Use of Electronic Medical Records

Goal three by the National Patient Safety Goal for 2014 is to use medicines safely. Many errors occur regularly with medications which is why communication is so important with the doctors, nurses and patients. One process that Joint Commission requires in accredited HCO’s is medication reconciliation “creating the most accurate list possible off all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician’s admission, transfer, and/or discharge orders with the goal of providing correct medications to the patients at all transition points within the hospital (Finkelman & Kenner, 2012, p. 388)”. Ensuring medication reconciliation to the patient, health providers and any new consults that are

The purpose of this paper is to bring forth awareness when it comes to patients and medication errors and further educates health care professionals on the importance of communication especially during transition of care. According to Williams and Ashrcoft (2013) “ An estimated median of 19.1 % of total opportunities for error in hospitals.” Although not all medication errors occur during transition it is the time most prevalent for these errors to occur. As per Johnson, Guirguis, and Grace (2015) “An estimated 60% of all medication errors occur during transition of care. The National Transitions of Care Coalition defines a transition of care as the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the patient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.”

Medication errors are the leading cause of morbidity and preventable death in hospitals (Adams). In fact, approximately 1.5 million Americans are injured each year as a result of medication errors in hospitals (Foote). Not only are medication errors harmful to patients but medication errors are very expensive for hospitals. Medication errors cost America’s health care system 3.5 billion dollars per year (Foote).Errors in medication administration occurs when one of the five rights of medication administration is omitted. The five rights are: a) the right dose, b) the right medication, c) the right patient, d) the right route of administration, and e) the right time of delivery (Adams). Medication administration is an essential part of

Due to the large number of consumers being prescribed multiple medications, and the complexity of managing those medications, it is of a major safety concern that systems are in place for clinicians to reconcile patients medications to resolve any discrepancies in what the patient is using, or should be using, and newly added ones.

Medication Reconciliation is defined by the Joint Commission as the process of checking and rechecking a patient’s current medication list to the patient’s orders. Within a MedRec program, three steps must be followed to ensure patients have the correct medications at admission and discharge: Verification, Clarification, and Reconciliation (Greenwald et al., 2010; Ruggiero et al,. 2015). MedRec should not occur once, but multiple times especially when a patient moves from department to department. The more a patient moves, the more liable they are for a medication error due to poor communication. MedRec is done for the simple reason of catching those medication errors and correcting them before they can do any harm (The Joint Commission, 2006). Medication errors effect nearly 1.5 million people who enter the hospital setting in the USA. At least every patient has one medication discrepancy between admission and discharge, which leads to rehospitalizations due to hospital-setting medication errors (Institute of Medicine as cited by Wilson et al,. 2015). With nurses at the forefront of a patient’s medication regime, pressure is put on them to provide the necessary education and safety to prevent medication related rehospitalizations. Included in the causes for medication errors is miscommunication between departments taking care of the same patient (Allison et al., 2015). Many medication errors are preventable by the implementation of electronic orders. The use of electronic

Adverse drug events are the sixth leading cause of death in the United States and represent a significant financial burden to healthcare institutes at an estimated cost of $5.6 million per hospital per year (Meguerditchian N, Krotneva, Reidel, Huang, & Tamblyn, 2013). According to The Joint Commission (2006), medication reconciliation is the process of comparing a patient’s medication orders to all of the medications the patient has been taking. This reconciliation is done to identify and resolve medication discrepancies, which are unintended or unexplained

Discrepancies in patient’s medication reconciliation (MR) can have consequences that are potentially lethal. While many of these discrepancies are potentially avoidable, facilities are not utilizing all of the resources readily available. With evidence-based practice (EBP) guidelines in place it is possible to improve the medication reconciliation process, and provide safe care to patients across all transitions in healthcare. The purpose of this paper is to show improved medication accuracy, during the medication reconciliation process, through increased collaboration between Advance Practice Nurses (APN) and pharmacists.

According to HealthIt.gov (2014) Meaningful Use (MU) is defined as a “certified electronic health record that helps improve patient quality; safety; efficiency and reduces health gaps; engage patients and

Medication error is defined as the following by the National Coordinating Council for Medication Error Reporting and Prevention: “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (Anthony, Wiencek, Bauer, Daly, & Anthony, 2010). Medication errors cause increased length of patient hospitalization and morbidity and mortality (Pape

The new federal healthcare laws are now requiring clinics and hospitals to focus more on medication reconciliation. This is an improvement, but it will take a combined effort of healthcare providers and patients to make this successful. Another helpful application is the creation on the Prescription Monitoring Database. This database has been created in the effort to allow healthcare providers a resource to simply key in some of their patient’s basic information, such as name and date of birth, and review a patient’s prescription medication history particularly narcotics. While this database is not completely “fool proof”, it is a concerted effort in the battle against prescription drug

Mediation reconciliation is the process of gathering all the medications, including over the counter meds, herbal supplements, and multivitamins a patient is taking regarding their care. Within the parameters of mediation reconciliation, dosage, frequently, name,and route are the prime factors of developing a medication regimen. The goal of knowing all medications of a patient before continuing with care or being admitted to specialized settings like hospitals or clinics will avoid over-medicated adverse effects and possibly death. According to the article, Medication Reconciliation to Facilitate Transition of Care after Hospitalization states that, “ It is estimated that 20% of patients experience adverse effects during the two weeks after hospital discharge (2015). With that in mind, image ho many patients experience this disparity throughout their lives with the advised medications given at the hospital. The nurse, as well as the patient and their families should be encouraged to be more involved in their care to avoid inadvertent inconsistencies across the transition of care between admission, transfer, and discharge from and to specialized settings. Aside from preventing medication errors, we as nurses, can support the patient 's safety as the first line of defense in battles against unsanitary and explosive adverse effects that results from inadequate nursing skills.

The projected process improvement is to only perform medication reconciliation in the outpatient EHR versus performing this task in the legacy Composite Health Care System (CHCS) system. AHLTA and CHCS are incompatible for the medication reconciliation; this known flaw in the system creates opportunities for medication errors and is considered a patient safety issue. This is an important issue to fix because it has been shown in studies that “Adverse drug events (ADEs), defined as harm

Medication mistakes is a critical global issue and the utmost principle widespread dilemma that terrorizes patient safety that might spearhead to disability or death if not detected, and medication error are virtually never deliberate and regrettably occur in healthcare

According to the Institute for Healthcare Improvement, “Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders” (Institute For Healthcare Improvement, n.d). This process includes three steps: collecting the medication history, ensuring that the medications and dosages are appropriate for the patient, and documenting the changes in the orders. This occurs when the patient is admitted, transferred and discharged from the hospital (Institute for Healthcare Improvement, 2011). The purpose is to avoid any duplications, incorrect

In most organizations, a review of the most recent medication errors will likely uncover some aspect of an ineffective double-check process. Take the time to evaluate the procedures for which you require a double check, monitor compliance, assess how often the checks are conducted as designed, and then make the necessary revisions to promote effectiveness. When employed judiciously, conducted properly, and bundled with other strategies, manual independent double checks can be part of a valuable defense to prevent potentially harmful errors from reaching patients