Accuracy of Text Entries Within a Manually Compiled Anaesthetic Record

Rowe, Lynn; Galletly, D. C.; Henderson, Robert

doi:10.1093/bja/68.4.381

Cited by 18 publications

(10 citation statements)

References 22 publications

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“…A number of studies looking at handwritten records in isolation have shown completion rates that are generally lower than ours [16][17][18]39 . The relatively high completion rates for handwritten charts in our study may help to explain why we could not demonstrate a significant difference.…”

Section: Discussioncontrasting

confidence: 57%

“…There was no significant difference in the total score for completeness between electronic (78%) and handwritten (83%) records (P=0. 16). Handwritten records were more complete with respect to weight (P <0.0001), American Society of Anesthesiologists' physical status score (P <0.0001), the size and type of artificial airway used (P=0.003) and a record of the surgeons involved (P=0.0004).…”

mentioning

confidence: 97%

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A Comparison of Electronic and Handwritten Anaesthetic Records for Completeness of Information

Wrightson

2010

Anaesth Intensive Care

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Complete documentation in anaesthetic records is important for patient management, research and quality assurance and has medicolegal implications. This study compares the completeness of information contained in electronic versus handwritten intraoperative anaesthetic records. A sample of 70 handwritten records was randomly selected from anaesthesia performed in the month prior to implementation of the Integrated Injectable Drug Administration and Automated Anaesthesia Record System and compared to a similar sample of electronic records generated eight months later. A comprehensive scoring system, based on the Australian and New Zealand College of Anaesthetists’ guideline PS6, was used to compare the completeness of information throughout the entire intraoperative record. There was no significant difference in the total score for completeness between electronic (78%) and handwritten (83%) records (P=0.16). Handwritten records were more complete with respect to weight (P <0.0001), American Society of Anesthesiologists’ physical status score (P <0.0001), the size and type of artificial airway used (P=0.003) and a record of the surgeons involved (P=0.0004). Electronic records were more complete with respect to a record of drug administration including intravenous drugs (P <0.0001), vapour (P=0.0001) and nitrous oxide/oxygen (P <0.0001), a record of end-tidal carbon dioxide monitoring (P=0.006) and the level of trainee supervision (P=0.0002). There was no overall difference in the completeness of electronic versus handwritten records. Several differences did exist however, highlighting both clinically important advantages and deficiencies in the electronic system. Records from both systems sometimes lacked important information.

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Section: Discussioncontrasting

confidence: 57%

mentioning

confidence: 97%

A Comparison of Electronic and Handwritten Anaesthetic Records for Completeness of Information

Wrightson

2010

Anaesth Intensive Care

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“…Anaesthetic records are traditionally compiled by hand, a process that accounts for about 15% of an anaesthetist’s intraoperative time 1516 Handwritten records are often incomplete and inaccurate,6 17 18 which might reduce or negate their value for any of the above purposes.…”

