One fact, information technology is constantly evolving. Educate Simplify believe in this. The company has invested on its technology for quite some time and we are reaping the rewards. From classroom based learning we have adapted online education and learning materials. We made our system accessible to IOS and Android users. Therefore, we have made an extra step to go with the current technological rush – not just flow.
Technological advancement is not just applicable in continuing education providers and training centers like us. The use of technological advancement in the nursing profession has both Among the most common types are electronic health records (EHRs) and computerized physician order entry systems (CPOEs). Though these and other technologies offer advantages, they also pose new challenges and potential risks.
When properly implemented, information technology can simplify information retrieval, reduce medical errors, and improve communication, among other pluses. But information technology doesn’t eliminate the need for professional judgment. “People are not infallible. Neither are computers—but we tend to think they are,” said Melanie Balestra, JD, MN, NP, a California-based attorney. Always keep this warning in mind to protect your patients’ health and minimize your professional liability risk.
If your facility doesn’t already use an EHR, eventually it will. Compared with paper records, an EHR can store more information for longer periods. Also, an EHR is accessible concurrently from many workstations and can provide medical alerts and reminders. Despite these and other advantages, an EHR can make one of your key responsibilities—documenting patient care more difficult.
That doesn’t lessen your responsibility to document thoroughly and accurately, so you must understand how the system works and use it properly. For instance, what if you enter something into the wrong patient’s chart? How do you correct that? On paper you’d line through the entry once and initial or sign it, but you can’t do that in an EHR. And, if you are able to make a correction, will the system still save the mistake?
Another potential hitch is redundant charting. If you record the information in two different places and make a mistake in one of them, you introduce a conflict. Whether you can correct charting mistakes easily or at all may depend on the safeguards built into the system.
If the EHR’s limitations cause documentation problems, tell your risk manager promptly. “Later it’ll be harder to prove what happened,” said Melanie Balestra, JD, MN, NP, a California-based attorney. Remember, if medical errors cause a patient harm and the patient later sues, inadequate documentation will come back to haunt you.
Be very cautious
CPOEs, another up-and-coming technology, can eliminate illegible orders, check for inappropriate drugs, and prompt healthcare providers to get informed consent. But a study that evaluated systems in the United States, the Netherlands, and Australia found that they can also facilitate errors. The study revealed that a practitioner faced with endless lines of similar-looking text on a computer screen may click on the wrong line and select an inappropriate test, order the wrong drug, or enter instructions for the wrong patient.1
The study also found that trouble can result in emergency situations—for example, a physician tells a nurse to administer a drug immediately but enters the order into the system later. If that nurse isn’t around when the order shows up in the system, another nurse could give the patient an extra dose.
Overdependence on the system is another potential drawback. NPs, RNs, and other practitioners may accept the system’s output without question. Or they may not communicate directly with the patient’s other caregivers, incorrectly assuming that the system has done it for them.
As with EHRs, you need to understand the shortfalls as well as the advantages of a CPOE system and watch for trouble, especially if the system has just been introduced. Blindly following an unproven system could have lethal consequences. A case in point: According to a recent review of records at an academic tertiary-care children’s hospital, the mortality rate among children admitted for specialized care rose by 3.77% instead of dropping, 18 months after the rapid implementation of a new CPOE.2
High-tech or low, remember security
With all patient-related documents, whether paper or electronic, taking appropriate security measures to protect privacy remains a top priority. To comply with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), you must do everything possible to prevent unauthorized people from viewing patients’ health information. Don’t leave printed documents lying around for others to see. If you input or transmit information electronically, keep the computer screen turned away from prying eyes and don’t walk away from the computer without signing off first. Never share your user ID and password. If you’re faxing or emailing information to patients, get their permission for doing so, and follow up to make sure they received it.
When it comes to information technologies, learn what these systems can and can’t do and how to use them properly, so you can give patients the best possible care and minimize potential for professional liability. You must also scrupulously follow all policies and procedures outlined by your facility and ask about your potential professional liability for information-related errors. Technologic ignorance isn’t a valid defense. “Nurses are ultimately responsible for the patient outcome,” said Gerardi. “Using technology doesn’t usurp your accountability.”
- Ash JS, Berg M, Coiera E, et al. Some unintended consequences of information technology in health care: the nature of patient care information systemrelated errors.
- Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.
J Am Med Inform Assoc. 2004; 11, 121-124.Pediatrics. 2005; 116: 1506-1512.