January 2015
Swank Health: Your monthly news from Swank HealthCare


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In This Issue

Did You Know?

Health Information Technology

Top List
What's Going On?

50th USPHS Scientific and Training Symposium
National Nurses Week 2015

Now Trending

See how well you can guess how participants of the survey answered the following questions

Recommended Readings

Recommended Courses*
  • 32515 Documenting to Save Your License
  • 41411 Observation, Reporting, and Charting
  • 51013 Modern Medical Technology: A Revolution

* course numbers may vary by facility


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Did You Know?

Health Information Technology

This March, The Joint Commission issued a new Sentinel Event Alert on the safe use of health information technology. According to the alert, The Joint Commission identified 120 health IT-related sentinel events between January 1, 2010 and June 30, 2013. These events were categorized by the following characteristics:

  • 33% were human-computer interface issues related to ergonomics and usability issues resulting in data-related errors
  • 24% were issues relating to health IT support of communication and teamwork
  • 23% were design or data issues related to clinical content or decision support
  • 6% involved issues with organizational policies, procedures, and culture
  • 6% were linked to training and failure to follow established processes
  • 6% were hardware and software design issues and other hardware/software problems
  • 1% were caused by external factors
  • 1% were related to system measurement and monitoring issues

In addition to concerns highlighted in the Joint Commission’s latest Sentinel Event Alert, in April the ECRI Institute issued its annual list of the Top 10 Patient Safety Concerns for Healthcare Organizations. Making the list again in 2015, and coming in at number 2, was Data Integrity: incorrect or missing data in EHRs and other health IT systems. According to the report, organizations have difficulty identifying data integrity failures and applying fixes to prevent similar problems from recurring, partly because healthcare staff do not always recognize health IT’s contribution to an event. An example of an actual event was used to illustrate the scenario: staff reported an adverse event as a medication error when a pharmacist placed a medication order in the wrong patient’s record. Later, analysis of the event recognized that the error was facilitated by a medication management system that allowed users to have multiple patient records open on a screen at the same time. When reporting an adverse event or near miss, healthcare personnel are urged to consider whether or not some function or feature of health IT could have contributed to the problem.

Also in April, a new book was released about the challenges faced in this beginning era of the rapid computerization of medicine. The book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was written by Dr. Robert Wachter a professor and chief of the division of hospital medicine the University of California San Francisco. For more than two decades, he has been a leader in patient safety and quality, authoring hundreds of studies examining issues, like medical errors, physician communication, and quality reporting. Last month, Modern Healthcare listed Dr. Wachter as number 1 on their ranking of the 50 Most Influential Physician Executive Leaders.

In his book, Wachter highlights the wins and obstacles along healthcare’s digitalization journey. He describes specific events of patient harm where Health IT was an underlying cause. In the very hospital where he leads the medical team, a teenager was given a 39-fold overdose of a common antibiotic when a doctor failed to recognize that a computer screen was set on milligrams per kilogram rather than just milligrams. To make the situation worse, the error caused alerts that were ignored by both the physician and pharmacist. The boy suffered grand mal seizures and was sent to the I.C.U. where he almost died.

Despite these types of challenges, he remains an advocate for moving forward with thoughtful use of technology. He makes the case that computerized medicine is here to stay, and in the long run, will improve patient health and the practice of medicine.

“The answer to what ails healthcare is not going to be found in romanticizing how wonderful things were when your doctor was Marcus Welby. We can - - in fact, we must - - wire the world of medicine, but we need to do it with our eyes open, building on our successes, learning from our mistakes, and mitigating the harms that are emerging.”

“To do so effectively, we need to recognize that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12. Instead, they transform the work, the people who do it, and their relationships with one another and with patients. Sorting out all these issues will take deep thought and hard work on the part of clinicians, healthcare leaders, policymakers, technology vendors, and patients. Sure, we should have thought of this sooner. But it’s not too late to get it right.”


What's Going On?

50th USPHS Scientific and Training Symposium

May 18 - 21, 2015
The Sheraton - Atlanta, GA

More Information »

National Nurses Week 2015

May 6 – May 12
We offer a vast array of CE topics in our Nursing library at no cost to your Nursing staff. Thank you for all you do to improve the lives of others!

Nursing Library »


Recommended Readings


Top List

An article in American Nurse Today, What You Need to Know about Electronic Documentation, lists Tips on electronic documentation.

  1. As with paper records, always document everything, remain objective, and avoid unapproved abbreviations
  2. Make sure to document in the correct patient’s record
  3. If possible, document in real time to avoid late entries
  4. Don’t leave anything blank. Use “N/A” to indicate you looked at the item that was supposed to be documented there. Or write “Denies” or “Not observed” to indicate you asked about or assessed that item
  5. Double check your entries. It’s much easier to click on the wrong box accidentally than to manually checkmark the wrong box
  6. Never copy and paste someone else’s documentation – and never copy and paste your own unless you’re absolutely sure nothing has changed
  7. Use barcodes on both patients and medications. Don’t take shortcuts and override barcodes except in a true emergency

Catalano, L. A. (n.d.). What You Need to Know about Electronic Documentation. AmericanNurseToday.com, 9(11), pp. 24, 46


Now Trending

User-related errors are a common cause of adverse events. Test your knowledge of user-related errors by selecting the type of user error that corresponds with these scenarios below.

When using the mouse and keyboard to enter notes and medication lists, a user hits a wrong key, enters an incorrect date, or incorrect vital signs. Which type of error is this?

Data entry error
Cut and paste error
Chart management error
Chart completion error
Order entry error

Some practices “pre-start” notes for a patient prior to a visit. If the appointment is missed, notes are deleted. When deleting a pre-started note, other notes documenting an actual visit are inadvertently deleted. Which type of error is this?

Data entry error
Cut and paste error
Chart management error
Chart completion error
Order entry error

A user selects a narrative of details about a patient from a previous note, based on an assumption that there have been no changes, and moves them to a new note. Those details contain out-dated or false information that no longer pertain. The situation leads to inaccurate decision-making. What type of error is this?

Data entry error
Cut and paste error
Char management error
Chart completion error
Order entry error


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