JMIR Publications

ABSTRACT

Background:

Information distortion in nursing records pose significant risks to patient safety and impede the enhancement of care quality. The introduction of information technologies, such as decision support systems and predictive models, expands the possibilities for utilizing health data but also complicates the landscape of information distortion. Only through identifying influencing factors about information distortion, can care quality and patient safety be ensured.

Objective:

This study aims to explore the factors influencing information distortion in electronic nursing records within the context of China’s healthcare system, and provide appropriate recommendations to address these distortions.

Methods:

This qualitative study utilized semi-structured interviews conducted with 14 nurses from a Class-A tertiary hospital. The data were analyzed through qualitative content analysis.

Results:

The analysis identified 4 categories and 10 sub-categories: (1) Nurse-related factors—skills, awareness, and work habits; (2) Patient-related factors—willingness and ability; (3) Operational factors—work characteristics and system deficiencies; (4) Organizational factors—management system, organizational climate, and team collaboration.

Conclusions:

While some factors influencing information distortion in electronic nursing records (ENRs) are similar to those observed in paper-based records, others are unique to the digital age. As healthcare continues to embrace digitalization, it is crucial to develop and implement strategies to mitigate information distortion. Regular training and education programs, robust systems and mechanisms, as well as optimized human resources and organizational practices, are strongly recommended.