The use of information technology to enhance patient safety and nursing efficiency

1. Introduction

Patient safety is an issue that has received increasing attention from medical organizations. The 2012 study of Andel et al. noted that mortality due to preventable medical errors was the sixth largest cause of death in the United States, and preventable medical errors were also the cause of increased medical expenditures [1]. Similarly, in an analysis of medical errors reported by Taiwan’s patient safety notification system from 2005–2012, the Taiwan Joint Commission on Hospital Accreditation discovered that medical errors causing major injury or death accounted for close to 3% of all such errors, and affected more than 1,400 persons each year [2]. As a consequence, regardless of their professional role or the medical situation, all healthcare professionals must share responsibility for ensuring that patients receive safe care.

Nursing efficiency is also an important issue. Clinical nursing tasks include physical care, measurement of vital signs [3], medication administration, blood drawing, and the maintenance of nursing records. The content of nursing records includes the status of patient health and various assessments, nursing activities and implementation of physicians’ orders, and appraisal of various tasks in patient care. As a result, nursing records account for a large proportion of patient records. The keeping and management of records not only has an impact on the quality of care, but also provides legal protection for both patients and health professionals. Nevertheless, one half of all nurses must stay at work for 1–2 hours after the end of their shifts, and the chief reason for this is the need to complete nursing records [4]. The content of handwritten nursing records is not only repetitive, but also includes a broad scope of descriptive information. Because of this, when time is limited, handwritten records often contain errors and omissions, are difficult to read, and may lead to nursing errors or disputes [5].

According to estimates from the US Institute of Medicine, on average, each hospitalized patient is likely to experience an error in medication administration [6]. Shih et al. found that a majority of the 3,054 medical personnel at 309 participating hospitals indicated that errors in medication administration were the most commonly-seen medical incidents [7]. In addition to drafting clear technical standards for medication administration, ensuring that nurses do not commit errors also requires training and audits, and the names and photographs of drugs should be placed online for nurses’ reference. The use of barcodes to manage medication administration is another method of reducing errors [8, 9].

Specimen collection provides a basis for the correct diagnosis of hospitalized patients, and nurses play an extremely important role in that process. This process is very complicated, and one study reported that 46% of errors occurred during collection [10]; this leads to a high rejection percentage and the frequent need to collect new samples. Specimens may also be lost during transportation. Specimen errors not only increase the clinical workload and the cost of medical care, but may also delay treatment and risk patient safety [11]. Starting in 1970, medical organizations began to adopt barcode technology, especially for such clinical purposes as blood transfusions, specimen collection, and medication administration. Barcodes possess immediacy and repeatability, so when information is embodied in barcodes, users are able to employ barcode scanners to obtain correct information and confirm identification, which reduces human error [12].

Handing over their shift is one of the important, time-consuming tasks that nurses must perform every day. By correctly handing over their shift, nurses can ensure that their colleagues receive the latest information so that the continuity and integrity of care is maintained [13]. If the information transmitted at shift handover is incomplete or in error, then this can potentially harm patients, and may also result in complaints or a lack of trust among team members. When nurses hand over verbally or in writing, the average shift handover time is 83.6 minutes, shift handover satisfaction percentage is 48.5% [14], and shift handover completion percentage is 41% [15]. This approach to shift handover leads to poor nursing efficiency and may compromise patient safety.

In order to fully implement patient safety, some hospitals in Taiwan have established hospital-wide quality and patient safety management systems, such as by establishing hospital-wide patient safety and quality management frameworks [2], establishing quality and patient safety management operating models, and employing projects to reduce risks to patients’ safety [16]. In order to improve operating procedures and provide an effective safety management model, various safety management functions, including communications among personnel, incident notification, and risk management, can be implemented via an information platform [17].

Internationally, improving nursing informatics is seen as the best way to improve hospital system performance, collaboration, and the satisfaction of hospital personnel and patients as well [18, 19, 20, 21]. The aim of this study was to determine if the use, outcomes, and satisfaction with a mobile nursing information system (NIS) improved patient safety and the quality of nursing care in a hospital in Taiwan.

2. Methods

3. Discussion

As a result of the introduction of NIS at a hospital in Taiwan, physiologic values were easier to read and interpret, it took less time to complete electronic records, the number of errors in drug administration was reduced, barcodes reduced the number of errors in blood drawing and transportation of pathological samples, nurses’ satisfaction with electronic shift turnover increased significantly, there was a reduction in nursing turnover, and patient satisfaction increased significantly.

Data input improved and this result was similar to that of Chang et al. [23]. Although mobile devices are available to every health professional, internet coverage was available in only 85% of the hospital. Corners in certain hospital wards had poor signal reception and a change in location was required to stay connected This affected the level of convenience; this result was the same as that reported by Tseng et al. [24] and Lee [25].