Section: Introductionmentioning

confidence: 99%

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation

Merry

Webster

Hannam

et al. 2011

BMJ

178

175

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Objective To clinically evaluate a new patented multimodal system (SAFERSleep) designed to reduce errors in the recording and administration of drugs in anaesthesia. Design Prospective randomised open label clinical trial.Setting Five designated operating theatres in a major tertiary referral hospital.Participants Eighty nine consenting anaesthetists managing 1075 cases in which there were 10 764 drug administrations.Intervention Use of the new system (which includes customised drug trays and purpose designed drug trolley drawers to promote a well organised anaesthetic workspace and aseptic technique; pre-filled syringes for commonly used anaesthetic drugs; large legible colour coded drug labels; a barcode reader linked to a computer, speakers, and touch screen to provide automatic auditory and visual verification of selected drugs immediately before each administration; automatic compilation of an anaesthetic record; an on-screen and audible warning if an antibiotic has not been administered within 15 minutes of the start of anaesthesia; and certain procedural rules-notably, scanning the label before each drug administration) versus conventional practice in drug administration with a manually compiled anaesthetic record. Main outcome measuresPrimary: composite of errors in the recording and administration of intravenous drugs detected by direct observation and by detailed reconciliation of the contents of used drug vials against recorded administrations; and lapses in responding to an intermittent visual stimulus (vigilance latency task). Secondary: outcomes in patients; analyses of anaesthetists' tasks and assessments of workload; evaluation of the legibility of anaesthetic records; evaluation of compliance with the procedural rules of the new system; and questionnaire based ratings of the respective systems by participants. ResultsThe overall mean rate of drug errors per 100 administrations was 9.1 (95% confidence interval 6.9 to 11.4) with the new system (one in 11 administrations) and 11.6 (9.3 to 13.9) with conventional methods (one in nine administrations) (P=0.045 for difference). Most were recording errors, and, though fewer drug administration errors occurred with the new system, the comparison with conventional methods did not reach significance. Rates of errors in drug administration were lower when anaesthetists consistently applied two key principles of the new system (scanning the drug barcode before administering each drug and keeping the voice prompt active) than when they did not: mean 6.0 (3.1 to 8.8) errors per 100 administrations v 9.7 (8.4 to 11.1) respectively (P=0.004). Lapses in the vigilance latency task occurred in 12% (58/471) of cases with the new system and 9% (40/473) with conventional methods (P=0.052). The records generated by the new system were more legible, and anaesthetists preferred the new system, particularly

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“…The accuracy of text entry data on anesthetic records has been assessed previously (also in a New Zealand hospital). 26 The findings suggest that text entry data generally have a high degree of accuracy and that the major deficiency in the quality of text entries is completeness.…”

Section: Discussionmentioning

confidence: 99%

A randomized comparison between records made with an anesthesia information management system and by hand, and evaluation of the Hawthorne effect

Edwards

Hagen

Hannam

et al. 2013

Can J Anesth/J Can Anesth

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Purpose Anesthesia information management system (AIMS) technology is designed to facilitate high-quality anesthetic recordkeeping. We examined the hypothesis that no difference exists between AIMS and handwritten anesthetic records in regard to the completeness of important information contained as text data. We also investigated the effect of observational research on the completeness of anesthesiologists' recordkeeping. Methods As part of a larger randomized controlled trial, participants were randomized to produce 400 anesthetic records, either handwritten (n = 200) or using an AIMS (n = 200). Records were assessed against a 32-item checklist modified from a clinical guideline. Intravenous agent and bolus recordings were quantified, and data were compared between handwritten and AIMS records. Records produced with intensive research observation during the initial phase of the study (n = 200) were compared with records produced with reduced intensity observation during the final phase of the study (n = 200). Results The AIMS records were more complete than the handwritten records (mean difference 7.1%; 95% confidence interval [CI] 5.6 to 8.6%; P \ 0.0001), with higher completion rates for six individual items on the checklist (P \ 0.0001). Drug annotation data were equal between arms. The records completed early in the study, during a period of more intense observation, were more thorough than subsequent records (87.3% vs 81.6%, respectively; mean difference 5.7%; 95% CI 4.2 to 7.3%; P \ 0.0001). Conclusions The AIMS records were more complete than the handwritten records for 32 predefined items. The potential of observational research to influence professional behaviour in an anesthetic context was confirmed. This trial was registered at the Australian New Zealand Clinical Trials Registry No 12608000068369.

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Accuracy of Text Entries Within a Manually Compiled Anaesthetic Record

Cited by 18 publications

References 22 publications

A Comparison of Electronic and Handwritten Anaesthetic Records for Completeness of Information

A Comparison of Electronic and Handwritten Anaesthetic Records for Completeness of Information

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation

A randomized comparison between records made with an anesthesia information management system and by hand, and evaluation of the Hawthorne effect

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