title: Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.
abstract: Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined (p < 0.0001) and at the off-site locations (p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.
authors.affiliation: The University of Texas MD Anderson Cancer Center, USA erebello@mdanderson.org.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Rebello
authors.affiliation: The University of Texas MD Anderson Cancer Center, USA.
authors.forename: Spencer
authors.initials: S
authors.lastname: Kee
authors.affiliation: The University of Texas MD Anderson Cancer Center, USA.
authors.forename: Alicia
authors.initials: A
authors.lastname: Kowalski
authors.affiliation: The University of Texas MD Anderson Cancer Center, USA.
authors.forename: Nusrat
authors.initials: N
authors.lastname: Harun
authors.affiliation: The University of Texas MD Anderson Cancer Center, USA.
authors.forename: Michele
authors.initials: M
authors.lastname: Guindani
authors.affiliation: The University of Texas MD Anderson Cancer Center, USA.
authors.forename: Farzin
authors.initials: F
authors.lastname: Goravanchi
mesh_terms: D016009:Chi-Square Distribution; D004282:Documentation / Q000379:methods* / Q000592:standards*; D057286:Electronic Health Records / Q000592:standards*; D005568:Forms and Records Control / Q000379:methods* / Q000592:standards; D006801:Humans; D009873:Operating Rooms / Q000458:organization & administration; D012189:Retrospective Studies
keywords: electronic health records; healthcare service innovation and information technology; information and knowledge management; organizational change and information technology; quality control