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211 Patient safety through documentation: barriers identified by healthcare professionals and students
  1. Victor Valderaune1,
  2. Jorunn Bjerkan1,
  3. Rose Mari Olsen2
  1. 1Faculty of Health and Science, Nord-Trøndelag University College, Norway
  2. 2Centre for Care Research Mid-Norway, Norway

Abstract

Background Effective communication and accurate documentation is critical to delivering quality outcomes and patient safety in municipal elderly care. Yet it is becoming increasingly apparent that healthcare providers struggle to coordinate health information exchange, and are more likely to have inaccurate and incomplete clinical information. The aim of the study was to explore healthcare professionals’ and students’ perceptions of barriers to patient safety and quality in their documentation practice. This knowledge could facilitate the development and implementation of improved documentation practice and information exchange among healthcare professionals.

Methods A qualitative exploratory design with six focus group interviews were used. The study included a purposive sample of nurses and social educators (n = 12) from primary care, and nurse- and social educator students (at Bachelor’s level) (n = 11). The data were analysed by content analysis.

Results Four main themes about barriers to patient safety emerged from the analysis: “Individual factors”, “Social factors”, “Organisational factors”, and “Technological factors”. Each theme included several sub-themes. A conceptual model was developed to illustrate the relationships between the themes.

Conclusions According to the findings, several barriers negatively influence documentation and information exchange and may put the patients in primary care in a vulnerable and exposed situation. To achieve successful documentation, more awareness and effort from the individual professional is required. However, it is critical that primary care services facilitate this through adequate resources, clear missions, and understandable policies.

  • patient safety
  • documentation
  • primary health care
  • focus groups

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