Strategy to Ensure Compliance With Confrontational Examinations A Performance Improvement Patient Safety Project

摘要

The implementation of electronic medical records (EMRs) represents one of the most significant changes taking place in the medical field today. The purpose of this Performance Improvement Patient Safety initiative was to evaluate and improve the documentation of c-spine clearances by standardizing the confrontational spine examination for patients sustaining blunt trauma using the EMR. A retrospective audit of trauma charts was performed over a 6-month period to evaluate c-spine clearance documentation. Following the initial audit, a strategy, using the Donabedian Principle of problem identification, process establishment, and outcome measure, was created resulting in a template in the EMR whereby clearance of the cervical spine (confrontational examination) in nonobtunded trauma patients was standardized for all providers.