The Limits of Humans in Data Gathering: Documentation Error Rates in the Electronic Health Record in the Operating Room.
We studied the accuracy of nursing electronic health record (EHR) documentation during surgical procedures focusing on time-stamping of events. In high-end manufacturing these tasks would be considered simple routine with error rates of 0.1% to 0.5%. Documentation accuracy of six key events over 10...
| Publicado en: | Journal of Medical Systems Vol. 50; no. 1; pp. 1 - 8 |
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| Autores principales: | , , , , |
| Formato: | research tables/charts Journal Article |
| Publicado: |
Springer Nature
2/9/2026
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=191451323&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 191451323 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 01485598 4N0 jtl: Journal of Medical Systems issn: 01485598 maglogo: N pubinfo: dt: 2/9/2026 vid: 50 iid: 1 pid: 237 pub: Springer Nature place: New York, New York artinfo: ui: 191451323 191451323 191451323 10.1007/s10916-026-02346-9 191451323 ppf: 1 ppct: 7 formats: tig: atl: The Limits of Humans in Data Gathering: Documentation Error Rates in the Electronic Health Record in the Operating Room. aug: au: Bradley, Andrew R. Barbosa, Abner Younk, Logan Rocha, Naila Nichol, Peter F. affil: https://ror.org/03ydkyb10 Department of Surgery, University of Wisconsin School of MedicineUniversity of Wisconsin School of Medicine, and Public Health, H4/746 CSC 600 Highland Ave, 53792, Madison, WI, USA sug: subj: Data Collection Human Error Evaluation Operating Rooms Electronic Health Records Standards Nursing Records Standards Data Quality Evaluation Time Task Performance and Analysis Charting Operating Room Nurses Psychosocial Factors Risk Assessment Human Human Error Trends Descriptive Statistics Work Environment Health Facility Environment Surgical Patients Patient Identification Multitasking Behavior Operating Room Nurses Labor Supply Anesthesia Sutures Surgical Count Procedure Clinical Documentation Improvement Hospitals, Pediatric Chi Square Test Pearson's Correlation Coefficient Human Error Prevention and Control Simple Linear Regression Analysis of Variance Logistic Regression Odds Ratio Confidence Intervals ab: We studied the accuracy of nursing electronic health record (EHR) documentation during surgical procedures focusing on time-stamping of events. In high-end manufacturing these tasks would be considered simple routine with error rates of 0.1% to 0.5%. Documentation accuracy of six key events over 10 consecutive weeks was measured. Error rates, delays in documentation, and environmental variables including operating room (OR) size, number of nurses per OR, and service line were recorded. Statistical methods included regression models, correlation analysis and analysis of variance (ANOVA). From 202 cases, 98.10% of 1240 events were captured, revealing an overall error rate of 17.01%. Delays in documentation were observed in 51.40% of events. Larger ORs, multiple nurses documenting, and delays over 20 min were linked to higher error rates. Error rates increased from 1.30% without delays to 38.43% with delays exceeding 20 min. Documentation error rates for time-stamping tasks were at a minimum 2.6 times higher than predicted and increased significantly with delays in documentation indicating that environmental complexity and stress diminish human tasks performance as well as recall of events. Our data indicate that error rates in the healthcare space are higher than in the manufacturing space for tasks of identical or similar complexity. Given the certainty and immutability of human error in task performance, our findings highlight the need for technologies to improve accuracy of EHR documentation in this critical and high complexity space. pubtype: Academic Journal doctype: research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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