A case study in medical error the use of the portfolio entry

A cause-and-effect diagram, shown in Figure 1, was useful for developing strategy on moving from a high rate of errors to no errors.

A case study in medical error the use of the portfolio entry

Abstract While the adoption of electronic health record EHR systems promises a number of substantial benefits, including better care and decreased healthcare costs, serious unintended consequences from the implementation of these systems have emerged.

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Poor EHR system design and improper use can cause EHR-related errors that jeopardize the integrity of the information in the EHR, leading to errors that endanger patient safety or decrease the quality of care.

These unintended consequences also may increase fraud and abuse and can have serious legal implications. This literature review examines the impact of unintended consequences of the use of EHR systems on the quality of care and proposed solutions to address EHR-related errors.

This analysis of the literature on EHR risks is intended to serve as an impetus for further research on the prevalence of these risks, their impact on quality and safety of patient care, and strategies for reducing them. Adoption of HIT has failed to achieve projected benefits and cost savings because of shortcomings in the design and implementation of HIT systems, including safe and effective use of these systems.

Currently there are no regulatory requirements to evaluate EHR system efficacy and safety. There is no sense of shared accountability between system developers and users for product functioning.

While a primary goal of EHR implementation is the reduction of medical errors, reports of new types of errors directly related to EHR implementation that can compromise quality of care and patient safety have emerged.

This medical error could have been prevented if automated alerts had been activated.

A case study in medical error the use of the portfolio entry

No comprehensive study has been conducted to determine the industrywide incidence of EHR-related errors or adverse clinical events resulting from these errors.

EHR System Design Flaws The expanding capabilities of EHR systems require increasingly complex software, which heightens the likelihood of software failures that may harm patients. For example, a structured data field may indicate that one pill should be taken twice a day, while the free-text instruction field says to take two pills in the morning and one pill in the evening.

Also, competent human intervention depends on users having the time, motivation, and ability to reflect on and challenge computer-generated data and recommendations, which may not be true in the midst of surgery or in the intensive care unit. Additional types of user-related errors resulting from improper documentation capture can be found in Appendix A.

Current literature suggests there has been little or no improvement in the prevalence of EHR-related errors, which is not surprising since little has been done to identify the root causes and address them. Also, patient harm resulting from EHR-associated errors is likely underrecognized and underreported.

Inaccurate or outdated information; Redundant information, which causes the inability to identify the current information; Inability to identify the author or intent of documentation; Inability to identify when the documentation was first created; Propagation of false information; Internally inconsistent progress notes; and Unnecessarily lengthy progress notes.

For example, in Hussain v.

The Commentary

The clinical environment can contribute to the occurrence of a clinical decision support system error. For example, user distraction might cause data entry errors or inattentiveness to the information being presented by the decision support system.

Because another study demonstrated no negative impact on the accuracy of EKG interpretations when cardiologists were presented with an incorrect computer interpretation, 85 the tendency toward overreliance on computer decision support may be greater if clinicians are less skilled in the task involving computer assistance or less confident in their skills.

A study noted that a number of reports had documented the potential of EHRs to contribute to healthcare system flaws and patient harm, but few EHR risk management strategies had been published.

To achieve the high-level quality of care and improved patient safety anticipated from the use of HIT, the problems with EHR design and use that hinder achievement of these benefits need to be addressed.

The need for more rigorous data quality governance, stewardship, management, and measurement is greater than ever. By identifying EHR features that users believe present new opportunities for error and the tactics that physicians employ to work around them, EHR system developers can enhance current functionalities and create new tools to minimize new EHR-associated errors.

Federal regulations should be promulgated that establish approval and monitoring processes and EHR system standards and implementation specifications.

Strategies to address EHR usability problems and reduce improper system use include the following:Request PDF on ResearchGate | A Case Study in Medical Error: The Use of the Portfolio Entry | The Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement competency incorporates lifelong learning techniques and self-reflection.

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Identifying and Preventing Medical Errors in Patients With Limited English Proficiency: Key Findings and Tools for the Field.

Melanie Wasserman, wrote case study reports for each site, and completed a cross-case report to distill lessons learned across all three sites. Start studying 26 documentation practice questions. Learn vocabulary, terms, and more with flashcards, games, and other study tools.

Search. Create. Log in Sign up. Log in Sign up. 28 terms. nursecait Only centralized medical records use the client data. This lack of standardized practice creates opportunities for errors. A US Department of Health and Human Services study says that this type of mistake occurs in 1 in to 1 in persons.

A study published in Annals of Surgery found that mistakes in tool and sponge counts happened in % of surgeries.

A case study in medical error the use of the portfolio entry

title = "A Case Study in Medical Error: The Use of the Portfolio Entry", abstract = "The Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement competency incorporates lifelong learning techniques and .

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