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Electronic medical records and nursing
Importance of electronic medical records in health information system
Impact of technology on health care
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As many things do, nursing continues to evolve. In particular, nursing has gone from paper charting to electronic charting for various reasons. Our technology is not just limited to charting, but has also developed into performing more surgeries, bringing people back to life, and organ transplants among other things (Burkhardt & Nathaniel, 2014, p.260). I will be identifying two types of IT-related incidents. In addition, I will be discussing a case study. Lastly, I will be discussing how nursing leaders can establish a culture of safety related to IT. The purpose of this discussion is to discuss the culture of safety related to health information technology (IT).
The two types of IT-related incidents are human related and computer related
(Wallace, Zimmer, Possanza, Giannini, Solomon, 2013, p.7). Human related includes issues such as wrong input of data or the user ignored an alert (Wallace et al., 2013, p.7). Computer related issues include a down network or not up to date software (Wallace et al., 2013, p.7). The type of IT incident seen in the case study is computer related. I say computer related due to the computer cutting of important data. Although, why did the nurse not question this order or how was it not recognized in the Omni cell? The potential consequence could have been the patient expiring. Furthermore, nurse leaders can help establish a culture of safety related to IT. First, the staff must be fully educated, which can start through a training class (Wallace et al., 2013, p.12). Next, the staff needs to be encouraged to report issues or near misses (Wallace et al., 2013, p.12). It is important to have open communication amongst staff (Wallace et al., 2013, p.12). Staff needs to be ensured a blame free environment when reporting issues as well and have resources available (Wallace et al., 2013, p.13). Personally, I have encountered IT issues numerous times. The time that pops into my mind is when scanning in medications. A medication will match up exactly with the EMAR, but still will not accept it in the computer system. I usually have another nurse verify the medication with me. Then, I call pharmacy and tell them what the issue is. They either try to fix it or tell me it is safe to give to the patient. In conclusion, technology is nursing has evolved. We are faced with seeing incidents with technology. Particularly, there are two categories for IT related incidents. Incidents can help be fixed or prevent by reporting the incident. Nurse leaders needs to promote a safe and open environment to help see the best results. There are some incidents that are inevitable.
Human factors are derived from construction and adapted to a system of development in health care by carefully examining the relationship between people, environment, and technology. The consideration of human factors acknowledges the capability or inability to perform a precise task while executing multiple functions at once. Human factors provide an organized method to prevent errors and create exceptional efficiency. Careful attention must be exercised in all levels of care such as the physical, social, and external environment. It is also vital to carefully consider the type of work completed and the quality of performance. Applying human factors to the structure of healthcare can help reduce risks and improve outcomes for patients. This includes physical, behavioral, and cognitive performance which is important to a successful health care system that can prevent errors. A well-designed health care system can anticipate errors before they occur and not after the mistake has been committed. A culture of safety in nursing demands strong leadership that pays attention to variations in workloads, preventing interruptions at work, promotes communication and courtesy for everyone involved. Implementing a structure of human factors will guide research and provide a better understanding of a nurse’s complicated work environment. Nurses today are face challenges that affect patient safety such as heavy workloads, distractions, multiple tasks, and inadequate staffing. Poor communication and failure to comply with proper protocols can also adversely affect patient safety. Understanding human factors can help nurses prevent errors and improve quality of care. In order to standardize care the crew resource management program was
On the second day of March in the year 1955, a young, black girl named Claudette Colvin waited for the bus. She was 15 years old and lived in Montgomery. Colvin had just finished school for the day and was heading home. The city bus came, and she sat down in the area reserved for “black” passengers. As the bus filled up, left standing was a young, white woman. The seats in the white area were full, but there was an available seat in the opposite row of Colvin. Because of Jim Crows law- a law that said that a white person could not sit opposite of a colored person, the white woman refused to sit there. The bus driver ordered Colvin to move to the back of the bus so that the white female could sit down. Colvin refused to move.
When carrying out this model, all characteristics of the Culture of Safety should be well defined and structured to allow for the best possible outcome for patients and the healthcare team. References Cherry, B., & Jacob, S. R. (2011). Contemporary Nursing Issues, Trends, and Management (5th ed.). The VitalSource Bookshelf. Retrieved from http://www.pageburstls.elsevier.com.
