大多数医疗保健组织正在转向电子健康记录(EHR),充分理体。EHR可以实时在护理点提供准确的患者信息;工作人员必须破译提供商的难以辨认的写作,以确保执行正确的订单。通过正确的EHR过程到位,组织能够协调提供者之间的关心,并在连续轴之间进行缩小,以减少错误并提供更安全的护理。

然而,当一个组织开始实施电子健康记录的旅程时,甚至往往是,责任可以转移或遗忘。如果没有关键利益相关者的参与,认证测量师经常遇到患者安全的危险的解决方法。应包括前线员工以确保开发流程以缓解和使用效率。领导力应参与评估任何推荐的做法是否会影响医疗机构提供安全,有效和高质量护理的能力。

相信其EHR进程的组织在学习时往往会失望,他们在他们的认证报告中有没有认识到的关于文件的安全风险。可以进行主动风险评估,以减轻安全危害和已知风险。这些评估可以帮助您的组织专注于可能需要调整EHR配置参数的特定区域。他们还可以显示增加其他人参与加强工作流程的值。我们建议致辞三个普通风险领域。

1. Policy requirements vs. actual systems and processes

第一主要风险领域是捕获EHR的实际系统和流程与组织的政策要求不符。这不是巧合,即测量师在您的组织上进行的第一件事是通过您准备的文件列表,包括众多政策。他们想知道该组织需要员工做些什么和文件。

For instance, if an order is placed to titrate a drip to keep the Richmond Agitation-Sedation Scale (RASS) at a -2, the survey team will look for the documentation that supports the titration order. Far too often, surveyors find that key elements such as RASS are either not built into the system at all for the nurse to document or nurses are expected to navigate to another screen to document this component. Having the nurse toggle between multiple screens can be a risk to patient safety. There is also an increased probability that the nurse will assess the scale but not remember to document it because the documentation is not located in a place that mimics the required workflow.

2. Variation in electronic health record documentation

对患者安全的第二个常见风险与变异有关。你有没有听过旧的谚语,变异是敌人?在调查过程中,它可以是。认证机构不需要或推荐特定的健康记录格式。在调查时,根据认证机构的已定义标准,根据认证标准对健康记录进行评估。但是,当测量员审查ehr时,他们正在寻找整个组织的文件中的一致性。如果每个部门都有自己的方法来记录EHR,它可以是测量师的红旗。

一个示例可能是一个超时的文档。让我们说,在你组织的一个领域,护士记录时间出现为“正确的患者,正确的网站,正确的程序”。然而,在另一个部门,护士将其记录为“超时完成”。验船师将注意文档的差异,并参考您的组织的政策,以查看哪一个是正确的。

Standardization across all areas of your organization ensures that required elements are made clear to staff and practitioners. Wrong-site, wrong-patient, and wrong-procedure surgery continues to be one of the most frequently reported events voluntarily reported to the Joint Commission, with 95 reported events in 2017. High-reliability organizations reduce the variability within their documentation to achieve zero harm.

3. Staff confidence in electronic health record processes

您已经确定了风险区域和危险,并采取了措施来解决它们。然而,有一个更重要的是解决:您的组织的EHR流程只与您的员工自信地导航该过程的能力一样好。否则,由于在文档期间,护士可能会受到护士忘记关键步骤的关键步骤。

During the survey, your staff will need to feel comfortable sitting with the surveyor to look at the health record retrospectively in some cases. This can be very difficult if staff are not used to looking at a record in this environment. Staff might also be uncomfortable navigating the record if something requested was documented in a different department. The survey process will go smoother if staff are able to navigate the record with ease. Consider nominating someone on staff to be a “super user” who is available to assist staff in navigating the record to locate information requested by the surveyor.

Practice tracers are an excellent way for your staff to gain the confidence they need to locate the following key documents:

  • 历史和体检
  • Initial nursing assessment and physical exam
  • Pain assessments and reassessments after interventions
  • Screenings for suicide risk, including in-depth assessment and appropriate interventions if positive
  • 下跌风险和干预措施
  • Care plans
  • Physicians’ orders
  • Medication administration record
  • Informed consents
  • Operative report (immediate note and official report)
  • Pre-anesthesia assessment, anesthesia record, and post-anesthesia assessment
  • Restraint assessments/monitors
  • Discharge plans

Minimizing safety risks and ensuring compliance

Is your electronic health record process built to minimize safety risks and ensure compliance with required documentation elements? The best way to test that theory is to pull records throughout the organization on various topics. For instance, if invasive procedures are performed in numerous areas, then pull one from each area and look for areas in which staff are not documenting according to the policy and for variation in charting.

如果您注意到您有变体,请考虑完成重点风险评估。卫生信息技术(ONC)的国家协调员办公室发表了更安全的指南that assist healthcare organizations in identifying areas within the EHR to improve the overall safety of the health care system.

如果您涉及您的EHR流程,请联系指南针在(513)241.0142,m88.com手机网址via email, orM88.com to discuss how we can assist.

About Tabitha Garbart, DNP, RN

Fresh from the Joint Commission as a hospital nurse surveyor, Tabitha brings to Compass more than 19 years of experience in the industry and a commitment to helping healthcare organizations connect the dots and understand the “why” behind their work toward a goal of using evidence-based practices to reduce harm and improve quality of care. She previously served as the Chief Quality Officer at Mary Black Health System and has served as a consultant on a continuous survey readiness team assisting Veterans Affairs medical centers to prepare for accreditation visits.阅读有关Tabitha的更多信息。

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