Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review

• Published in: Journal of nursing management Vol. 27; no. 3; pp. 491 - 501
• Main Authors: McCarthy, Bridie, Fitzgerald, Serena, O’Shea, Maria, Condon, Carol, Hartnett‐Collins, Gerardina, Clancy, Martin, Sheehy, Agnes, Denieffe, Suzanne, Bergin, Michael, Savage, Eileen
• Format: Journal Article
• Language: English
• Published: England Hindawi Limited 01.04.2019
• Subjects: Documentation; Electronic health records; Evidence-based nursing; Falls; Inpatient care; Intervention; Nursing; Nursing administration; Patient safety; Patients; Quality; Quality of care; Safety measures; Systematic review
• ISSN: 0966-0429; 1365-2834
• DOI: 10.1111/jonm.12727

Aim To review the evidence on the effects/impact of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings. Background Electronic documentation has been recommended to improve quality care and patient safety. With the gradual move from paper‐based to electronic nursing documentation internationally, there is a need to identify interventions that can effectively improve quality care and patient safety. Evaluation We conducted a systematic review on the effectiveness of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings. Key Issues Six articles reporting on six individual studies met all eligibility criteria. They were uncontrolled pre/post intervention studies reporting positive impacts on at least one or more outcomes. Most outcomes related to documentation practice and documentation of content. Conclusion Some evidence from our review indicates that implementing electronic nursing documentation in acute hospital settings is time saving, reduces rates of documentation errors, falls and infections. Implications for Nursing Management A planned approach from management over time to allow nurses adapt to new electronic systems of documentation would seem a good investment in terms of efficiency of work time, possibly resulting in more time for clinical care.