title: Accuracy of manual entry of drug administration data into an anesthesia information management system.
abstract: OBJECTIVE
  Data on drug administration are entered manually into anesthesia information management systems (AIMS). This study examined whether these data are accurate regarding drug name, dose administered, and time of administration, and whether the stage of anesthesia influences data accuracy.
  
  
  METHODS
  Real-time observational data on drug administration during elective operations were compared with computerized information on drug administration entered by anesthesiologists. A trained observer (K.D.) performed the observations.
  
  
  RESULTS
  Data were collected during 57 operations which included 596 separate occasions of drug administration by 22 anesthesiologists. No AIMS records were found for 90 (15.1%) occasions of drug administration (omissions), while there were 11 (1.8%) AIMS records where drug administration was not observed. The AIMS and observer data matched for drug name on 495 of 596 (83.1%) occasions, for dose on 439 of 495 (92.5%) occasions, and for time on 476 of 495 (96.2%) occasions. Amongst the 90 omitted records, 34 (37.8%) were for vasoactive drugs with 24 (27.7%) for small doses of hypnotics. Omissions occurred mostly during maintenance: 50 of 153 (24.6%), followed by induction: 30 of 325 (9.2%) and emergence: 10 of 57 (17.5%) (P < 0.001). Time and dose inaccuracies occurred mainly during induction, followed by maintenance and emergence; time inaccuracies were 7/325 (8.3%), 10/203 (4.9%), and 0/57 (0%), respectively (P = 0.07), and dose inaccuracies were 15/325 (4.6%), 3/203 (1.5%), and 1/57 (1.7%), respectively (P = 0.11).
  
  
  CONCLUSIONS
  The range of accuracy varies when anesthesiologists manually enter drug administration data into an AIMS. Charting omissions represent the largest cause of inaccuracy, principally by omissions of records for vasopressors and small doses of hypnotic drugs. Manually entered drug administration data are not without errors. Accuracy of entering drug administration data remains the responsibility of the anesthesiologist.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hadassah - Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel, alex@avidan.co.il.
authors.forename: Alexander
authors.initials: A
authors.lastname: Avidan
authors.forename: Koren
authors.initials: K
authors.lastname: Dotan
authors.forename: Charles
authors.initials: C
authors.lastname: Weissman
authors.forename: Matan J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: Phillip D
authors.initials: PD
authors.lastname: Levin
mesh_terms: D000758:Anesthesia / Q000379:methods*; D000776:Anesthesiology / Q000379:methods*; D006801:Humans; D019451:Information Management / Q000379:methods* / Q000592:standards; D016347:Medical Records Systems, Computerized; D011446:Prospective Studies