The Importance of Accuracy Assignment In the article JCAHO Forbidden Abbreviations it discussed how JCAHO National Patient Safety goals are to verify an order if a forbidden abbreviation is used and to improve effectiveness and efficiency of the caregivers. The reason for verify ensures the safety of the patient and covers and issues for the pharmacies and the care givers. In the article I think the recommendations made by the JCAHO to verify forbidden terms will help in the long run. In the end it will correct errors that will be made without verification. Even symbols that can be mistaken for numerals and even letters will be clarified so a patient does not receive the wrong prescription or dosage. It is also a good thing that facilities can add to the list of forbidden abbreviations since medicine is always advancing and changing. The ISMP is like also like the JCAHO in that the both have similar forbidden terms that the look for to prevent confusion. The ISMP has created a list of error-prone abbreviations that should never be used when communicating medical information for any reason including filling prescriptions and medical records. These recommendations help keep medical information correct and filled properly to ensure care-giver …show more content…
Now while it incorporates tall-man letters to easily define words easily. This can also make it more difficult to establish correct medications. I think these recommendations can help and hinder in the medical field. It can help by more easily figuring out which word a physician is trying to use. Especially when health care professionals are using between each other. This list could eventually become a certified list since the table two portion of the list is words not yet approved by the FDA. Though at the same time the list could also cause problems between the physician and the pharmacy since the words are not yet
During the 1980’s and 90’s there were many studies done that showed that medical errors were occurring in inpatient and outpatient settings at a very high rate. Computer Provider Order Entry (CPOE) systems were designed to reduce or eliminate mistakes made by using hand written orders. The CPOE system allows users to directly enter their orders into the system on computers which are then sent directly to the healthcare providers that will be implementing the orders. Previously orders were placed by writing on order sheets on patient charts. This was sometimes done by the doctor or by a nurse acting on behalf of the doctor. Order sheets were then signed by the doctor and then the information was input into the patient’s record. This left room for error due to misreading bad handwriting, confusing medications with similar names, etc.
The American Health Information Management Association provides guidelines of elements to be included in a health care organization’s policies of a coding compliance plan. (“Coding Compliance: Practical Strategies for Success,” ahima.org, 1998).
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
2. What are some of the advantages and disadvantages to having a standardized terminology within electronic health record
As we go through our daily routine in our jobs in any medical facilities, we are bound to make an occasional error. Misspelling a word on a chart may be one of them. If you make a mistake while you are writing in a patient's medical chart, just draw one straight line through the word and put your initials to the top right of it, and write what you meant to say next to it. Do not make any big swirly lines through the incorrect word. The chart must look as neat and professional as possible. You might try to keep track of the mistakes you make so you can be sure not to make them in the future. Common sense, I know. But this could make a huge difference in the medical profession concerning someone's life.
The use of abbreviations shortens length of many words thus really help healthcare professionals in saving time spent in writing notes. Abbreviations however do not always provide positive contributions due to misconceptions, misunderstandings, and misinterpretations leading to commitment of errors in the practice. Similarities in abbreviations for instance could root to a grave mistake. For instance the q.d. which an inscriber would like to indicate as every day could be erroneously interpreted as q.i.d. which means four times a day. Such error could result to over dosage when a certain medication is taken four times in a day instead of just once. Though some abbreviations can be easily understood clearly and exactly as to what meaning they communicate, the use of abbreviations generally invite error potentials particularly the error-prone abbreviations (ISMP, 2007) which can be best avoided by eliminating abbreviations.
This finding supports claims that, despite a reduction in omission errors, dose errors are still prevalent with a computerized system and minimizing this risk may require consideration of alternative or additional strategies to the introduction of MMS (Friend, 2011). These findings suggest that medical practitioners may have experienced difficulties prescribing using the MMS, which may in part be explained by the relative novelty of the MMS at a new hospital site. Similarly, the research claimed a causative link between MMS and medication errors, attributed to electronic systems that were not very useful or easy to use by medical personnel, generating human-machine interface errors and work flow problems that were not consistent with the usual pen and paper drug
Pharmacy technicians are truly a specialized discourse community and they satisfy all aspects of Swales’s criteria. Most notably, they share common public goals, have participants who possess a general level of expertise, and who use a highly specialized lexis. The structure and purpose of this group allows one discourse community, pharmacy technicians, to help care for another. Their unique language heavily emphasizes medical acronyms and allows for effective completion of common purpose, intercommunication, feedback, and the successful transferring of vital information.
Many medication errors occur due to abbreviated words symbols, and dosage that cant be read and become misunderstood. These mistakes can cause harm if no one notices it. Many patients end up with a life threatening problem due to a medical error. A nurse might give the patient the wrong dose because of the handwritten abbreviation the doctor wrote is not clear. Many abbreviations are similar and this can cause complication. If abbreviations are similar the best thing to do is write the abbreviation completely out and always ask if not sure. Providing unabbreviated prescriptions, communication, and writing all abbreviations out can reduce errors in the healthcare setting. Another consideration would be to make sure in the healthcare setting written policies are mentioned and used.
If there were any incorrect abbreviations in the health record, they may have diagnosed her with something that she didn’t actually have. Or the doctors could’ve given her prescriptions to medications she wouldn’t have needed. It is so important that they use correct abbreviations and correct terms
Medication Errors one of the biggest issues happening in an acute care setting today . Although, Medications are given based on the five rights principles: the right patient, right medication, right route, right dose, and right time. Even with the five rights principles medication errors are still happening. However, some of the errors that are occurring are due to poor order transcriptions and documentation, drug interactions, proper drug name and not paying enough attention and environment factors.
“Go on, dive in. You’ll have to do some digging... she’s big heifer”. Such was one of my earliest forays into surgical medicine. As a student new to the clinical environment, I was somewhat surprised by the pervasiveness of derogatory slang used to describe patients, and I questioned how I wanted to interact with those around me - be they doctors, patients or students. Reading around this topic led to an excerpt by Komesaroff (2008) in which he presents his theory of micro ethics. Addressing the disparity between traditional bioethical teachings and the realities of clinical practice, he ultimately emphasises the importance of the smallest of ethical decisions in patient care - be it facial expression, tone of questioning or the often inconspicuous acts of trust.
Young, J., Slebodnik, M., & Sands, L. (2010). Bar code technology and medication administration error. Journal of Patient Safety, 6(2), 115-120. doi:10.1097/PTS.0b013e3181de35f7
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
The American Health Information Management Association is a body of health information professionals that majorly concerns itself with the improvement of the quality of medical records (Harman 104). These health data records are vital for the purposes of monitoring the progress of patients, performance improvements and for improving outcomes.