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When i receive the patient from the or nurse, the electronic medical record of the patient has complete list of patient medication that was administered during the surgery in the or and therefore it helps me give clear picture of what medication i can give and what medication i should not give.

by | Oct 29, 2022 | Healthcare and Nursing | 0 comments

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Responses to Other Students: Make a separate Response to at least 2 of your fellow classmates reply about their Primary Task Response regarding items you found to be compelling and enlightening. Each response should have at least a 250-word use 1 scolarly reference per post response. And don’t forget to thank them for a well written post. To help you with your discussion, please consider the following questions:
What did you learn from your classmate’s posting and thank them for a well written post?
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Zemenu Mestesalem’s Post:
Unit 1 – Discussion Board 2
If there is a profession which has gone through dramatic shifts in the past century it will be nursing. The profession has gone through several changes to deliver quality and caring services to the patients. One of the changes that happened is the implementation of the use of electronic medical records (EMR). Electronic Medical Records (EMR) is the digital record or the computerized version of the health records of the patient which includes patient demographics, patient medical history, patient allergies and other pertinent patient health related information are all compiled in one digital record.
The invention and implementation of the use of electronic medical records are one of the best positive changes that dramatically enhanced patient safety and resulted in truly positive outcomes. Before the electronic medical record came into use, nurses were using what is called paper charting and basically it has all patient’s demographic and health data which is written on a piece of paper put in a binder. This paper charting, I believe can be a source of medication errors at times even though it is an important tool in the delivery of the patient care and sometimes it can compromise patient safety because I have personally seen handwritten prescription orders written by the admitting physician which is very difficult to discern. In other words, the use of paper charting has a wiggle room for mistakes to happen and can compromise patient safety unless due diligence is applied to prevent unnecessary mistakes.
I find the use of electronic medical records to be extremely helpful for the overall delivery of health care delivery and promotes patient safety. It promotes patient safety by establishing clear line of communication among the health care teams. The patient laboratory, prescription order, patient home medications, patient allergies and vital signs are documented in the electronic medical records for all to see. It also promotes patient safety by making it easily trackable to find out what medication took and what time there by preventing confusion. For example, as a PACU nurse, I receive surgical patients from the operating room and treat their pain and discharge them home when patient’s pain and health is optimized. When I receive the patient from the OR nurse, the electronic medical record of the patient has complete list of patient medication that was administered during the surgery in the OR and therefore it helps me give clear picture of what medication I can give and what medication I should not give. If a patient received IV Tylenol, I now know not to give that patient po or IV Tylenol even if the patient requests. We can see how it improved the patient by establishing clear line of communication and health delivery overall. To be fair, this can be done via paper charting but sometimes if the doctor forgets to write the prescription order on the paper, we do not know what is given or not given. The other important patient safety of the electronic medical record is that it prevents medication error by prompting a question if you we are still going to administer that medicine since it was given at a particular time there by avoiding mistakes. Even though there are still gaps and safety concerns that can compromise patient safety, the use of electronic medical records has significantly improved patient safety in numerous ways.
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Mariah Robbins Post:
I previously worked at a Correctional facility; we implemented electronic health records. Until May 2020, we used paper charting as well as handwritten MARs. As everyone knows, paper charting can lead to many nursing errors, and many of those errors, unless self-reported, would go unnoticed. According to the US National Library of Medicine, before electronic medical records, 84% of all patient’s charts had one or more errors. This is a vast number and a scary statistic regarding patients’ health.

Electronic Health Records have changed how healthcare providers care for their patients. This makes the documentation portion of seeing the patient more efficient. It makes it, so all providers on the same network can access the chart for smooth, intergraded care. Electronic Health Records have changed the healthcare field and have reduced medical errors. According to The US National Library of Medicine, before electronic medical records, 84% of all patient’s charts had one or more errors. Since introducing HER, new technology has presented itself. Scanning medications to further reduce medical errors.
Barcode scanning before medication administration is crucial for a fourth check before administering medication to a patient. The order is first placed by a provider, checked by the pharmacy, reviewed by the nurse, and finally matched by the scanned barcode. The barcode scanning for medication administration is being pushed to all departments to reduce the number of medication errors. Medication errors are the third leading cause of death in the United States for patients in the hospital. According to the article Impact of a Barcode Medication Administration System on Patient Safety. After implementing this as mandatory and watching the numbers. This oncology clinic reduced the number of errors by 85%.
Before EHRs and medication administration barcode scanning, medication errors were only self-reported if the nurse recognized that they had given the wrong medications. Now with barcode scanning, the nurse can check the last time before administering medications. If the drug is incorrect, the documentation is supposed to be labeled as a near miss to help further understand how this medication got out of the pyxis to the patient before scanning. Some nurses look at this as a way to find the bad in someone when it tracks the hospital’s problems and how to create a more safe working environment. The medication barcode scanning also follows the number of medications given without scanning. This tool is also tracked due to safety. If scanning medications can reduce medication errors by 85%, the question becomes, why are we not scanning medications? Using the appropriate response can also reduce the frustration that the nurse may feel when they cannot use the barcode scanner in the patient’s room.
This tracking initiative would only be successful with EHRs due to no electronic tracking records. If there aren’t any medications or patients to scan, there would not be any data to follow. Therefore medication errors would only go self-reported if they were noticed.

 

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