There are three very important benefits to CPOE. They are to improve medication safety, reduce unnecessary variation in care, and to improve the efficiency of care delivery. CPOE is also beneficial to the medical world because it allows for less medical errors related to poor handwriting or transcription of medicated orders.…
Discussion of different three examples first begins with registration errors. Many times when a patient registers at the same facility, they also have similar names to previous or current patients on a patient list. Unless all staff members are well trained to follow standard procedure to distinguish patient identification, these type of errors will be a constant. Confirming a patient’s date of birth, social security number, and full name is just one step to preventing this error. Secondly, having the patient to verbally confirm their personal identifiers can also prevent this error.…
In these cases, charting was a very important part of the care provided by her. Per her, improper charting and incompetent care could have potentially led to legal ramifications for her and the institution. She also addressed some of the ethical issues by stating that in her practice, she made sure that she didn’t release the patient information to the party that was not directly involved in that patient’s care.…
When it comes to writing labels it is very crucial to ensure that spelling and order are correct. Two types of labeling done in the emergency field are medications and specimens. When it comes to labeling medication the minimum information needed on the label is the name of medicine, strength, concentration and expiration date. (Fuller & Armistead, 2013, p.261). What happens is the circulator pours medication into medicine cup or pitcher. As the circulator is pouring medication the scrub tech is verifying medicine and filling out the label with the medication name, strength, concentration, and date.. Then the surgical tech places label the medicine cup, or pitcher (Fuller & Armistead, 2013, p.433). For example the circulator walks up to the scrub tech back table and pour Xylocaine, with a strength of 1%, is concentrated with epinephrine and expiration date is June 1, 2016. As the circulator is telling the scrub what is being poured the scrub writes on the label: Xylocaine with epi 1% 10/16. The next item to label is towards the end of the case, a specimen. When labeling a specimen labeling ensure to have positive site identification by the read back verification (AORN, 2016 ). Site identification includes confirming location of specimen, which can be anything from tissue, foreign object or body substance (Fuller & Armistead, 2013, p. 433). Before placing the specimen in…
It's very important to always double check your work, You should make it a habit, so you don't make any mistakes. Always make sure you fill out paper work right the first time, Each person who enters information in a medical chart must make sure the notations are mistake-free, complete and tell a story. Any missing, or excessive, detail can affect charges on a final bill and determine how much is covered by insurance. A patient should never get charged if a physician makes the mistake, and always be careful with double billing you don't want to get billed twice. Any errors that happen can get lost or delayed. Listen and correct any information that's needed. You don't want to put in the wrong codes. The wrong date or code can be as simple as…
Outcome one Understand the need for secure handling of information in health and social care settings.…
These mistakes are in direct violation of Hippa (the Health Insurance Portability and Accountability Act). A physician not completing a chart is also “Medical Records” 3 a common mistake that should be corrected by the assisting nurse. But there will be times when these records reach the medical records department personnel and as a professional, these records should be brought to the attention of the assisting nurse or the acting physician. When falsifying occurs, despite the reason, it should also be brought to the attention of the assisting nurse or the acting physician. As we all know, that’s the correct way of approaching something like this but in reality it would be a different…
Spend some time interacting with your prospective patient before you spend a lot of time gather data from the chart. Some students have made the mistake of selecting a patient who they have not…
Data quality is vital to patient safety. If information is inaccurately recorded it can lead to all sorts of complications. “Patient safety is affected by inadequate information, illegible entries, misinterpretations, and insufficient interoperability.” (Wager, Lee, & Glaser, 2009, p.…
The first goal listed by the Joint Commission (2013) includes improving the accuracy of resident identification. This primary goals focuses on helping to identifying a resident by using two specific identifiers. These identifiers are what help identify patients who are being treated with services and when given care (Joint Commission, 2013). Joint Commission’s safety goals confirm that wrong-resident mistakes can happen all stages of patient diagnosis and treatment.” For this reason, it is even more important to be able to get the proper identification to avoid such errors. The first goal in place was specifically set to identify the resident as the person who would be receiving care and to verify the service that the patient would be receiving at the same time. The Joint Commission (2013) allows for a residents name, identification number, and date of birth, telephone number or other person-specific identifiers to be acceptable.…
The use of two patient identifiers to verify that the correct medicine and/or treatment is being given to the correct patient is the first National Patient Safety Goal of 2016. In an acute care setting, nurses implement this during medication administration by scanning patient identification bracelets and confirming the patient’s name and date of birth verbally.…
The patient interviewed is a 72 year old Caucasian male. He was in the grocery business for 40 plus years and served in the Vietnam War in 1967-1968.The patient has suffered from back pain for many years, part due to war related injuries and part due to many years of heavy lifting in the grocery business. The patient is considered 100% disabled by the VA health care system. This pain has also increased pain in other regions of the body such as the neck and knees. When asked to rate pain using the Verbal Analog Scale (VAS), the patient rated his pain 7/10 without medication and a 6/10 with medication. The patient takes Gabapentin, used to treat nerve pain, and Aleve/Tylenol for generalized pain and inflammation, daily. He also takes Hydrocodone in emergencies when his pain reaches a 10/10 on the VAS. He has also had a left total knee arthroplasty (TKA) in 2011, and an anterior cervical discetomy and fusion (ACDF) on the 5th and 6th cervical vertebrae.…
Across the healthcare system there are universal themes that can be applied to several fields of medicine, such as ambition to make a difference, maintaining effective communication, and overcoming obstacles that one encounters throughout his/her career. Six University of West Florida students procured six individual healthcare providers and performed semi-structured interviews with the professionals in order to gain insight into the patient-provider relationship. Five of us interviewed providers in the field of nursing, while one us interviewed a provider in the field of pharmacology. Within the domain of Nursing, our professionals included: a lead RN in the field of cardiovascular/thoracic surgery, a RN that works in the oncology department, a trauma RN who works in the emergency room, a RN who specializes in labor and delivery, a RN midwife, and a pharmacist. While both the midwife and pharmacist practice privately, all the RNs interviewed practice in a hospital setting. In the interest of length, the authors of this paper concluded that there were three characteristics most important to those interviewed: Why they chose their career, communication as a healthcare provider, and obstacles faced. In conclusion of these…
As nursing has progressed from paper charting to electronically charting, health care workers are allowed to work collaboratively and more efficiently to provide the best care to all individuals seeking professional treatment. According to the video, Introduction to Nursing Informatics, “ Information systems gives us the tools in order to collect data , then when it is put into our system it allows other nurses to access that information immediately. In the past when we were paper charting, half of the battle were trying to find the patient’s chart. Now that we are documenting electronically multiple people can access the patient’s chart and get the information they are looking for” (Laureate Education, 2012). With that said, when multiple…
Complete and accurate clinical documentation will help to improve the quality of care given to a patient and will also aid in financial claims for patient encounters. Clinical documentation programs can be very beneficial for physicians to be involved and aware of what information is needed for a complete record. There are also software systems that can aid physicians in completing all necessary fields for a record. These systems can aid or harm documentation by allowing copying and pasting or inputting less details (“The right documentation strategy,” 2013). Not only have these systems been a challenge to documentation, the implementation of ICD-10 has also had an impact on medical error. If records are not complete and detailed and contain errors in documentation, coding will also contain errors and effect payment systems (“The right documentation strategy,” 2013). This article discusses the importance of proper clinical documentation without errors and impacts complete charts have on increased…