Culture of Safety Related to Health Information Technology
Incidents in IT are broken down into two types. The first is when a person does not use the IT system in the correct manner. Where I work, this is most noted with older nurses who havenâ€™t had the privy of using computers their entire life but can happen with anyone. The second is related to problems within the software or system. I canâ€™t recall any time that Iâ€™ve seen this occur where Iâ€™m currently employed.
In the case study on page 13, it describes an incident where the eMAR was cutting off the end of certain medication names. This one involved an extended release morphine and an immediate release morphine which led to a patient being given wrong doses and ending up in respiratory failure. Luckily, the patient was intubated and recovered from the incident. This was a problem with the software and not due to any human error when interfacing with it. This is a serious error and couldâ€™ve resulted in the patientâ€™s death. This led to the IT developer correcting the issue (Wallace, Zimmer, Possanza, Giannini, & Solomon, 2013).
Now, although the case study showed a major error, research shows a significant reduction in medication errors with use of health information technology (Lee, 2018). In order for nursing leaders to establish a safety of culture related to IT, I feel we need to understand the possible ways that errors can occur with its use. This information needs to be disseminated to the rest of the nursing staff so that any errors are avoided. We need to have a channel for our nurses to be able to voice technical problems and make sure they get fixed in a timely manner. We also need to make sure that our nurses are trained adequately in the use of our software. There are many forms of HIT out there and each one has specific nuances. Also, for those that are not tech savvy, they may need additional training to become competent with the programs used.
Lee, T. Y. (2018, January 1). The use of information technology to enhance patient safety and nursing efficiency . Studies In Health Technology And Informatics, 250, 192. Retrieved from https://eds-b-ebscohost-com.proxy.library.ohio.edu…
Wallace, C., Zimmer, K. P., Possanza, L., Giannini, R., & Solomon, R. (2013). How to Identify and Address Unsafe Conditions Associated with Health IT. Retrieved from www.healthit.gov: https://www.healthit.gov/sites/default/files/How_t…
28 hours ago
Culture of Safety Related to Health Information Technology
Andrea M Eis
In this discussion board I will be addressing health information technology and its role in health care. Communication in health care is evolving and becoming more complex with all the electronic media available. Patient care is discussed over e-mails, sent by fax, telephone, and now text messages. Health care professionals have a responsibility to protect patient information by following their institutionâ€™s policies regarding electronic communications (Burkhardt, 2014).
There are two common informational technology (IT) related problems in health care electronic communication. The first problem can occur when the user uses the health care information system incorrectly. A simple example of this is when nurse enters the wrong information on a patient in the electronic chart. This has happened to me and I had to mark the entered information as erroneous. The second, is a temporary malfunction between equipment and the software functions, an example of this is when the software is not functioning properly or slowly (Wallace, et al., 2013). I have seen this occur at my facility, especially after a software update. We were unable to review lab, x-ray, histories, current treatment, and medication delivery.
In this case study the patient was overdosed with morphine due to the electronic medication administration record (eMAR) leaving off the data indicating if the morphine was extended-release or immediate-release. The physician ordered an extended-release morphine to be given every 12 hours and an immediate release dose for breakthrough pain. The e-MAR did not clearly indicate the correct dosing. The paper medication administration record (MAR) would have clearly contained this information. The facility had recently transferred from paper to electronic records and the IT department shortened vital information on the medication. The patient was given both doses of the morphine which caused him to go into respiratory distress and intubated. This event could have been fatal for the patient. The nurse should have recognized this immediately on the e-Mar and contacted the pharmacy for clarification. The system my facility uses allows the nurse to click on the medication order and the entire order will open up, as it was entered by the physician for review. I have been a nurse for a long time and my past experiences would have caused me to question the order with the missing information. I can see how a nurse with little experience or a nurse who was extremely busy could miss this error. Pharmacy has a responsibility to the patient and the health care team to make sure the order is entered in the system correctly. All orders in our facility must be reviewed and signed off by a pharmacist before they are entered on the eMAR for administration. The physician would not have been aware of the shortened version of the order on eMAR after he entered without prior knowledge from the IT department (Wallace, et al., 2013).
This type of incident was a software function or computer related problem. The IT department did not allow for the correct entry for the medication to be safely administered to the patient. This type of incident was avoidable by the pharmacy reviewing and approving the data entry for the medication (Wallace, et al., 2013). The nurse also holds a responsibility to safely administer the medication to the patient. The facility where I work, the medication delivery system would not have allowed the nurse to give both doses of the morphine. The second dose would not have been able to be dispensed. All medications are scanned with a bar code to the eMAR and then to the patientâ€™s name band bar code. The combination of a bar code scanning system and the nurse critically thinking could have prevented this error.
Health care facilities need to encourage nurses to voluntarily encourage its staff to report errors. The data would be used to improve the electronic health care record, informational technology, and patient safety. Creating a safe clinical workflow is the goal of every health care facility. This will allow the nurse to deliver care in a dependable and secure environment. Hospital leadership can adopt a safe culture for reporting errors and make positive changes for a safer environment for everyone. The staff should not fear reporting an error but see this as an opportunity to improve and learn from the event. Punishing staff for making a mistake will decrease the reporting of errors, and create a distrust between staff and leadership (The Joint Commission, 2018)
In conclusion medical care will continue to be managed by IT and electronic health care. Nurses need to continue to be aware that information technology is not perfect, and we need to continue to practice safe technique. If the information is inaccurate or there is a system failure, nurses will need to continue practicing safe care by collaborating with fellow nurses and interdisciplinary departments for clarification.
Burkhardt, M. A., & Nathaniel, A. K. (2014). Ethics & issues in contemporary nursing (4th ed.). Toronto, Ontario: Nelson.
The Joint Commission, Developing a reporting culture: Learning from close calls … (2018, December 11). Retrieved December 5, 2019, from https://www.jointcommission.org/assets/1/18/SEA_60_Reporting_culture_FINAL.pdf.
Wallace, C., Zimmer, K. P., Possanzae, L., Giannini, R., & Solomon, R. (2013, November 15). How to Identify and Address Unsafe Conditions Associated … Retrieved December 1, 2019, from https://www.healthit.gov/sites/default/files/How_t…
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