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…
and patient safety. This in turn makes recording information more efficient and correct when filling prescription and orders for meds. Also, dosing for prescription is correct and overdosing is avoided. The list of confused drug names formed by ISMP gives multiple list with drug names along with the correct name of the drug. This list allows doctors or nurses or even pharmacists to compare names to ensure they have the correct name. With the correct name it ensures the correct medication for patients. These lists should help decrease the inaccuracies of prescriptions medications and help insure the correct drugs for patients. This list also will allow for patients to check the name of their prescription to ensure the drugs name just in case it ever gets that far. This list also brings in tall man letters since some words have tall man letters which can change the meaning of medications and can be confused with similar words. In the last list it is just like the confused drug names but this time it incorporates tall-man letters.
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
listed.
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.
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 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.
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.
Nurses were the professional group who most often reported medication errors and older patients were those most often affected in the medication errors reports analyzed for this study (Friend, 2011). Medication error type’s revealed omitted medicine or dose, wrong dose, strength or frequency and wrong documentation were the most common problems at Site A where the traditional pen and paper methods of prescription were used; and wrong documentation and omission were the most common problems associated with medication errors at Site B where the electronic MMS was introduced (Friend, 2011). Reports of problems such as wrong drug, wrong dose, strength or frequency, quantity, wrong route, wrong drug and omitted dose were less frequent at Site B (Friend, 2011). The reduced incidence of omission errors at Site B supports suggestions that an advantage of the MMS is easy identification of patient requirements at each drug round time slot. Despite the finding of less omission errors at site B where the MMS had been introduced, there was a relatively high frequency in the incident reports of medication errors related to both omission and wrong dose, strength and frequency at both sites (Friend, 2011).
Some method such as audits, chart reviews, computer monitoring, incident report, bar codes and direct patient observation can improve and decrease medication errors. Regular audits can help patient’s care and reeducate nurses in the work field to new practices. Also reporting of medication errors can help with data comparison and is a learning experience for everyone. Other avenues that has been implemented are computerized physician order entry systems or electronic prescribing (a process of electronic entry of a doctor’s instructions for the treatment of patients under his/her care which communicates these orders over a computer network to other staff or departments) responsible for fulfilling the order, and ward pharmacists can be more diligence on the prescription stage of the medication pathway. A random survey was done in hospital pharmacies on medication error documentation and actions taken against pharmacists involved. A total of 500 hospital were selected in the United States. Data collected on the number of medication error reported, what types of errors were documented and the hospital demographics. The response rate was a total of 28%. Practically, all of the hospitals had policies and procedures in place for reporting medication errors.
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
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.
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
“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.
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.