Archive for October, 2009

The 6 rights of medication administration, comment

October 26, 2009

Medication administration is going to be a difficult task with all the new and different types of computer documentation systems available. Medication administration will always be the responsibility of many parties, not just nursing. One of the post mentions nurses as the last line of defense, and there are many steps where errors can occur. The physician writes the order, hopefully correctly and legibly. It is then the responsibility of the pharmacy to ensure the medication is available and that it has been profiled against all current medications and allergies. The nurse must need to teach the patient the effects of the meds, the reason for the med and side effects. Last line of defense in an era where too many people rely on computers for correct information, but we must remember that information within the computer is only as good as the people inputting that information. So every one should think of themselves as the last line of defense against med errors. That, and only that, will lead to a decrease in med errors. As long as excess meds are stocked on units and physicians are allowed to write illegibly, and pharmacists don’t verify everything that comes out of the pharmacy, errors will always be there.

Original Post
July 17, 2009
Title: The 6 rights of medication administration, comment
Coming across this post, l recognised the device (scanner) which the writer says her facility uses. On the face value, JAHCO will applaud this device because it acted as if the cases of med errors have been eliminated. Yet as the writer said, it still goes back to knowing your patients and knowing your medications. Nurses are the final check point in the health team providers list. We are in between the ordering physicians and the releasing pharmacists. Nurses have to see that the parameters for which the drug is being administered is not in violation. For instance, nurses know by common sense that once the med is due, the scanner will scan and does not tell if the parameter for using a betablocker is checked for not. It is up to the nurse to make sure that the blood pressure is stable and the heart rate is within normal range. Despite these technologies, we are still required to do our checks before trusting the device.

Original Post:
June 30, 2009
Title: The 6 rights of drug administration
The 6 rights of drug administration did not prevent the cause of death in one particular case. The problem lies with the incorrect labeling of medication. The key is to trace what happened, review for any outlying causes or "what happened" and correct that as soon as possible. While the nurse I am sure will have to live with that the rest of her life, and that’s not easy, I feel that she has comfort in knowing she did not cause this. Many hospitals are using the computerized medical dispenser where you scan the patients ID bracelets then you scan the drug that is being administered which is on a time schedule also. The thinking is this will correct and help make sure the 6 rights of drug administration are followed, while this looks good for JACHO, the bottom line is a human is still keying in the information and we all make mistakes. I am not so sure the technology we have today in practice is as good as the old fashion, "know your patient and the medications being administered".

Defense Attorney Lawyer Medication Drug Error

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Web, Communication and Information Management, comment

October 26, 2009

Computer communication is here to stay and we must be cautious on not leaving behind the idea of human networking. Networking involves interaction, and when humans stop networking, the flow of communication and ideas slows to a trickle or just dams up altogether. My facility is currently undertaking the implementation of an Electronic Health Record (EHR) and the staff are beginning to see what a daunting project it really can be. We have three separate teams working under one administrator and it appears as if no one is coordinating the efforts of all 3 teams. Each team says one thing, then another happens and another team has to scramble. The implementation is costly, and not just in dollars. There is the "umbrella" or main team, a surgical services team and a pharmacy team. Just to show what is occurring, the pharmacy team has no idea of the workflow of the nursing team and vice versa. And we go live with eMAR in 2 weeks. And new issues crop up that no one can answer. And the conversations between the clinical people and the IT people can be interesting to say the least. Our teams are small and that may be one of the issues. For projects like this, all members of the teams should have an understanding of the projects each team is involved in. And one person should coordinate the team. In a perfect world……….

Original Post
October 7, 2009
Title: Web, Communication and Information Management
Review of Introduction to Computers for Healthcare Professionals, Fourth Edition, 2005/2006. Authors: Irene Joos, Nancy Whitman, Marjorie Smith, and Ramona Nelson. Within Dr. Johnson’s course.
I found a lot of the information in these chapters to be stuff that I already knew for the most part. Although I did learn the definition of the world wide web. I just thought that the web was the Internet. One of the activities at the end of chapter 9 did walk you through creating your own web page. I did not know how to do that. Chapter 12 did go over all the computer crimes and some of them I had never heard of either. The IT professionals at work only address the most common threats.

