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By Richard Scarry - Apr 01, # Last Version Quick Hit Medical Facts Volume 1 #, quick health facts selected state data on older americans 1 i.
Table of contents
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For example, the following was one of statements by nurses about EHR experiences:. Yes, the documentation of "quality standards" has greatly improved, but patient care and patient safety has not. In fact nurses have to enter false information sometimes and work around the system I use vendor X, Y and Z and all have similar issues. I know first-hand of 2 sentinel events caused by the systems X and Y. This case scenario can be examined in terms of the overall context of ethical implications in use of the EHR. This committee was to evaluate the changing health technology environment and make recommendations to the TNA Board regarding steps needed to prepare Texas nurses for the rapid uptake of technology in healthcare settings required by this legislation.
A statewide study was initiated to evaluate nurse perceptions about clinical information systems such as EHRs. However, analysis of text comments found patterns and trends that reflected distress related to moral issues and ethical dilemmas please note that we are using the terms "moral" and "ethical" interchangeably in accordance with the current literature. We believe the ethical issues, in particular, warrant further exploration and require models of decision making to support clinical interprofessional teams in appropriate decision-making and subsequent action.
In the Texas-based statewide study McBride et al. A thematic content analysis of the narrative responses to the open text question was used to analyze the data. The text narrative responses were then reorganized according to concepts and summarized into categorical statements. Further immersion and analysis of the categories by two researchers with informatics expertise resulted in a synthesis of comments within the categories that revealed several primary themes.
These are noted in Figure 1. A conceptual model that reflects the overall common concepts detected in the thematic analysis was developed by the research group and is also noted in Figure 1. We learned that these were reflected, among other ways, in the EHR-based documentation that varied from established interprofessional practice standards.
Figure 1. Major and minor themes related to qualitative study comments. A sampling of these comments is provided by categories in Table 1. They are grouped by category of content.
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I have almost no training on the "System. System was not designed by the people who would use it. It does not capture the data required by the state to successfully use it. Very frustrating because we constantly have to do double work. Our preop department uses entries in both the nursing module and the OR module, which necessitates constantly switching from one menu to another - time consuming and inefficient. Because most of the notes are copy and pasted, there are many discrepancies on one line, the patient is intubated; on the next line of the same patient, the patient is on nasal cannula.
It's made the notes semi-worthless. This system has quadrupled our workload. It is not accurate and orders tend to disappear.
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The pharmacy part allows expired orders to carry on and continue to be active even after stop dates which lead to medication errors. This system is difficult to view orders and communicate with others. Things do not work well. It takes several hours to get thru discharges due to links that do not work.
With the ER after two weeks on the program, it developed an application error that would not let nurses go back to add information while the patient is still active and document is active. Our computers at times freeze inside the room.
During am med pass, it is so stressful finding a good computer that does not freeze. Sometimes I have to go through computers before finding one that works. Sometimes I feel that the barcode scanning system for medication administration hinders critical thinking and prevents truly looking at what you are giving the patient.
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The FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action The case scenario above provides an opportunity to explore a holistic framework, the Four Component Model Rest, , to identify and address ethical issues in nursing practice. Ethical Sensitivity Ethical sensitivity is described as our ability to recognize an ethical problem, the moral implications of our decisions, and how our actions affect other people Milliken, Having practiced in the ED for ten years, Nancy may be respected by her nursing peers and physician colleagues and may question how her actions could potentially affect those professional relationships.
Ethical Judgment Not all issues will require an in-depth consideration of all elements in a specific model, and the goal is to reach a prudent choice, not certainty. The second component of the FCM is ethical judgment or decision-making, a deliberative process reflecting knowledge of ethical principles, theories, and codes.
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Recognizing the potential harm of following the sepsis guidelines in a patient with suspected pulmonary edema, Nancy decides to share her concerns with the physician. The University of Washington School of Medicine. A case-based approach to ethical decision-making. Brown University. A framework for making ethical decisions. Ethical decision making.
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Ethical Motivation All nurses want to be ethical and live in a manner consistent with their personal and professional values. The third component in the FCM, ethical motivation is the bridge between decision-making and action Robichaux, Competing personal values Wolf et al. The stress felt by Nancy in the presented ED case scenario is an example of this type of moral distress. These same issues are reflected in a number of comments in Table 1 e. Could additional actions have been taken? Developing moral courage may assist in overcoming personal and institutional barriers to further nurse advocacy.
