Introduction

Adequate documentation within the Electronic health record (EDUS) is an essential mechanism for recording in­formation during clinical care and enables the standard­ization of medical records. However, this process may lead to delays in the execution of medical orders by personnel. Previous studies have reported that nursing staff spend up to 40% of their time documenting aspects of patient care⁽¹⁾, and one-quarter of respondents state that this task is sometimes cumbersome and negatively affects commu­nication between nursing staff and patients⁽²⁾.

Digital records are designed to support data entry, but their accuracy and timeliness depend on the personnel re­sponsible for entering the information. Although nursing staff are the primary users of this tool, other healthcare workers also enter data, and improper use or incompatible workflows worsen the challenges of patient care, especial­ly in complex environments⁽³⁾. Quality improvement meth­odology must be part of the routine work in emergency services due to their complexity, in order to monitor pro­cesses and ensure patient safety⁽⁴⁾.

The Emergency Service at our hospital comprises sev­eral functional areas staffed by physicians and nursing personnel. Documentation of clinical procedures and care must be completed in the EDUS, implemented in our insti­tution in 2018. Incomplete or inadequate documentation, as well as the failure of nursing staff to finalize medical orders, leads to prolonged patient presence on worklists, resulting not only in delays in care but also in uncertainty regarding medication administration.

Currently, the reasons for prolonged patient stays and incomplete medical orders are not known. The primary objective of this study is to optimize procedure documen­tation within the EHR of the Medical Emergency Service (SEM), and the specific objective is to reduce the comple­tion time of orders in the injectable-medication module of the EHR from six hours to two hours within a three-month period.

Methods

This study was conducted at the National Children’s Hospital “Dr. Carlos Sáenz Herrera” in San José, Costa Rica, over a five-month period (October 2023 – February 2024). This hospital is the country’s only tertiary-level pediatric center, with 300 inpatient beds and approximately 95,000 annual emergency department visits. The Emergency Service includes multiple functional areas, such as the ambulatory area with consultation rooms, the injectable-medication and inhalation-therapy area, and the observa­tion area, which includes resuscitation rooms, the suture room, and minor surgery.

An operational issue was identified in the injectable-medication area involving prolonged presence of am­bulatory patients on the system’s worklist, even after they were no longer physically present in the Emergency Service.

This situation was associated with the failure to final­ize medical orders in the system, which may be attributed to two main causes: omission of the medical order in the corresponding section for nursing personnel, or failure to update the patient’s status in the system. Both factors dis­tort the service’s management indicators.

Data collection included a review of statistical cubes from the Electronic Health Record (SIES Urgencias). In addition, a five-item closed-question survey was admin­istered to nursing personnel, and selected records of pa­tients with prolonged stays in the injectable-medication area were analyzed.

No conflicts of interest were identified during the ex­ecution of this study, including the interventions or the analysis and interpretation of the data. This study was approved as a non-biomedical study by the institution’s Scientific Ethics Committee.

Improvement Strategy

Once the problem was identified, an improvement strategy was implemented to correct deficiencies in the clinical documentation process. The planning process took place during the last two weeks of October 2023. The first step consisted of training nursing personnel, aiming to raise awareness of the issue, foster collaborative work with the medical team, and ensure compliance with the estab­lished goals. These training sessions took place in Novem­ber 2023.

Multiple training sessions were conducted, addressing the clinical and operational implications of failing to prop­erly finalize indications in the system. Additionally, visual reminders (brightly colored signs) were placed in key areas of the process, including the computer area (where proce­dures are recorded), the medication-preparation area, and the vital-sign station.

Interventions were implemented in late November and December 2023. The first intervention stipulated that no injectable medication would be administered unless it was previously entered into the EDUS. The supervising nurse continually promoted verification of indications in the functional area, both verbally and through visible signs placed on the computers, ensuring orders were reviewed before the end of each shift. Telephones were also installed to facilitate smoother communication between nursing staff and prescribing physicians. Finally, ongoing training sessions were provided to new staff members to ensure continued compliance with the established goals. This con­tinuous process took place in January and February 2024.

These actions were designed to reinforce good doc­umentation practices and reduce unnecessary prolonged stays on system worklists, thus improving the service’s operational efficiency.

