RESUMO
Drug information tools help avoid medication errors, a common cause of avoidable harm in health care systems. We sought to describe the design, development process and architecture of an electronic drug information tool, as well as its overall use by health professionals. We developed a tool that can be accessed by all health professionals in a tertiary level university hospital. The functionalities of eDrugs are organized into two main parts: Drug Summary sheet, and Prescription Simulator. Most users accessed eDrugs to use the Drug summary sheet. Clinical information and antimicrobial drugs were the most accessed drug information and drug group. The analysis of log data provides insights into the information priorities of health professionals.
Assuntos
Eletrônica , Pessoal de Saúde , Humanos , Hospitais Universitários , Erros de Medicação/prevenção & controle , PrescriçõesRESUMO
While medications can improve the health of patients, the prescription process is complex and prone to errors. The structured medical order entry systems (CPOE) with clinical decision support (CDS) are increasingly implemented to improve patient safety, however the organizations that decide to implement them will have several challenges: understanding which classes of CDS can admit their systems, ensure that clinical knowledge is adequate and design tools for proper monitoring. We share our experience of over ten years of development and implementation of clinical decision support tools during drugs prescription process and tools that have allowed us to monitor them correctly.
Assuntos
Sistemas de Apoio a Decisões Clínicas , Prescrições de Medicamentos , Sistemas de Registro de Ordens Médicas , Argentina , Humanos , Erros de MedicaçãoRESUMO
Clinical terms are noisy descriptions typed by healthcare professionals in Spanish language in the electronic health record system (EHR). Thus, an evaluation of terminology search engine that extends SNOMED CT and an approach that uses historical data of clinical terms is described. We show how to measure precision and recall using historical search data, and we show how the performance of the search engine can be improved significantly using the technology available in the search engine.
Assuntos
Registros Eletrônicos de Saúde , Ferramenta de Busca , Idioma , Systematized Nomenclature of MedicineRESUMO
ICD-10 (International Classification of Diseases 10th revision) is a classification code for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. This paper describes an automatic information retrieval approach to map free-text disease descriptions to ICD-10 codes. We use the Hospital Italiano de Buenos Aires (HIBA) terminology data mapped to ICD-10 codes as indexed data to find an appropriate ICD-10 code using search engine similarity metrics.