When moral courage and ethical action are thwarted by constraints outside the nurse's control, moral distress can result. Nurses experience moral distress, a concept first highlighted by Andrew Jameton in , when they "know the right thing to do while being in a situation in which it is nearly impossible to do it.
Jameton described three components that can apply to the pain expressed by the nurses that contributed to the Texas study: knowing what is right, being in a situation that constrains acting on that knowledge, and the psychological distress resulting from that inability to do the right thing Jameton, It may be challenging to remember what actions to take when encountering a situation that requires moral courage.
The CODE mnemonic strategy helps nurses to recall these actions and includes ways to overcome fear and reluctance to speak up including reflection, reframing, and assertiveness skills. The accelerated growth and adoption of the EHR has produced a situation that repeatedly occurs in the history of technology and parallels the rise of bioethics.
While nurses are aware of this ethical obligation in relation to the EHR, they may be less familiar with additional ethical issues inherent in its use and development. From cardiopulmonary resuscitation CPR to genetic engineering, the creation and use of an innovative tool may surpass the knowledge and resources required to ensure an ethical and appropriate use Goodman, The current and potential positive impact of the EHR on quality care is not disputed.
Effective communication is vital to this relationship, and the EHR may have a negative effect. Perhaps the most troubling ethical issue noted is the potential erosion of the patient-nurse relationship. The use of computers and communication technologies will impact more lives in the 21st century than any other technology, including stem cells, transplants, and nanomedicine Goodman, As indicated in the case scenario and the study findings, the use of the EHR can result in a unique set of ethical and legal challenges.
Nurses must be prepared to face these challenges and recognize the requirements of state and federal law, workplace policies, and obligations of the profession. A study in revealed that nurses spent a majority of indirect nursing time documenting in the EHR, demonstrating the critical necessity of proper usage to satisfy quality of patient care Kim, Documentation must be clear and accurate to provide a basis for the contribution of nurses to patient outcomes and the viability of healthcare organizations ANA, Documentation that fails to meet these principles can result in undesirable outcomes for the nurse, patients and families, or for the healthcare organization ANA, Nursing documentation, electronic or handwritten, are legal documents that can, under some circumstances, be used in legal proceedings.
Nurses maintain competence regarding the legal significance of documentation and therefore must demonstrate legible and comprehensive reporting Larsen, Once documentation has been electronically recorded and signed by the nurse, the liability of that acknowledgement is not clear. The copy and paste functionality includes copying, pasting, cloning, auto-filling, carrying forward, replicating data and reusing content from one section to another within the EHR Scruth, The copy and paste phenomenon has caused significant debate from those who argue its necessity for time efficiency weighed against the significant risk of inaccuracy and patient safety errors Harrington, These practices can result in timeliness issues or time-related accuracy of documentation in any EHR.
EHRs are designed to facilitate easier provider order entry and have been shown to reduce prescription errors Scruth, They have tremendous potential to improve efficiency of healthcare delivery and improvement of quality patient care. However, healthcare providers have experienced notable challenges to balance necessary time for patient care with computer entry McBride et al.
Historically, it was assumed that all standards of care were met unless documented otherwise.
However, with the introduction of the EHR, complete documentation requires charting of all clinical assessments, care plans, interventions, and outcomes requiring more time for documentation de Ruiter et al. Additionally, alert fatigue and clinical information overrides must be addressed within the organization. Overriding content in what is often an undesirable system design can result in misinformation in charting that can have detrimental effects on the nurse, patient, and healthcare organization. For example, a false entry into an EHR can follow a patient for years.
The patient is likely unaware of the false entry, but subsequently applies for health or life insurance. The patient may be denied insurance coverage based on a one-time false entry that was replicated over time. We conclude with a call to action for interprofessional teams, associations, industry, and others to collaboratively address these issues on behalf of the health and safety of the nation, and equally as important, the health and well-being of the healthcare workforce.
To do that, the authors suggest the following recommendations to address challenges with EHRs.
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