关键词: 高可靠性组织；病历质量控制；无纸化；护理信息化

Abstract: Objective: To establish a paperless quality control system for nursing records based on High Reliability Organization Theory and evaluate its usability. Methods: Since February 2023, a paperless quality control system for nursing records was implemented. Information technology was employed for nursing record generation, quality control, submission, and archiving processes. The quality of nursing records, time consumed for quality control, nurse satisfaction, printer maintenance, and consumable expenditure rates were compared before and after system implementation over a period of six months. Results: The overall quality of nursing records and nurse satisfaction improved (P<0.05), while the time consumed for quality control, printer maintenance, and consumable expenditure rates decreased. Conclusion: The paperless quality control system for nursing records, based on the High Reliability Organization Theory, focuses on process control and data flow, enhance nursing work efficiency and improve the quality of final nursing records. This system can promote the scientific, standardized, and efficient management of clinical nursing records.

Key words: High Reliability Organization Theory; quality control of medical record; paperless; nursing information