Nursing practice and patient safety go hand in hand n the healthcare industry. In part three of our quality improvement plan, documentation and privacy errors from Electronic Medical Records (EMRs) or use of Information Technology in the healthcare industry is the chosen problem. The reason as to why it is the problem of choice is because it is rampant in ‘Hospital X.' Many complaints have been received by the administration from patients on threat on their safety during treatment due to lack of their medical information or due to wrong treatments. The setting for the project is a hospital specifically ‘Hospital X' and targets major stakeholders in the hospital such as the physicians, nurses and the patients as they are concerned with patient safety in the facility (Bravo, Cochran, & Barrett, 2016, p. 335).
This chapter shall cover the background of the problem and what current data at the hospital reveals. It shall also discuss why the problem is patient safety risk. The safety, ethical and patient safety standards apply to the above-stated problem and the impact that the problem might have in the nursing practice. This paper shall also look at how the problem is being managed currently and formulate project plan by the stakeholders (internal and external) who will be involved in implementing the plan for the project.
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BACKGROUND
Documentation and privacy errors from the use of EMR or use of Information Technology has been a problem that had prevailed in Hospital X for a long time without detection until when complaints started coming into the administrations through patients who developed complications after treatment. Current data from the hospital reveals that a large percentage of the patients treated in the hospital get correct treatment, but a large number also gets wrong treatments due to lack of former medical records that are lost during documentation or due to the fact that their medical information has been altered in one way or another causing physicians to treat wrong diseases (Kalra, 2011, p. 15). A good example is the statistics, from the hospital that elaborate the above issue, for patients who have undergone cataract surgery in the past one year. The statistics show that the number of patients that had a problem with their medical records because of documentation and privacy errors in the use of Information Technology and EMR was greater than 50% of the total number of patients who went through the surgery as shown below.
Correct records added up to 120 which was 36.92%
Omissions were 100 which was30.7 %
Documentation errors 90 which is equivalent to 27.6%
Errors caused by unauthorized alteration of patient information (privacy errors) added up to 15 cases which translate to 4.7%
Out of the 63.08% of patients that had medical errors in their records due to use of systems and Information Technology in the process of documentation, 10% which accounts for 21 patients were harmed by problems arising from the issue of wrong documentation and interference of data. Most of them developed worse conditions only for the physicians to realize the error was in the medical records they used to make the treatment decisions.
From the above current data at the hospital, the problem above is patient safety risk area in that it causes grave consequences as it can lead to other errors such as wrong medication errors due to an omission of relevant medical information on the patient. The use of Electronic Medical Records is of great relevance today but if not constantly monitored can cause problems in the health industry.
Studies by ECRI Institute in May 2015 show that EMRs (Electronic Medical Record systems) have been adopted in many healthcare facilities. However, these systems still have their drawbacks which should be considered by health institutions. The systems are manned by humans and as the saying goes ‘human is to error' so these machines record errors especially during the process of feeding medical data. The ‘cut and paste' option in the interference of the systems make the errors more likely to happen ("Wrong-Record, Wrong-Data Errors with Health IT Systems," 2015). This is because those delegated with the duty of keying in the data are not vigilant enough to avoid errors or feed meaningless data. NAHQ (National Association for Healthcare Quality) code of ethics and standards of practice should apply to this problem. This will ensure healthcare professionals do their jobs with integrity, accountability, and honesty. It will also ensure competency for all healthcare professionals and also ensures that customer satisfaction and safety is the priority of the healthcare professionals.
The above standards such as the code of ethics of professionals, customer satisfaction, quality and quality management standards have a great impact on the nursing practice in that nurses are able to maintain quality services to the patients at the same time ensuring the safety of the patient and their satisfaction with the services that are offered at the healthcare institution. They also ensure that strategic quality planning is carried out by the stakeholders in the hospital and that management of the quality processes is efficient (Wu & Juhasz, 2017, p. 13).
MANAGING THE PROBLEM
Hospital X has plans underway for managing the problem of documentation and privacy errors from EMRs. The hospital aims at achieving 97% efficiency when it comes to patient safety about the use of information technology or EMRs. Currently, the administrators have sought the cause of the problem, and it is on the major stakeholders, that is, the nurses and the patients. Patients sometimes give the wrong information on their medical histories which may affect what is fed into the systems (Van Matre & Slovensky, n.d., p. 344). An awareness campaign team has been put in place in Hospital X, and they are educating all patients on the importance of sharing the correct medical histories with healthcare professionals to protect them from the harm that is caused by medical decisions made using wrong medial information of the patient. This has improved the situation at the hospital and patients are more honest as they now believe that their medical history is kept secret. This has reduced errors so far by 5%.
