Royal Adelaide Hospital Case Summary

Reducing the incidence of medical error by improving the accuracy and clarity of medical records.

Electronic health records is a major component in the United States health care system. It has been proven to improve health care quality by saving time and reducing

Benefits Increase quality of care Bedside charting access Ability to access your patients records at one time All information in one place

These systems will also help cut down on medication errors by comparing the patient’s to medications or interventions so that it is given to the correct patient. Also documents the care given so there would be no human error in the case of questioning whether care had been given as long as the caregiver documents in the record. These features of the electronic health record are in place to promote patient safety by reducing errors.

We rolled out a new electronic health record in 2010. In 2011 we added additional applications to that, including electronic physician order entry and medication reconciliation. In the very early stages we decided that we needed to have policy’s in place. We wanted to have them ready to go when the applications were activated. Not to wait until we had been on them for a while and see what was working and what was not. We reached out to other facilities, and the EMR system staff to see what suggestions they had. We went on site visits to multiple facilities and job shadowed clinical users. Consulted with our clinical managers, staff, and physicians. Held weekly meetings to review, edit and revise the policies before we finalized them.

Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (Ehlke & Morone, 2013). The incentives from both of this articles will result in the delivery of quality care to many individuals in

Adoption of EHR can derive a great amount of benefits in clinical outcomes such as patient safety and quality of care. Qualtiy of care can be measured with different dimensions such as patient safety, effectiveness, and efficiency. Patient safety is defined as ‘avoiding injuries to patients from the care that is intended to help them’(Menachemi and Collum, 2011, p. 49). Often times, lack of time can contribute to omission of asking patients important questions such as drug allergy information and confirming important patient identifiers such as addresses/phone numbers. Improvement of medication error is a well-noted benefit of EHR as seen in numerous researches. According to a study, researchers found that a CPOE system was contributory in reducing serious medication errors by 55% in the hospital setting (Bates, 1998). Many other studies have reported similar findings in patient safety improvement. When e-prescribing is used, prescriptions can be checked for any drug interactions with

My facility has rolled out the implementation of Epic electronic health system. The implementation process started at the primary acute hospital setting, beginning on a test unit. It was then rolled out to the other hospital locations. All health care providers were mandated to

E prescribing can be a part of the EHR in Epic, which would include patient data, and not just prescription information. When e prescriptions are utilized in Epic, the medication is checked for interactions with the patient’s other medications and allergies. Check systems within Epic look for drug-allergy, drug-drug, and how the medication reacts with the disease. In a case study of 17 physicians in an ambulatory clinic conducted by Abramson et al., error rates from prescribing decreased from 35.7 per 100 prescriptions to 12.2 per 100 prescriptions in a year of e-prescribing as reviewed in this study. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 stated that healthcare providers would have access to EHRs to ensure the meaningful use standards per the Centers for Medicaid and Medicare Services (CMS). Meaningful use is attained by increasing the quality of patient outcomes by having access to the medication data, the patient’s history, and diagnosis by the prescriber. Prescribing is safer, when the provider is aware of the patient’s history, current medications, and allergies, therefore better patient outcomes. In the United States, the HITECH Act and the meaningful use standards stated by CMS have increased the use of e-prescribing per Friedman (2009). The CMS made e prescribing a

Electronic retrieval of patient demographics, allergies, current medications, complete medical history, diagnostic and radiologic results, etc. occurs by clicking a few buttons. Electronic patient charts provide quick and easy access to physicians, hospitals, independent labs, and pharmacies. EHRs allow simultaneous access by independent providers and allow a collaborative effort for health care management of the patient. “EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians”. (Electronic Health Records Overview, 2011)

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Remember when everything was paper based and computers never existed, what happen to those days? What happen to having to do things manual? Well technology sure has changed and had made things easier and more cost effective in some ways. In the 1980s and the 1990s, Electronic Health Records (EHR) was just being introduced in such organizations such as Intermountain Health Care-Utah, Partners Healthcare-Boston, and Wishard Memorial Hospital-Indiana were among the few to see the quality and efficiency of EHR. (Byers, 2011)

Communication between physicians is improved as well as access to all the patients’ medical history. This allows for more comprehensive accurate evaluations and better care.

“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an

Electronic medical records had a great impact in the ushering in of the age of Nursing Informatics. (Himss, 2010)EMRS present healthcare professionals with the ability to retrieve and organize data in a quick and efficient approach. With information so readily available, patient safety increases and we know that patient cost goes down. This happens because patient medications, allergies, history, demographic, and treatment information is more collectively available.