Security interventions are frequently undocumented in emergency department clinical notes.
OBJECTIVE
To compare the documentation of security interventions in ED presentations between clinical notes and security records.


METHODS
Presentations (n = 680) were randomly selected from all ED presentations to a public tertiary referral hospital in Queensland, Australia between April 2016 and August 2017 that were perceived by the treating clinician as alcohol-related. Retrospective data, manually extracted from clinical notes and the security service database, were compared for the documentation of any security interventions. Security interventions were defined as observation without physical contact, verbal de-escalation or physical restraint by security officers.


RESULTS
Forty-one presentations had security interventions documented in the security services database and, of those, 20 (48.8%) had documentation in the clinical notes. Patients who required security interventions were admitted to hospital in higher proportions compared with those who did not (73.2% vs 26.8%, respectively, P < 0.0001).


CONCLUSION
The rate of documentation of security interventions in clinical notes was less than 50%. Documentation of critical information, including alerts and risks, in the clinical notes is an essential component of communication that the multi-disciplinary team use to ensure patient safety. Strategies aimed at improving the documentation of security interventions in clinical notes will help to optimise risk management and the safety of patients, staff and visitors along the continuum of care.
['Duncan|Jill|J|', 'Brown|Nathan J|NJ|0000-0001-7149-8895', 'Hughes|James A|JA|0000-0001-9387-2489', 'Trudgett|Scott|S|', 'Crilly|Julia|J|0000-0002-1455-8983', 'Rothwell|Sean|S|', 'Rosengren|David|D|']
D000328:Adult D004282:Documentation D004636:Emergency Service, Hospital D005260:Female D006801:Humans D008297:Male D008875:Middle Aged D011793:Queensland D012189:Retrospective Studies D012308:Risk Management D012637:Security Measures D018709:Statistics, Nonparametric D064450:Workplace Violence
emergency medical service emergency medicine health information systems medical records workplace violence