The hospital administrator has also stationed supervisory nurses who check the data that is fed into the EMR systems in the hospital. This will ensure that errors of omission and entry of wrong patient data or confusion in documentation processes are eliminated. The management is installing a new up to date system in the hospital that has features such as limited accessibility and encryption to protect the patients' information from third-party interference. This procedure is still underway.
PROJECT PLAN
Mission statement
The mission statement is to be the best hospital in the region engraved in patient safety and ethical standards to ensure the satisfaction of the customer and provision of top-notch medical services, using Information Technology and new Electronic medical record systems to increase effectiveness and efficiency of the said services.
Purpose
The purpose of the project is to ensure that all standards (ethical and patient safety) are followed in all departments in Hospital X to reduce the problem of documentation and privacy errors from EMRs. The purpose of the project plan is to outline each step that will be used by the hospital to achieve the 97% efficiency target and to block all loopholes in the hospital's systems that contribute to patient risks.
Project Goals
To ensure patients learn to communicate truthfully on their medical history to nurses to avoid errors due to false information. Another goal of the project is to ensure that new, up to date Electronic Medical Records are set in place in the hospital by the period stipulated on. This will be beneficial to the hospital as the systems will be more secure through software such as encryption software which stops unauthorized access to data and audit trail software that tracks who has been in the system, when and what they changed.
The potential risk that may affect the plan includes non-compliance by patients or the nurses in the process of being more careful in the information they feed into the systems. Another risk factor that should be considered is the loss of medical data which might occur when systems are being changed to better ones or incompatibility of already existing data with the new systems (Bieber & Annable, 2015, p. 129). The standard I would apply is the ‘making systems to work together' standard set by HHS (Health and Human Science department) to govern interoperability of EMR systems. This means that different systems can be able to communicate with each other using different software.
INITIAL PLAN
Once the project has taken off, outcomes of the same are the only indicators of whether the plan is successful or not. If the number of medical errors in Hospital X's IT systems reduces, this is a positive indication that the plan is working. Employing supervisors who will constantly monitor the new electronic medical record systems will be a worthwhile resource to ensure a positive outcome. Those who are part of the cause of the problem should also be trained on the importance of trying to improve their skills in performing certain tasks and ultimatums should be set by administrators of Hospital X.
Stakeholders who will be involved in the project include patients- they will care about the initial data they provide to the healthcare professionals at the hospitals. This is because lack of honesty in the data they give on their medical histories will increase errors; hence they should provide clear and correct information on their health. Nurses will also be involved in that they take most of the notes on patient health and feed them to the electronic medical records systems (Roeder, 2013, p. 16). The information they record on the condition of the patients determines the treatment decisions the physicians make. Administrators are also involved, and they take care of all the businesses of the hospital and ensure that the customer gets quality services from their staff. External stakeholders such as regulatory agencies are involved in that they check the technological systems such as EMR in the hospital and make sure they are up to set standards.
CONCLUSION
Patient safety and satisfaction is the most important aspect in the healthcare industry. It is the duty of Hospital X to make sure that all the stock holders, who are involved in patient safety, abide to code of ethics and medical standards when dealing with patients and medical records and data relating to the patient. The above will reduce instances of documentation and privacy errors that have great negative impacts on the hospital
References
Bieber, E. J., & Annable, W. (2015). Quality Improvement in Healthcare. MBA for Healthcare , 127-140. doi:10.1093/med/9780199332052.003.0007
Bravo, K., Cochran, G., & Barrett, R. (2016). Nursing Strategies to Increase Medication Safety in Inpatient Settings. Journal of Nursing Care Quality , 31 (4), 335-341. doi:10.1097/ncq.0000000000000181
Kalra, J. (2011). Medical Errors and Patient Safety. doi:10.1515/9783110249507
Roeder, T. (2013). Managing Project Stakeholders. doi:10.1002/9781118654491
Van Matre, J. G., & Slovensky, D. J. (n.d.). Reducing medical errors. Handbook of Healthcare Management , 332-350. doi:10.4337/9781783470167.00018
Wrong-Record, Wrong-Data Errors with Health IT Systems. (2015, May). Retrieved from https://www.ecri.org/Resources/In_the_News/PSONavigator_Data_Errors_in_Health_IT_Systems
Wu, A. W., & Juhasz, R. S. (2017). 1. Principles of healthcare quality and patient safety. New Horizons in Patient Safety: Understanding Communication , 10-17. doi:10.1515/9783110455014-001