Health Care Informatics online certificate program

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Documentation on Bedsores, comment

October 26, 2009

Documentation of pressure ulcers MUST begin in the ED. With approximately 50% of admissions coming through the ER, this is an essential, albeit very difficult task that goes by without any thought. With all the patient types seen in the ED, it can be difficult to apply all the assessments to all patients. However, skin breakdown needs to become a priority and can be made a priority if performed appropriately and at the right time. ER nurses think in the NOW; what can be treated now, what med can be given now, what test can be performed now, who can be admitted now, who can be discharged now. In order to incorporate skin assessment into the ER nurses list of tasks, it can be added to the LATER list, but care needs to be taken to not forget this important step. Once the patient has been stabilized, the skin assessment can occur. With the advent of computer charting, this step can be made easier with drop-downs and body charts. Performing this valuable assessment will help decrease cost to the facility and cost to the patient as well as decrease the risk to a patient if they are identified early in the admission process.

Original Post
September 7, 2009
Title: Documentation on Bedsores, comment

Having worked in the NICU for many years, we see several issues with skin breakdown. For the micro-preemies who are lacking the epidermis (or extremely thin epidermis)- it is especially hard to not have skin breakdown, anything that potentially touches their skin will cause breakdown. All of these babies are considered critically ill therefore require several EKG leads, pulse oximetry probes and other transcutaneous monitors. These monitors should be repositioned every couple of hours to minimize the damage and burns. Documenting and notifying the physician of skin breakdown is EXTREMELY important with these patients as they are at such high risk for infections.

Original Post
August 20, 2009
Title: Documentation of Bedsores, comment

This is very true about the documentation of bed sores being incorrect. In the ICU where I work at, we actually document initially if there are any sores as soon as the patient arrives. It is located in the admission assessment. After that it is up to the nurses top document if there have been any changes in the skin integrity of the patient. Multiple time we see a skin assessment documented with a stage one/two pressure ulcer when reality is that it is incontinence associated dermatitis. Most time the IAD can resolved by either timely cleansing of the person, the insertion of a rectal tube and foley catheter (if not previously present) and some type of barrier ointment. In a way prevention is the best medicine for IAD and Pressure Ulcers, in companied with good core and forensic assessment skills. If the pt is having large loose stools, create a prevention to keep the skin intact.

Original Post
August 3, 2009
Title: Documentation of Bedsores, comment

The hospital where I currently work also includes documentation of existing pressure ulcers on admission of a patient. However, the protocol asks you to assess the patient’s skin then to document on paper what the ulcer looks like, stage, size, drainage, etc. The paper charting does not require a picture of the pressure ulcer that was found by assessment of the RN. I think this leaves a wide margin for error. It is probable that some ulcers will not be documented correctly. I believe that a photo would be advantageous to the medical record along with perhaps a computerized charting system where you can label with an X any area of the body that has breakdown and then attach a photograph to the document. Also the documentation I work with does not allow for updates on how the pressure ulcer heals or worsens. This also leaves room for criticism and error. I think my place of work would benefit from photo/computerized documentation of pressure ulcers.

Original Post:
July 31, 2009
Title: Documentation of Bedsores, comment

I found this post and other comments relative to my new nursing job. As an experienced ER nurse, we found little time to assess or document pressure ulcers. With the new CMS guidelines that came out this past October, Medicare will not longer be reimbursing for facility acquired pressure ulcers. My new nursing role focuses on prevention and education. I was very surprised how little I knew about pressure ulcers from working in the ED. Yet it is so vital that our assessment starts there. The photo proof documentation mentioned in this Post sounds like an excellent idea. One of the hospitals I work with, just installed a whole new soft ware program for nursing documentation. It is really easy to chart your skin assessments and pressure ulcers. With drop down choices, body diagrams. But the wound care nurse still has to validate the floor nurses documentation with her own patient assessment every month. I helped her with this, and it was very time consuming. It was double the work in my eyes. Yet we did find, many pressure ulcers that were resolved and many that were staged incorrectly, as well as several that were missed by the RN. Even though we have many different technologies to help us with our documentation and assessment, it still comes down to basic education.

