Use of a falls incident reporting system to improve care process documentation in nursing homes.
Use of a falls incident reporting system to improve care process documentation in nursing homes.
复制标题
使用跌倒事件报告系统来改进疗养院的护理流程记录。
DOI：
10.1136/qshc.2007.022947
复制
发表时间：
2008
影响因子：
--
通讯作者：
Ouslander,JG
中科院分区：
文献类型：
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作者：
Wagner,LM;Capezuti,E;Clark,PC;Parmelee,PA;Ouslander,JG
跌倒是体弱的疗养院居民中最常见的不良事件，是一个重要的居民安全问题。事故报告系统已成功用于提高医疗保健的质量和安全性。本研究的目的是测试一个系统的指导菜单驱动的事件报告系统（MDIRS）的文件后下降的评估过程中nursings.MethodsSix营利性疗养院在美国东南部参加了这项研究的效果。在4个月的时间内，MDIRS被用于三家养老院，与另外三家养老院相匹配，继续使用现有的叙述性事件报告来记录福尔斯。训练有素的老年护理执业审计员使用数据收集审计工具，收集医疗记录文件的过程中照顾居民谁下跌。采用多元协方差分析方法对住院跌倒患者的跌倒护理过程进行分析。根据最小数据集，超过75%的样本被触发为福尔斯的高风险。只有18.4%的经历过跌倒的居民记录了充分的神经系统评估。虽然三分之二的样本有失禁的诊断，不到20%的记录有失禁相关的干预护理计划。总体而言，有更完整的文件的医疗记录中使用的MDIRS比在疗养院使用标准的叙事事件reports（p<0.001）。Conclusionfurther improvements are necessary in reporting mechanisms to improve the post-fall assessment in nursing home residents.
BackgroundFalls are the most frequently reported adverse event among frail nursing home residents and are an important resident safety issue. Incident reporting systems have been successfully used to improve quality and safety in healthcare. The purpose of this study was to test the effect of a systematically guided menu-driven incident reporting system (MDIRS) on documentation of post-fall evaluation processes in nursing homes.MethodsSix for-profit nursing homes in southeastern USA participated in the study. Over a 4-month period, MDIRS was used in three nursing homes matched with another three nursing homes which continued using their existing narrative incident report to document falls. Trained geriatric nurse practitioner auditors used a data collection audit tool to collect medical record documentation of the processes of care for residents who fell. Multivariate analysis of covariance was used to compare the post-fall nursing care processes documented in the medical records.Results207 medical records of resident who fell were examined. Over 75% of the sample triggered at high risk for falls by the minimum data set. An adequate neurological assessment was documented for only 18.4% of residents who had experienced a fall. Although two-thirds of the sample had a diagnosis of incontinence, less than 20% of the records had incontinence-related interventions in the nursing care plan. Overall, there was more complete documentation of the post-fall evaluation process in the medical records in nursing homes using the MDIRS than in nursing homes using standard narrative incident reports (p<0.001).ConclusionFurther improvements are necessary in reporting mechanisms to improve the post-fall assessment in nursing home residents.