Care Lecture 2: Informatics and Safety

informatics

science that encompasses information science and computer science to study the process, management, and retrieval of information

nursing informatics

use of information and computer technology to support all aspects of nursing practice, inclusion delivery of care administration education and research

-prevent medical errors

-create cultural, social, organizational and intellectual change

-improve quality of care

-reduce costs

how does informatics help health providers?

-HIPAA concerns

-documentation accuracy

what are unintended consequences of informatics & safety?

-maintain privacy and security

-only use own password

-log off computer when leaving

-only look at your own client's files

how can we prevent HIPAA issues regarding informatics?

make sure documentation is:

-complete

-concise

-current

how can we promote documentation accuracy?

NANDA

nursing diagnosis that is widely used in the nursing world; focuses on the nursing problem from your initial assessment

interventions

what is NIC focused on?

outcomes

what is NOC focused on?

problem, intervention, and outcomes

what is the OMAHA system focused on?

public health setting

what setting uses the OMAHA system most often?

diagnosis, interventions, and outcomes

what is PNDS focused on?

-computerized providers order entry

-clinical decision support system (CDSS)

-electronic medication admin records

-barcode medication administration

-clinical documentation

what are some basic clinical applications of informatics?

-protect patient confidentiality

-document appropriately in EHR

-use communication technologies to coordinate patient care

-respond correctly to clinical decision-making alerts

what are the QSEN standards for informatics?

safety

minimizes harm to patients and providers through both system effectiveness and individual performance

delineate general categories of errors and hazard in care

how can knowledge promote safety?

foster open communication, mutual respect, and shared decision-making to achieve quality patient care

how do teamwork and collaboration contribute to safety?

near miss safety error

an unplanned event that did not result in injury, illness, or damage, but had the potential to do so

-surgical

-patient-protection

-care management

-product or device

-environmental

-criminal

what are some examples of serious reportable events?

sentinel event

unanticipated event resulting in death of serious physical or psychological injury that is not related to the natural course of the patient's illness

-confidential

-provides legal protection for you

-not part of the chart

-patients not aware of it being filed

-NOT a discipline to staff

what are some characteristics of an incidence report/document?

when an actual or potential adverse event occurs

when should a nurse complete an incidence report?

objective data (time, location, patient's condition, treatment and response, who was involved, etc.)

what should be documented in an incidence report?

goes to a risk manager/risk management team to be evaluated

what becomes of an incidence report?

-allows organization to identify trends

-allows improvement

-adhere to evidence based principles of safety

-promotes "culture of safety"

how do incidence reports contribute to promoting safety, communication, and teamwork?

culture of safety

acknowledges the influence of complex systems and human factors that influence safety; focus is on teamwork to accomplish the goal of safe, high-quality care

communication failures

what is the leading cause of inadvertent patient harm?

"just culture"

a system's explicit value of reporting errors without punishment; people can report mistakes or errors without reprisal or personal risk

1. right patient

2. right drug

3. right dose

4. right route

5. right time

what are the 5 patient rights?

-safe

-effective

-patient centered

-timely

-efficient

-equitable

what are the six aims to improve healthcare?

form the underlying basis of every federal healthcare policy

what is the significance of the six aims of healthcare?