title: Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.
abstract: OBJECTIVE
  To examine information flow, a vital component of a patient's care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement.
  
  
  METHODS
  This was a qualitative study of a sample of eight medical-surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staff's communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices.
  
  
  RESULTS
  Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patient's electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication.
  
  
  CONCLUSIONS
  The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patient's plan.
authors: University of Illinois Chicago, College of Nursing, Chicago, IL 60612, USA. gmkeenan@uic.edu
authors: Gail
authors: G
authors: Keenan
authors: Elizabeth
authors: E
authors: Yakel
authors: Karen
authors: K
authors: Dunn Lopez
authors: Dana
authors: D
authors: Tschannen
authors: Yvonne B
authors: YB
authors: Ford
mesh_terms: D000884:Anthropology, Cultural; D004282:Documentation; D017598:Efficiency, Organizational; D057286:Electronic Health Records / Q000458:organization & administration*; D006801:Humans; D016247:Information Storage and Retrieval; D033183:Interdisciplinary Communication; D062209:Patient Handoff / Q000458:organization & administration*; D036301:Qualitative Research; D012015:Reference Standards; D013647:Task Performance and Analysis; D014481:United States; D014584:User-Computer Interface; D057188:Workflow