Original Post:
June 17, 2009
Title: Documentation of Bedsores
Joint Commission and CMS (Medicare) has set a Patient Safety Goal of not allowing bedsores to occur during hospitalizations. My institution uses technology to document existing wounds at the time of admission assessment. We are a totally computerized charting hospital. When we identify an existing wound, we bring up a screen of the body and insert a photo of the wound into the patient’s medical record. This feature allows us to prevent lawsuits and receive the correct reimbursement of that patient’s hospitalization. Health assessment no longer has to rely on a verbal or hand written dictation to describe history and physical assessments!

Defense Lawyer Attorney decubitis pressure ulcer bedsore

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The Need for Standardization. Is it necessary?

October 19, 2009

I have had the opportunity to listen to Steve Shaha twice now in my career. He is able to place standards of care in a completely different perspective. He uses charts and slides and math and statistics. He makes his information usable and understandable. He assists hospitals with the information that he gleans from charts and is able to make correlations. He was able to work with a NICU out west and decrease there infant mortality by 75% in one year after discovering through patient chart reviews and collection of data that there was a cycle associated with the mortality rate at this institution. The cycle, he found, happened to correlate with feeding, and his discovery led to a change in how lipids were administered. This small change in care brought about the 75% decrease in mortality. Steve is also able to put his numbers into useful categories for us non-math people. The change that was instituted at this facility saved the lives of 21 premature infants in one year. Numbers of a different kind for me. His work has brought care standards to the forefront to people who will listen. Hopefully the right people are listening.

Healthcare Informatics Online Course

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Project Managers – Managing Projects, comment

October 9, 2009

Shouldn’t project managers manage? Take accountability and ownership and decision-making? What happens when the project manager doesn’t take ownership? Things begin to fall apart. As part of an implementation team for an Electronic Health Record (EHR) system, I am finding that there are many questions and not enough answers. The facility where I work is currently piece-mealing an EHR and it seems that every time we turn around, there is a new glitch. We are currently implementing several systems that don’t seem to interface with each other. Not all staff had being included in the original education and now we are back pedaling to get them educated. Every one in the facility should be taught how to use this system, and that should have been a project managers decision. Alas, it was not and now we are scrambling to educate staff on the nuances of a system that we are only just learning how to use. Caution with the EHR, it can be painful and not just because humans hate change.

Original Post
June 1, 2009
Title: Project Managers – Managing Projects
The project manager must know what the project is, what it is suppose to accomplish, and the time frame it in which should be accomplished in. They must also be aware of the budgetary constraints. The project manager needs to form a team to work on the project with. Each team, and team member, must be aware of his or her responsibility to the team and the project. They must know goals and expectations. To be successful, the project manager must be able to delegate tasks. The project should be broken down in parts and each part be given to the team best suited for completion of that task. In project managements they must be lots of communication. The project manager must be able to communicate with the team (s), individually and as groups. There must be regular scheduled meetings to gage and monitor progress, and to feed back to the stakeholders the progress of the project. These meeting should also include the vendors and the clients of the project and where necessary the end-users. The project manager should keep clear documentation on the progress of the project, to ensure the stakeholders are kept up to date with the progress of the project. This documentation should show any problems encountered during the implementation process, what steps were taken to fix the problem or any changes that were made, and the rational behind the changes. Regular progress reports, and information sharing are essential to good project management and project completion.

