How to Maintain Efficient Communication and Reduce Medical Errors

As every government seeks to provide better health services for its citizens, healthcare facilities are also striving to prepare for the numbers for effective information management. Healthcare is also becoming more seamless, cutting across departments and professions since the emergence of insurance covers, advanced hospital care, mobile health services, and home-based care. In a bid to maintain efficient communication and reduce medical errors, facilities have adopted nursing record systems. Nurses play a central role in the collection, generation, and keeping of patient information; thus, the record system is centered on the nursing care plan as part of the interventions. In 2018, Christine et al. conducted a study to assess the effectiveness of nursing record systems and their effect on nursing practice and health outcomes. The study involved nurses and practitioners working under nurses who answered both open and close-ended questionnaires on the effect nursing records have had on their practice. Since record-keeping forms an essential part of nursing care plans, the study provided essential information to scholars and financial analysts on whether it is worth the cost. 

Analysis of the Study 

The development and implementation of the invention were described in detail in the study. The researchers also interviewed practitioners in different hospitals and locations to have a wider variety of results. The more significant sample makes the conclusions drawn from research more accurate, as long as the data is captured accurately. In the study, the researchers used written questionnaires, which made ensured the results were valid despite the large sample. Additionally, the study utilized both quantitative and qualitative data collection methods. Combining the two methods ensures the weaknesses of one are covered up by the inadequacies of the other (Zhu et al., 2016). The variety provides all necessary details on the effectiveness of nursing record systems. 

The design of the study promotes the investigation of the effects of the study. The researchers provided well-structured questions to ensure answers directly met the rationale of the study. The data was obtained from the Cochrane Effective Practice and Organization of Care Group (EPOC) Module. The study also included controlled before and after studies, randomized controlled trials, interrupted time series analyses, and control groups. Interviewing nurses, nursing students, midwives, home-based caregivers, and all health workers working under nurses also provided a large sample, which contributes to more accurate conclusions. It was also necessary due to the changing concept of healthcare being spread across professions, to understand how different professional feel about nursing records systems. Patients were also included in the study since they experience the effectiveness of the systems through diagnosis, prescription, or management, in and outside of the facility. Theoretical systems such as educational systems were left out since the study was investigating the effect of the systems from a patient-centered approach. 

However, some variables imparted the findings yet were not part of the intervention. Since humans primarily operate nursing records systems; therefore, its effectiveness can be lowered by human errors. Although some advanced systems can correct some errors, a mistake in the history-taking of the patient could be replicated until the last stage ( Akhu ‐ Zaheya et al., 2018 ). For instance, if a nurse in the triage records that a patient is allergic to sulfur, all practitioners involved will avoid prescribing drugs that contain sulfur. In a case where the most effective medication contains sulfur, the patient will receive the second option, which could prolong their stay in the hospital or increase their chance of readmission. In some cases, such mistakes or omissions can be fatal, causing worse health, permanent damage, or death. The individual entering the initial plan when designing a nursing care plan should, therefore, verify all information. 

The study did not pose any safety hazards since it was simple and straightforward; therefore, there was no safety concern. The study could, however, have been improved by also seeking to hear the opinion of non-medical practitioners since healthcare nowadays goes beyond the healthcare facility. Professionals in insurance companies and financial risk analysis have become part of healthcare with the implementation of both private and government-sponsored health insurance. For instance, in the US, the establishment of the Affordable Healthcare Act, health records have become a concern for both medics and non-medics. Americans also sue medical practitioners and facilities more than most countries; therefore, lawyers may need health records to ascertain the practice of their clients. Interviewing such professionals would have resulted in conclusions with broader applicability. 

Although the research was successful and yielded expected results, the researchers faced several challenges. There was insufficient literature work on nursing health records, thus despite having data, forming conclusions was cumbersome (Christine et al., 2018). Literature determines what conclusions researchers can draw since it presents evidence-based facts. By comparing what literature projects in theory to application and execution of record systems, the researcher draws conclusions that are supported by the literature. Additionally, the researchers complained of a shortage of abstracts, as well as changing indexing methods over the years. Therefore, in cases where data was available, it was hard to retrieve or understand (Christine et al., 2018). The challenges were, however, overcome by allowing researchers to do database searches without year restrictions, which were then sorted according to relevance. 

In the future, the same challenge is unlikely to be present since information is published online. Since the introduction of websites and online archives, literature can easily be retrieved, no matter how old since analog information has also been converted into soft copies. 

Conclusion 

Healthcare is also becoming more seamless, cutting across departments and professions since the emergence of insurance covers, advanced hospital care, mobile health services, and home-based care. In a bid to maintain efficient communication and reduce medical errors, facilities have adopted nursing record systems. The study was done by Christine et al. (2018) was conducted to assess the effectiveness of the systems, which were found to be effective. Nursing health records also reduce the chances of readmission, reinfections, human error, and increase health outcomes. Besides medical practitioners, other professionals have also benefitted from the systems, as they make information readily accessible and easy to understand and manipulate. 

References 

Akhu ‐ Zaheya, L., Al ‐ Maaitah, R., & Bany Hani, S. (2018). Quality of nursing documentation: Paper ‐ based health records versus electronic ‐ based health records.  Journal of clinical nursing ,  27 (3-4), e578-e589. 

Chrstine, C., Currell, R., Grant, M. J., & Hardiker, N. R. (2018). Nursing record systems: effects on nursing practice and healthcare outcomes.  The Cochrane Database of Systematic Reviews ,  5 , CD002099-CD002099. 

Zhu, H., Colgan, J., Reddy, M., & Choe, E. K. (2016). Sharing patient-generated data in clinical practices: an interview study. In  AMIA Annual Symposium Proceedings  (Vol. 2016, p. 1303). American Medical Informatics Association. 

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