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”Viskleken”: Informationsöverföringen från operationsavdelning till vårdavdelning.
The Swedish Red Cross University College.
The Swedish Red Cross University College.
2012 (Swedish)Independent thesis Advanced level (degree of Master (One Year)), 10 credits / 15 HE creditsStudent thesisAlternative title
“Chinese Whispers” : Information transfer from surgical ward to care unit. (English)
Abstract [sv]

Bakgrund: En bra kommunikation är en förutsättning för god kvalitet och patientsäkerhet i vården och när två olika system används har vi funderat över vad som händer med omvårdnadsdokumentationen när patienten förflyttas mellan vårdenheterna. Syftet: Vårt syfte med studien var att undersöka om de omvårdnadsåtgärder som operations-sjuksköterskan dokumenterat i operationsplaneringssystemet och rapporterat vidare, återfinns i omvårdnadsjournalen. Metod: En kvalitetsgranskning av journalanteckningar har utförts. Inklusionskriterierna var att patienterna opererats under minst tre timmar och att vårdtiden efter operationen var minst 24 timmar, då det var det första dygnets journalföring som kvalitetsgranskades. Sammanlagt granskades 40 stycken journaler. Resultat: I studien granskades sex stycken sökord ur operationsplaneringssystemet, vilka var; hudstatus, operationsläge, dränage, KAD, förband samt hudsuturer. Studien visade att överföringen av informationen var bristfällig. I en del fall framkommer det att information saknades eller förändrades när patienten förflyttades från operationsavdelningen till vårdavdelningen. Vidare framkom det att patienten förflyttades mer än en gång mellan vårdenheter. Slutsats: Resultatet i vår studie anser vi tyder på att en gemensam standardiserad journal med tydliga riktlinjer skulle underlätta för informationsöverföringen mellan de olika enheterna. Klinisk betydelse: Risken för att fel eller missförstånd uppstår minskar om ett gemensamt journalsystem används, vilket vi anser ökar patientsäkerheten.

Abstract [en]

Background: Good communication is prerequisite for good quality and patient safety in health care and when two different systems are used, we wondered what happens to the nursing documentation when the patient moves between different care units. Aim: The aim of the study was to examine whether the operation theatre nurses nursing care documentations in the operations planning system was reported on and can be found in the nursing journal. Method: A quality review of nursing care journal documentations was performed. Inclusion criteria was that the patient should have had an operation for at least three hours and aftercare for at least 24 hours, since it was the nursing care documentation that were done during the first day that were being quality reviewed. A total of 40 journals were examined. Results: Six keywords out of the operation planning system were examined, which are; skin status, operation position, drainage, KAD, dressing and skin sutures. Result of the study showed that the transfer of data was incomplete. In some cases it revealed that information was missing or altered when the patient was moved from the surgical ward to the care unit. Furthermore, it was found that the patient was moved more than once between different units. Conclusion: According to our study, we suggest that a common standardized journal with clear guidelines could make it easier to transfer the information between the different units. Clinical significance: Risk of error or misunderstandings are reduced in a common journal system, which we believe increases the patient safety.

Place, publisher, year, edition, pages
2012. , 32 p.
Keyword [en]
Patient safety, Nursing documentation, Perioperative documentation, Electronic nursing journals
Keyword [sv]
Patientsäkerhet, Omvårdnadsdokumentation, Perioperativ dokumentering, Elektronisk omvårdnadsjournal
National Category
Nursing
Identifiers
URN: urn:nbn:se:rkh:diva-277OAI: oai:DiVA.org:rkh-277DiVA: diva2:539163
Educational program
Postgraduate Program in Specialist Nursing
Uppsok
Medicine
Available from: 2012-07-03 Created: 2012-07-03 Last updated: 2017-07-07Bibliographically approved

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