¶ … Electronic Medical Records (E-SIHI) in King Khalid University Hospital on Patient Safety The objective of this study is to demonstrate the impact of e-SIHI (Electronic Medical Records) on patients with regards to their security and safety. The King Khalid University Hospital has implemented the e-SIHI since May 2015 for all departments. Two weeks after the implementation, QMD (Quality Management Department) conducted an audit to measure a compliance for the system and ascertain whether the e-SIHI can improve health and safety of patients. However, the QMD found that there are many areas requiring improvement in the system. The paper discusses the methodology used to evaluate the system to ascertain whether e-SIHI is beneficial to the patient.

Research Methodology

The research methodology reveals research design discussing the method of data collection, sample population, sample size, and project tool.

Study Design: The team audits the e-SIHI using a checklist to verify whether the EHRs are up-to-date, accurate, and meet organizations procedures and policies for effective information management.

Project Tool: The documents are reviewed using the JACHO checklist that consists of a review of medical records. The paper also uses the open record review to monitor the standard of care and quality of care delivered to patients. The open record review plays an important role towards making the documentation more streamlined and systematic. Approximate 3,500 patient's admissions are recorded by King Khalid University Hospital each month, and the study selects and reviews 350 files, which are 10% of the entire patient records. However, the study only reviews the files of patients admitted more than 48 hours and who have not yet been discharged

Data Collection: The study collects data from open electronic medical records, carries out the analysis and presents the final results to the department head to highlight the gaps that need improvement.

Data Source

The data are collected from the open electronic patient files. The study collects data from the departments that include surgery, medicine, pediatric, KFCC, critical care,...

Moreover, the quality facilitators collected data, the secretaries entered the data into the system and the evaluation and monitoring specialists analyzed the data
Sample Size

The study reviews a number of 324 files from approximately 3,500 patient admission files per month. The files reviewed are 20 KFCC, 20 Critical Care, 40 OB, 150 Medicine, 45 Pedia, 77 Surgery and 10 Psychiatry.

Sample Group: The study carries out the internal audit by randomly selecting a group of files, and reviewing each of the files contents for completeness.

Leader: The leader is Heba Bou Mahdi, Quality Management Department, a Healthcare Quality and Monitoring and Evaluation Specialist.

Team: The quality facilitators collected data, encoded by the secretary, which was analyzed by the Quality Specialist

M&E Duration: The study carries out a comparative report between 3rd Quarter of 2015 and December 15-January.

The paper collects data to compare the clinical documentation, medication, medication error, and lab (phlebotomy) before the implementation of the system and after the system implementation.

Data Analysis

The data analysis is carried out using the quantitative technique. The comparative analysis is carried out to compare the impact of the system before and after the implementation. The study also uses out the descriptive statistics to summarize the data in a manageable form presenting the Mean value of the data.

Findings

The study presents the findings of the clinical documentation, medical reconciliation, medical errors, and phlebotomy of the King Khalid University Hospital before and after the implementation of the systems.

Clinical Documentation

The study carries out the descriptive statistics of the data collected for the clinical documentation between 2015 and 2016. The paper uses the data in Table 1 to develop the descriptive statistics. As being revealed in the descriptive statistics table, the Mean value of the clinical documentation before the system implementation is 69.32%, however, the…