Informatics, the QSEN competency regarding electronic documentation used in healthcare facilities is intertwined with interdisciplinary communication because of the stringent dependence on the technology of Epic to share information on a common database between professionals, units, facilities, etc. (Henry, 2016, p. 21). I was alloted time to explore this system and learn about my patient’s lab test results, psychosocial information, medication information, nurse work orders, and SBAR charts, etc. Epic allowed me to easily fill out my patient-care worksheet because of the copious amount of information readily available through this system. This accessibility coupled with the interdisciplinary communication aspect is utilized to make clinical …show more content…
Additionally, one of my patient’s left the unit to undergo pacemaker implantation, and during this procedure I was unable to access their EHR. Accordingly, this inhibition of access ensured that I did not accidentally document information in a patient’s chart that was not currently on the unit, which in turn, protects the patient from medication errors, and the nurse from incorrect documentation. In addition, my nurse informed me that viewing the nurse’s work orders is an expedient way to view the medication orders given throughout the day by exhibiting meds that need to be given, that have been discontinued, or that have already been administered. Furthermore, Micromedex is a computer software program used at by Cone health facilities to provide evidence-based information about pharmaceuticals including their mechanism of action, adverse effects, indications, contraindications, etc. Because of this information, the likelihood of medication errors is significantly diminished. This experience provided insight of the incredible strides that the healthcare system has accomplished recently, and it is evident that care is being given in a more timely manner than before because of these
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.
Epic is system wide throughout the hospital and its ancillary centers that is an electronic medical record system. It was implemented into the hospital to streamline and organize the records of patients so that no matter where they are in the hospital, their record is instantly accessible to healthcare providers and all departments at any time. Epic has received the Best in KLAS award in 2014 and also is the #1 software suite five years running. KLAS is dedicated to providing “the single best source of honest, unbiased information about the software and equipment that keeps healthcare moving forward.” KLAS has stated that epic is a leader in the market for adding clients because their system is low risk and
This technology assist the nurse in confirming patients identify by confirming the patients’ dose, time and form of medication (Helmons, Wargel, & Daniels, 2009). Having an EHR also comes with a program that allows the medical staff to scan medications so medication errors can be prevented. According to Helmons, Wargel, and Daniels (2009) they conducted an observational study in two medical –surgical units one in the medical intensive care (ICU) and one in the surgical ICU. The researchers watched 386 nurses within the two hospitals use bar code scanning before they administrated patients’ medications. The results of the research found a 58 % decrease in medication errors between the two hospitals because of the EHR containing a bar code assisted medication administration
Today, I will be speaking about the Epic System and why it is so significant. The Epic system is a software that majority of hospital and health clinic’s practice. Epic is a private company with private owned employees. It is a system in the computer that keeps files confidential and secluded. Epic system is used often in hospitals and healthcare clinics because it is easy to learn, organized, safe and secure. As stated in Epic.com “EpicCare EMR is known for being fast and physician-friendly”. With this said more health care facilities prefer to use this system. Also, most of these businesses are beginning to start their employees out on this program. Another key point, with this system patients are benefiting from it as well. A lot of patients
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).
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
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.
In the late 1960s, the first computer systems were installed in hospitals (Murphy,2010). The computer systems started in the basements of hospitals and now are in every nursing unit. Nursing informatics allows for a more efficient and faster delivery of health care. Nursing informatics is a way of keeping patient information properly organized and creating patient care plans.
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
Nursing documentation is an important factor of healthcare delivery today. The use of information and communication technology offers opportunities for improving patient care delivery while reducing nurses’ documentation load and increasing the time available for caring for various patient populations (Munyisia, Yu, & Hailey, 2012).
Electronic-prescribing, often referred to as e-prescribing, is a fairly new, innovative way for physicians and other medical personnel to prescribe medications and keep track of patients’ medical history. Not only has e-prescribing enabled prescribers to electronically send a prescription to the patients’ pharmacy of choice, in the short amount of time it has been available, it has significantly reduced health care costs, not only for the patient, but for the medical facilities as well. In 2003, e-prescribing was included in the Medicare Modernization Act (MMA) which jumpstarted the role of e-prescribing in healthcare. It has proven to significantly reduce the yearly number medication errors and prescription fraud, and its widespread publicity has helped build awareness of e-prescribing’s role in enhancing patient safety. Although it has not been in practice for very long, e-prescribing has already made a positive impact in the field of health care.
Medication errors made by medical staff bring about consequences of epidemic proportions. Medical staff includes everyone from providers (medical doctors, nurse practitioners and physician assistants) to pharmacists to nurses (registered and practical). Medication errors account for almost 98,000 deaths in the United States yearly (Tzeng, Yin, & Schneider, 2013). This number only reflects the United States, a small percentage in actuality when looking at the whole world. Medical personnel must take responsibility for their actions and with this responsibility comes accountability in their duties of medication administration. Nurses play a major role in medication error prevention and education and this role distinguishes them as reporters of errors.
Over the last several years, electronic medical records are becoming more prominent in health care facilities, replacing traditional written records. As many electronics are becoming more prevalent with the invention of numerous smartphones and tablet devices, it seems that making medical records available electronically would be appropriate for the evolving times. Even though they have been in use to some extent for many years, the “Health Information Technology for Economic and Clinical Health section of the American Recovery and Reinvestment Act has brought paperless documentation into the spotlight” (Eisenberg, 2010, p. 8). The systems of electronic medical records mainly consist of clinical note taking, prescription and medication documentation,
Information Systems/Technology and patient care technology for the improvement and transformation of health care is an important part of the DNP. Technology has transformed every aspect of human life in positive ways. Technology brought efficiency and improved healthcare deliverance system. Healthcare technologies enabled practitioners to better understand disease process and how to implement best treatment plan. DNP programs across the country embrace information systems and technology in their nursing curriculum because, it prepares nursing students to be innovative and deliver best care (AACN, 2006). DNP graduates must have the ability to use technology to analyze and disseminate critical information to find solutions that
Nursing informatics is a branch of nursing or area of specialty that concentrates on finding ways to improve data management and communication in nursing with the sole objective of improving efficiency, reduction of health costs and enhancement of the quality of patient care (Murphy, 2010). It is a growing area of nursing specialty that combines computer science, information technology and nursing science in the management and processing of nursing information, data and knowledge with the sole objective of supporting nursing practice and research. Various nursing theorists have formulated various theoretical frameworks or models related to nursing informatics (Wager, Lee, & Glaser, 2013). They are defined as a cluster of related concepts or ideas that establish actions that act as major guidelines in nursing informatics to issues related to the central concept of data, information and knowledge. Some of the theories that inform and assist in the framing of nursing informatics include Turley's nursing informatics model, Goossen’s framework for nursing informatics research and Staggers & Parks’ nurse-computer interaction framework (Elkind, 2009).