Any progress towards moving the healthcare system to a culture of quality and safety has to begin with student education. The safe and effective delivery of patient care necessitates nursing students to understand the complexity of healthcare systems, human limitations, safety design principles, the traits of reliable systems and resources for patient safety (Barnsteiner, 2011). Therefore, integrating and incorporating QSEN helps to place considerable emphasis and steer students towards appreciating and understanding the complexity of care delivery systems. This assignment has actually demonstrated how effective the QSEN can be if the principles offered are applied to each patient in the healthcare system.
Integrating safety into nursing practice, education and research has a lot of significant implications for the instructor, practitioner, patient and the facility’s management. These are discussed below in detail.
The overall goal for the Quality and Safety Education for Nurses (QSEN) plan is to meet the challenge of educating and preparing future nurses to have the knowledge, skills and attitudes that are essential to frequently progress the quality and safety of the healthcare systems in the continuous improvement of safe practice (QSEN, 2014).Safety reduces the possibility of injury to patients and nurses. It is achieved through system efficiency and individual work performance. Organizations determine which technologies have an effective protocol with efficient practices to support quality and safety care. Guidelines are followed to reduce potential risks of harm to nurses or others. Appropriate policies
Ever felt annoyed, frustrated and above all alone because you are just simply different? Fifteen-year-old Christopher Boone experiences every day. Christopher struggles every day due to his autism, his problems include troubles understanding and communicating. Despite these deficits, Christopher is able to problem solve and deal with his problems.
Safety is focused on reducing the chance of harm to staff and patients. The 2016 National Patient Safety Goals for Hospitals includes criteria such as using two forms of identification when caring for a patient to ensure the right patient is being treated, proper hand washing techniques to prevent nosocomial infections and reporting critical information promptly (Joint Commission, 2015). It is important that nurses follow standards and protocols intending to patients to decrease adverse
Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521
Over the past decade, technological advances have paved the way for nurses to provide, quality, safe, standardized and individualized patient care (Saba & McCormick, 2015). The use of the Electronic Health Records (EHR) to manage patient data is quickly becoming widespread in the healthcare industry. The emerging use of the Electronic Health Record, is transforming how nurses care for patients. By creating and implementing an electronic, comprehensive, standardized method of recording patient data, nurses can facilitate and coordinate patient care with members of the multidisciplinary healthcare team. The use of the Electronic Health Record will promote positive
Technology and innovation have transformed the way people function personally and professionally. In the past, writing and mailing a letter was standard but now most people send electronic messages and text messages to phones. Healthcare has been changing tremendously as well, not only are paper charts and records becoming obsolete, but now many facilities are sharing test results, visit information details, and prescribed drug lists. This move into the digital age has helped improve healthcare by cutting costs in the long-term, increasing efficiency with decreased wait times, and reducing medical errors. This evolving technology expansion, commonly referred to as nursing informatics has created many opportunities for nursing professionals with information technology experience to move into this growing field.
Safety is a primary concern in the health care environment, but there are still many preventable errors that occur. In fact, a study from ProPublica in 2013 found that between 210,000 and 440,000 patients each year suffer preventable harm in the hospital (Allen, 2013). Safety in the healthcare environment is not only keeping the patient safe, but also the employee. If a nurse does not follow procedure, they could bring harm to themselves, the patient, or both. Although it seems like such a simple topic with a simple solution, there are several components to what safety really entails. Health care professionals must always be cautious to prevent any mishaps to their patients, especially when using machines or lifting objects, as it has a higher
The Nurses avoid mistakes and unfavourable occurrence using proper technology. For an example, late treatments, miscommunications between nurses and disappointment of rescue. Technology is the way which can improve health care conditions and give a
2. Detection of Incidents: It cannot succeed in responding to incidents if an organization cannot detect incidents effectively. Therefore, one of the most important aspects of incident response is the detection of incidents phase. It is also one of the most fragmented phases, in which incident response expertise has the least control. Suspected incidents may be detected in innumerable ways.
William Goossen’s theory can be applied in nursing practice to develop nursing informatics skills and knowledge, as well as develop technological system competencies among nurses to collect, process, retrieve and communicate pertinent information across health care organizations (Goossen, 2000). This theory is highly applicable in addressing matters related to electronic health records, which are currently characterized with issues of privacy and confidentiality in relation to storage, retrieval and reproduction of patient health information. The model also provides broad applicability in guiding research at any clinical setting and contributes to the discipline of nursing by simplifying and enhancing documentation and storage of patient’s health information and by allowing better utilization of nursing resources (Elkind, 2009).