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Would it be helpful for nurses to have actual X-rays on the computer? (comment)

October 9, 2009

In some cases it would be very helpful for nurses to have access to xrays on computer. In critical areas such as ER and ICU this would be very helpful, however, we must use caution and educate nurses into what they are actually viewing. It is important to know how to deconstruct a CXR from the cspine down to the diaphragm. Know where the level of the carina is. Has anyone ever tried to Google "level of carina"? Try it and see what you get. It would be helpful for Critical Care RNs to be taught how to read xrays, not by other nurses, but by Radiologists, to show us how THEY break down a film. Many questions arise when looking at CXRs. What is too dark, what is too light? Does over- or under-penetration even matter? Depends on what you are looking for. Having quick access to xrays would assist the nurse who is proactive in their patient care. You can prepare for certain treatments if you have a basic understanding of radiologic exams. What does free air look like? What should you be looking for when following an NG tube down below the diaphragm? Nurses should use caution though. Too much knowledge can be harmful also. Take care with reading xrays, and ask for assistance.

Original Post
April 20, 2009
Title: Would it be helpful for nurses to have actual X-rays on the computer? (comment)
As a nurse who has worked in various settings,
I believe it would be beneficial for nurses to have access to the
actual film. Most hospitals and some smaller facilities are now able to
place these films online so that the physicians can review them from
anywhere. Agreeably most nurses do not know how to read xrays but some
are able to look at the xray and see a broken rib, a white out or such.
This would be helpful to the nurse to understand the patients problem
and to anticipate treatment. The other part of this is if the nurse has
access and it is in an area where she could show it to the family and
TEACH and INSTRUCT them as to what is wrong with their loved one it may
decrease anxiety and assist with the treatment of that patient. I don’t
believe nurses should be the first one to observe the xray and share it
with others because this would be above their scope of practice.
However, to be able to utilize these tools to learn and teach others
would be a great asset.

Original Post:
April 7, 2009
Digital images, such as X-rays and scans, will be stored on computer –
enabling them to be sent by email or stored in a USB device. This ends
the need to physically transfer X-rays or scans by hand from hospital
department to another. This is extremely important that the diagnosis
could be made faster and so as the treatment. Also, other health
professional could share the same information and of course we need the
patient’s consent.
This will also eventually see patient records
being stored electronically and all GPs making hospital appointments
for their patients from computers in their surgeries.
People in
rural areas will especially benefit because it will save many journeys
to hospital. The digital image will follow the patient wherever they go
and will be able to be recalled whenever and wherever they need to be
accessed by a patient’s healthcare professional. In addition to
patients not having to wait whilst their X-rays are processed and
delivered by hand from one department to another, clinicians will no
longer have to hold X-rays up to a light box in A and E to make a
There will be improved staff and patient safety due to
reductions in radiation dosages from X-rays and avoiding the use of
hazardous chemicals for film processing.
Apart from that, health
professionals should learn to read the X-rays and scans so this would
be more beneficial to patients through different other therapies.
Although, protection of client’s private details would be another issue
to be considered.

Original Post:
March 6, 2009
physicians can pull up the actual x rays and ct scans on the computer
but nurses can only pull up the report. Now I agree not all nurses can
read X rays but in the ER, ICU and Recovery Room seasoned nurses can
read basic films (chest x ray, bones for fractures, etc). I was taught
this skill when I first trained in critical care. As a nurse I always
appreciate the ability to look at a film and be able to see if my
patient has fractured ribs, which would prepare me to understand the
complications for this type of fracture. Or to see a pneumo following
central line placement and have a chest tube set up at the bedside when
the physician arrives. In the ER I can set up for a closed reduction if
I have access to the films. Most of the time a nurse has more time to
keep checking for results than do physicians. Additionally, printed
reports are, in most cases, not downloaded into the computer system
until long after the patient receives treatment. I am an advocate for
electronic documentation and medical records however nursing education
and the level of knowledge we have these days is under estimated. Yes,
the radiologist reads the results and the physician orders the
treatment but most nurses can anticipate what the treatment will be
which in turn decreases both patient and physician wait time and
decreases the risks associated with those wait times.

