3.3 Documentation and Informatics
3 min read•june 18, 2024
Medication management is crucial for patient safety and quality care. competencies guide nurses in key areas like patient-centered care and evidence-based practice. The 's abbreviation guidelines help prevent errors by standardizing medical terminology.
Technology plays a vital role in drug administration safety. Electronic health records, barcode systems, and smart infusion pumps reduce errors and improve patient outcomes. integrates these technologies, enhancing care coordination and across healthcare settings.
Documentation and Informatics in Pharmacology for Nurses
QSEN competencies for medication management
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- QSEN competencies aim to improve patient safety and healthcare quality by focusing on:
- Patient-centered care involves prioritizing patient preferences and needs in medication management (shared decision-making)
- Teamwork and collaboration among healthcare professionals enhances communication and coordination in medication processes (interdisciplinary rounds)
- Evidence-based practice guides medication-related decisions using the best available research and clinical expertise (clinical practice guidelines)
- Quality improvement initiatives continuously monitor and optimize medication processes to reduce errors and improve outcomes (medication error reporting systems)
- Safety emphasizes the prevention of medication errors through strategies like and double-checking high-risk medications ()
- Informatics leverages technology to support medication safety, such as electronic health records and barcode scanning systems ()
Joint Commission's abbreviation guidelines
- The Joint Commission's "Do Not Use" abbreviation list reduces medication errors caused by ambiguous or confusing abbreviations
- Examples of "Do Not Use" abbreviations:
- "U" or "u" should be replaced with "unit" to avoid confusion with other abbreviations or numbers
- "IU" should be written as "international unit" to prevent misinterpretation
- "Q.D.," "QD," "q.d.," or "qd" should be written as "daily" to avoid confusion with other abbreviations like "QID" (four times daily)
- "Q.O.D.," "QOD," "q.o.d.," or "qod" should be written as "every other day" for clarity
- Trailing zeros after decimal points should be avoided (write 1 mg instead of 1.0 mg) to prevent tenfold dosing errors
- Leading zeros before decimal points should be used (write 0.5 mg instead of .5 mg) to avoid misinterpretation
- "MS," "MSO4," or "MgSO4" should be written as "" or "" to prevent mix-ups
Technology in drug administration safety
- Electronic health records () provide a centralized, comprehensive patient record that enables real-time access to medication history and facilitates communication among healthcare providers
- Computerized provider order entry (CPOE) systems allow electronic prescribing, integrate with drug databases to check for interactions and dosing errors, and reduce errors associated with illegible handwriting (transcription errors)
- Barcode medication administration () systems ensure the "five rights" of medication administration by scanning patient wristbands and medication barcodes to verify accuracy and alert nurses to potential errors (wrong patient)
- Smart infusion pumps incorporate drug libraries with preset dosing limits and alerts to prevent programming errors and overdoses while providing real-time data on medication administration (continuous infusions)
- Clinical decision support systems () offer evidence-based recommendations and alerts based on patient data to assist in drug selection, dosing, and monitoring, helping prevent adverse drug events (renal dose adjustments)
Health Informatics and Data Management
- Health informatics integrates healthcare information technology systems to improve patient care and outcomes
- enables different healthcare information technology systems to exchange and use data seamlessly, enhancing coordination of care across various settings
- Data security measures protect sensitive patient information from unauthorized access or breaches, ensuring confidentiality and compliance with regulations
- processes use health informatics tools to compare a patient's medication orders to all medications they have been taking, reducing medication errors during transitions of care
- applies information technology to nursing practice, education, and administration, supporting evidence-based practice and improving patient care quality
Key Terms to Review (29)
“Do Not Use” list of abbreviations: The 'Do Not Use' list of abbreviations is a compilation of terms and symbols that should be avoided in medical documentation to prevent errors. This list aims to enhance patient safety by promoting clear and unambiguous communication.
Adverse drug event: An adverse drug event (ADE) is any unintended and harmful reaction to a medication. ADEs can occur due to medication errors, side effects, or allergic reactions.
Agency for Healthcare Research and Quality: The Agency for Healthcare Research and Quality (AHRQ) is a U.S. government agency tasked with improving the safety and quality of America's healthcare system. It develops evidence-based guidelines and fosters research to enhance healthcare outcomes and inform policy decisions.
Basal insulin dosing: Basal insulin dosing involves the administration of long-acting insulin to maintain blood glucose levels within a target range during fasting periods, typically over 24 hours. It is essential for managing diabetes mellitus, particularly Type 1 diabetes.
BCMA: BCMA, or Barcode Medication Administration, is a technology-based system used in healthcare settings to improve patient safety and medication administration accuracy. It involves the use of barcodes to verify the patient, the medication, and the administration process, reducing the risk of medication errors.
CDSS: CDSS, or Clinical Decision Support Systems, are computer-based tools designed to assist healthcare providers in making informed clinical decisions. These systems integrate patient-specific information with medical knowledge to provide personalized recommendations and support during the decision-making process.
Charting: Charting is the systematic recording of a patient's medical history and care by healthcare professionals. It ensures accurate communication and documentation of patient data for legal and clinical purposes.