Results

To gather information and diagnose the problem, re­sults are presented according to the processes carried out.

Nursing Staff Survey

A total of 44 nurses from the service were surveyed. When asked whether they reviewed patients with pending indications on the worklist at the end of their shift, 16% responded that they did not. Additionally, when asked whether they finalized the indication when a patient with a pending intramuscular medication had already been discharged from the Emergency Service, one-third of re­spondents (29.5%) stated that they did not, as they were uncertain whether the medication had actually been admin­istered. Finally, 77.3% (n=34) reported that, whenever pos­sible, they attempted to coordinate injectable-medication orders with medical staff throughout their shift.

Review of Statistical Cube Data

A total of 74 patients with prolonged stays were iden­tified, with the cause being an injectable medication order that had not been closed. The median age was 60 months (IQR 37–108). According to care shifts I, II, and III, the second shift showed the highest frequency of this error: Shift I (17; 23%), Shift II (30; 40.5%), Shift III (27; 36.4%). The average length of stay in the functional area with unfinished indications was six hours.

Three interventions were required during the study period to maintain the target reduction in patients remaining on this functional area’s list with unfinished injectable-medication orders—from six hours to two hours over the three-month period.

Subsequently, patients were prospectively identified, and their data were plotted on the run chart shown in Figure 2, allowing visualization of changes over time fol­lowing the interventions.

Discussion

Digital clinical records are a fundamental tool for the permanent documentation of a patient’s medical history and for ensuring continuity of care. Their use supports safer, evidence-based clinical decisions while improving traceability of actions performed by different healthcare professionals. The transition from paper to electronic sys­tems has brought increased efficiency, fewer errors, im­proved real-time access to information, and the ability to standardize clinical and administrative procedures. This standardization promotes more consistent, safer, and pa­tient-centered care⁽⁵⁾.

This study demonstrates that implementing good prac­tices in the use of electronic clinical records can lead to significant improvements in documentation quality and patient safety. One concrete example is the reduced risk of errors such as duplicate administration of an injectable medication—an event that is potentially preventable through timely, clear, and complete documentation. How­ever, we found that a single, isolated intervention was insufficient to achieve sustained improvement, especially in settings such as our emergency service, where staff ro­tation is high. This high turnover, combined with fluctua­tions in patient volume—particularly during periods of high occupancy—creates conditions in which medical orders may remain incomplete or unexecuted⁽⁶⁾.

Raising awareness of these issues within the healthcare team is essential for fostering collective responsibility and encouraging change. Promoting shared responsibility in system use—avoiding attributing this task solely to nurs­es or physicians—facilitates collaboration and strengthens team cohesion. This, in turn, leads to better adherence to new practices and greater sustainability of improvements over time.

Implementing simple interventions alongside practi­cal and continuous training has proven more effective for achieving sustainable results. Consistency in training pro­cesses is key, especially given the frequent onboarding of new personnel. It is fundamental that every new team mem­ber receives standardized training from the moment they join, and that periodic updates are available for all staff⁽⁷⁾.

Quality improvement methodology must be considered a priority and implemented across all emergency services. Understanding the perspectives of frontline personnel can help guide meaningful and sustainable changes in the set­tings where interventions are applied. Training healthcare workers to identify situations where quality improvement methodology may be applied will enhance the quality of care delivered in our services⁽⁸⁾.

Among the study’s limitations is the challenge of pro­viding uniform training to all staff due to rotating sched­ules and the unavailability of trainers 24 hours a day. Ad­ditionally, although data collection was prospective, it only occurred when investigators were present, which may in­troduce bias in result representativeness.

In conclusion, this study illustrates how applying con­tinuous quality-improvement methodologies within hos­pital settings can positively impact the quality of care. Although challenges persist, team commitment, ongoing training, and adoption of robust digital systems are essen­tial pillars for advancing toward a safer and more efficient healthcare system.

Funding

This research did not receive any specific grant from public, commercial, or non-profit funding agencies.

Conflicts of Interest

The authors declare no conflicts of interest.

Author Contributions

The authors certify equal contribution to the concep­tion, design, scientific content, intellectual input, and writ­ing of the manuscript.

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