It was discovered during development of the nursing record system that there were differences between wards in the hospital. In addition to the database’s original standard NANDA classification, various customized “commonly-used classifications” were added on the basis of a ward’s attributes during the optimization process in order to facilitate the rapid determination of suitable nursing diagnoses by users. Similarly, a medical terminology library reflecting a ward’s attributes was also added to save time and to make it easier and more convenient for nurses to complete nursing records. As a result, satisfaction with the system has increased. Development of the system took advantage of innovation diffusion theory and the designers and users communicated with each other and came up with new ideas during the process of system development; this ensured that the system’s information design met the need for customization [26].

The design of the medication administration system allowed nurses to move a mouse cursor to a drug’s location, and this causes the system to automatically display the appearance and effect of the drug. This system allowed nurses to identify the drugs and provide consultation to patients with regard to the use of the medication. It also improved work flow, a result similar to the observations of Early et al. [27] and Huang ane Lee [28]. The fact that near misses in medication administration have increased since the implementation of the system indicates that system design can effectively prevent errors. Furthermore, the system uses sounds to draw nurses’ attention to errors in identification; this has increased nurses’ vigilance and increased the safety of medication administration. The enhanced efficiency resulting from the system is consistent with the findings of Song et al. [8].

The design of the specimen barcode scanning system requires the signatures of two persons in order to complete computerized tasks. This design has eliminated the difficulty in obtaining both signatures which was often encountered when the tasks were performed manually. It also lessened the risk of error during the process of specimen transportation. Because of computer-controlled procedures, both parties must now sign before the system can proceed to the next step. Many problems with patient safety are associated with procedures, and the computerization of operating procedures will significantly improve patient safety [29]. Although the system was designed to be user-friendly, if users fail to follow standard operating procedures, they may commit errors. Even with computerization, the hospital’s administration must still continue to educate personnel and perform process audits to ensure effective handling. This observation is similar to that of Early et al. [27] and Chen et al. [30].

The nurses had a favorable impression of the electronic shift handover system. Because this system is fully linked with other systems and provides clear reports from the testing and examination systems, it is extremely convenient and can provide information very rapidly. The nurses were uncomfortable with fully paperless operations during the initial period after the system went online, however, and remained in the habit of manual transcription of information when performing shift handover. At such times, designers must give users support in the form of additional training and awareness; this will ensure that users become more confident and gradually accept the new system [31]. In addition, nurses’ levels of satisfaction with the level of convenience of the electronic shift handover system and the level of completeness of the provided information were mostly above the level of somewhat satisfied, which is consistent with the result of the study conducted by Lai et al. [32]. In the event of an unstable internet connection or a system crash, however, data acquisition will be interrupted and an obstacle to work. Therefore, maintaining internet stability via hardware is a very important supplementary measure.

With regard to information and communications integration, the increase in satisfaction with regard to “Speed of response and assistance after a nurse has been called” was statistically significant. This indicates that patients used this system to directly contact primary nurses, which increased the nurses’ service speed and efficiency. Unexpectedly, medical personnel including physicians, medical technologists, operating room personnel, and testing personnel also had quite positive assessments of the system. This was because physicians and examination room, testing room, and operating room personnel also need to contact primary nurses, and can use this system to quickly locate them. This system has not only increased correct communication, but also boosted the efficiency of communication between different areas of specialization. The system complies with the Taiwan Joint Commission on Hospital Accreditation requirements for strengthened professional communication between different teams for the purpose of increasing patient safety [33].

One problem with this system is that personnel must have the ability to immediately revert to a manual operating mode if the system temporarily cannot be used due to power outage or a computer crash, and to be able to use paper and pen to record measurement results and times, so that clinical work can proceed normally. Nevertheless, hospital personnel have gotten into the habit of implementing various clinical tasks with assistance from the information system, and would find it very difficult to re-accustom themselves to manual tasks. As a consequence, in order to minimize disruption from system stoppage, all hospital wards and units currently implement regular manual drills. In addition, unstable wireless transmission may make it difficult to accomplish tasks.

There were limitations to this study. Data were obtained from only a single hospital and six or 12 months after subsystems of the NIS went online. More sites and longer follow-up periods are recommended. The respondent sample size was small and results may not be generalized. Because of the sampling procedure, the same patient may have completed the questionnaire more than once, but this is unlikely to have affected the results. Because the hospital’s Wi-Fi coverage was only 85% during the period of system construction, this may have influenced their assessment of system efficiency. A satisfaction survey for written shift handover was not conducted before completion of the electronic handover system; therefore, this survey shows the difference in satisfaction only after development and after optimization of the system.

4. Conclusions

This study provided solid evidence for the importance of NIS in the care of hospitalized patients. Patient safety was improved as was the level of satisfaction of both nurses and patients. The next step in the process would be to link systems via a wireless network [34, 35]. The rapid development of the internet and its use in accessing a vast array of information has created a unique computing environment. Cloud technology enables medical personnel to query information via the internet to enhance the immediacy of medical applications. Medical organizations must continually improve if they are to provide patients with high quality service in a competitive environment.

Conflict of interest

All authors declare that they have no conflict of interest.

Funding

This study was sponsored by Cheng Hsin General Hospital (Grant number: CHGH106-31).