Computerized prescriber order entry (CPOE): Computerized Prescriber Order Entry (CPOE) is an electronic process where medical professionals directly enter medication orders and treatment instructions into a computer system. This system reduces errors associated with handwritten prescriptions and enhances patient safety.
CPOE: CPOE, or Computerized Physician Order Entry, is a digital system that allows healthcare providers to electronically enter and manage patient orders, such as medications, laboratory tests, and diagnostic procedures. This system is a crucial component in the field of healthcare informatics, as it aims to improve patient safety, reduce medication errors, and enhance the efficiency of clinical workflows.
Data Security: Data security refers to the measures and practices employed to protect digital information from unauthorized access, modification, or destruction. It is a critical component in the context of documentation and informatics, ensuring the confidentiality, integrity, and availability of sensitive healthcare data.
Documentation: Documentation is the accurate and complete recording of patient care, including medication administration, in medical records. It ensures continuity of care, legal compliance, and serves as a communication tool among healthcare providers.
EHRs: EHRs, or Electronic Health Records, are digital versions of a patient's medical history that are maintained by healthcare providers. EHRs contain a comprehensive record of a patient's health information, including medical diagnoses, treatments, test results, and other critical data, which can be accessed and updated by authorized healthcare professionals across different settings.
Electronic health record: An electronic health record (EHR) is a digital version of a patient's paper chart. It provides real-time, patient-centered records that make information available instantly and securely to authorized users.
Electronic medication administration record: An electronic medication administration record (eMAR) is a digital version of the traditional paper MAR used by nurses to document the administration of medications to patients. It enhances accuracy and efficiency in medication administration, ensuring compliance with legal and safety standards.
Hard-stop alert: A hard-stop alert is a type of electronic warning in clinical software systems that requires immediate attention and resolution before further actions can be taken. It is designed to prevent potentially harmful medical errors by enforcing mandatory intervention.
Health Informatics: Health informatics is the interdisciplinary field that focuses on the application of information technology and data management to healthcare. It encompasses the study, design, development, and implementation of information systems to improve patient care, enhance clinical decision-making, and optimize healthcare operations.
Institute for Safe Medication Practices: The Institute for Safe Medication Practices (ISMP) is a nonprofit organization dedicated to preventing medication errors and ensuring safe medication use. It provides resources, guidelines, and education to healthcare professionals to enhance patient safety.
Insulin: Insulin is a hormone produced by the pancreas that regulates blood sugar levels by facilitating the uptake and utilization of glucose by cells throughout the body. It plays a crucial role in maintaining homeostasis, managing electrolyte balance, and supporting various physiological processes, making it an essential consideration in drug administration, documentation, and the treatment of conditions like diabetes and weight management.
Interoperability: Interoperability is the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged. It is a critical aspect of healthcare documentation and informatics, enabling seamless data sharing and integration across various healthcare settings and systems.
Joint Commission: The Joint Commission is a non-profit organization that accredits and certifies healthcare organizations in the United States, ensuring they meet specific performance standards. It aims to improve healthcare quality and patient safety.
Magnesium Sulfate: Magnesium sulfate is a mineral supplement and medication used to treat a variety of conditions, including electrolyte imbalances, preterm labor, and certain heart rhythm disorders. It is an important drug that has applications in several different medical contexts.
Medication reconciliation: Medication reconciliation is the process of creating an accurate list of all medications a patient is taking to ensure consistency and safety in drug administration. This includes prescription drugs, over-the-counter medications, and supplements.
Medication Reconciliation: Medication reconciliation is the process of creating the most accurate list of a patient's current medications and comparing that list to the medications ordered for the patient to ensure accuracy, identify and resolve any discrepancies, and provide the correct medications to the patient at all transition points of care.
Morphine Sulfate: Morphine sulfate is a potent opioid analgesic medication used to manage moderate to severe pain. It works by binding to specific opioid receptors in the central nervous system, altering the perception and response to pain signals. As a key term in the context of documentation and informatics, morphine sulfate is an important consideration for healthcare providers in terms of proper recording, monitoring, and management of this controlled substance.
Nursing informatics: Nursing informatics integrates nursing science, computer science, and information technology to manage and communicate data, information, knowledge, and wisdom in nursing practice. It enhances the quality of care by improving documentation accuracy and patient safety.
Nursing Informatics: Nursing informatics is the specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. It focuses on the use of technology and information systems to support and enhance nursing care delivery.
QSEN: QSEN (Quality and Safety Education for Nurses) is a framework that provides a comprehensive approach to integrating quality and safety competencies into nursing education and practice. It aims to prepare nurses to continuously improve the quality and safety of the healthcare systems within which they work.
Quality and Safety Education for Nurses (QSEN) initiative: The Quality and Safety Education for Nurses (QSEN) initiative aims to prepare nurses with the knowledge, skills, and attitudes necessary to continuously improve the quality and safety of the healthcare systems in which they work. It focuses on integrating core competencies into nursing education.
Soft-stop alert: A soft-stop alert is a non-mandatory notification in electronic health record (EHR) systems that warns healthcare providers of potential safety concerns but allows them to proceed with their actions if they choose. These alerts are designed to flag issues like drug interactions or dosage errors without forcing immediate corrective action.