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Stress and workload, comment

October 7, 2009

My upcoming workload is a bit overwhelming, during the next two months, with out the added stress of my online course. Although I only have to complete Advanced Anatomy, Physiology, and my Capstone project, I truly feel no end in site or even worse, the fact that I may not pass my A&P. I now feel that I must register for my last course when I am about to start my second half of this course, just to finish prior the end of November. This is because hopefully I can relax and enjoy the holidays with my family and be done by the deadline of the end of the year. Each day I work to do the best job an educator can do, and try to accomplish each of my tasks in a rather timely fashion, but in nursing, there are always speed bumps in the road to prevent you from getting out on time, which is usually around 4-5pm. I can function pretty well with my computer but I am having quite a bit of trouble at times accessing the Evolve website. I really do not have the time to call tech support as that usually means an entire evening is wasted trying to solve a computer problem. When I finally can get on, it is either to take a quiz, or submit my forum post. Taking a quiz. (Alternatively, mid-term or final) is extremely stressful to me. Not only do I generally freeze up during quizzes or tests, but also, there is a little clock in the right hand corner, quietly ticking down the time left before my test should be complete. In addition, if that is not enough stress on my plate, every now and then, a small box appears in the center of my test questions, letting me know exactly how many minutes I have left. This, I do not need on top of my already high anxiety level. I talk frequently to a few of my fellow clinicians that are in the same boat as I, trying to obtain their BS in Nursing before the end of the year and they are stressed to the max. With both the flu epidemics fast approaching, we all wonder what kind of condition we all will be in by the time we are done. We will all push on to do our jobs, do our homework, complete our quizzes and hopefully finish in time to meet our dead lines.

Original Post
July 15, 2009
Title: Stress and workload
Stress and workload; I thought it was appropriate to discuss stress because that’s exactly what I am feeling about my degree program. It does feature online interaction and computer use. The purpose of my degree program was to prepare myself on how to be a better Community Health Nurse; I did not think it was to send time on academic work. I went to bed last night feeling very stressed. My workday is already 9 hours long and by the time I get to my computer at night I am already tired and stressed. What am I going to do about it? I don’t know. I am sure I am not the only one feeling this way. Many Nurses are already feeling the strain of work, family, education etc. I graduated from Nursing in 1982 at the ripe age of 19; it was a 3-year diploma program. Now it’s all about the degree and it is becoming increasingly difficult for diploma nurses to move forward in their career. With the national nursing shortage one would think the government would concentrate on more effective ways for diploma nurses to bridge over to their degree. I can’t afford to take 2 years off to go back to school and taking a course at a time I will be ready to retire by the time I get my degree.

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Overall Leasons Learned

October 7, 2009

Review of Introduction to Computers for Healthcare Professionals, Fourth Edition, 2005/2006. Authors: Irene Joos, Nancy Whitman, Marjorie Smith, and Ramona Nelson. Within Dr. Johnson’s course.

When I received the book I quickly flipped through it and thought that it was very basic and that this may have been a waste of money. I soon learned that when I sat down and read the book there was a lot of information that I did not know or actually thought I knew but was wrong. I was pleasantly surprised at the information presented and would recommend this course as part of any type of administrative program.

Health Care Informatics online certificate program

Barter and Online Healthcare Informatics Education

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Web, Communication and Information Management

October 7, 2009

Review of Introduction to Computers for Healthcare Professionals, Fourth Edition, 2005/2006. Authors: Irene Joos, Nancy Whitman, Marjorie Smith, and Ramona Nelson. Within Dr. Johnson’s course.
I found a lot of the information in these chapters to be stuff that I already knew for the most part. Although I did learn the definition of the world wide web. I just thought that the web was the Internet. One of the activities at the end of chapter 9 did walk you through creating your own web page. I did not know how to do that. Chapter 12 did go over all the computer crimes and some of them I had never heard of either. The IT professionals at work only address the most common threats.

Health Care Informatics online certificate program

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Introduction to Word Processing, Presentations, Spreadsheets and Databases

October 7, 2009

The most important part of this Unit for me was the database chapter. I learned the difference between hierarchical, network and relational database models. I had no idea there were different models. We use Access a little where I work but not a lot. I would like to learn more about creating databases. I feel this chapter gave me the basic knowledge; now I would like to expand on it in the near future.

Health Care Informatics online certificate program

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