Respond to each discussion post separately with references, asking questions to help clarify the scenario and application of data, or offering additional/alternative ideas for the application of nursing informatics principles.
Discussion 1
COLLAPSE
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Informatics in Nursing Practice
The introduction of informatics concepts in nursing has improved the practice in various ways, including improving the coordination of care and the quality of care through information systems to collect, store, and disseminate information. The situations in which the concepts of informatics can be applied are during patient assessment. The clinician requires information about the patients’ medical history, which is essential when making a diagnosis. The clinician will be able to obtain data from electronic health records (EHRs). EHRs contain patient health information such as medical history and administrative clinical data, including medications, problems, clinical notes, and demographic information relevant to patient care (Dutta & Hwang, 2020). A patients’ medical history is necessary when making a diagnosis.
A nurse leader would rely on clinical reasoning and judgment by collecting subjective and objective information about the patient’s condition before making a diagnosis. Clinical reasoning is required in comparing the patient’s medical history with the present symptoms to identify whether there is any relationship. The nurse leader will be able to make an informed and better decision than in the absence of EHRs because patients may not share all information about their medical history. As a result of the use of EHRs, the patient will get a proper diagnosis and treatment intervention. According to Kruse et al. (2018), EHRs improve the clinical decision-making process, efficiency, and positive patient outcomes. A precise diagnosis is the first step towards achieving positive patient outcomes since misdiagnoses are associated with poor patient outcomes
(Nasrallah, 2015).
References
Dutta, B., & Hwang, H. G. (2020). The adoption of electronic medical record by physicians: A PRISMA-compliant systematic review. Medicine, 99(8). https://doi.org/10.1097/MD.0000000000019290
Kruse, C. S., Stein, A., Thomas, H., & Kaur, H. (2018). The use of electronic health records to support population health: A systematic review of the literature. Journal of Medical Systems, 42(11), 214. https://doi.org/10.1007/s10916-018-1075-6
Nasrallah, H.A. (2015). Consequences of misdiagnosis: inaccurate treatment and poor patient outcomes in bipolar disorder. Journal of Clinical Psychiatry, 76(10), e1328. https://doi.org/10.4088/JCP.14016tx2c
DISCUSSION 2
My healthcare facility has been experiencing high cases of reported medical errors as a result of using paper documentation for the last two fiscal years. On one occasion, a patient at the mental health facility where I work was wrongly prescribed Inderal medication used to treat high blood pressure instead of Adderall for treating the patient’s depression episodes. The staff responsible for the medication error traced the issue to illegible writing of the physician due to the extensive use of paper documentation in the facility at the time. The administration is planning to transition to electronic documentation, where patient data and information regarding diagnosis and disease management will be recorded in electronic health records.
Studies by Cowie et al. (2016) and Neves et al. (2018) suggest that the use of electronic health records such as clinical decision systems could facilitate faster access, collection, and application of health data to lower the rates of medication errors. As Agrawal (2019) recommends, the healthcare facility will further implement the use of the computerized physician order entry (CPOE) to help with precision dispensing of patient medications, barcode-guided administration of medications, and automated dispensing as key strategies to lower the likelihood of medication errors. McGonigle & Mastrian (2017) posits that the use of barcoded wristbands among mental health patients and consistent use of electronic health records could reduce the rates of medication errors with approximately 98% specificity and reliability.
References
Agrawal, A. (2019). Medication errors: prevention using information technology systems. British Journal of Clinical Pharmacology, 67(6), 681–686. https://doi.org/10.1111/j.1365-2125.2009.03427.x
Cowie, M. R., Blomster, J. I., Curtis, L. H., Duclaux, S., Ford, I., Fritz, F., Goldman, S., Janmohamed, S., Kreuzer, J., Leenay, M., Michel, A., Ong, S., Pell, J. P., Southworth, M. R., Stough, W. G., Thoenes, M., Zannad, F., & Zalewski, A. (2016). Electronic health records to facilitate clinical research. Clinical Research in Cardiology, 106(1), 1–9. https://doi.org/10.1007/s00392-016-1025-6
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
Neves, A. L., Carter, A. W., Freise, L., Laranjo, L., Darzi, A., & Mayer, E. K. (2018). Impact of sharing electronic health records with patients on the quality and safety of care: A systematic review and narrative synthesis protocol. BMJ Open, 8(8), 34–39. https://doi.org/10.1136/bmjopen-2017-020387
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